South African Psychiatry - February 2018 Edition
South African Psychiatry - February 2018 Edition
South African Psychiatry - February 2018 Edition
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ISSN 2409-5699<br />
ABOUT the discipline FOR FOR the the discipline discipline issue 14 • <strong>February</strong> <strong>2018</strong><br />
MUSIC THERAPY<br />
AND THE NEGATIVE SYMPTOMS<br />
OF SCHIZOPHRENIA<br />
THE US/UCT MRC UNIT<br />
ON RISK AND<br />
RESILIENCE<br />
IN MENTAL DISORDERS<br />
SASOP PARTICIPATES<br />
IN THE PUBLIC DEBATE<br />
ON HEALTHCARE<br />
WORKER<br />
ADVOCACY<br />
PUBLISHED IN ASSOCIATION WITH THE SOUTH AFRICAN SOCIETY OF PSYCHIATRISTS<br />
TRANSCRANIAL<br />
MAGNETIC STIMULATION<br />
TO TREAT<br />
MENTAL ILLNESS?<br />
PREJUDICE,<br />
DISCRIMINATION<br />
and mental illness<br />
www.southafricanpsychiatry.co.za<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 1
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2 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
Features<br />
PREJUDICE,<br />
DISCRIMINATION<br />
7<br />
AND MENTAL<br />
ILLNESS<br />
A MIXED-METHODS STUDY<br />
ON GROUP MUSIC THERAPY<br />
13<br />
AS AN INTERVENTION FOR<br />
THE NEGATIVE SYMPTOMS<br />
OF SCHIZOPHRENIA<br />
THE US/UCT MRC UNIT<br />
ON RISK<br />
19<br />
AND RESILIENCE<br />
IN MENTAL DISORDERS<br />
THE 4TH BIENNIAL<br />
NATIONAL FORENSIC<br />
22<br />
MENTAL HEALTH SERVICE<br />
(FMHS) CONFERENCE<br />
CAN TRANSCRANIAL<br />
MAGNETIC STIMULATION<br />
27<br />
BE USED TO TREAT<br />
MENTAL ILLNESS?<br />
SASOP PARTICIPATES<br />
IN THE PUBLIC DEBATE<br />
30<br />
ON HEALTHCARE<br />
WORKER ADVOCACY<br />
NOTE: “instructions to authors” are available at www.southafricanpsychiatry.co.za<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 3
CONTENTS<br />
CONTENTS<strong>February</strong> <strong>2018</strong><br />
5 FROM THE EDITOR<br />
SCHIZOPHRENIA<br />
MENTAL DISORDERS<br />
21 WPA NEWS<br />
SERVICE (FMHS) CONFERENCE<br />
26 GMHPN NEWS<br />
TREAT MENTAL ILLNESS?<br />
WORKER ADVOCACY<br />
CONGRESS<br />
34 PMHP NEWS<br />
FIRST AID - OVERVIEW AND REFLECTIONS<br />
HEALTH PROFESSIONAL<br />
42 DEPARTMENTS OF PSYCHIATRY NEWS<br />
AFRICA” - EXECUTIVE SUMMARY<br />
50 CULINARY CORNER<br />
& ELEGANCE<br />
57 MOVIE REVIEW: VICTORIA & ABDUL<br />
7 PREJUDICE, DISCRIMINATION AND MENTAL ILLNESS<br />
13 A MIXED-METHODS STUDY ON GROUP MUSIC THERAPY AS<br />
AN INTERVENTION FOR THE NEGATIVE SYMPTOMS OF<br />
19 THE US/UCT MRC UNIT ON RISK AND RESILIENCE IN<br />
22 THE 4TH BIENNIAL NATIONAL FORENSIC MENTAL HEALTH<br />
27 CAN TRANSCRANIAL MAGNETIC STIMULATION BE USED TO<br />
30 SASOP PARTICIPATES IN THE PUBLIC DEBATE ON HEALTHCARE<br />
32 LEADING PSYCHOLOGISTS FROM AFRICA CONGREGATE IN<br />
DURBAN FOR FIRST-EVER PAN-AFRICAN PSYCHOLOGY<br />
35 A WORKSHOP ON COMMUNITY-BASED PSYCHOLOGICAL<br />
38 THE ROLE OF MELATONIN IN TREATING INSOMNIA<br />
40 THE PROVISION OF EXPERT OPINION AND EVIDENCE AS A<br />
47 WPA WHO AFRICAN MENTAL HEALTH FORUM: “CONTINENTAL<br />
ALLIANCE FOR INTEGRATED MENTAL HEALTH CARE IN<br />
55 WINE FORUM: LE RICHE: DECADES OF QUALITY, CONSISTENCY<br />
59 RECOVERY PLAN FOR THE GAUTENG DEPARTMENT OF HEALTH<br />
61 SASOP POSITION STATEMENT ON CANNABIS<br />
64 SASOP SPECIAL INTEREST GROUP FOR ADULT ADHD<br />
65 SASOP HEADLINE<br />
* PLEASE NOTE: Each item is available as full text electronically and as an individual pdf online.<br />
Disclaimer: No responsibility will be accepted for any statement made or opinion expressed in the publication.<br />
Consequently, nobody connected with the publication including directors, employees or editorial team will be held liable for any<br />
opinion, loss or damage sustained by a reader as a result of an action or reliance upon any statement or opinion expressed.<br />
© <strong>South</strong> <strong>African</strong> <strong>Psychiatry</strong> This magazine is copyright under the Berne Convention. In terms of the <strong>South</strong> <strong>African</strong><br />
Copyright Act No. 98 of 1978, no part of this magazine may be reproduced or transmitted in any form or by any means,<br />
electronic or mechanical, including photocopying, recording or by any information storage and retrieval system,<br />
without the permission of the publisher and, if applicable, the author.<br />
COVER PHOTOGRAPH: Adobe Stock Imge<br />
Design and layout: The Source * Printers: Imagine It Print It<br />
4 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
FROM THE EDITOR<br />
Dear Reader,<br />
Welcome to our first publication of <strong>2018</strong>. It is a landmark issue in that we<br />
are publishing data from a successfully examined higher degree for the<br />
first time - in this instance related to music therapy and schizophrenia.<br />
Further such content is anticipated for the May <strong>2018</strong> issue, more specifically<br />
the literature reviews of successfully examined MMeds. This will see the<br />
publication reach one of its intended goals, namely to provide a fast track<br />
for publication of such content. Following the publication of the May <strong>2018</strong><br />
issue the previously mentioned application for DoHET accreditation will<br />
take place (<strong>South</strong> <strong>African</strong> <strong>Psychiatry</strong>, August 2017). I had hoped to submit<br />
the application sooner but noted that submissions needed to be received by the 30th June in a<br />
given year so held back until closer to that date. If successful, we will indeed enter a new era for the<br />
publication.<br />
The current issue carries a number of Reports – all once again demonstrating the range of activities<br />
taking place across the country that speak to the vibrancy of psychiatry and related disciplines,<br />
and the commitment of authors to ensuring that such content reaches the widest possible<br />
audience. One in particular deals with a public debate related to healthcare worker advocacy,<br />
with specific reference to the Life Esidimeni tragedy. Of note was the position of Ms Tendai Mafuma,<br />
Legal Researcher of Section 27, on the issue of dual loyalty whereby health professionals may find<br />
themselves pulled in different directions under certain circumstances i.e. loyalty to patient versus<br />
institution. In a previous Dear Reader column (<strong>South</strong> <strong>African</strong> <strong>Psychiatry</strong>, November 2017) I stated<br />
that …clinicians have only one focus – optimal patient care… Ms Mafuma advances the position<br />
that actually we all have only one loyalty i.e. to the Constitution…hence there is actually no dual<br />
loyalty. An important pronouncement, and certainly an appropriate filter for decision making and<br />
responding to institutional demands that conflict with clinical judgement. We have not heard the<br />
last of deliberations regarding responsibility for the tragedy and no doubt by the time the May <strong>2018</strong><br />
issue goes to press the situation will have unfolded further.<br />
A special mention for our regular contributors, something I have omitted to do previously – Franco<br />
Visser, Dave Swingler, Ian Westmore (and more recently Ethelwyn Rebelo). They have consistently<br />
delivered content that adds richness and information that is much valued…thanks and looking<br />
forward to further such content. It goes without saying that as readers, your contributions are most<br />
welcome as per the Instructions to Authors content.<br />
A final thanks… to industry…your involvement in 2017 was much valued and we look forward to<br />
your company as we continue this journey .<br />
All the best for the year ahead and I hope you will enjoy the issue!<br />
Zuki Zingela - Head, Department of <strong>Psychiatry</strong>, Walter Sisulu University<br />
Bonga Chiliza - Head Department of <strong>Psychiatry</strong> UKZN; President Elect <strong>South</strong> <strong>African</strong> Society of Psychiatrists<br />
Bernard Janse van Rensburg - President <strong>South</strong> <strong>African</strong> Society of Psychiatrists<br />
Headline Editor: Ian Westmore<br />
Acknowledgement: Thanks to Lisa Selwood for assistance with proof reading<br />
Design and Layout: Rigel Andreoli Printer: Imagine It Print It<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 5
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6 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
FEATURE<br />
PREJUDICE,<br />
DISCRIMINATION<br />
AND MENTAL<br />
ILLNESS<br />
Hemant Nowbath<br />
“THE TRUE TEST OF A CIVILISED SOCIETY IS THE WAY IT TREATS ITS MOST<br />
VULNERABLE CITIZENS” (DINESH BHUGRA, PAST PRESIDENT, WORLD PSYCHIATRIC ASSOCIATION) 1<br />
The stigma suffered by those with mental illness<br />
is well documented… “It’s difficult to work with<br />
people who don’t understand your illness.<br />
They pick on you. I’m labelled because I see<br />
a psychiatrist. I lie to keep appointments with you.<br />
I may have a mental illness but I’m not stupid” (A<br />
patient’s words)…<br />
The rights of the mentally ill are grossly neglected,<br />
as demonstrated by the deaths of over a hundred<br />
patients of Life Esidimeni Hospital when they were<br />
transferred to unregistered non-governmental<br />
facilities as part of a cost cutting exercise by the<br />
Gauteng Department of Health. The investigation<br />
by the Health Ombudsman Professor Malegapuru<br />
Makgoba found gross neglect and despite the<br />
resignation of the MEC for Health Qedani Mahlangu,<br />
no criminal prosecution has been started. This<br />
incident has served to highlight the lack of provision<br />
of services for those with mental illness and the<br />
criminal neglect of their needs.<br />
The World Psychiatric Association<br />
(WPA) has advocated the<br />
formulation of a Bill of Rights for the<br />
mentally ill. 2 Amongst the provisions<br />
included are the rights to:<br />
• Accessible and affordable<br />
mental and physical healthcare<br />
• Work, training and education<br />
• Accessible, integrated and<br />
affordable housing<br />
Hemant Nowbath<br />
• Freedom of movement<br />
• Equality before the law<br />
• Freedom from cruel, inhuman degrading<br />
treatment and punishment<br />
These are basic human rights that should be the<br />
preserve of all citizens. The mentally ill, however, have<br />
been discriminated against for centuries. Historically<br />
they were isolated and placed in asylums. They were<br />
subjected to cruel and inhumane treatments and<br />
their needs were neglected.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 7
FEATURE<br />
The current paper explores various aspects of<br />
discrimination and mental illness. The substance<br />
has been derived from a talk presented at the Dr<br />
Reddys academic weekend in June 2017. Based<br />
on specific terms that will be used it is important to<br />
define them 3 :<br />
Bigotry - an obstinate or intolerant devotion to one’s<br />
own opinions and prejudices.<br />
Prejudice – an irrational attitude of hostility directed<br />
against an individual, a group, a race or their<br />
supposed characteristics.<br />
Discrimination - the practice of unfairly treating<br />
a person or group of people differently from other<br />
people or groups of people.<br />
There are many issues to consider: Does prejudice<br />
cause mental illness? What is the nature of such<br />
illness? Do people with mental illness suffer prejudice?<br />
What are the consequences of this prejudice? This<br />
paper explores these and associated issues, looks at<br />
some of the relevant literature, and tries to shed light<br />
on the way forward.<br />
DISCRIMINATION IS DEROGATORY,<br />
DAMAGING AND DEMEANING. IT<br />
STOPS PEOPLE FROM REACHING<br />
THEIR FULL POTENTIAL. THE<br />
DISCRIMINATION SUFFERED BY<br />
THOSE WITH MENTAL ILLNESS IS<br />
WORSE THAN THAT SUFFERED<br />
BECAUSE OF RACE, AGE,<br />
GENDER, RELIGION AND SEXUAL<br />
ORIENTATION. 1 THE RELATIONSHIP<br />
BETWEEN VARIOUS FORMS OF<br />
DISCRIMINATION AND MENTAL<br />
ILLNESS HAS BEEN THE SUBJECT OF<br />
MUCH DISCUSSION AND DEBATE. IT<br />
IS A COMPLEX ONE.<br />
Funding for mental health lags behind that<br />
for physical illness. This is largely as a result of<br />
stigma. 1 Substance use disorders are seen as selfinduced<br />
and not taken seriously. These disorders<br />
are neglected despite their significant impact on<br />
individuals, family and society.<br />
Patients with mental illness suffer more physical<br />
illness and have shorter lives. They are poorer,<br />
have more stressors, less education and are more<br />
likely to be victims of domestic violence. This filters<br />
through generations. In many countries they do<br />
not have the right to vote or to engage in legal<br />
contracts. 4<br />
Corrigan and Watson (2002) 5 held that people<br />
with mental illnesses were doubly challenged. 5<br />
They struggled with symptoms and disabilities of<br />
the disease and were challenged by stereotypes<br />
and prejudices that stemmed from misconceptions<br />
of mental illness. As a result they were denied<br />
good jobs, safe housing, satisfactory healthcare<br />
and social affiliation. The stigma suffered is<br />
twofold (1) self-stigma: prejudice which people<br />
with mental illness have against themselves,<br />
(2) public-stigma: A reaction that the general<br />
population has towards people with mental illness.<br />
PREJUDICE CAN CAUSE MENTAL<br />
ILLNESS DUE TO MANY FACTORS –<br />
UNEQUAL POWER RELATIONSHIPS,<br />
PERSONAL INSULT, DEROGATORY<br />
ACTS, DEVALUING THE VICTIM. THIS<br />
PROVOKES FEELINGS OF LOW SELF-<br />
ESTEEM AND POWERLESSNESS AND<br />
CAN CAUSE ANGER, DEPRESSION<br />
OR ANXIETY.<br />
Prejudice may lead to emotional responses to<br />
stigmatised groups and prejudice turned inwards<br />
leads to self-discrimination. Prejudice, which<br />
is a cognitive and affective response, leads to<br />
discrimination, a behavioural reaction. 5<br />
Misconceptions about mentally ill people are many<br />
and include the following – they are violent and<br />
should be feared; they are irresponsible; they are<br />
childlike and need to be cared for.<br />
Corrigan and Watson (2002) 5 also describe<br />
4 forms of discrimination - withholding help;<br />
avoidance; coercive treatment and segregated<br />
institutions.<br />
Allport’s seminal work defined the nature of<br />
prejudice. 6 He determined a 5-point scale of<br />
increasingly dangerous acts:<br />
1. Verbal expression of antagonism<br />
2. Avoidance of members of disliked groups<br />
