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What should the ideal mental health care system resemble?

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Medecine concept - Blackboard with text "Mental health" and stethoscope on blue wooden backgroundPHOTO:
Medecine concept - Blackboard with text "Mental health" and stethoscope on blue wooden backgroundPHOTO:

During the past two years, the mental health care system in South Africa has been revealed as being beset with challenges. But what should such a system actually look like?

What is required for a person with psychosocial disabilities to function and thrive?

What kind of system can nurture and protect those among society’s most vulnerable?

July 2018 is Psychosocial Disability Awareness Month.

This represents an opportunity to look back at the past, examine the present, and importantly also to look towards the future.

It represents an opportunity to not only consider the deficits in the system, but also to take cognisance of what people with psychosocial disabilities need to live full and happy lives despite the challenges they face.

Ideally, the system should have three predominant areas of focus: The first of these is the recovery model.

The model does not have as its focus the resolution of all symptoms, but places an emphasis on resilience and support in times of emotional distress.

It involves more than simply warehousing a mental health care user in a hospital and “spitting them out” into a community, but instead on providing the ever-important continuum of services so that once their mental health has improved they can remain healthy, hopefully for the rest of their lives.

There also needs to be a mechanism through which recovery can be tracked.

The devising of these plans must include the mental health care user and should not simply be decided for them.

One example of how this could be done is through the provision and maintenance of a treatment and recovery log, detailing the person’s history psychosocial disability symptoms and courses of treatment.

Simpson A, Hannigan B, Coffey M, et al have developed a Care Plan Review Template which concerns itself with aspects such as “inclusion of a person’s views … system-based goals … the person’s views in risk assessment … recovery-oriented practice … the person’s views in crisis plan … orientation to medical outcomes … encouragement for self-management.”

It is submitted that such a template is much-needed in South Africa.

The second area of focus is deinstitutionalisation. This is premised on the fact that hospitalisation ought to be utilised as a mechanism of last resort only and that it is much better for mental health care users to be rehabilitated and integrated into their communities.

The hospital setting is overly restrictive for most patients; however, this medical model has been in place for centuries.

The difficulty with the medical model is that there is that there is an over-emphasis of medication in a controlled setting, limited social interaction and isolation from daily stressors.

It is therefore not a reflection on recovery. It is only since the advent of the Constitution that heed has been paid to the notion that people with psychosocial disabilities and intellectual disabilities could benefit from something more than being treated in this restrictive environment that they do not need in order to function.

Life Esidimeni was an example of how not to do deinstitutionalisation and, unfortunately, its devastating effects have painted the practice in a poor light.

A third essential component of an effective mental health care system is the need for a basket of services which follows the person from one part of the system to another.

This is required in order to eliminate the “revolving door phenomenon”, whereby patients in hospital are discharged- usually for cost-cutting reasons or to make room for others in need of beds- and cannot access the necessary services for them to maintain their good health outside of the hospital.

The effect is that they often relapse and end up being hospitalised again.

Hospital environments in South Africa are not always conducive to recovery, but it is unfortunately at present even worse outside in the community where there is little to no support.

The department of social development ought to play a role in providing social services but this is not done adequately, leaving mental health care users to languish.

Social grants are not adequate for mental health care users to live with dignity.

The departments of labour and education should provide the necessary education and skills to enter into the labour market but this is all too often not done, leaving people unable to find work and support themselves.

There is also little to no effort to ensure that information about where to access the necessary services that are available is provided to people with psychosocial disabilities, with the effect that they become non-compliant with their treatment regimes.

The chain of provision, so to speak, is all important, but is at present woefully inadequate in South Africa.

There is also a lack of community care services available, which means that when patients are discharged they have nowhere to go.

The system indeed requires a considerable overhaul, but how is this to be done?

South African law and policy is, to an extent, aligned to international and constitutional standards but there could be more structures and imperatives in place; for instance a roadmap to recovery, or a deinstitutionalisation framework.

But in order for this to be done, the Mental Health Care Act would have to be reviewed and changes made to the Mental Health Policy Framework and Strategic Action Plan once it comes to the end of its trajectory.

There is also the option of introducing new policy specific to people with psychosocial and intellectual disability espousing the recovery model, deinstitutionalisation and the need for a basket of services.

A multi-disciplinary approach is required in order to make this a reality. Practitioners of all kinds need to ensure that sectors such as legal, medical, social, human rights and others assist in making the rights of people with psychosocial disabilities realisable.

Decisions must be taken as to what kinds of hospitals, facilities, homes, services etc. are required for different people, what the inherent prerequisites for these amenities are and what kind of action needs to be taken in order for this to come to fruition.

Importantly, there must be effective monitoring and evaluation of progress made by the state in its implementation of the required changes. The change catalysed must be meaningful, which up to now has not been the case.

To date, as illustrated with the state’s action in consequence of the Life Esidimeni Ombudsman’s report, it appears to be a mere exercise in the checking of boxes rather than a drive to catalyse real change.

In summary, the system needs to look wholly different from what it currently resembles.

Structures must be put in place, attitudes must be changed and concerted efforts must be made to make the changes required for mental health care users to have a better quality of life.

The reality is that lives are in jeopardy, but we can make it work if the aforesaid changes are made. But when? The answer to this is simple: the time is now.

Nicole Breen is project leader for information and awareness at the South African Federation for Mental Health

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