Mental Health in South Africa

Mental Health in South Africa

As imperfect as the patients 


Please Note: This post has been updated since original publication. 


Promoting a healthy lifestyle has become very popular, and on the surface, it seems all good.

But as they say: eat healthy, stay fit and die anyway.

Even cancer is now called a “lifestyle disease” although anyone seems to get it – especially those genetically prone to it.

Yet, I’ve never heard anyone make a “healthy lifestyle” comment to the face of a cancer patient.

Despite campaigns to lessen the stigma surrounding mental health, the entire system – and everyone in it – has one bloody long way to go – not just in losing the stigma, but also in reaching effective treatment.

Let’s start with the basics: No one drinks too much soda and develops a mental health problem. Some people have unfortunate childhoods (and some don’t), but often a mental health issue is as genetically traceable as heart disease.

The first major gripe: In South Africa, Bipolar Disorder is a prescribed minimum benefit, Major Depression isn’t. The reasoning behind this is, presumably, that Bipolar patients are statistically more likely to commit suicide since they are more impulsive.

It really is a raw deal if you have nothing more – on official diagnosis at least – than Major Depression (even if it is with psychosis!). Psychiatrists refrain from sharing a diagnosis with patients – in fact, they might not even make one at all. You’ll have to look up the ICD-10  code on your account if you want to know the direction of their thinking.

Although psychologists also have to use ICD-10 codes on their accounts they are not really supposed to diagnose. Even therapists open-minded enough to explain matters in academic terms will, for obvious reasons, not tell you if you are a black belt nutbag. Generally, it takes bloody long to dawn on you exactly how mentally “fucked” you are.

In theory, should you land in a psychiatric hospital, you should be admitted and discharged by your psychiatrist. In practice, you have to leave as soon as your mental health benefit is depleted which could be much sooner than the standard 21 days if you had seen your psychiatrist a few times before admission. As the kind (and attractive) lady at the accounts department once said, “In mental health, we are the armpit of the system.”

Then, of course, many psychiatrists – like too many other medical specialists –  find no reason to charge actual medical aid rates, and you will almost always pay a shortfall from your own pocket. Generally, psychiatrists are booked months in advance and shopping around for a good fit is hardly a feasible option.

Also, in what I would think is a vile desecration of constitutional rights, once you have been admitted to a psychiatric hospital by psychiatrist A, you will not be allowed to switch to psychiatrist B.

Should you – obviously during an emergency – be admitted to a psychiatric hospital over a weekend, it is highly unlikely that you’ll see a psychiatrist until Monday.

Once in a psychiatric hospital, you’ll spend your mornings with young, friendly occupational therapists who will treat you exactly like you were treated in your kindergarten class. If you want actual professional help, you’ll have to pay extra for your own psychologist, or one recommended by your psychiatrist, and this psychologist will have to leave his/her practice during the busiest part of his/her day (i.e. the afternoon) to come see you – often when you would have liked to see your family.

In the evenings the well-meaning, friendly nursing staff will often call your name over the intercom system until you wake up, get out of bed and walk down the passage to take your sleeping tablet. They are somewhat obliged to do this since they cannot have wide away loons running around throughout the night.

In terms of the stigma surrounding mental health, the nurses are some of the worst offenders. As sweet and caring as they will be to your face, behind your back you’ll be discussed in the greatest of detail. Don’t be fooled: they are never just randomly walking down any corridor … they are checking what you are doing and noting with whom you associate … and they are reporting it to anyone who will listen.

Now let’s say you have to be hospitalised after a suicide attempt. If you happen to be close to a decent private hospital, especially one with a good physician, you’ll receive the very highest standard of medical care … but there will be no psychiatrist or psychologist in sight. It is a well-known fact that many suicide attempts are desperate cries for help rather than honest attempts to die. Unfortunately, much too often, no one is listening.

As soon as you are fixed up physically you’ll be sent home and no-one will have the faintest regard for the mental health condition which caused you to harm yourself in the first place. That is except for the gossipy admin staff member tapping on your shoulder to wake you in order to ask exactly how many pills you actually took out of pure curiosity.

When it comes to psychiatric hospitalisation and suicide attempts you will have to convince your fractured mind, even when it is at its most dysfunctional, not to try the same stunt twice per calendar year, because it will leave you in a state hospital … or completely without help.

Next, if you’ve survived this far, you probably visit your psychiatrist – who is strangely not in the least interested in hearing about the suicide attempt. Oh no, psychiatrists want to know all sorts of menial detail. For instance: How are you doing at home? Do you get along with your colleagues? Would you say that you are sleeping well? My personal favourite: How is your appetite? And: Have you recently gained/lost any weight?

These doctors are finely attuned to your physical appearance. They will believe you are faking your condition for attention if you show up looking groomed and normal. I cannot emphasise this enough: if you need treatment, see to it that you look like a zombie. Show up in pyjamas, if you can.

Depending on who you see, the questioning process can feel like cross-examination in court or an incidental conversation with a stranger at the airport.
Then after a process of fervent note taking, this doctor will ask: So, what would you like to do? By this, they mean: “What meds would you like me to script you?” (See, I told you to look like a zombie.)
This, of course, is the point where you see that you should have spent some time on Google beforehand, and might as well have seen your GP at a fraction of the price (and much closer to your home), but you still try to convince yourself you are doing “the right thing” by seeing the psychiatrist. Don’t expect any sympathy if you complain about side effects … they will give you that loony-worthy raised eyebrow to show you that your sort should get used to expecting “less” from life.