3. Active discrimination<br />
4. Physical attack<br />
5. Extermination – lynchings, massacres, genocide.<br />
RACE<br />
In a country that emerges slowly from a past<br />
bedevilled by racial discrimination and inequality of<br />
immeasurable proportions it would be expected that<br />
the incidence of mental illness is disproportionately<br />
high. Research in this regard however is scant.<br />
Many facets of racism have been explored over<br />
the years. Leopold Sedar Senghor (1906-2001),<br />
Senegalese poet and cultural theorist, first President<br />
8 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
FEATURE<br />
of Senegal, coined the term “negritude’’ in response<br />
to the racism present in France. He tried to turn<br />
the racial slur “negre’’ into a positive celebration of<br />
<strong>African</strong> culture and character.<br />
Franz Omar Fanon (1925-1961), psychiatrist,<br />
philosopher and revolutionary writer analysed<br />
the negative psychological effects of colonial<br />
subjugation upon black people in “Black skin,<br />
White masks” published in 1952. He radically revised<br />
methods of treatment and started “sociotherapy’’ to<br />
connect with patients’ cultural backgrounds.<br />
In “The Wretched of the Earth” (1961) Fanon<br />
defended the rights of a colonised people to use<br />
violence to gain independence. He felt that those<br />
who were not considered human could not be<br />
bound by principles that apply to humanity. Fanon<br />
influenced amongst others Malcolm X, Che Guevara<br />
and Steve Biko.<br />
A conference at the University of the Witwatersrand<br />
in <strong>February</strong> 2017 explored the social determinants<br />
of health. Amongst issues examined was the role<br />
of doctors in addressing health inequities in <strong>South</strong><br />
Africa and the need to identify solutions. 7<br />
This conference was held against a background of<br />
crucial issues that confront the country and have a<br />
marked impact on health delivery. There is an ever<br />
widening Gini coefficient (a measure of inequality),<br />
with service delivery protests occurring almost<br />
daily as disadvantaged communities grapple<br />
with the ravages of poverty. As levels of crime<br />
increase exponentially, minority groups experience<br />
xenophobia, and revelations of “State Capture”<br />
shake confidence in the economy and the political<br />
stability of the country. All these issues add to the<br />
burden of disease.<br />
THE STARK REALITY OF LIFE IN SOUTH<br />
AFRICA TODAY IS THAT 26.7% OF THE<br />
LABOUR FORCE IS UNEMPLOYED<br />
AND 14 MILLION PEOPLE GO TO<br />
BED HUNGRY. THE SPIRAL OF UNMET<br />
BASIC NEEDS, POVERTY, CRIMINAL<br />
BEHAVIOUR AND VIOLENCE IS A<br />
FERTILE BREEDING GROUND FOR<br />
A VARIETY OF MENTAL ILLNESSES<br />
INCLUDING ANXIETY, DEPRESSION<br />
AND POST-TRAUMATIC STRESS<br />
DISORDER. ADVERSITY MAY MOTIVATE<br />
PEOPLE, STIMULATE GROWTH<br />
AND FOSTER RESILIENCE. THE RISK<br />
HOWEVER IS POOR MENTAL HEALTH.<br />
Many people in <strong>South</strong> Africa have been victims<br />
of racism. Entire communities were discriminated<br />
against under the iniquitous system of Apartheid<br />
after the National party assumed power in 1948. The<br />
enactment of the Group Areas Act (1950), the Job<br />
Reservation Act and the Immorality Act determined<br />
where people lived and worked and whom they<br />
married. 8 The unwritten social discrimination of the<br />
colonial power was now law.<br />
Apartheid had a major impact on the lives of<br />
all <strong>South</strong> <strong>African</strong>s. Black <strong>South</strong> <strong>African</strong>s suffered<br />
discrimination in all spheres of life. The social<br />
and economic deprivation, lack of proper<br />
housing, education and health care proved a<br />
rich breeding ground for a host of physical and<br />
mental illnesses.<br />
Post democracy very little has changed for many<br />
people. The socio-economic barriers to good<br />
mental health remain. The unmet expectations<br />
have led to anxiety and depression. Substance<br />
abuse is rife in impoverished communities.<br />
In addition many people are disillusioned by<br />
affirmative action. They feel unfairly discriminated<br />
against because of race. There is a belief that<br />
affirmative action, as practised, is racism in reverse.<br />
HUYNH (2012) 9 FOUND THAT<br />
THOSE WHO WERE DISCRIMINATED<br />
AGAINST ON THE GROUNDS OF<br />
RACE SUFFERED SIGNIFICANT<br />
NEGATIVE CONSEQUENCES<br />
INCLUDING AN IMPACT ON<br />
GENERAL WELL-BEING, SELF-<br />
ESTEEM, SELF-WORTH, AND SOCIAL<br />
RELATIONS. THIS LED TO INCREASED<br />
LEVELS OF STRESS, ANXIETY AND<br />
DEPRESSION.<br />
Fisher 10 explored the case of Dylan Roof who killed<br />
nine black people in a church in Charlestown.<br />
He holds that racism is not a mental illness but<br />
some aspects are similar, for example, thoughts<br />
of superiority are delusional or there may be<br />
paranoia that the ‘superior’ race is under threat.<br />
Racism does not have a biological basis but it<br />
is learnt then accepted as the truth. Hate too is<br />
learnt and its behavioural manifestations, bigotry<br />
and prejudice, are socialised in people when<br />
they are young by the adults who raise them.<br />
Terrorism, the use of violence to achieve political<br />
objectives, is a vehicle to eliminate the object<br />
of hate. Mental illness however has a biological<br />
basis. Racism, hate and terrorism may cause<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 9
FEATURE<br />
mental illness. 9 Poussaint 11 differs in that he feels<br />
that extreme racism is a mental illness and not to<br />
regard it as such and not to see it as pathological<br />
gives it legitimacy. Poussaint sees it as a delusional<br />
disorder. 11 The counter argument is that if racism is<br />
seen as a mental illness it would provide an excuse<br />
for prejudiced behaviour.<br />
Poussaint 11 concludes “Clinicians need guidelines<br />
for recognising delusional racism in all its forms<br />
so that they can provide appropriate treatment.<br />
Otherwise extreme delusional racists will fall through<br />
the cracks of the mental health system, and we<br />
can expect more of them to explode and act out<br />
their deadly delusions.” This was written some years<br />
before Dylan Roof exploded.<br />
VULNERABLE GROUPS<br />
Vulnerable groups of people have higher than<br />
expected rates of psychiatric disorders. These groups<br />
include the following: lesbians, gays, bisexual,<br />
transgender and intersex (LGBTI), migrants, prisoners,<br />
minorities and women. 12 They have higher rates of<br />
suicide. Discrimination is also associated with higher<br />
rates of depression, anxiety and psychosis. 13<br />
SEXUAL ORIENTATION<br />
HOMOSEXUALITY WAS REGARDED<br />
AS A MENTAL ILLNESS UNTIL ITS<br />
REMOVAL FROM THE SECOND<br />
EDITION OF THE DIAGNOSTIC AND<br />
STATISTICAL MANUAL FOR MENTAL<br />
ILLNESS (DSM) IN 1973.<br />
The LGBTI community has been the victim of<br />
prejudice for centuries. They have borne the brunt<br />
of the anger and discrimination by those who see<br />
them as lesser beings because of misguided belief.<br />
There are those, who, bereft of current scientific<br />
knowledge, who use ancient religious texts to brand<br />
gays and lesbians “sinners.’’ Anti-gay prejudice is rife<br />
in many areas and homosexuality is regarded as a<br />
crime in many <strong>African</strong> countries and religious states<br />
in the Middle East.<br />
There have been psychiatrists who have attempted<br />
to “treat’’ homosexuals by cruel and inhumane<br />
procedures. <strong>South</strong> <strong>African</strong> psychiatrist, Aubrey<br />
Levine, who “treated’’ recruits in the <strong>South</strong> <strong>African</strong><br />
Defence Force in this manner was subsequently<br />
found guilty of abusing male patients in Canada<br />
and imprisoned.<br />
The LGBTI community is particularly vulnerable and<br />
prone to a range of psychiatric illnesses.<br />
Meyer (2003) 12 held that the LGB community<br />
had a higher prevalence of mental disorders.<br />
The conceptual framework to understand this<br />
was “minority stress’’ – stigma, prejudice and<br />
discrimination create a hostile and stressful social<br />
environment that causes mental health problems.<br />
AS A STIGMATISED MINORITY<br />
GROUP THEY SUFFER MORE<br />
MENTAL HEALTH ISSUES INCLUDING<br />
SUBSTANCE USE DISORDERS, MOOD<br />
DISORDERS AND HIGHER RATES<br />
OF SUICIDE. FAMILY SUPPORT AND<br />
ACCEPTANCE IS OFTEN LACKING.<br />
PSYCHOLOGICAL MECHANISMS<br />
EXPLAIN THE ASSOCIATION<br />
BETWEEN VICTIMISATION AND<br />
PSYCHOLOGICAL DISTRESS.<br />
WOMEN<br />
Women experience gender discrimination despite<br />
widespread efforts to educate and enlighten people.<br />
In patriarchal societies they still suffer prejudice and<br />
abuse. They are denied the vote and regarded as<br />
minors. Even in religious matters many faiths bar<br />
them from the priesthood, limit their growth and<br />
education and prevent their movement.<br />
AGE<br />
There are other forms of discrimination that contribute<br />
to mental illness. Ageism is an often unrecognised<br />
problem. The elderly are a particularly vulnerable<br />
population. They suffer abuse as a result of omission,<br />
neglect or ignorance. Their needs are ignored and<br />
at times they suffer physical abuse too.<br />
ADDRESSING<br />
DISCRIMINATION:<br />
TREATMENT<br />
Prevention is paramount. Children should be<br />
raised with broad value systems and taught to<br />
respect all people of different races, gender<br />
and religious belief. They need to be exposed to<br />
all belief systems and not trained to think that<br />
theirs is a superior faith or the only one. Efforts to<br />
engage with people of all cultures and creeds<br />
must be encouraged and artificial barriers that<br />
separate eliminated.<br />
Egbe et al (2014) 14 explored psychiatric stigma and<br />
discrimination in <strong>South</strong> Africa and offered, amongst<br />
others, the following recommendations:<br />
• psychoeducational interventions to address the<br />
myths and traditional beliefs in the causes of<br />
mental illness which influence stigma<br />
10 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
FEATURE<br />
• media campaigns to create awareness and<br />
supportive community environments to reduce<br />
stigma and discrimination in communities<br />
• advocacy interventions to the development of<br />
policy and services.<br />
To paraphrase previous rector of the University of<br />
the Free State, Jonathan Jansen – “invite to your<br />
next braai people who don’t look the same way as<br />
you do… pray the same way as you do… dress the<br />
same way as you do….” This would help break down<br />
barriers and engender respect and tolerance.<br />
Psychiatrists have been trained to treat patients<br />
holistically. Medicine, especially psychiatry,<br />
cannot be practised in a vacuum. We need<br />
to consider the social, economic and political<br />
realities that affect health. It is now imperative<br />
that psychiatrists become advocates on behalf<br />
of patients. There is a need to get involved and<br />
address root causes of mental illness, a need to<br />
move from the hallowed halls of academia and<br />
become active citizens.<br />
CONCLUSION<br />
The cause must be treated and delusions of belief<br />
addressed. It is necessary to confront, challenge and<br />
if need be, legislate against discrimination. There<br />
can be no better justification for getting involved<br />
in the struggle to support human rights for patients<br />
than the case presented by Protestant pastor, Martin<br />
Niemoller (1892-1984), who spent 7 years in Nazi<br />
concentration camps:<br />
“FIRST THEY CAME FOR THE<br />
SOCIALISTS, AND I DID NOT<br />
SPEAK OUT BECAUSE I WAS NOT A<br />
SOCIALIST.<br />
THEN THEY CAME FOR THE TRADE<br />
UNIONISTS, AND I DID NOT SPEAK<br />
OUT BECAUSE I WAS NOT A TRADE<br />
UNIONIST.<br />
THEN THEY CAME FOR THE JEWS,<br />
AND I DID NOT SPEAK OUT BECAUSE<br />
I WAS NOT A JEW.<br />
THEN THEY CAME FOR ME, AND<br />
THERE WAS NO ONE LEFT TO SPEAK<br />
FOR ME.”<br />
REFERENCES<br />
1. Bhugra D. Social discrimination and social<br />
justice. International Review of <strong>Psychiatry</strong> 2016.<br />
28.4 336 – 341<br />
2. Bhugra D. Bill of Rights for Persons with mental<br />
illness. International Review of <strong>Psychiatry</strong> 2016.<br />
28.4 335<br />
3. Merriam-Webster online dictionary. 2017.<br />
Merriam-Webster Inc.<br />
4. Bhugra D. Mental Health for Nations.<br />
International Review of <strong>Psychiatry</strong> 2016 28.4 342<br />
– 374<br />
5. Corrigan PW, Watson AC. Understanding the<br />
impact of stigma on people with mental illness.<br />
World <strong>Psychiatry</strong> 2002.1.1 16-20<br />
6. Allport GW. The Nature of Prejudice. 1954.<br />
Addison-Wesley<br />
7. Mutsago R, Mametja S. International Conference<br />
on social determinants of health tackles huge<br />
inequities in SA. SAMA Insider 2017 April 6-9<br />
8. Meer I. A Fortunate Man. Zebra Press 2002<br />
9. Huynh Q-L. The Psychological Costs of<br />
Painless but Recurring Experiences of Racial<br />
Discrimination. Cultural Diversity and Ethnic<br />
Minority Psychology 2012; 18(1): 26-34<br />
10. Fisher MB. Racism, hate, terrorism and mental<br />
illness: Roanoke Times (Opinion) 2015<br />
11. Poussaint AF. Is Extreme Racism a Mental Illness?<br />
Western Journal of Medicine 2002; 176 (1): 4<br />
12. Meyer IH. Prejudice, Social Stress and Mental<br />
Health in Lesbian, Gay and Bisexual Populations:<br />
Conceptual Issues and Research Evidence.<br />
Psychological Bulletin 2003; 129(5): 674-697<br />
13. Bhui K. Discrimination, poor mental health, and<br />
mental illness. International Review of <strong>Psychiatry</strong><br />
2016 28.4 411-414<br />
14. Egbe CO, Brooke-Summer C, Kathree T, Selohilwe<br />
O, Thomicroft G, Petersen I. Psychiatric stigma<br />
and discrimination in <strong>South</strong> Africa: perspectives<br />
from key stakeholders. BMC <strong>Psychiatry</strong> 2014; 14<br />
(191): 14-19<br />
Hemant Nowbath is a psychiatrist in private practice in Durban. He sees no ethical conflict between<br />
the socialist ideology of his youth and his current taste for good whisky and golf. A Wits undergraduate he<br />
specialised in Natal. Despite an undistinguished academic career, bereft of any honours, he is the President<br />
