‘Mental health the Cinderella of health care’- President of the South African Federation for Mental Health

I recently attended the 5^th Global Mental Health Summit in Johannesburg, South Africa, which looked at mental health issues on a global scale. Many similarities across continents were noted, such as; the lack of awareness around mental health issues, the stigma that continues to surround mental illness, the increase of mental health concerns amongst the youth and the lack of resources.

It was truly an awe inspiring event, as professionals from various disciplines came together, echoing the World Health Organisation’s (WHO) slogan: “there is not health without mental health”. The presentation given by Crick Lund (Professor and Director at the Alan J Fisher Centre for Public Health, University of Cape Town) stands out for me in particular, as he highlighted the importance of including the role of persons with lived experience in shaping and informing mental health research, to in turn inform policy and strengthen mental health systems. To me this spoke not only to the formulation of policy but also to informing interventions and practices, as these voices are often lost, forgotten or dismissed. This rings true in the #LifeEsidimeniTragedy, with the deaths of mental health patients, who had no say in where they were going to be moved and whose family members could not advocate for them. What happened to human rights? What’s the purpose of having policies such as the Mental Health Policy if we fail to refer to it when implementing? As stated by Dr Lochandra Naidoo (President of the South African Federation for Mental Health), ‘Mental health is the Cinderella of health care’. The forgotten child? The imaginary friend? If not seen, does not matter and if they don’t matter, we can do what we want with them?

This de-valuing of individuals that have a mental illness can be explored in relation to how we have been socialized into understanding mentally ill individuals and mental illness as a whole. As my mother often would say to me, to understand the present you have to go back to the beginning. Pre 16^th Century, mental illness was attributed to the supernatural, witchcraft and insanity simply meant possession by the devil. By the 16^th Century, individuals with psychological disorders were seen as dangerous and needed to be locked away to protect society. By the 17^th Century, the mentally ill could participate with society but still needed to be understood as ‘mad’. With the term ‘lunatics’ becoming more common in reference to the mentally ill, who were also considered weak, in the 18^th Century. Thus, from this brief history, we can see how we may have been socialized to perceiving the mentally ill as less and mental illness as something that makes one incapable of participating in society and not the norm. If you have a mental illness, there must be something horribly wrong with you. By the 19^th and 20^th Century things started to change, as punitive treatments were abolished, an investment was made in understanding mental health as a health issue, which led to research being done to understand the causes of mental illness and in turn the establishment of more appropriate treatments and most importantly protecting the human rights of the mentally ill was emphasized.

So we have made progress over the years. Yet a stigma around mental illness still exist in the fabric of our societies. More needs to be done clearly, but what does this more look like? Dr Lochandra Naidoo calls for the creation of a ‘society in which mental health receives the attention it deserves’. I fully agree with this statement and to be honest I was shocked that mental health was not getting the attention it deserves. But as I reflected on this, I came to the realization that as a mental health practitioner, I engage with mental health issues on a daily basis, moreover, I studied it for 7 years, so I got a good base when it comes to understanding it in the context of myself, the family, community and broader society I live in. But, not everyone has this background. And even though in South Africa, we have been advocating, raising awareness and campaigning about mental health and illness, there’s a gap. And I say there’s a gap because I do believe that our government is a microcosm of the broader society. And the treatment by the government of mentally ill individuals in the Life Esidimeni tragedy speaks to an overall lack of understanding of mental health and mental health care. A disregard for the one of the most vulnerable groups in our society.  We have come a long way, but clearly, still have a long way to go.

I invite you to share your thoughts on the way forward, how do we create a society in which mental health receives the attention it needs?

Written by: Sumaiya Mohamed

 

‘An empty stomach has no ears’…..What do your ethics say?

