Urgently rethinking mental health in South Africa

As troops of psychologists flocked into Joburg last month, Emperors Palace morphed into a marketplace of ideas. My everyday work context is a busy public hospital setting, so as I prepared for this annual congress, mental health was on my mind. And it still is, because October is mental health month, and Saturday was World Mental Health Day.

In writing this column, I tried to avoid see-sawing between two extremes. The one temptation is to get lost in the sentimentality of helping people who suffer from anxiety, depression, psychosis, or trauma. It is a harrowing but rewarding journey into the depths of human experience, laced with dark and colourful exposés of unpredictable personalities and the psychodrama of everyday life. It is a privilege to be invited and entrusted into the lives of so many people every day.

The other temptation is more academic. Wanting to write about the brilliant advances in our understanding of the brain and behaviour, in psychotherapy, and in philosophical and social theorising that has mobilised the vastly multidisciplinary field we call mental health.

But somewhere between emotion-infused nostalgia and academic rationality, I pause for a reality check, to consider the many factors that must work together in the real world, in order for our health system to deliver a service that is both friendly to patients and supportive of staff. Mental health, whether you see it as a product on offer, or a process to engage in, does not exist in isolation of all the other social issues facing South Africa.

Take a hypothetical patient, Jane, consulting a hypothetical therapist John. She had just tried to kill herself, citing relationship and family problems. Very soon, she threatened, she would try again. She sees no hope for her future. What issues could be at play here?

– The first problem is access. She cannot afford to travel to the hospital for regular psychotherapy.
– The second problem is psychotherapy itself. The idea of talking openly about deeply guarded feelings to a stranger in a hospital is culturally odd.
– Thirdly, this stranger, John, did not speak her first language, and the means of treatment, talking, was being done in broken English.
– The fourth problem is medication. It restores appetite and sleep and may lift her mood, but her drunken boyfriend still hits her every night and she feels stigmatised for being diagnosed as mentally ill. She hopes nobody finds out.
– The fifth problem is blame. The discourse around mental illness is that if people change their thoughts or behaviour, they will get better, which indirectly blames the victim.

Once the symptoms that accompany her apparent mental illnesses, perhaps depression, disappear, nobody would have addressed the social roots of her distress: patriarchy, violence, troubled masculinities, political apathy, and waning ubuntu. This requires a radical intervention that goes beyond individuals changing the content in their heads, their faulty thoughts, bad behaviours or mysterious chemical imbalances. It requires a shift in our society.

From the couch to the community
As we move from the couch to the community, others before me have debated these issues extensively. Part of this debate is around whether we should be diagnosing society instead of the individual, because we live in societies that are increasingly less communal, with the collapse of previously available support structures, such as extended families and neighbours. In general, while the quantity of our interactions has increased, they are short-lived and superficial and exist largely electronically, on email or social media or cellphones. The quality of our interactions appears weakened, resulting in fewer people we can truly depend on, increasing our sense of isolation, anxiety, and fear about the future. These social factors impact on us as individuals. Therefore, the usual “treatment options” are limited because our patients’ symptoms are mostly socially rooted.

This idea might not seem that radical to a sociologist or a political scientist, but psychology has unfortunately developed in isolation from a broader consideration of the world around us, as we have delved deeply into fantasies, dreams, cognition and other individualistic pursuits. The obviousness of South Africa being a deeply troubled country emerging from a horribly traumatic past is that we are now confronted with a violent, desperate present.

Psychological pathologies therefore cannot be located exclusively inside the brains and minds of individuals because historical and political legacies have predisposed massive segments of people to be socially and occupationally dysfunctional. The triple oppression of race, gender and class barriers, together with government’s failures of dealing with crime, unemployment, poverty, housing, and quality education, equals a culture of chronic inequality. This state of continuous traumatic stress is emotionally damaging and inhumane.

In response, critical viewpoints on mental health have emerged, which emphasise promoting healthy communities, rather than narrowly treating individual symptoms, blindly following Western psychology. Given the unequal distribution of resources, we cannot rely on that mainstream model any longer, and we all need to band together to come up with creative new ways of promoting health and preventing mental distress.

This is critical, because in South Africa, our current model is not sustainable, and the public and private sector would collapse if every single symptomatic person decided to seek treatment tomorrow.

So, we need creative community interventions where we don’t only treat the sick, we prevent the healthy from getting sick. Well-coordinated mental health promotion activities are lacking, as we get bogged down in curative, reactive models.

Fortunately, the comprehensive scope of what counts as “mental health” creates many entry points for intervention. The World Health Organisation broadly defines mental health as “a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. This goes beyond just the absence of a medical disease; it includes psychological, social, and occupational wellbeing. This inclusive definition means that the assessment and treatment of mental health problems for patients such as Jane must be equally expansive. Diagnosis, medication, counselling, occupational therapy, social services, and nursing are pieces of a much larger picture, which must also include social, cultural, spiritual, and even political determinants of health. The challenge we faced at Emperors Palace was in being brave enough to be that kid that calls out the naked emperor, and take honest stock of where we’ve come from and where we’re heading. Any ideas?

@suntoshpillay

This article first appeared in the Cape Times, September 18, 2015, p9 “Mental Health and SA’s community”.

Image – jessicahtam/flickr/CC BY