of the <strong>South</strong> <strong>African</strong> Addiction Medicine Society and sits on the executive of the Durban Chess Club.<br />
Correspondence: hemant@saol.com<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 11
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12 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
ORIGINAL<br />
A MIXED-METHODS STUDY ON<br />
GROUP MUSIC THERAPY<br />
AS AN INTERVENTION FOR<br />
THE NEGATIVE SYMPTOMS<br />
OF SCHIZOPHRENIA<br />
Bruce Malcolm Muirhead, Andeline Julia Dos Santos, Marc Roffey<br />
T<br />
his<br />
article is a summary of a mixed-methods research study that was conducted by<br />
the first author in 2017. It includes some introductory material on music therapy, for<br />
readers new to the discipline. The study was a requirement to fulfill music therapy training<br />
needs at a Masters level at the University of Pretoria (UP), and the full version of it was<br />
successfully submitted as a dissertation.<br />
ABSTRACT<br />
The study, which was small in terms of participants and duration, explored group music therapy as an<br />
intervention for negative symptoms of in-patient forensic clients with schizophrenia, and was conducted at<br />
the forensic unit at Valkenberg Hospital. Negative symptoms are a clinical group of symptoms that may be<br />
present in schizophrenia, and include apathy, social withdrawal, blunted emotional responses and reduction<br />
in speech. A closed group of eight participants attended a total of eight music therapy sessions over a<br />
period of six weeks. Qualitative data consisted of session video footage, and semi-structured interviews<br />
that were conducted with each participant after the intervention. Quantitative data were generated both<br />
pre- and post-intervention using the Positive and Negative Syndrome Scale (PANSS). Qualitative data were<br />
analysed thematically, and indicated that group music therapy afforded benefits for these participants’<br />
negative symptoms during sessions, although these were still present to a degree. The quantitative data did<br />
not demonstrate a statistically significant change before and after the study. The qualitative and quantitative<br />
data were mixed at the interpretative stage of the analysis process, enabling an in-depth exploration of the<br />
relationship between both data sets. Although participants continued to present with negative symptoms<br />
in day-to-day life, there was a temporary relief from these during the music therapy sessions.<br />
MUSIC THERAPY<br />
Since 1999 music therapy has been offered as a Master’s degree at UP, which is currently the only university<br />
in <strong>South</strong> Africa offering this qualification. The UP music therapy course is held over two years, and includes<br />
theoretical and practical modules and placements. Entrance requirements are either a four-year music degree<br />
with at least a third year level of psychology, or another, non-music four-year degree with at least three years<br />
of psychology, together with a satisfactory level of musical proficiency. Students rotate through various hospital<br />
placements, including the acute-care and forensic units at Valkenberg Hospital, where the current study was<br />
conducted. Others, either historically or currently, include Lentegeur and Weskoppies psychiatric hospitals,<br />
the Port Elizabeth Mental Health organisation, and Cecilia Makiwane, Rob Ferreira and Windhoek Hospitals.<br />
Other sectors include paediatric oncology, special needs, autism, neuro-rehabilitation, psycho-geriatric and<br />
intellectual disability. At the conclusion of the training period a dissertation must be submitted.<br />
Music therapy is recognised by the HPCSA and BHF bodies as a health discipline, and practitioners require<br />
registration with the HPCSA. Music therapy consultations can be claimed from those medical aids that pay for<br />
the Arts Therapies. To date there are no government-funded music therapy posts in the state sector. It is hoped<br />
that this will change, especially with regard to state-sector provision of mental health care, as awareness of<br />
evidence-based studies increases.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 13
ORIGINAL<br />
Music therapy itself is an intervention that has been<br />
in existence as an academic discipline since the<br />
mid-twentieth century. 1 It is gaining credibility as an<br />
evidence-based intervention, as a result of significant<br />
gains in understanding the neural processes<br />
involved in musical activity (perception, auditory<br />
and cognitive processing, performance etc.), and<br />
how these may be applied in a therapeutic way.<br />
The strongest music therapy research, with<br />
accumulating evidence for its effectiveness in<br />
these fields, has been in dementia, Parkinson’s<br />
disease, autistic spectrum disorders, behavioural<br />
and developmental disturbances in childhood, and<br />
cancer care. 2 A review of the literature reveals that<br />
research into its effectiveness as an intervention in<br />
severe mental illness, including major psychotic and<br />
mood disorders, is ongoing.<br />
An often-quoted definition of music therapy is that it<br />
is “a systematic process of intervention wherein the<br />
therapist helps the client to promote health, using<br />
music experiences and the relationships that develop<br />
through them as dynamic forces of change.” 3 As<br />
this definition implies, music therapy is primarily nonverbal,<br />
which is helpful for clients who may have<br />
difficulties addressing issues through the use of words<br />
alone, and it also suggests that the therapeutic<br />
process extends beyond the passive listening of music<br />
- there is a therapist, a client-therapist relationship,<br />
and the music experience, which usually includes<br />
participating in making music.<br />
The music therapy process may be conducted<br />
singly, or in groups. Typically, the act of making<br />
music includes playing or singing, which clients are<br />
invited to participate in with the music therapist.<br />
Musical activities range from free improvisation,<br />
to reproducing or creating songs. Commonly<br />
used instruments include drums and percussion<br />
instruments, keyboards, thumb pianos, guitars, and<br />
the human voice. It is important to emphasise that<br />
the music therapy process does not require or presuppose<br />
any formal musical training or ability in<br />
participants.<br />
STUDY INTRODUCTION<br />
The effective management of the negative<br />
symptoms of schizophrenia is a therapeutic<br />
obstacle. 4,5,6 The efficacy of medication is limited, and<br />
symptom specificity is unsatisfactorily targeted. 7,8<br />
In addition, the negative symptoms themselves<br />
make conventional speech-based psychological<br />
interventions difficult to implement.<br />
A 2017 Cochrane review of music therapy and<br />
schizophrenia reviewed eighteen trials in which<br />
people with schizophrenia or schizophrenialike<br />
disorders were randomised to receive either<br />
music therapy or standard care. 9 Symptom-related<br />
outcomes, using standard instruments and rating<br />
scales, were typically measured in these studies. The<br />
currently available evidence is of low to moderate<br />
quality, with bias in these studies reported as being<br />
low. Results suggest that music therapy improves<br />
global state, mental state, functioning, and quality<br />
of life if a sufficient number of music therapy sessions<br />
are provided. The duration of the studies was<br />
between one and six months, and greater benefits<br />
were found with studies of a longer duration, and<br />
with a higher frequency of sessions.<br />
With respect to specific symptom groups, the<br />
Cochrane review revealed overall significant short,<br />
medium, and long-term effects in favour of music<br />
therapy on negative symptoms. Trials focusing on<br />
positive symptoms or combined symptomatology<br />
were of better quality, and revealed significant<br />
effects on general functions in the short, medium<br />
and long term, and poor short term effects on<br />
positive symptoms.<br />
Current research therefore suggests support for<br />
music therapy as a potential therapeutic intervention<br />
for a group of symptoms in which pharmacological<br />
approaches have been less successful.<br />
To further contribute to this body of knowledge, the<br />
main research question of the current study was:<br />
How can service users in a psychiatric hospital<br />
who are diagnosed with schizophrenia benefit<br />
from group music therapy sessions in relation to<br />
their negative symptoms? Sub-questions were<br />
then generated which specified the negative<br />
symptoms that were investigated: How can music<br />
therapy sessions contribute as an intervention<br />
for i) emotional withdrawal and blunted affect?,<br />
ii) relational withdrawal and conversational flow?,<br />
iii) difficulties in abstract and stereotyped thinking?,<br />
and iv) anhedonia?<br />
METHOD<br />
An embedded design 10 was used in this exploratory<br />
study. Qualitative data were predominant, and<br />
quantitative data were integrated into the study<br />
supportively.<br />
CONTEXT<br />
This study took place at the forensic unit at<br />
Valkenberg Psychiatric Hospital in Cape Town.<br />
The forensic psychiatry unit assesses adult male<br />
defendants referred by the courts, and treats and<br />
rehabilitates offenders diagnosed with severe mental<br />
illness. Patients undergoing rehabilitation are known<br />
as ‘state patients’. Female forensic patients are<br />
not treated at Valkenberg Hospital, and none were<br />
therefore represented in this study. As the length of<br />
admission for forensic patients is significantly longer<br />
than for acute patients, the forensic population is a<br />
better suited group for a six-week study, and this was<br />
a principal reason for the study being conducted<br />
within this group.<br />
PARTICIPANTS<br />
Eight ‘state patients’ with schizophrenia, each with<br />
prominent negative symptoms, were included in<br />
the study. Potential participants were identified by<br />
the hospital’s forensic staff, based on the prominent<br />
presentation of negative symptoms, and the<br />
sampling method used was therefore a purposive<br />
one. 11 Informed consent forms were signed by the<br />
participants, and ethical permission to conduct the<br />
study was granted by the University of Cape Town’s<br />
faculty of Health Sciences ethics committee.<br />
INTERVENTION<br />
Eight group music therapy sessions were held<br />
regularly over a six-week period. Music therapy<br />
was offered as complementary to standard<br />
14 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
ORIGINAL<br />
pharmacological treatment, and to standard<br />
occupational therapy and nursing programs.<br />
The sessions included the following elements:<br />
i) listening to recorded music while participating<br />
in physical stretching exercises, ii) group djembe<br />
drumming, including opportunities for participants<br />
to lead, iii) semi-structured improvisations involving<br />
singing, chanting, and the playing of pitched<br />
and non-pitched percussion instruments, iv) freeimprovisation,<br />
and v) song-writing. Goals included<br />
providing opportunities for collaboration, interactive<br />
communication, free self-expression, and the fostering<br />
of creativity.<br />
DATA COLLECTION<br />
QUALITATIVE DATA COLLECTION<br />
Qualitative data were collected from two sources:<br />
the music therapy sessions, which were video<br />
recorded, and from audio recorded semi-structured<br />
interviews, which were conducted at the end of<br />
the intervention. Three excerpts were selected from<br />
video recordings taken from the first, fourth and<br />
last session. Thick descriptions were then written for<br />
each excerpt, as a rich articulation of the observed<br />
event 12 .<br />
Semi-structured interviews were conducted with<br />
participants after the final music therapy session. Nine<br />
open questions were presented to each participant,<br />
including: i) how they experienced making music<br />
together in sessions, ii) how they experienced<br />
themselves in the group, iii) how they experienced<br />
communicating with others in the group, and iv)<br />
how they experienced their levels of motivation<br />
during sessions and after sessions. Interviews were<br />
audio recorded and then transcribed verbatim.<br />
QUANTITATIVE DATA COLLECTION<br />
The Positive and Negative Syndrome Scale (PANSS)<br />
is a well-validated clinical symptom scale and<br />
consists of three subscales, viz. positive symptoms,<br />
negative symptoms, and general psychopathology<br />
symptoms, such as anxiety, motor abnormalities<br />
and poor insight. 13,14 The scale was used to collect<br />
quantitative data on the patients.<br />
The PANSS questionnaire was completed for each<br />
participant before and immediately after the group<br />
music therapy process. Seven negative symptoms<br />
are represented in the questionnaire (blunted<br />
affect, emotional withdrawal, poor rapport, passive/<br />
apathetic social withdrawal, difficulty in abstract<br />
thinking, lack of spontaneity and flow of conversation,<br />
and stereotyped thinking), and each is graded from<br />
one to seven, where 1 is ‘absent’, and 7 is ‘extreme’.<br />
DATA ANALYSIS<br />
The qualitative data were analysed using thematic<br />
analysis, which consists of specifying, examining<br />
and assembling themes in a data set. 15,16 The thick<br />
descriptions of the video data were analysed in this<br />
way, and this process led to the initial identification<br />
of over a hundred codes, which are main ideas<br />
that emerge from studying the transcripts. Codes<br />
captured: key concepts expressed verbally by the<br />
participants; affective material; and interactional<br />
dynamics that became evident through the making<br />
of music. Codes that shared similarities were<br />
then grouped into forty-four categories, finally the<br />
categories were grouped together, and six emergent<br />
themes were identified. The same procedure was<br />
used to analyse the thick descriptions that had<br />
been written for the interview data. Throughout<br />
these processes cognizance of the negative<br />
symptoms specified in the study’s sub-questions,<br />
and their resonance with the thematic analysis, was<br />
