Implementation in mental health lags behind policy

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Prof Melvyn Freeman, the 2013 recipient of the Department of Psychology’s social change award, devoted most of his working life to create the conditions for better mental health services in South Africa.

He presented a public lecture entitled, ‘Towards better Mental Health in South Africa – A Luta continua’ (the struggle continues).

“I’m pretty sure of the first part [of the slogan],” he says, “though not too sure about the second [‘vitória é certa’ (victory is certain)]”.

In his lecture, Prof Freeman pointed to the main concerns surrounding mental health services at the point of political transition in South Africa. These were: racially based services with conditions for black patients being particularly bad; human warehousing where patients were “stored” rather than treated in psychiatric institutions; human rights abuses (including physical and psychological abuse, stigma, facilities being protected from the media by law).

He says racially based services were vertical rather than integrated mental health care; little consideration of indigenous healing methods; virtually non-existent mental health promotion and prevention of mental illness; virtually no services for children; few services for people with “common mental disorder”; large numbers of people who had been “dehumanised” through the Apartheid system.

In response to these challenges, policy guidelines were developed in 1997 that proposed a model of deinstitutionalisation and development of community care. It also suggested more emphasis on prevention and promotion and on psychological interventions – especially with people that had experienced trauma.

Lots of work went into making the Mental Health Care Act comply with international mental health and human rights standards and to introduce innovations that would shift mental health care into a new era. At the time of its passing (2002), the Act was regarded as probably the most progressive legislation in the world.

Prof Freeman then posed the question whether, 19 years on, conditions had changed for people with mental disorders. He indicated that, like many other areas of delivery, implementation in mental health lags behind policy and legislation.

On the positive side, there is significantly less human warehousing, reasonable racial integration of services, an integration of mental health in the general health care environment, an improvement in facilities, better rights afforded to patients and more psychological services.

What requires attention are the promotion of mental health and prevention of mental disorder, social and psychological services for people with severe psychiatric disorders in communities (the money seldom follows the patient), services for “common mental disorders” such as depression, PTSD, and anxiety disorders, and a reduction of the inequities in care between rural and urban areas and between the rich and poor.

He then went on to speak about the UN Convention on the Rights of people with Disability that South Africa has ratified. He suggested that the interpretations of this Convention by the committee responsible for interpretation of the Convention as well as the UN Special Rapporteur on Torture, Cruel and Inhumane Treatment could however lead to rights of both people with mental disabilities and the public being undermined.

This issue requires countries to intervene so that people with disabilities are not denied required treatment and that people with mental disabilities are not criminalized for acts for which they cannot assume responsibility.

Lastly Prof Freeman raised the issue of the mental health status of the population and its impacts on development.

He argued that for both improved mental health and improved social and economic development it would be necessary to make changes to the environment that people are brought up into and live in, as well as making changing to the internal or psychological worlds that then impact on the outside world. 

He suggested that an “outside in” and an “inside out” approach was needed.  

Dr Sizwe Mabizela closed the evening by thanking Prof Freeman for his careful analysis of the challenges facing mental health in South Africa and for drawing our attention to the complexities around human rights debates with regard to people with mental illnesses.

Dr Mabizela presented Prof Freeman with the social change award.

The Social Change award was initiated by the Psychology Department in 2008. In this event the department honours prominent members of the Psychology community in South Africa for their contribution to social change in the country.

Photo by Stephen Penney