‘An empty stomach has no ears’ is an African phrase commonly used by clients within our context. Referring to a hungry person not being able to concentrate on anything else, except their need to get their basic needs met. Many times as clinicians we sit and contemplate the contextual realities of many of our clients. My client has nowhere to live, another has no job, there’s no money for school fees and ones that can’t even afford food for their children. In sitting with these things an overwhelming sense of helplessness can become all consuming (which is often an echoing of the helplessness the individual is feeling about their situation). When I first started I used to have immense feelings of guilt and sadness, really just wanting to be able to give my client money to get food for her children. But that goes against two important aspects of my training, the first being to empower the individual to be able to do this for themselves and secondly that my professional ethical code of conduct prohibits it. Rationally being able to understand why I couldn’t did not help with the feelings. I eventually found myself switching off to it and constantly telling myself that that is not my role as a therapist. But my training also told me that you cannot do therapy with a hungry person and that can at times be so present in the therapy room that no amount of rationalisation can make it feel better.

Then we start coming towards the end of the year, which to me means Christmas time and holiday. Things that my socioeconomic status allows me to look forward to, but it is also a time where I reflect on the many things that I have in my life. So this year as the clinic we decided to try something a little bit different. We know that we cannot really give our clients things directly but technically that does not stop us from getting things donated. Some may have heard of the Santa shoe-box initiative whereby people can sponsor a child and pack a shoe-box with some essential toiletries, stationery, a toy and clothing. So we decided to do one for the children of the clients that we see at the trauma clinic. This was done specifically because many parents are often filled with sadness at not being able to give their children anything over the Christmas period and that the beginning of the year is often filled with such stress at getting basic stationery for the children old enough to go to school. Initially once we put together the list of children the task began to seem a bit overwhelming and I doubted the ability to get everything together and ensure that all the children got something. But truly sometimes the universe aligns itself and hears what is needed and the people that were approached began offering to help and helped in abundance of what was requested of them. And as a result 60 children’s Santa shoe-boxes were donated and given in December. Of course, this did not meet the greater basic needs of clients and perhaps it just met my own need to do something about my own levels of despair regarding client’s contextual realities.

What this also really speaks to the ethical dilemma that many individuals may face when working in impoverished settings, the professional ethics of what one is supposed to do and the human ethics of what one wants to do as a human being for another and this constant tug of war between the two. So before we begin to feel completely shut off to this aspect of others it was worthwhile seeing what could be done in the confines of what we could do. Being mindful of the reality that one small parcel does not solve the hunger that will be in the therapy room with me in the next session.

Written by Jacqui Chowles

The power of the human spirit prevails

The Centre for the Study of Violence and Reconciliation (CSVR), well known for its research into violence and clinical and community intervention work, has in recent years become a learning organization. Moving towards developing our learnings and the learnings of others. This was evident at an event we had yesterday: a graduation ceremony for interpreters that provide interpretation to the clinical team in their therapeutic work with clients who speak French, Swahili, Kinyaruwandi, Lingala, Amaric and Somali. The event followed the interpreters completing an introductory course in interpreting skills at the WITS Language school.

I recall the beginning of this journey, as interpreters were filled with feelings of anxiety and concern. ‘im too old to go back to school’, ‘I don’t know if I can do this’, ‘if I fail I have to pay back the money, where will I get this money?’. Concerns around time commitments and being able to pass were noted.

This may seem like normal concerns and anxieties before one embarks on an academic venture, but what you need to understand is this is no ordinary group of individuals. These are individuals that come from war torn countries and have been able to survive in an environment often known for its xenophobic sentiments. They face many challenges as they navigate personal, family and communal life on a daily basis. So embarking on this journey was no easy task. Our Executive Director (Nomfundo Mogapi) captured the perseverance of their human spirit best by acknowledging their endurance in their home country, coming to South Africa which has given them good and bad experiences and making a life despite the bad experiences. Contributing to a country which has been unwelcoming at times and being a part of the change they want to see in the world and in South Africa.