maintained.<br />
RESULTS<br />
QUALITATIVE RESULTS<br />
Examples of codes generated by the analysis<br />
included:<br />
• motivation to keep personal stability,<br />
• rhythmic continuity,<br />
• the sessions being a safe space where “there is<br />
no violence in the joy”,<br />
• medication as not the “end of being”,<br />
• affirmative lyrical content,<br />
• impassive affect,<br />
• narrowing of melodic range.<br />
Examples of categories included:<br />
• warmth and safety,<br />
• physical wellbeing,<br />
• equality,<br />
• sense of freedom,<br />
• positive group experience,<br />
• irritability,<br />
• stunted musical exchange.<br />
Six themes were generated by these categories, as<br />
follows:<br />
‘Holding’ related to a sense of emotional security<br />
and stability that was experienced within the music<br />
therapy group.<br />
‘Positive experiences of music therapy’ included<br />
categories relating to favourable and beneficial<br />
experiences during the sessions.<br />
‘Togetherness’ comprised processes of experience<br />
in the group, and adjustments in the group context,<br />
that arose from empathic cooperation.<br />
‘Activation’ included instances where motivation,<br />
energy, leadership and agency emerged through<br />
participating in the music therapy intervention.<br />
‘Flexibility’ referred to how participants could sustain<br />
variation in a healthy and constructive manner.<br />
‘Inflexibility’ incorporated the presentation of<br />
stagnated or immobilised characteristics that<br />
were evident in the data, including blunted affect,<br />
emotional withholding, relational withdrawal, lack<br />
of conversational flow, stereotyped thinking and<br />
anhedonia.<br />
Table I details two examples of the relationships<br />
between the codes, categories and themes, and<br />
the sub-questions to which they relate.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 15
ORIGINAL<br />
CODE EXAMPLES<br />
CATEGORY<br />
EXAMPLES<br />
THEMES<br />
SUB – QUESTIONS<br />
Silent participant drawn into<br />
group expression;<br />
Participant initiates singing<br />
again;<br />
Responsiveness;<br />
Leadership.<br />
ACTIVATION<br />
Emotional withdrawal<br />
and blunted affect;<br />
Relational withdrawal<br />
and conversational flow;<br />
(Music) requires devotion.<br />
Anhedonia.<br />
Impassive affect;<br />
Narrowing melodic range.<br />
Stunted musical<br />
exchange;<br />
Irritability;<br />
Music therapist’s<br />
communication<br />
challenges.<br />
INFLEXIBILITY<br />
Emotional withdrawal<br />
and blunted affect;<br />
Relational withdrawal<br />
and conversational flow;<br />
Abstract thinking and<br />
stereotyped thinking;<br />
Anhedonia.<br />
Table I: Two examples of the emergence of themes from categories and codes, and the sub-questions to which<br />
they relate.<br />
QUANTITATIVE RESULTS<br />
The PANSS scores confirmed that all the participants<br />
in the study presented with negative symptoms of<br />
schizophrenia. The pre-intervention mean score for<br />
the negative symptoms was 20. The mean postintervention<br />
score for negative symptoms was 19.1,<br />
which is not a statistically significant change. Within<br />
the negative symptom subscale, no striking preand<br />
post-intervention changes were present in the<br />
specific negative symptom scores. The maximum<br />
attainable score is 49.<br />
Lower mean scores were obtained for the positive and<br />
general psychopathology subscales, suggesting<br />
that negative symptoms were well represented in<br />
the selected patients. No significant mean changes<br />
were recorded post-intervention for the positive and<br />
general psychopathology symptoms.<br />
DISCUSSION<br />
A viewing of the video recordings, from the first to<br />
the final music therapy session revealed a notable<br />
trajectory from poor to enthusiastic engagement.<br />
Session one was characterised by long periods of<br />
perseveration and withdrawal, while session eight<br />
revealed enhanced interconnecting, cohesion and<br />
creative expression.<br />
Examples of participant responses, as related to<br />
the themes of ‘holding’ and ‘positive experiences of<br />
music therapy’, included the following: when asked<br />
how he experienced relating to group members,<br />
one participant answered, “I think about a band<br />
around say, on me, who are back in now here by<br />
me. There’s no violence. And there’s no violence in<br />
the joy.” Music therapy was similarly described as<br />
being enjoyable by other participants. One of the<br />
participants frequently left sessions smiling and<br />
laughing, whereas he entered them in a withdrawn,<br />
sullen and reluctant manner.<br />
Within these themes of ‘holding’ and ‘positive<br />
experiences of music therapy’ the category<br />
‘organisation, stability and structure’ portrayed a<br />
regulated and ordered state. Several codes within<br />
this category made reference to the observed<br />
musical receptivity of the group to highly structured<br />
activity, such as successive turn-taking in group<br />
drumming with a steady pulse. This is an interesting<br />
finding, in the context of the difficulties that people<br />
with schizophrenia frequently display in their ability to<br />
maintain structure and organisation, both internally<br />
and externally. 17<br />
The theme of ‘activation’ included instances where<br />
motivation, energy, leadership and agency emerged<br />
through participating in the intervention. The theme<br />
relayed a sense of awakening and emergence,<br />
reflecting a change in the manner that participants<br />
would hear and see themselves and one another.<br />
One of the categories in this theme, ‘sense of<br />
achievement and self-belief’, arose from activities<br />
such as workshopping individual poems into one<br />
group song, or featuring all the participants as drum<br />
soloists. ‘High energy’ is an example of a category<br />
within this theme that derived from codes expressing<br />
raised vigour and vitality.<br />
Codes and categories within the theme of<br />
‘flexibility’ indicated that participants could sustain<br />
musical variation in a healthy and constructive<br />
way, could flexibly negotiate playing an instrument<br />
communicatively with others, and could engage<br />
in congruent, creative expression. One of the<br />
categories included in this theme was abstract<br />
thinking, and one participant related that music is like<br />
a romantic partner he had keenly felt the absence<br />
of since being hospitalised. The theme of ‘inflexibility’<br />
was juxtaposed with this, and incorporated<br />
the presentation of stagnated or immobilised<br />
characteristics that were evident in the data. Its<br />
presence indicated that negative symptoms were<br />
still present in sessions. Interestingly however, codes<br />
in the category ‘disjointed relational responses and<br />
engagement’, within this theme, mainly stemmed<br />
from the interviews. This suggests that there were<br />
more cohesive relational interchanges when<br />
participants were engaged in music, rather than<br />
when communicating verbally in the interview.<br />
16 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
ORIGINAL<br />
In conclusion, the themes ‘holding’, ‘positive<br />
experiences of music therapy’, ‘togetherness’,<br />
‘activation’ and ‘flexibility’ indicate that within the<br />
sessions the participants were afforded opportunities<br />
to experience themselves in more vibrant and<br />
socially interactive ways, and in this way music<br />
therapy was seen to have a beneficial impact on<br />
the negative symptoms.<br />
The post-intervention interviews revealed that little<br />
change in the experience of negative symptoms<br />
was reported in daily life on the ward after the<br />
music therapy had concluded. Given the small<br />
number of participants (n=8), no statistically<br />
significant changes were expected, nor present, in<br />
the pre- and post-intervention PANSS scores (the<br />
quantitative data). A principal value of the PANSS<br />
evaluation was to confirm that the participants,<br />
who were selected on clinical grounds, did indeed<br />
have significant negative symptoms. In order for<br />
a study to prove, quantitatively, the hypothesis<br />
that music therapy can have enduring effects<br />
outside of the sessions, there would need to be a<br />
far greater number of participants, and the study<br />
would need to be conducted over a much longer<br />
period of time.<br />
LIMITATIONS<br />
The number of participants in the current study was<br />
small, the duration of the intervention was short,<br />
and there was no control group. The diagnosis<br />
of schizophrenia, in all of the participants, was<br />
established clinically, and not through the use<br />
of diagnostic research instruments such as SCID<br />
(Structured Clinical Interview of DSM-5). Addressing<br />
anhedonia was a specific aim of one of the subquestions<br />
of the study: as this symptom is not<br />
specifically measured in the PANSS, its analysis was<br />
only addressed qualitatively.<br />
CONCLUSION<br />
This pilot study suggests that reductions in the<br />
experience of some negative symptoms, in people<br />
with a diagnosis of schizophrenia, are possible<br />
during music therapy sessions. It is the first such<br />
study to be conducted in this country, and supports<br />
the findings of other, larger studies.<br />
In view of the lack of available therapeutic<br />
interventions that significantly improve negative<br />
symptoms, including medication, the question<br />
of whether music therapy can address this in an<br />
enduring way is an important one. A larger study<br />
would be needed to address this question.<br />
Finally, as stated earlier, it would be desirable if<br />
state mental health service administrators in<br />
<strong>South</strong> Africa would gain an increasing awareness<br />
of the status of music therapy: as a formal HPCSA<br />
accredited discipline, and as an increasingly<br />
evidence-based intervention for a range of<br />
mental health problems.<br />
REFERENCES<br />
1. Karhou V, Sanderson P. Arts therapies: A researchbased<br />
map of the field. London: Elsevier. 2006<br />
2. The Nordoff Robbins Evidence Bank , 3rd <strong>Edition</strong>.<br />
2014<br />
3. Bruscia KE. Defining Music Therapy. 2nd <strong>Edition</strong>.<br />
Gilsum, NH: Barcelona Publishers.1998<br />
4. Chue P, Lalonde JK. Addressing the unmet needs<br />
of patients with persistent negative symptoms<br />
of schizophrenia: emerging pharmacological<br />
treatment options. Neuropsychiatric disease and<br />
treatment 2014; 10: 777-789.<br />
5. Fusar-Poli, P, Papanastasiou , Stahl D, Rocchetti<br />
M, Carpenter W, Shergill S, McGuire P. Treatments<br />
of negative symptoms in schizophrenia: Metaanalysis<br />
of 168 randomized placebo-controlled<br />
trials. Schizophrenia Bulletin 2014; 41(4): 892-899.<br />
6. Millan M J, Fone K, Steckler T, Horan WP.<br />
Negative symptoms of schizophrenia: clinical<br />
characteristics, pathophysiological substrates,<br />
experimental models and prospects for improved<br />
treatment. European Neuropsychopharmacology<br />
2014; 24(5): 645-692.<br />
7. Barnes SA, Der-Avakian A,Young JW. Preclinical<br />
models to investigate mechanisms of negative<br />
symptoms in schizophrenia. Schizophrenia<br />
Bulletin 2017; 43(4): 706-711.<br />
8. Buchanan RW. Persistent negative symptoms in<br />
schizophrenia: an overview. Schizophrenia Bulletin<br />
2007; 33(4), 1013-1022.<br />
9. Cochrane Library (2017): Music therapy for<br />
schizophrenia or schizophrenia-like disorders.<br />
Music therapy for people with schizophrenia<br />
and schizophrenia-like disorders (Review),<br />
Geretsegger M, Mössler KA, Bieleninik, Chen XJ,<br />
Heldal TO, Gold C.<br />
10. Creswell JW, Plano Clark VL. Designing and<br />
conducting mixed methods research (2nd ed.).<br />
Thousand Oaks, CA: Sage Publications, Inc. 2011<br />
11. Onwuegbuzie A, Collins K. A typology of mixed<br />
methods sampling designs in social science<br />
research. The Qualitative Report 2007; 12(2): 281-<br />
316.<br />
12. Tracy S. Qualitative quality: Eight “big tent” criteria<br />
for excellent qualitative research. Qualitative<br />
Inquiry 2010; 16(10): 837-851.<br />
13. Blanchard JJ, Cohen AS. The structure of negative<br />
symptoms within schizophrenia: implications for<br />
assessment. Schizophrenia Bulletin 2006; 32(2):<br />
238-245.<br />
14. Kay SR, Flszbein A, Opfer LA. The positive<br />
and negative syndrome scale (PANSS) for<br />
schizophrenia. Schizophrenia Bulletin 1987; 13(2):<br />
261-276.<br />
15. Braun V, Clarke V. Using thematic analysis in<br />
psychology. Qualitative Research in Psychology<br />
2006; 3(2): 77-101.<br />
16. Grbich C. Qualitative data analysis: an<br />
introduction. London: Sage.2007<br />
17. Breier A, Schreiber JL, Dyer J, Pickar D. National<br />
Institute of Mental Health longitudinal study of<br />
chronic schizophrenia: prognosis and predictors<br />
of outcome. Archives of General <strong>Psychiatry</strong> 1991;<br />
48(3): 239-246.<br />
Bruce Malcolm Muirhead obtained a Master’s degree in Music Therapy, Music Therapy Unit, University of Pretoria, Tshwane,<br />
<strong>South</strong> Africa, in 2017. Correspondence: bmmuirhead@gmail.com<br />
Andeline Dos Santos is a co-director of the Music Therapy unit at University of Pretoria, Tshwane, <strong>South</strong> Africa, and supervised<br />
Mr Muirhead’s research.<br />
Marc Roffey is a psychiatrist and holds a consultant post in Forensic <strong>Psychiatry</strong> at Valkenberg Hospital as well as being affiliated<br />
to the Department of <strong>Psychiatry</strong> and Mental Health, University of Cape Town, Cape Town, <strong>South</strong> Africa.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 17
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References:<br />
1. Javitt DC. Balancing therapeutic safety and efficacy to improve clinical and economic outcomes in schizophrenia: Exploring the treatment landscape. Am J Manag Care 2014;20:S166-S173. 2. Attard A, Olofinjana O, Cornelius V, et al. Paliperidone palmitate long-acting injection –<br />
prospective year-long follow-up of use in clinical practice. Acta Psychiatrica Scandinavica 2013:1-6. 3. Newton R, Hustig H, Lakshmana R, et al. Practical guidelines on the use of paliperidone palmitate in schizophrenia. Curr Med Res & Opin 2012;28(4):559-567.