Now when I say “less” … there is no easy way to break this to the ignorant … for the most part, the meds scripted to us with mental health issues – especially depression – will ruin your sex life … listen carefully: I’m not saying “alter” or “affect negatively” or “have a depreciating effect” … I’m saying RUIN!

The really cruel part: You’ll probably still WANT sex, but it will be like pulling teeth, wasting time, ruining your self-esteem or that of your partner.

Of course, if you take antidepressants you’re also not supposed to drink alcohol. Inevitably, at some point, you’ll wonder if the cure isn’t worse than the disease. It may well be when you realise that the 28 tablets per pack are now forcing you to visit your pharmacist technically more than once per month. If not then, wait for the day you accidentally run out and miss two or three dosages. The first day you’ll be worried, but you’ll think you’ll be  OK. The second day you’ll realise that your irritation has nothing to do with PMS. If you reach day three you’ll be planning your new career as a serial killer, albeit slowly between bouts of dizziness and other weird symptoms. Suffice to say, I’ve never reached day four.

Let me not even explain too much about the withdrawal symptoms you will suffer if you decide to stop taking an antidepressant altogether.  If you have clinical depression you really shouldn’t stop in the same way that no diabetic should stop taking insulin.

If you were taking an antidepressant in an effort to cope with a particularly stressful time or after suffering some sort of trauma and what to stop taking them, then that is where you will need professional help and where paying a visit to a psychiatrist might actually be worthwhile.

One would think if you have developed – in that utterly disturbed mind – an idea/inclination/desire to “off” yourself and you have enough rationality left to know it should not be so, then you should tell your psychiatrist.

This is a mistake!

Find and write down one of those toll-free numbers (OK, I don’t know one, but you must have gathered by now that I’m writing from the patient’s point of view. I’ve never tried this myself.) I suspect the people answering the phone – although probably poorly trained – are the only ones you can tell about your suicide ideation. (I don’t know what they’ll do – you’re on your own here.) You’re supposed to go the closest hospital, but I suspect the closest bar will be less embarrassing.

No psychiatrist wants you to confess your suicidal thoughts. It forces them to take some sort of action and the only thing they actually want to do is to write a script (mostly the exact same one the previous patient has received) and get you the hell out of their office so that the next R1000 can enter from the waiting room.

Somehow medical aids in SA are willing to fork out thousands of rands to pay for psychiatric consultations – they are the most overpaid doctors in the entire system. Meanwhile, most antidepressants will take weeks, if not months, before a patient feels better – and during this time you are on your own.

Although modern antidepressants are wonderful drugs, they are never going to help you understand yourself, the reason for your problems or teach you to cope with your condition.

To actually achieve change you will have to find a good psychologist. The catch is, South African medical aids are almost completely unwilling to pay them.

Even the most expensive and comprehensive medical aid plans will pay for around three sessions with a psychologist. Getting somewhere in therapy is more likely to take around three years of weekly sessions. If you happen to come across one of those shrinks who are willing to take you on for six sessions – these are generally the ones who will ask you to list “what you want from therapy” (in six weeks) by the second session and dish out “homework” – then move rapidly to the exit point and don’t return.


A few things I’ve learnt about therapy

It’s complicated. It’s hard. And it takes a long time.

They have all sorts of ethical rules and secretive ideas on how to “handle” you and there is no way you’ll be completely informed of all of these at the start – there is just too much to it. You’re also not supposed to be bombarded.

Therefore expect to be flabbergasted at some point – it’s part of the process – find a way to fall in line and ask what you need to know.

A well-trained shrink might have you fairly figured out before the end of the first session. The problem is to get you on the same page without telling you to your face that you’re a nutbag (because it’ll only make things worse).

Finding a good psychologist can be incredibly hard. They are not allowed to advertise and the GP or psychiatrist making the recommendation might know the shrink, but not as a patient.

If you find a good, kind, caring and wise therapist … be truthful, do exactly as they say, work really, really hard and show them tremendous respect – because not only are the good ones few and far between, but losing one you have come to trust will be the worst possible setback … one from which you might never recover.

If you have a good shrink you will gradually, gradually develop a trusting relationship with this complete stranger which is a beautiful, sacred thing … but don’t let that fool you: Therapy is hard. You’ll have to be brave, think hard, talk the truth and go to every session even when you wish you could have an enema instead.

9 November 2016



Please note:

  • This post is a general satirical comment and does not intend a reference to any specific individual.
  • It is intended to be comment on an imperfect system, in an imperfect world, not criticism of those working within it.
  • During the course of treatment, I have been in contact with many health care professionals and many patients – the reflected content is an amalgamation of experience.
  • You should still see the psychiatrist instead of your GP, even if he/she does ask you what meds you want – you should also Google everything.
  • The nurses are supposed to give you the sleeping tablet.
  • I’m in favour of therapy and have never had a bad or even a mediocre therapist. Obviously, the aim is to find someone you can get along with, but people who disagree with you can also help you.
  • If not for the dedication, kindness and wisdom of a certain psychologist, I would not have been here to write this blog.

Karen Dowd


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