As I watched them go through the course and there life journey, I marveled at their spirit. Their willingness and ability to engage with the content and be present and still do life. It made me reflect on my own resistance to re-entering the academic realm or creating change in my status quo, and yes I feel-‘l im too old’, ‘I got a lot on my plate’ (kids, family responsibilities, bills), ‘how will I manage to study and work at the same time’ and ‘I don’t know if I can do this now’. And then I think about these women and men, whom have been dealt a bad hand, not of their own choice and continue to persevere, continue to find meaning in life, continue to seize opportunities and work towards a better future. Continue to give life their all and all my reasons seem mundane. And so these words come to mind: The power of the human spirit prevails, it is self- doubt that keeps us stagnant.

Written by: Sumaiya Mohamed

Pardon Me I Think I Have Lost Me, Have You Perhaps Seen….I Last Saw Her….

Stop all the clocks, cut off the telephone,

Prevent the dog from barking with a juicy bone,

Silence the pianos and with muffled drum

Bring out the coffin, let the mourners come.

Wystan Hugh Aude

 

I am a therapist and have been ever since I could remember and it has become my identity, and I have never had qualms about my profession being a part of my identity but lately I find myself missing something. I find myself searching as though I have lost myself. It was not till I had a tiff with a friend a few days ago that I had to sit myself down and find out what is happening. What one needs to understand about this tiff of ours is that words were thrown out there and I can’t say I was offended at the time, but I was a bit irritated later. I mean the woman said I was no longer fun, all because the one time we went out and it was all hip hop,I dissociated and couldn’t wait till we went home, but then she went on saying I was not even bothering to compromise and I said, ‘it’s that time of the year’. I mean really, and she went on to say, ‘what do I mean it’s festive’. So I went home and came to the conclusion that I was a not fun friend and with all my complaints about my friend neglecting me, truth of the matter is, I am tired and I don’t enjoy some of the things I used to before. When did I become this person who looks for excuses when friends call up for coffee or a night out? As I sat to think about the person I have become it dawned on me that I am someone else, but where did I lose me?

 

I sat down and recalled  times when life was simple, when I had my innocence and naivety and I was accepting of that, I recalled  days when I could go to the park,throw a ball and run around and fall on the grass and look at the sky and  see forms in clouds and just be content with that. I remembered days when I could still go out with friends and drink, jive and flirt shamelessly and come back on Monday and go out for Mogodu night. Those were the days I could laugh from my belly. It’s days when I looked at the Soweto light and felt I am going home and be happy. The truth is, being a trauma therapist, that identity has swallowed me whole. My world is no longer a simple black and white, it’s got grey linings now, even as I laugh from my belly my eyes have a tint of grey. I look for soul music now as hip hop does not make sense. I usually feel too tired and old to run around the park but once in a while I still see forms in the clouds, but it’s usually with the help of my daughter. I have in my head stories of people and at times I look for their truths in my world so that I can go back and we can have meaningful conversations. I may have become a bit more dismissive and boring, even my physical self has changed: I need navy beans now, but I have not lost myself, I have merely taken a different shape. My friend must get with the program.

Written by: Thembisile Masondo

Dreading my 18th birthday: the plight of refugee children in detention centers

The CSVR Trauma Clinic presented two oral presentations at the 10^th annual International Society for Health and Human Rights conference held in Novi Sad, Serbia from the 26-29 September 2017. While the two oral presentations were well received, I would like to focus on one of the interesting learnings from that event: The treatment of unaccompanied minors and the implications for them across countries and age cut-offs. An example of this was a presentation given by Lilla Hardi, Medical Director of the Cordelia Foundation for the Rehabilitation of Torture Victims which operates in Hungary. One of the factors which increases the risk for further trauma in children seeking refuge in Hungary, is the fact that children over the age of 14 years are kept in what is known as a transit zone for the duration of their refuge period. A quote from the UNHCR sums up this transit zone best, “Hungary’s transit zones are really just detention centers, said UN High Commissioner for Refugees Filippo Grandi after wrapping up a two-day visit to Hungary. In his meetings Grandi expressed his concern that asylum-seekers, including children, were being kept in the “transit zones” during their asylum process. “Children, in particular, should not be confined in detention,” he said Tuesday after touring the Röszke transit zone on Hungary’s border with Serbia”. [i]