REPORT<br />
THE US/UCT<br />
MRC UNIT<br />
ON RISK AND RESILIENCE<br />
IN MENTAL<br />
DISORDERS<br />
Nienke Pannekoek<br />
The Medical Research Council of <strong>South</strong><br />
Africa aims to improve the health and<br />
quality of life of the nation through research.<br />
The MRC has nearly 50 units; some are<br />
intramural (based at the MRC) while others are<br />
extramural (based at Universities). Given that a<br />
substantial proportion of the country’s disease<br />
burden came from mental, neurological and<br />
substance use disorders, the MRC support work<br />
devoted to these conditions. In particular, in<br />
<strong>South</strong> Africa there are 2 units with such foci, i.e.<br />
an intramural unit on substance use and related<br />
disorders, and an extramural unit focused on risk<br />
and resilience in mental disorders.<br />
The MRC Unit on Risk and Resilience in Mental<br />
Disorders is a cross-university unit at the<br />
Department of <strong>Psychiatry</strong> and Mental Health<br />
at the University of Cape Town (UCT) and the<br />
Department of <strong>Psychiatry</strong> at Stellenbosch<br />
University (SU). This unit builds on the legacy of<br />
the MRC Unit on Anxiety and Stress Disorders<br />
that was initiated at SU in 1997. The vision of the<br />
original unit was a translational one; moving from<br />
bench to bedside, and from bedside to bundu<br />
– with work including a focus<br />
on animal models of anxiety<br />
disorders, on clinical research on<br />
these conditions, and on public<br />
health aspects.<br />
The MRC Unit on Risk and<br />
Resilience in Mental Disorders<br />
which came into effect 1<br />
April 2017, headed by Profs Nienke Pannekoek<br />
Dan Stein (UCT) and Christine<br />
Lochner (SU), builds on past achievements.<br />
These include the <strong>South</strong> <strong>African</strong> Stress &<br />
Health Study (SASH), the first nationally<br />
representative study of mental disorders<br />
on the continent; work on OCD and related<br />
disorders that played an important role in<br />
providing a rationale for the new chapters in<br />
DSM-5 and ICD-11 on obsessive-compulsive<br />
and related disorders; and some of the first<br />
genetic and brain imaging studies in key areas<br />
of neuropsychiatry locally, including work on<br />
HIV/AIDS and substance use disorders. The<br />
current unit goes beyond anxiety and stress, to<br />
embrace a number of additional conditions.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 19
REPORT<br />
RISK AND RESILIENCE<br />
Going forwards, it is the mission of the MRC Unit<br />
on Risk and Resilience in Mental Disorders to<br />
undertake research that encompasses two interlinked<br />
areas:<br />
a) PROMOTING CLINICAL RESEARCH AND<br />
THE TRANSLATION OF BASIC SCIENCE INTO<br />
CLINICAL RESEARCH, TO IMPROVE DIAGNOSIS,<br />
PREVENTION AND MANAGEMENT OF MENTAL<br />
DISORDERS IN SOUTH AFRICA WITH A FOCUS<br />
ON RISK AND RESILIENCE FACTORS, AS THEY<br />
APPLY TO KEY CONDITIONS IN THE LOCAL<br />
CONTEXT.<br />
b) TRANSLATING CLINICAL EVIDENCE INTO<br />
POPULATION-LEVEL INTERVENTIONS TO<br />
IMPROVE MENTAL HEALTH THROUGH PRIMARY<br />
HEALTH CARE AND COMMUNITY INITIATIVES<br />
THAT CAN BE APPLIED IN DIVERSE SETTINGS<br />
ACROSS THE COUNTRY AND THE CONTINENT,<br />
WITH A FOCUS ON PRIORITY ILLNESSES GIVEN<br />
THE LOCAL BURDEN OF DISEASE.<br />
In their commitment to fulfilling this mission,<br />
researchers at the unit collaborate with researchers<br />
around <strong>South</strong> Africa, Africa, and the world on<br />
a number of projects. For example, ENIGMA is<br />
a worldwide network that aims to understand<br />
brain structure and function in neuropsychiatric<br />
disorders, using various neuroimaging<br />
modalities as well as genetic information. The<br />
Drakenstein Child Health Study follows motherchild<br />
pairs from pregnancy, and aims to map<br />
potential risk factors that impact child health.<br />
NeuroGAP (Neuropsychiatric Genetics in <strong>African</strong><br />
Populations), investigates psychosis across<br />
several <strong>African</strong> countries. Under the umbrella<br />
COMPIMP (compulsivity/impulsivity), the unit<br />
has ongoing studies on obsessive-compulsive<br />
disorder (OCD), trichotillomania (TTM; hairpulling<br />
disorder), Parkinson’s Disease, gambling<br />
disorder, and methamphetamine abuse disorder,<br />
aiming to shed light on compulsivity-impulsivity<br />
phenotypes that cut across traditional diagnostic<br />
categories. In addition, the unit is part of a global<br />
collaboration on university student health and<br />
wellness, utilizing e-surveys to identify students at<br />
risk of disorders and dysfunctional behaviours.<br />
The unit continues to welcome referral of patients<br />
suffering from anxiety and related disorders, as<br />
such individuals may be eligible for genetic and<br />
other studies. OCD and TTM patients receive a<br />
comprehensive evaluation at the unit, and can<br />
participate in a number of different studies. The<br />
unit is one of the sites of the first international<br />
NIH-funded project aimed at identifying brain<br />
signatures of OCD using standardized methods<br />
across the world. Similarly, the unit collaborates<br />
with sites abroad on clinical, genetic and brain<br />
imaging underpinnings of TTM, again using<br />
standardized methods.<br />
THE UNIT ALSO CONTINUES TO<br />
PUT SIGNIFICANT EFFORT INTO<br />
MENTORSHIP AND TRAINING. SEVERAL<br />
POSTGRADUATE STUDENTS AND<br />
POSTDOCTORAL FELLOWS ARE BEING<br />
TRAINED ON THE UNIT, AND MANY<br />
HAVE BECOME NATIONAL AND<br />
INTERNATIONAL LEADERS IN THEIR<br />
RESPECTIVE FIELDS OF INTEREST.<br />
STEIN AND LOCHNER EMPHASIZE<br />
THAT SUCH STUDENTS ARE THE<br />
DRIVING FORCE OF SCIENCE, AND<br />
THEY ARE ALWAYS ON THE LOOK-OUT<br />
FOR YOUNG SCIENTISTS WHO ARE<br />
INTERESTED IN THE NEUROSCIENCE OF<br />
MENTAL DISORDERS, AS WELL AS FOR<br />
CLINICIANS WHO ARE INTERESTED IN<br />
CAREERS AS CLINICIAN-SCIENTISTS.<br />
Stein and his team are thankful to the MRC for<br />
the resources that the unit has provided them,<br />
and remain passionate about the possibilities<br />
for future work in psychiatry and clinical<br />
psychology. They are always open to referral of<br />
individuals suffering from anxiety and related<br />
disorders, who may be eligible for one of the<br />
unit’s studies.<br />
Justine Nienke Pannekoek (PhD) is a Research Fellow, SU/UCT MRC Unit on Risk & Resilience in Mental Disorders, Stellenbosch<br />
University/University of Cape Town Brain-Behaviour Unit, Department of <strong>Psychiatry</strong> and Mental Health, University of Cape<br />
Town, Western Cape, <strong>South</strong> Africa. She is currently working on various neuroimaging projects involving vulnerable adult<br />
and child patient groups, varying from methamphetamine use to obsessive-compulsive disorder, and Parkinson’s Disease.<br />
Correspondence: nienke@sun.ac.za<br />
20 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
WPA NEWS<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 21
REPORT<br />
THE 4TH BIENNIAL<br />
NATIONAL FORENSIC<br />
MENTAL HEALTH<br />
SERVICE (FMHS)<br />
CONFERENCE<br />
(5 th - 6 th OCTOBER 2017)<br />
Sean Kaliski<br />
In 2009, when the first conference was held,<br />
forensic psychiatry was not a registrable subspecialty<br />
and the number of practitioners solely<br />
dedicated to the discipline was small. At the 4 th<br />
conference, held at Valkenberg hospital on 5 th - 6 th<br />
October 2017, we could congratulate ourselves on<br />
having at least 20 psychiatrists now registered as<br />
forensic psychiatrists with the HPCSA. The week after<br />
the conference the College of <strong>Psychiatry</strong> graduated<br />
the first psychiatrist (and Wits standard bearer),<br />
Dr. Cassimjee, with the new Certificate in Forensic<br />
<strong>Psychiatry</strong>. The next stage obviously is to establish<br />
similar sub-specialty registrations for psychologists,<br />
occupational therapists, social workers and nursing.<br />
The heartening consequence of this progress has<br />
been the impressive depth and variety of research<br />
and expertise that were displayed by members of<br />
multidisciplinary teams around the country during<br />
a full 2 days. Some commented that there is now so<br />
much activity and interest among all mental health<br />
colleagues that the conference in future could be<br />
held over several days.<br />
The talks were clustered into themes. There were<br />
sessions on Human Rights, Women & Children,<br />
Rehabilitation, Novel Therapeutic Interventions,<br />
Fitness to Stand Trial, Sex offending and Interesting<br />
case presentations. Dr. Liza<br />
Grobler, a criminologist with the<br />
Department of Correctional<br />
Services, opened proceedings<br />
with a fascinating narrative of how<br />
prison gangs are structured and<br />
function. Even those who have<br />
been in the field (sometimes known<br />
as the coalface) for decades<br />
Sean Kaliski<br />
were astonished at the complexity<br />
of their organisation, although<br />
apparently in recent years new recruits have diluted<br />
their strict discipline and secret codes. Sean Kaliski<br />
attempted to convince all that the forensic mental<br />
health service structurally abuses the rights of those<br />
referred for observation and state patients, and<br />
complained that no one seems to care. Seems he<br />
was wrong as a task team has now been formed by<br />
the Department of Justice to study these issues.<br />
Not enough attention has been focussed on female<br />
offenders. Mo Nagdee reported on his multisite<br />
national survey of offenders who had been referred<br />
for a 30-day observation. He noted that although<br />
women comprise about 3% of inmates they are<br />
increasingly being convicted for serious violent<br />
offences (usually against people they know). Almost<br />
22 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
REPORT<br />
Some delegates were intrigued by the straitjacket they found in<br />
a restored padded cell in the Valkenberg hospital museum<br />
half suffer from either a psychotic or mood disorder.<br />
Filicide is a leading cause of death of children,<br />
although the incidence seems to be declining in<br />
developed countries. Ugash Subramaney noted that<br />
there are no overriding theories or classifications to<br />
explain why parents kill their children. Nevertheless,<br />
she emphasised that most filicidal parents<br />
had psychiatric and psychological problems<br />
beforehand. Amanda Edge described the Graphic<br />
Family Sculpting programme at Sterkfontein hospital<br />
that aims to overcome obstacles that state patients<br />
often experience in re-engaging with their families.<br />
WHILE THEY ARE INPATIENTS THEIR<br />
YOUNG CHILDREN CANNOT VISIT FREELY<br />
AND THERE ARE FEW FRIENDLY SPACES<br />
TO ACCOMMODATE FAMILIES WHEN<br />
THEY DO VISIT. STERKFONTEIN HOSPITAL<br />
IS PROBABLY THE ONLY PSYCHIATRIC<br />
HOSPITAL THAT HAS A UNIT DEDICATED TO<br />
CONDUCT ASSESSMENTS OF CHILDREN<br />
BETWEEN THE AGES OF 10 AND 14<br />
YEARS THAT ARE REFERRED UNDER<br />
THE CHILD JUSTICE ACT. INCREASING<br />
NUMBERS OF CHILDREN ARE BEING<br />
CHARGED WITH OFFENCES, WHICH ARE<br />
OFTEN VIOLENT. NICOLE RAUTENBACH<br />
AND BARRY VILJOEN OUTLINED<br />
THE PANOPLY OF DIFFICULTIES THAT<br />
CONFRONT THEM WHEN CONDUCTING<br />
THESE ASSESSMENTS. THESE RANGE<br />
FROM GEOGRAPHICAL (CASES ARE<br />
BROUGHT FROM FAR AWAY AND<br />
CANNOT BE ADMITTED), LANGUAGE<br />
DIFFICULTIES, RECALCITRANT FAMILIES<br />
AND THE FREQUENT INACCESSIBILITY OF<br />
COLLATERAL INFORMATION. APPARENTLY<br />
CHANGES TO THE LEGISLATION ARE<br />
ENVISAGED BUT THEY WERE UNCERTAIN<br />
WHETHER THEIR ASSESSMENTS ARE<br />
ADDRESSING LEGAL REQUIREMENTS.<br />
Rehabilitation of forensic patients has generally<br />
been almost indistinguishable from traditional<br />
long term chronic care. The re-integration into the<br />
community of forensic patients who are doubly<br />
stigmatised, firstly because of their mental illness<br />
and secondly because of their criminality, identifies<br />
them as a group with special needs. Among the<br />
many considerations that must be addressed<br />
their risk assessment for violence, ability to work<br />
and placement in the community are among the<br />
most important. Virtually no FMHS in SA routinely<br />
performs formal risk assessments, and there are<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 23
REPORT<br />
THE 4TH BIENNIAL NATIONAL FORENSIC MENTAL HEALTH<br />
SERVICE (FMHS) CONFERENCE (5 th - 6 th OCTOBER 2017)<br />
Many forensic patients respond well to non-verbal therapies.<br />
Every forensic unit has an active occupational therapy<br />
service and also offers art therapy. A music therapy<br />
graduate student from the University of Pretoria, Bruce<br />
Muirhead, presented the findings of a study he conducted<br />
with Marc Roffey in which they conducted 8 music therapy<br />
sessions with forensic patients. Although their sample was<br />
small and the intervention too brief they demonstrated that<br />
after the course patients’ negative symptoms showed some<br />
improvement. It is hoped that this treatment modality can<br />
be used routinely. Similarly, under the aegis of Equinox, Marc<br />
Roffey, Nafisa Abdullah and Rowdah Hawtrey introduced<br />
a novel use of Equine Assisted therapy. Horses apparently<br />
are exquisitely sensitive to human behaviour and provide<br />
direct honest feedback to patients who interact with them.<br />
Many patients were able to display affection to and enjoyed<br />
easier verbal communication with horses. This led some to<br />
speculate whether the head of the unit should also be a<br />
horse. Or at least behave like one.<br />
Dr. Nyameka Dyakalashe, UCT<br />
