We need more mental health activists

Under apartheid some mental health professionals called for political and social reform. After Esidimeni, it’s clear we still need such activism, write Jason Bantjes and Leslie Swartz.

Recent public hearings have again focused attention on the deaths of psychiatric patients in government-funded community-based organisations. As many as 118 patients, who were formerly under the care of the Gauteng health department, died as a result of inadequate care and negligence in February this year.

The Esidimeni tragedy occurred against the backdrop of broader concerns about mental health in the country. It is estimated that fewer than 10% of people with mental disorders receive treatment. Where treatment is available, it is often provided under stressed and difficult circumstances. It is also well-known that both poverty and social inequality are risk factors for mental disorders.

During apartheid there were vociferous calls for social and political reform by a small but vocal group of mental health professionals. These activists used their positions and professional status to draw attention to the deleterious impact of oppressive and discriminatory nationalist state policies on the psychological wellbeing of the country’s citizens.

Writing more than 20 years ago, activists envisaged a new democratic country in which there would be a more equitable distribution of wealth and a more just society. They described the impossibility of providing ethical mental health care within an oppressive society, characterised by inequality, discrimination and injustice. But they remained optimistic that reforms would come, provided they continued to resist the state.

In 2017, it is clear that much of what anti-apartheid mental health activists hoped for – a substantially more equal, more peaceful society, with a vastly expanded mental health care system – has not materialised. During the decades leading up to the fall of apartheid, mainstream psychology was harshly criticised for being complicit in maintaining oppressive state structures. One of psychology’s dirty secrets is that many professionals stood by while the state enacted its policy of separate and unequal development, creating conditions that had devastating effects on many people’s mental health.

And while apartheid is no longer the law of the land, and we have a democratically elected government, many of the conditions which concerned anti-apartheid mental health activists are still with us.

Feeling overwhelmed and powerless

Research we’ve conducted at Stellenbosch University’s psychology department (together with our master’s students) over the past three years has documented the experiences of healthcare professionals working with suicidal patients in various settings.

This research makes for depressing reading. Mental health care providers working in state hospitals, prisons and addiction treatment centres consistently describe being overwhelmed by their work and feeling powerless to provide the care patients need. Not only do they say they feel despondent about their ability to meet patients’ mental health care needs, but they are not optimistic that the changes that are needed, both within the health care system and broader society, are forthcoming. They describe working under conditions that are distinctly anti-therapeutic.

Many South Africans, including mental health professionals, are working hard to change the situation. There is now strong evidence that innovative, low-cost interventions can prevent emotional distress and provide effective treatment for mental health problems.

Nevertheless, there is good reason to be alarmed about the enduring social conditions which predispose large sectors of the population to mental ill-health. There is equally real cause for concern about inadequate mental health care services, and about the neglect and deaths of psychiatric patients.

Under these circumstances, it is somewhat disappointing that the central concern of contemporary professional psychology seems to be the policing of fine distinctions among different fields of psychological practice.

In recent years, much effort and expertise, and many resources have been expended by psychologists and the Professional Board for Psychology, focused on debating and contesting the organisation of categories within the profession.

At the heart of this discussion is a turf war within the profession about what services can be provided by which category of psychologists.

Health Minister Dr Aaron Motsoaledi has been given until November 2018 to revise the regulations about the scope of the practice of psychology, following a ruling by the Western Cape High Court that the psychologists’ Scopes of Practice regulations (issued in 2011) were invalid.

We agree that it is important that no psychologists should undertake work which they are not competent to perform. But the reality is that in June 2017 there were less than 13 000 psychologists in the country, serving a population of about 57 million people. There are clearly so few psychologists that arguments about scope of practice within the profession are unlikely to have any meaningful impact on the state of mental health in South Africa. Why then is there such a high level of concern about demarcating boundaries within the practice of psychology, without commensurate concern with questions about access to effective, evidence-based mental healthcare services for all?

It is not a simple matter to undertake research on effective mental healthcare, especially in a diverse and unequal country. But surely this is where psychologists should be investing their energy, rather than attempting to police boundaries among professional categories? Especially when these boundaries may not be particularly relevant to contemporary mental health concerns or aligned with international trends.

In the future, organised psychology and the current generation of mental health professionals may well be judged by the extent to which they took up the struggle to reform mental healthcare delivery. Clearly, a new form of activism is needed in mental health.

But this is unlikely to be achieved unless the majority of the country’s psychologists put aside their inward focus on demarcating boundaries within the profession, and rather turn their attention to questions about how best to promote mental health in South Africa.

Bantjes is a senior lecturer and Swartz is a distinguished professor in the Department of Psychology at Stellenbosch University

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