Similarly, Gunnar Eide and Torunn Fladstad from RVTS South in Norway reported during their workshop session that unaccompanied minors are returned to their country of origin when they turn 18 years old. Essentially, they are returned to the source of their trauma and to a country often still in conflict after having been provided with education and support from the government up to that point. The Nordic Page, reported on the impact that this new legal restriction has on children, “This permit has come under criticism from NGOs and other commentators, and it appears that some permit holders abscond from reception centerss prior to the transition to adulthood in order to avoid return. Also, the number of suicides attempts and anxiety disorders among this group has dramatically increased since the introduction of the law. Norwegian Immigration directorate (UDI) saw a significant deterioration in the situation of UAMs at reception centers.”[ii] Speaking to other colleagues in the field and doing some research on my own, it became apparent that this was not unique to Norway. An organization called The Bureau conducted a study on how different countries in Europe treated unaccompanied minors. Their report can be found here:

https://www.thebureauinvestigates.com/which_countries_treat_children_like_children/#Netherlands.

Unaccompanied minors appear to have two experiences, either they are sent back to their countries (which are often still in conflict) or they have to apply for asylum as an adult (which may be rejected and then they are deported).

So, what does this mean for the mental health of children? Especially children who have experienced high levels of trauma within country; en-route to refugee receiving countries; and within the country of refuge itself? A research paper written by Catherine Gladwell and Hannah Elwyn in 2012 with the assistance of the United Nations Refugee Agency around the impact of deportation on Afghan children is a good indication of the organic as well as psychological impacts on children who live in fear of their 18^th birthday. While other children cannot wait for the 18^th birthday as it means that they have greater legal independence from their parents such as the right to drive a car, and in South Africa drink alcohol and smoke legally; other children from around the world, who had no part in the war that has robbed them of their home; family; friends and safety, live in perpetual fear of being sent back to a country where there is a very real possibility that they may be killed. Add to that the fact that they were unaccompanied at the time of seeking refuge; and so often do not know where their family members are or even if they are alive. Add further to that the realization that depending on their age of arriving in their host country, that life is the only life that they know, and you can see the reason why anxiety and depression are at a critical high within this group.

Think of yourself at 18. How equipped were you to navigate the world as an “adult’? Would you have been employable and able to sustain yourself with just a Matric certificate? These children are severely traumatized; they do not have a University degree, they do not have skills that can be used to support themselves back in their countries. They have learned the language of their host country and possibly to read and write in that country. We now send them back to Iraq and Syria and expect them to still be able to speak Arabic; to read and write Arabic, which uses a completely different system to what they have learned. Once again, they need to adapt and adjust into the unfamiliar. This time with no support.

We as Nations need to consider the atrocities that we perpetuate against each other, both “big” and “small”. We need to examine ourselves and our so called humanity and see whether our fear of the other (even children) is able to co-reside with our sense of compassion. As a mental health practitioner we have to ask ourselves some very hard questions. What is our role in ensuring that we stand by our ethics of believing that every person matters, every life matters? Are we doing enough to advocate on behalf of these and other vulnerable groups, whether they are part of our Nation or another’s? Is it enough to sit in a counselling room and deal with the aftermath of these and other practices or should we be extending our boundaries and scope of practices to include the active call for change regarding political migrant/refugee laws and practices across the world? In my opinion, it is unequivocally our job to ensure that all people are protected, not just when they become our clients. Otherwise we are just like these law makers who state that you are worth help only if you are a child and then lose value when you become an “adult”. We should work tirelessly to combat this hierarchy of which people matter and which do not.

By Celeste Matross

[i] (Novak, B. (13/09/2017). The Budapest Beacon. https://budapestbeacon.com/unhcr-chief-says-hungarys-transit-zones-are-really-just-detention-centers/.

[ii] ) (Norway to send back half of unaccompanied minors (UAMs) (07/07/2017) https://www.tnp.no/norway/panorama/norway-send-back-half-unaccompanied-refugee-minors