few tools available that specifically can monitor<br />
the progress of high risk state patients as they<br />
traverse through the service. Tania Swart presented<br />
the findings from her PhD, which confirmed that<br />
the stronger the therapeutic alliance between<br />
patients and the multidisciplinary team the<br />
less likely they were to have acted violently in<br />
the preceding year. Therefore it is possible that<br />
measuring the quality of the therapeutic alliance<br />
may be a reasonable surrogate measure of risk.<br />
Theoca Moodley & Nafisa Abdullah reported on<br />
their ongoing programmes of supported learning<br />
and supported employment. Most forensic<br />
patients lack important basic work skills, and even<br />
when they find employment, need occupational<br />
therapists to interact with their employers and<br />
to provide them with ongoing support. In the<br />
Cape there are people who provide board and<br />
lodging for groups of forensic patients under the<br />
supervision of the hospital social workers. They are<br />
called Rose Parents. Kay Cikiswa presented on<br />
the planning at Alexandra Hospital to recruit Rose<br />
Parents for their learning disabled residents.<br />
THE CRIMINAL PROCEDURE ACT IS<br />
UNDERGOING CHANGES. ADV CARINE<br />
TEUNISSEN FROM THE DPP OUTLINED THE<br />
CHANGES TO SECTIONS 77 & 78, UNDER<br />
WHICH COURTS HAVE NOW BEEN GRANTED<br />
DISCRETION CONCERNING THE REFERRAL<br />
OF THOSE WHO ARE UNFIT TO STAND TRIAL<br />
BUT WOULD NOT BE WELL SERVED BY BEING<br />
DECLARED STATE PATIENTS. THESE PROVISIONS<br />
ARE ESPECIALLY AIMED AT ASSISTING THOSE<br />
WHO ARE JUVENILES OR LEARNING DISABLED.<br />
OBSOLETE TERMINOLOGY WAS REPLACED,<br />
SUCH AS “INTELLECTUAL DISABILITY” FOR<br />
THE ARCHAIC “MENTAL DEFECT”. THERE IS<br />
NO LONGER A REQUIREMENT TO APPOINT A<br />
PSYCHIATRIST NOT IN STATE EMPLOY TO PANELS.<br />
THIS WILL LIGHTEN THE BURDEN IN PLACES<br />
WHERE THERE IS A DEARTH OF PSYCHIATRISTS. A<br />
3RD PSYCHIATRIST CAN ONLY BE APPOINTED ON<br />
BEHALF OF THE ACCUSED IF GOOD CAUSE CAN<br />
BE ADVANCED. THANKFULLY PSYCHOLOGISTS<br />
CAN STILL BE APPOINTED TO PANELS AS THEIR<br />
CONTRIBUTIONS ARE VALUABLE. CANDICE<br />
JACOBSON COMPLETED HER MMED THESIS<br />
THAT AUDITED WHETHER THE FORENSIC<br />
TEAM ACTUALLY INVESTIGATES WHETHER ALL<br />
IMPORTANT ASPECTS OF COMPETENCE TO<br />
STAND TRIAL ARE CANVASSED BY THE FORENSIC<br />
24 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
REPORT<br />
UNIT DURING THE OBSERVATION PERIOD.<br />
MANY, SUCH AS THE ROLE OF COURT<br />
OFFICIALS AND WHAT THEY INTENDED<br />
TO PLEAD, WERE ALMOST ALWAYS ASKED,<br />
WHEREAS OTHERS, SUCH AS WHAT THE<br />
MEANING OF A “NOT GUILTY” OR THAT<br />
THEY WERE WARNED THAT THEY HAD THE<br />
RIGHT TO REMAIN SILENT WERE ALMOST<br />
NEVER ASKED.<br />
Another highlight was Eddie Pak’s presentation<br />
on mental illness and the SA civil aviation industry.<br />
Designated Aviation Medical Examiners (DAMES)<br />
assess pilots for fitness to fly for the Aeromedical<br />
committee. He reassured the audience that the<br />
odds of dying in an aircrash are 1:11 million (but<br />
100% if you are in a crash). Although neurological<br />
and cardiovascular illnesses remain the most<br />
important causes of unfitness, psychiatric disorders<br />
are increasingly the leading cause. In 2013 a “Mood<br />
Disorder Protocol” was published in which strict<br />
guidelines stated which and how many drugs a<br />
pilot could be prescribed. Pilots who are psychotic,<br />
severely depressed, need ECT, are on more than<br />
one antidepressant or other psychotropics are<br />
not allowed to fly. A pilot may not fly if he/she has<br />
consumed alcohol less than determined hours<br />
before reporting for duty. A pity that the same rules<br />
do not apply to leaders of countries.<br />
Our forensic units are awash with sexual offenders,<br />
yet we generally pretend they are like the others and<br />
do not need special attention. Nyameka Dyakalashe<br />
presented data noting that 40% of women report<br />
having been sexually assaulted at least once. Less<br />
than 25% of rapes are estimated to be reported, and<br />
of these only 14% result in convictions. Between 1979<br />
and 2015 117 defendants were certified as state<br />
patients following charges of rape. She pointed out<br />
that some DSM diagnoses, such as paedophilia,<br />
are regarded as criminal, whereas many others<br />
are regarded merely as disorders. Funeka Sokudela<br />
concluded the session by discussing the common<br />
breaches of human rights surrounding the rights<br />
of those charged with sexual offences, especially if<br />
mentally ill. These included the conditions in prisons,<br />
the attitudes of officials and court procedures.<br />
The conference ended with two case presentations.<br />
Claudia de Clercq presented a case of<br />
psychogenic catatonia that highlighted the<br />
difficulties in distinguishing between factitious and<br />
real disorders in forensic settings, especially when<br />
there is some urgency to provide timeous opinions<br />
to the courts. Marc Roffey similarly presented a case<br />
of pseudologica fantastica in which grandiose<br />
tall stories could easily have been confused with<br />
delusions.<br />
Every biennial conference has been supported by<br />
Sanofi, whose representative, Greg Sinovich, has had<br />
a long dedicated association with our service, and<br />
has indicated that they would like us to hold this<br />
event more often...<br />
THE NEXT CONFERENCE SHOULD<br />
BE SOMETIME IN 2019. SEE YOU<br />
THERE!<br />
Sean Kaliski is a Forensic Psychiatrist at Valkenberg Hospital, Cape Town and an Associate Professor in the Department of<br />
<strong>Psychiatry</strong> and Mental Health, University of Cape Town, Cape Town, <strong>South</strong> Africa. Correspondence: sean.kaliski@uct.ac.za<br />
The Sterkfontein Team<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 25
GMHPN NEWS<br />
26 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * Full text is available at www.globalmentalhealth.org
REPORT<br />
CAN TRANSCRANIAL<br />
MAGNETIC<br />
STIMULATION<br />
BE USED TO TREAT<br />
MENTAL ILLNESS?<br />
Tanya Calvey<br />
Dr. David Pitcher (lecturer and neuroscientist<br />
at the Department of Psychology, University<br />
of York) presented a seminar on the topic:<br />
‘Can Transcranial Magnetic Stimulation be<br />
used to Treat Mental Illness?’ The event, organised<br />
by the Wits Cortex Club, was held on Monday, 4<br />
December 2017, at the Adler Museum of Medicine,<br />
Wits Medical School. The event was well attended<br />
by psychiatrists, neuropsychologists, neuroscientists,<br />
epidemiologists and students of medicine, science<br />
and the humanities.<br />
SUMMARY OF THE SEMINAR:<br />
Transcranial magnetic stimulation (TMS) is a noninvasive<br />
neuro-stimulation technique using a<br />
magnetic coil to create an intracranial electrical<br />
field. The electrical field induces local depolarization<br />
of the neurons leading to measurable changes in<br />
the local macroscopic neuronal activity, blood flow<br />
and metabolism which leads to changes in function<br />
and ultimately, behaviour. TMS can, therefore,<br />
modulate human brain activity and is widely used<br />
in psychology and neuroscience departments<br />
around the world to study basic cognitive and motor<br />
functions.<br />
Since the late 1990s there has been growing<br />
interest in using TMS as a treatment for a variety of<br />
different mental health disorders. This interest was<br />
significantly strengthened in 2008 when the US<br />
Federal Drug Administration (FDA) approved TMS<br />
as a treatment for depression. TMS is also approved<br />
as a treatment for depression in Canada, Germany,<br />
Japan, Australia and the United Kingdom. Following<br />
clinical trials and research, the current scientific<br />
and clinical consensus is that repetitive TMS (rTMS)<br />
is a safe, effective treatment for major depression.<br />
rTMS over the pre-frontal cortex results in significant<br />
improvements in symptom scores measured by<br />
the Montgomery-Asberg Depression Rating Scale<br />
(MADRS), the Beck Depression Inventory (BDI) and<br />
the Hamilton Depression Rating Scale (HAM-D)<br />
in drug-resistant depression with effect sizes and<br />
numbers needed to treat (NNT) similar to antidepressant<br />
medications and cognitive behavioural<br />
therapy (CBT). rTMS also results in a significant<br />
increase in remission rates after 6 weeks of treatment.<br />
Recent improvement to the method (theta-burst<br />
stimulation, TBS) further improves the efficacy by<br />
improving symptoms in patients non-responsive to<br />
10Hz TMS. Recent research has shown that TMS to the<br />
pre-frontal cortex might also be effective in treating<br />
substance use disorder (SUD) but further research<br />
needs to be conducted to verify these findings.<br />
THE EFFICACY OF TMS IN TREATING<br />
DEPRESSION AND POSSIBLY SUD<br />
LIES, PARTLY, IN ITS ABILITY TO ALTER<br />
CONNECTIVITY BETWEEN THE PRE-<br />
FRONTAL CORTEX AND SUBCORTICAL<br />
REGIONS. THIS ASPECT OF TMS HAS<br />
EXCITING POSSIBILITIES FOR RESEARCH<br />
INTO BRAIN CONNECTIVITY AS THE<br />
STIMULATION CAN EITHER INCREASE<br />
OR DECREASE CONNECTIVITY WITH THE<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 27
REPORT<br />
UNDERLYING STRUCTURES. THE CHANGES<br />
IN CONNECTIVITY ARE ASSESSED USING<br />
FUNCTIONAL MAGNETIC RESONANCE<br />
IMAGING (FMRI). THIS RESEARCH<br />
COULD UNCOVER THE SPECIFIC BRAIN<br />
CONNECTIONS IMPLICATED IN SPECIFIC<br />
MENTAL HEALTH DISORDERS AND ALSO<br />
THE CONNECTIONS IMPLICATED IN THOSE<br />
RESPONSIVE AND NONRESPONSIVE<br />
TO TREATMENT. TMS IS NOT ONLY AN<br />
EFFECTIVE TREATMENT FOR CERTAIN<br />
MENTAL HEALTH DISORDERS BUT ALSO<br />
A USEFUL RESEARCH TOOL TO UNCOVER<br />
THE UNDERLYING NEUROBIOLOGY OF<br />
THE DISORDERS.<br />
If you would like to stay up-to-date with the activities<br />
of the Wits Cortex Club, please send an email to<br />
witscortexclub@gmail.com.<br />
Dr David Pitcher and audience members<br />
Standing at the back, Dr David Pitcher. Front row, the Wits Cortex Club, from left to right: Mr Joseph Tewson (medical student, MSc neuroscience candidate), Dr Tanya<br />
Calvey (co-founder, anatomy lecturer and neuroscience researcher), Ms Victoria Williams (PhD neuroscience candidate), Ms Funiwe Mkele (BHSc student), Ms Danika<br />
McElhenny (co-founder, medical student, BSc Hons neuroscience).<br />
Tanya Calvey is a Lecturer, Anatomical Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg,<br />
<strong>South</strong> Africa. Correspondence: Tanya.Calvey@wits.ac.za; Website: www.wits.ac.za/anatomicalsciences<br />
28 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
Don’t miss AfCNP <strong>2018</strong><br />
4 th <strong>African</strong> College of Neuropsychopharmacology Congress<br />
www.afcnp<strong>2018</strong>.com<br />
The smart choice for all your ECT needs<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 29
REPORT<br />
SASOP PARTICIPATES<br />
IN THE PUBLIC DEBATE<br />
ON HEALTHCARE<br />
WORKER ADVOCACY<br />
Mvuyiso Talatala, Lesley Robertson<br />
The <strong>South</strong> <strong>African</strong> Society of Psychiatrists<br />
(SASOP) represented by Dr Mvuyiso Talatala,<br />
Past President of SASOP, and Dr Lesley<br />
Robertson, Pubsec Convener, participated<br />
in a public debate hosted by Rural Health<br />
Advocacy Project (RHAP), Section 27 and Wits<br />
School of Public Health on the 22 November 2017.<br />
The public debate was titled, “Raising alarm and<br />
being heard. What is the change we need to<br />
promote and support Healthcare Worker (HCW)<br />
Advocacy?”<br />
THE DEBATE WAS HELD AT THE WITS<br />
SCHOOL OF PUBLIC HEALTH AND<br />
PROVED TO BE A VERY INTERACTIVE<br />
FORUM WITH A PRIMARY FOCUS ON<br />
HCW ADVOCACY FOLLOWING THE LIFE<br />
ESIDIMENI TRAGEDY WHERE OVER 141<br />
MENTALLY ILL PATIENTS DIED IN GAUTENG<br />
PROVINCE AFTER THE CLOSURE OF LIFE<br />
ESIDIMENI FACILITIES. THE DEBATE TOOK<br />
NOTE THAT THERE ARE OTHER EVENTS<br />
LIKE THE LIFE ESIDIMENI TRAGEDY THAT<br />
ARE HAPPENING IN THE COUNTRY<br />
AND HEALTHCARE WORKERS NEED TO<br />
BE STRENGTHENED IN THEIR DUTY OF<br />
ADVOCACY. DURING THE TERMINATION<br />
OF THE LIFE ESIDIMENI CONTRACT AND<br />
THE SUBSEQUENT CLOSURE OF THE<br />
LIFE ESIDIMENI FACILITIES, HEALTHCARE<br />
WORKERS (HCWS) WERE IGNORED IN<br />
THEIR ATTEMPT TO WARN GOVERNMENT<br />
OF THE CONSEQUENCES OF RAPIDLY<br />
MOVING THE SEVERELY MENTALLY ILL<br />
PATIENTS TO FACILITIES THAT WOULD<br />
OFFER INFERIOR CARE.<br />
Other members of the panel were Mr Anele<br />
Yawa from the Treatment Action Campaign<br />
(TAC); Ms Tendai Mafuma from Section 27, Ms<br />
Shelly Wilsnach, an Occupational Students’<br />
Representative and Prof Letitia Rispel from the<br />
Wits School of Public Health. Ms Marije Versteeg-<br />
Mojanaga, Director of RHAP, welcomed everyone<br />
and opened the debate. She spoke of the need<br />
for HCWs to overcome intimidation by senior<br />
health care staff, management and political<br />
structures to advocate for their patients and<br />
contribute to an improved health care system.<br />
She explained how The Voice Project, established<br />
by RHAP in partnership with Section 27, Médecins<br />
Sans Frontières and various <strong>South</strong> <strong>African</strong> clinical<br />
Mvuyiso Talatala<br />
30 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
REPORT<br />
associations, hoped to equip HCWs in providing<br />
more effective advocacy through such debates<br />
and more structured training workshops.<br />
DR TALATALA GAVE A THOROUGH REVIEW OF<br />
ACTIONS TAKEN BY SASOP AND HCWS IN<br />
ORDER TO PREVENT THE LIFE ESIDIMENI<br />
TRAGEDY. THESE INCLUDED LETTERS<br />
WRITTEN TO THE GAUTENG DEPARTMENT<br />
OF HEALTH BY SASOP AND CLINICIANS<br />
IN GAUTENG, SEVERAL MEETINGS HELD<br />
WITH THE GAUTENG DEPARTMENT OF<br />
HEALTH AS WELL AS SEVERAL LITIGATION<br />
STEPS TAKEN BY SASOP TOGETHER WITH<br />
THE SOUTH AFRICAN DEPRESSION AND<br />
ANXIETY GROUP, SECTION 27, SOUTH<br />
AFRICAN MENTAL HEALTH FEDERATION<br />
AND PATIENTS’ FAMILIES. MEDIA<br />
ENGAGEMENT WAS ANOTHER TOOL<br />
USED BY SASOP WITH ITS PARTNERS.<br />
DR ROBERTSON, REFLECTING ON<br />
WHAT HCWS HAVE LEARNT ABOUT<br />
HCW ADVOCACY FROM THE LIFE<br />
ESIDIMENI TRAGEDY, DESCRIBED HER<br />
PERSONAL JOURNEY ON ADVOCACY<br />
BOTH IN THE PRE- AND POST-1994 ERA.<br />
SHE HIGHLIGHTED THE NEED FOR THE<br />
HCWS TO OWN THE PROBLEMS OF<br />
OUR COUNTRY AND THE HEALTHCARE<br />
AGENDA, THEN ADVOCACY FOLLOWS<br />
INSTINCTIVELY. IT WAS OBVIOUS IN THIS<br />
DEBATE THAT HCWS NEED TO ACTIVELY<br />
ENGAGE WITH HEALTHCARE ADVOCACY<br />
AND THEY NEED TO BE REMINDED OF<br />
THEIR ETHICAL RESPONSIBILITIES. MR<br />
ANELE YAWA REMINDED PARTICIPANTS<br />
THAT HEALTHCARE IS A POLITICAL ISSUE<br />
THAT NEEDS POLITICAL INTERVENTIONS.<br />
HCWS CANNOT DISTANCE THEMSELVES<br />
FROM ADVOCACY AS WELL AS ANY STEP<br />
THAT WILL IMPROVE THE HEALTHCARE<br />
SYSTEM.<br />
Other speakers and the audience made very<br />
critical contributions. Ms Tendai Mafuma, the<br />
Legal Researcher of Section 27, brought an<br />
interesting argument in which she disputed the<br />
existence of Dual Loyalty in the post 1994 period.<br />
Dual Loyalty is the situation in which HCWs feel<br />
conflicted between the need to provide treatment<br />
to a patient as expected and guided by their<br />
ethics and the need to satisfy the needs of the<br />
administrator or funder such as government.<br />
This conflict must have been experienced by the<br />
HCWs of Life Esidimeni who had to discharge<br />
patients to inferior conditions because the<br />
government demanded so. Ms Mafuma argued<br />
that all HCWs and the government itself must own<br />
one allegiance and that is to the Constitution of<br />
the Republic of <strong>South</strong> Africa. If all <strong>South</strong> <strong>African</strong>s<br />
appreciate that they live in a Constitutional<br />
democracy under the prescriptions of the<br />
Constitution they will not feel conflicted as their<br />
loyalty should be to the Constitution.<br />
That all HCWs can be patient advocates was<br />
made real in Ms Shelley Wilsnach’s testimony. She<br />
described an incident in which she and a fellow<br />
occupational therapy student felt it necessary to<br />
confront a senior medical officer in a case where<br />
they felt a hand injury had been neglected. The<br />
difficulty in confronting seniority and gender<br />
roles was illustrated clearly in this incident. This<br />
theme was continued by Prof Rispel, who referred<br />
to the Lourdes hospital enquiry in Ireland. The<br />
enquiry was of unnecessary hysterectomies<br />
and oophorectomies performed by a male<br />
obstetrician in the 1980s and ‘90s until finally a<br />
group of midwives drew attention to the unethical<br />
practice. A central question of the investigation<br />
was “Why did it take so long for someone to say<br />
‘STOP!’?”<br />
Panel Discussion (Lesley Robertson holding the microphone)<br />
Mvuyiso Talatala is a psychiatrist in private practice, Dr SK Matseke Memorial Hospital, Soweto, as well as an honorary lecturer<br />
in the Department of <strong>Psychiatry</strong>, University of the Witwatersrand, Johannesburg, <strong>South</strong> Africa, He is also the immediate past<br />
president, <strong>South</strong> <strong>African</strong> Society of Psychiatrists. Correspondence: mvuyiso@talatala.co.za<br />
Lesley Robertson is a psychiatrist working in the Sedibeng District as well as a lecturer in the Department of <strong>Psychiatry</strong>, University<br />
of the Witwatersrand, Johannesburg, <strong>South</strong> Africa. She is also the Convenor of the Public-Sector Psychiatrists, <strong>South</strong> <strong>African</strong><br />
Society of Psychiatrists.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 31
REPORT<br />
LEADING<br />
PSYCHOLOGISTS<br />
FROM AFRICA<br />
CONGREGATE IN<br />
DURBAN FOR<br />
FIRST-EVER<br />
PAN-AFRICAN<br />
PSYCHOLOGY<br />
CONGRESS<br />
Sumaya Laher<br />
The Pan-<strong>African</strong> Psychology Union (PAPU) and<br />
the Psychological Society of <strong>South</strong> Africa<br />
(PsySSA) hosted the first-ever continental<br />
Psychology Congress from 18 th to 21 st<br />
September 2017 at the International Convention<br />
Centre in Durban, <strong>South</strong> Africa.<br />
PAPU2017 represented a historic moment in which<br />
local, regional and international collaborations<br />
set the scene for a more responsive Psychology<br />
that speaks to issues of social justice and equity.<br />
The comprehensive congress programme<br />
included a wide range of scholarly and practiceoriented<br />
presentations. The programme included<br />
over 60 keynote presentations and 50 symposia<br />
by leading <strong>African</strong> and international scholars,<br />
pre-congress workshops, and several hundred<br />
paper and poster presentations (see http://<br />
papu2017.com/programme/). These addressed<br />
key focal areas within the broad discipline of<br />
psychology, including <strong>African</strong> psychologies,<br />
human rights, public health, gender and sexuality,<br />
and violence. The congress abstract book may be<br />
accessed at http://papu2017.com/wp-content/<br />
uploads/2017/10/PAPU-Durban-abstracts-21-<br />
September-2017.pdf. The congress chair, Prof<br />
Anthony Pillay commented: “This gathering<br />
of psychology scholars and practitioners is<br />
particularly significant given colonial histories in<br />
Africa. It is for this reason that the decolonisation<br />
of psychology and knowledge production feature<br />
prominently in the congress programme and<br />
offer exciting opportunities for critical discussion,<br />
interrogation and debate.”<br />
Members of the PAPU Executive - representing<br />
psychological associations in Ghana, Botswana,<br />
32 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
REPORT<br />
Cameroon, Zimbabwe, Nigeria, <strong>South</strong> Africa<br />
and Ethiopia – participated in deliberations<br />
at the congress. They were joined by leaders<br />
of the American Psychological Association,<br />
the Association of Black Psychologists, the<br />
International Union of Psychological Science, the<br />
International Association of Applied Psychology,<br />
the International Test Commission, the British<br />
Psychological Society, the Forum for <strong>African</strong><br />
Psychology together with Chinese, Russian and<br />
other Psychological Associations in Africa and<br />
others further afield. SADAG and MHIN-Africa<br />
were also visible at the congress. Prof Saths<br />
Cooper delivered the welcome address at the<br />
congress. To view click https://www.youtube.com/<br />
watch?v=Pxqom0RkFpo<br />
SOME CONGRESS HIGHLIGHTS INCLUDED:<br />
• Psychology in meta-colonised Africa: New challenges in a new era<br />
- Prof Hussein Bulhan, President and Professor of the Frantz Fanon University, Somaliland –<br />
see https://www.youtube.com/watch?v=c7ndD-cYA78<br />
• Psychology and the public interest in Africa: Breakthroughs and setbacks<br />
- Prof Andrew Zamani, President of the Nigerian Psychological Association<br />
• Clinical supervision through a global lens<br />
- Prof Carol Falender, UCLA Department of Psychology, USA<br />
• Disability and <strong>African</strong> Psychology: Some dilemmas and an agenda for action<br />
- Prof Leslie Swartz, Distinguished Professor, Stellenbosch University, SA<br />
• Potential for psychology to improve the lives of <strong>African</strong>s and what needs to be done<br />
- Dr Yogan Pillay, Deputy Director-General, National Department of Health, SA<br />
• Collaboration between Western trained medical practitioners and traditional healers<br />
- Prof Tholeni Sodi, President – PsySSA, HOD – Psychology, University of Limpopo, SA<br />
• Early intervention in psychosis in Africa: Time to implement early intervention services<br />
- Prof Bonginkosi Chiliza, HOD – Dept of <strong>Psychiatry</strong>, University of Kwazulu-Natal, SA<br />
• Competency to testify and the intellectually disabled rape survivor<br />
- Prof Anthony Pillay, Nelson Mandela School of Medicine, University of Kwazulu-Natal, SA<br />
• Treatment of Post-Traumatic Stress Disorder: Where do we currently stand?<br />
- Prof Soraya Seedat, HOD - Dept of <strong>Psychiatry</strong>, University of Stellenbosch, SA<br />
PAPU Congress highlights are available at:<br />
https://www.youtube.com/watch?v=C2agtCN_9Ks<br />
In a province that predates written history, PAPU offered an opportunity to draw on knowledge systems and ideas<br />
from the often-marginalized communities of Psychology practice, to engage in deliberation and dialogue to<br />
create a Psychology for all. The ancestors of the KZN region would often say, ‘The bones must be thrown in three<br />
different places before the message must be accepted.’ PAPU2017 certainly lived up to this with the diversity of<br />
discussion in every session.<br />
About PAPU and PsySSA:<br />
• PAPU is the representative body for the science and profession of psychology in Africa. Its mission is to be a<br />
collaborative union of psychological societies and psychologists in Africa committed to scholarship and<br />
human development in our communities, countries, Africa and the World.<br />
• PsySSA, formed in 1994, is Africa’s largest scientific and professional psychology organisation and is the<br />
representative body of the profession in <strong>South</strong> Africa.<br />
• For more on the Congress visit https://www.youtube.com/watch?v=BDXSi1iP6tc&feature=youtu.be<br />
• Download the full Congress programme at http://papu2017.com/programme/<br />
Sumaya Laher is an Associate Professor – Psychology School of Human & Community Development, University of the Witwatersrand,<br />
Johannesburg, <strong>South</strong> Africa and Past President, Psychological Society of <strong>South</strong> Africa Correspondence: sumaya.laher@wits.ac.za<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 33
NEWS PMHP<br />
Dear colleagues, supporters, partners<br />
and friends of PMHP<br />
2017 has mostly been a successful year for the<br />
PMHP with some major achievements. We have<br />
seen our strategic model realised in concrete<br />
terms in many of the arenas where we work: we<br />
identify key service gaps - conduct research<br />
- develop policy - support the widespread<br />
implementation by others.<br />
THE GOOD: A HIGHLIGHT<br />
A highlight has been the recent agreement by<br />
the DoH’s National Committee for the Confidential<br />
Enquiries into Maternal Deaths to mandate<br />
mental health screening as part of routine<br />
maternity care, where referral resources are<br />
available. PMHP has been invited to write a new<br />
chapter for the National Guidelines: Maternity<br />
Care in <strong>South</strong> Africa in which our validated, ultrashort<br />
screening tool will be incorporated. This<br />
represents a fitting example of the success of the<br />
PMHP strategic model<br />
THE SAD: DECLINE IN FUNDING<br />
Significant funding constraints have required that<br />
we make several critical changes. There will be a<br />
shift away from providing direct services that do<br />
not allow full cost recovery. It is thus, with enormous<br />
regret that we will be closing our Mowbray<br />
Maternity Hospital and False Bay Hospital service<br />
sites, which we hope will be absorbed by the<br />
DoH. We have been motivating strongly for this<br />
to occur over many years. Several of our beloved<br />
staff will be retrenched, some of whom will be reemployed<br />
on a consultancy basis, according to<br />
the specifications of particular income streams.<br />
While some income sources have been confirmed<br />
in the past few months, others are pending in early<br />
<strong>2018</strong> and more will be applied for throughout the<br />
year. Donations are welcome and the details for<br />
donations are at the end of this article.<br />
THE WAY FORWARD<br />
We have reflected very seriously on the structure<br />
and sustainability of the PMHP. Over several<br />
months, we undertook a series of consultations<br />
with our board, academic and DoH colleagues,<br />
NGO partners, our donors and with strategic<br />
consultants. We developed a range of potential<br />
scenarios for moving forward and spent much time<br />
fundraising. Although not complete, our strategy<br />
is evolving towards becoming an organisation<br />
that is based on three core elements, all of which<br />
will be supplemented by resource development:<br />
1. training and capacity building,<br />
2. advocacy and policy development<br />
3. implementation research.<br />
In order to achieve universal access to mental<br />
health care for all mothers in the first 1000 days<br />
by 2030, the PMHP will continue to work to change<br />
and build the health and social development<br />
systems in the country and beyond.<br />
With your help, we know this can be achieved.<br />
Thank you for your support.<br />
UNIVERSITY OF CAPE TOWN<br />
DONATIONS ACCOUNT<br />
Contact: Sally Field<br />
Position: Project Coordinator<br />
Tel: +27 21 689 8390<br />
Fax: +27 86 6482844<br />
Email: sally.field@uct.ac.za<br />
BANKING DETAILS:<br />
Bank: Standard Bank of <strong>South</strong> Africa Limited<br />
Account Name: UCT Donations Account<br />
Branch: Rondebosch<br />
Branch Code: 02 50 09<br />
Branch Address: Belmont Road,<br />
Rondebosch, 7700 Cape Town, Republic of<br />
<strong>South</strong> Africa<br />
Account Number: 07 152 2387<br />
Type of Account: Current<br />
Swift address: SBZAZAJJ<br />
Reference: PMHP donation – ‘your name/<br />
company’<br />
Once a deposit or electronic payment has<br />
been made, please notify UCT by email<br />
at giving@uct.ac.za explaining what the<br />
donation is for.<br />
Tax exemption: Section 18A(1)(a) of the<br />
Income Tax Act<br />
www.pmhp.za.org<br />
34 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
REPORT<br />
A WORKSHOP ON<br />
COMMUNITY-BASED<br />
PSYCHOLOGICAL<br />
FIRST AID - OVERVIEW<br />
AND REFLECTIONS<br />
Nabeelah Bemath<br />
On the 18 th September 2017, the inaugural<br />
Pan-<strong>African</strong> Psychology Union Congress<br />
hosted a pre-Congress workshop on<br />
community-based psychological first<br />
aid (CBPFA). The workshop was presented by Prof.<br />
Gerard A. Jacobs from the Disaster Mental Health<br />
Institute at the University of <strong>South</strong> Dakota.<br />
The workshop was structured into three components:<br />
an overview of CBPFA and its link to traumatic stress,<br />
community development in CBPFA, and an overview<br />
of the CBPFA training component on traumatic<br />
stress.<br />
Prof. Gerard A.<br />
Jacobs<br />
Jacobs starts with the premise that<br />
traumatic stress can negatively affect<br />
the functioning of the exposed person<br />
and indirectly affect the community<br />
they are in contact with. CBPFA teaches<br />
general community members how to<br />
provide basic psychological support<br />
to others within their community who<br />
are experiencing traumatic stress, and<br />
to manage their own stress more effectively. Far<br />
more people experience traumatic (as opposed to<br />
psychopathological) stress, and so focusing on this<br />
can help the community recover much more quickly.<br />
Hence the first component of the workshop began<br />
with Jacobs discussing the concept of traumatic<br />
stress; or normal, and not pathological, reactions<br />
to extraordinary events. In this component of the<br />
workshop, he outlined the 7 foundation principles of<br />
CBPFA, namely: 1) Non-maleficence; 2) Communitybased<br />
(design and day-to-day running); 3)<br />
Sustainable in terms of ease of operation, cost and<br />
usefulness; 4) Develop on community’s strengths;<br />
5) Use local skills and knowledge; 6) Concentrate<br />
on common reactions to extraordinary events; 7)<br />
Serve each community member who is (directly<br />
or indirectly) affected by traumatic stress (see<br />
Psychological First Aid: Clarifying the concept)<br />
JACOBS ALSO BRIEFLY DISCUSSED THE<br />
8 GENERAL COMPONENTS OF CBPFA<br />
TRAINING, NAMELY: 1) HOW TO BE A HELPER;<br />
2) TRAUMATIC STRESS; 3) THE NEED, AND<br />
SKILLS, REQUIRED FOR ACTIVE LISTENING;<br />
4) COPING AND PROBLEM-SOLVING<br />
STRATEGIES; 5) BEREAVEMENT; 6) WHEN<br />
AND HOW TO REFER TO PROFESSIONALS;<br />
6) CARING FOR ONESELF; 7) ETHICS; 8) A<br />
WRAP-UP SESSION IN WHICH AN OVERVIEW/<br />
SUMMARISATION OF THE TRAINING IS<br />
PROVIDED (SEE COMMUNITY-BASED<br />
PSYCHOLOGICAL FIRST AID: A PRACTICAL<br />
GUIDE TO HELPING INDIVIDUALS AND<br />
COMMUNITIES DURING DIFFICULT TIMES)<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 35
REPORT<br />
The second component of the workshop focused<br />
on describing the community-based nature of<br />
CBPFA. The importance of evaluating the feasibility<br />
of a CBPFA programme in a community was<br />
emphasised. He argued that the design of a CBPFA<br />
programme specifically occurs through working<br />
with a committee of members who represent all<br />
sectors of the community. This is done in order to<br />
adapt the general CBPFA programme such that it<br />
fits everyone within that community, corresponding<br />
with the community’s strengths and requirements.<br />
This leads to the community owning the programme,<br />
and being equipped to run the programme upon<br />
the professionals’ exit from the community. It was<br />
interesting to hear Jacobs’ personal experiences in<br />
implementing various adapted CBPFA programmes<br />
in various countries, and the success that these<br />
programmes have had.<br />
More information can be obtained from Jacob’s<br />
book titled ‘Community-Based Psychological First<br />
Aid: A practical guide to helping individuals and<br />
communities during difficult times’.<br />
IN THE THIRD COMPONENT OF THE<br />
WORKSHOP, ATTENDEES WERE EXPOSED<br />
TO WHAT JACOBS REFERRED TO AS THE<br />
“TWITTER VERSION” OF THE CBPFA’S<br />
TRAINING ON TRAUMATIC STRESS. THE<br />
TRAINING IN THIS COMPONENT COVERS<br />
COMMON EMOTIONAL, PHYSICAL,<br />
BEHAVIOURAL AND COGNITIVE<br />
REACTIONS TO TRAUMATIC STRESS.<br />
THIS ENABLES TRAINEES TO RECOGNISE<br />
WHAT THESE REACTIONS CAN BE.<br />
FURTHERMORE, TRAINEES ARE EDUCATED<br />
ON WHAT SYMPTOMS INDICATE THE<br />
NEED FOR PROFESSIONAL REFERRAL.<br />
TRAINEES ARE ALSO EDUCATED WITH<br />
REGARDS TO THERE BEING INDIVIDUAL<br />
DIFFERENCES IN RESPONSES TO<br />
TRAUMATIC STRESS, THE FACTORS THAT<br />
MAKE EVENTS MORE TRAUMATIC AND<br />
THOSE THAT MAKE TRAUMATIC EVENTS<br />
LESS STRESSFUL.<br />
While time constraints prevented covering the<br />
topic within the workshop, notes were provided on<br />
the active listening aspect of the CPBFA training.<br />
This focuses on exposing trainees to the skills and<br />
attitudes involved in using effective listening in<br />
order to provide others with psychological support.<br />
Jacobs at CBPFA training in Nepal, which occurred after the 2015 earthquake<br />
The workshop overall was extremely valuable.<br />
Insightful and interesting examples of the<br />
implementation of CBPFA models were highlighted,<br />
particularly in terms of how models have been<br />
adopted in different communities. The importance<br />
of using community psychology principles when<br />
entering a community to implement a CBPFA<br />
programme was also discussed and examples<br />
of CBPFA implementation in Muslim-Thailand<br />
and Native American communities were used to<br />
highlight this. However, only one example of how<br />
CBPFA has been used within the <strong>African</strong> context<br />
was provided; most examples came from North<br />
American, European or Asian contexts. It would be<br />
interesting to see if and how this model can work in<br />
different <strong>African</strong> contexts, including <strong>South</strong> Africa.<br />
The content presented in the workshop suggests<br />
that CBPFA would be valuable in the <strong>South</strong> <strong>African</strong><br />
context, particularly given the high exposure to<br />
traumatic stress, yet limited mental health care<br />
resources and personnel, in the country. The CBPFA’s<br />
sustainable nature and flexibility in being adapted<br />
for cross-cultural use further suggests that this would<br />
be a practically and ethically feasible solution to the<br />
challenges that <strong>South</strong> <strong>African</strong> mental health care<br />
professionals face in trying to address the mental<br />
health of the population. In this way, communities<br />
affected with traumatic stress can be empowered to<br />
psychosocially support themselves, decreasing their<br />
sense of fear and helplessness while promoting their<br />
mental wellbeing. Mental health care professionals<br />
should take cognisance of the potential offered by<br />
CBPFA programmes for <strong>South</strong> <strong>African</strong> communities.<br />
Nabeelah Bemath is an intern research psychologist in the Department of Psychology at the University of Witwatersrand,<br />
Johannesburg, <strong>South</strong> Africa. The details provided in relation to the components of the workshop were paraphrased from the notes<br />
provided by Jacobs during the workshop and the author’s own notes taken during the course of the workshop. Correspondence:<br />
Nabeelah.Bemath@wits.ac.za<br />
36 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 37
UPDATE<br />
THE ROLE OF<br />
MELATONIN<br />
IN TREATING<br />
I N S O M N I A<br />
Alison Bentley<br />
THE SECRETION OF MELATONIN HAS BEEN LINKED TO SLEEP FOR MANY YEARS AND IN THE CORRECT<br />
PATIENTS, ITS EXOGENOUS ADMINISTRATION CAN BE VERY USEFUL IN IMPROVING SLEEP. HOWEVER,<br />
AS THERE ARE MANY DIFFERENT CAUSES OF INSOMNIA, MELATONIN IS UNLIKELY TO BE EFFECTIVE IN<br />
ALL OF THEM.<br />
Melatonin is linked to circadian rhythms –<br />
the rest-activity patterns, which extend<br />
over 24 hours and which are common to<br />
all living things. In humans the rest period<br />
is usually at night and is associated with sleep. Restactivity<br />
cycles in humans are driven by melatonin, a<br />
hormone secreted by the pineal gland during times<br />
of darkness. During the day melatonin release is<br />
inhibited by light falling on the retina.<br />
Melatonin secretion begins in the early evening, after<br />
which the level rises significantly. Melatonin binds<br />
to M1 and M2 receptors on the suprachiasmatic<br />
nucleus in the hypothalamus. This leads to a drop<br />
in body temperature, during which the ability to fall<br />
asleep increases quite dramatically. The melatonin<br />
levels remain high for a few hours and contribute<br />
to sustained sleep during the night. A rise in body<br />
temperature in the morning, due to a reduction in<br />
melatonin, indicates the natural waking up time.<br />
Insomnia occurs when there is insufficient or poor<br />
quality sleep. People suffering from insomnia<br />
complain of one or more of the following symptoms:<br />
difficulty falling asleep, difficulty maintaining sleep<br />
and/or early morning wakening. More importantly,<br />
for insomnia to be diagnosed there needs to be a<br />
deficit in daytime functioning, with symptoms such<br />
as fatigue, poor concentration and decreased<br />
memory being linked to the lack of sleep.<br />
THERE ARE MANY CAUSES OF<br />
INSOMNIA INCLUDING:<br />
• Medical causes: Most commonly insomnia<br />
occurs in the psychiatric disorders of depression<br />
and mania. Other medical conditions that can<br />
cause insomnia include: endocrine disorders, and<br />
conditions that cause either<br />
nocturnal pain or breathing<br />
problems. Many medications<br />
such as statins, ARVs, cortisol and<br />
anti-depressants can cause<br />
sleep disruptions severe enough<br />
to cause clinical insomnia.<br />
• Environmental causes: Many<br />
people are lucky enough to be<br />
Alison Bentley<br />
able to control their sleeping<br />
environment so that it is warm, dark, quiet and<br />
safe. In situations where this is not possible,<br />
insomnia may result.<br />
• Restless legs syndrome: This neurological<br />
disorder presents with an urge to move the legs,<br />
often in relation to a strange sensation in the legs.<br />
These sensations are particularly severe in the<br />
evening, are worse with rest and can be relieved,<br />
at least temporarily, by moving. Patients struggle to<br />
fall asleep and are often only able to fall asleep in<br />
the early hours of the morning after the sensation<br />
eases. During sleep, periodic leg movements can<br />
fracture sleep, leading to a disturbance during<br />
the night. The disorder is often successfully treated<br />
with dopamine agonists.<br />
• Psychophysiological insomnia: This is the most<br />
common type of insomnia and is often triggered<br />
by an organic cause such as acute and severe<br />
stress. In this situation, insomnia is a symptom<br />
of that external stress. When the stress resolves<br />
the insomnia often also resolves. However, any<br />
concern or anxiety about not being able to<br />
fall asleep is likely to lead to a self-sustaining<br />
insomnia - the severe anxiety about falling asleep<br />
actually creates an independent insomnia<br />
disorder. Poor sleep hygiene usually ensues,<br />
including spending an increasing amount of<br />
“awake time” in bed, trying to fall asleep, in<br />
an attempt to increase the sleep opportunity.<br />
38 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
UPDATE<br />
During these prolonged attempts to fall asleep,<br />
people experience catastrophising and<br />
dysfunctional thoughts regarding sleep, which<br />
help to sustain the insomnia for many years.<br />
Cognitive behavioural therapy (CBT), which<br />
aims to improve the behaviours and thoughts<br />
relating to sleep, and thereby improving sleep<br />
itself, is the most useful treatment.<br />
• Circadian rhythm disorders: there are two<br />
main types - The first group have normal<br />
melatonin secretion and a normal length of<br />
sleep, but the timing of their sleep is out of<br />
phase with night and day. Patients present with<br />
a clear history of a good period of sleep (up<br />
to 8 hours) as long as they can sleep at the<br />
times they prefer. Examples include: delayed<br />
sleep phase syndrome, shift work and jet lag.<br />
Delayed sleep phase syndrome is most<br />
common in adolescent men. Sleep is<br />
delayed by 2-3 hours, with the earliest sleep<br />
onset time being from 12 to 2 am, and a<br />
wake up time delayed until 10 am or later.<br />
Advanced sleep phase syndrome is most<br />
common in the elderly. Sleep onset is very early<br />
in the evening and the person wakes up at 2<br />
or 3 am.<br />
The second group have abnormal or lowered<br />
melatonin secretion, which leads to disturbed<br />
sleep with difficulties in falling asleep and<br />
staying asleep. This group includes elderly<br />
people, blind people, people with Alzheimer’s<br />
disease and children with neurodevelopmental<br />
disorders such as autism spectrum disorder<br />
and ADHD.<br />
Insomnia is often considered an inconvenience<br />
rather than a medical disorder and hence no<br />
treatment is sought or offered. There is, however,<br />
good evidence that untreated insomnia increases<br />
the risk of other disorders such as anxiety, depression<br />
and cardiovascular disease such as hypertension.<br />
Poor daytime function due to fatigue, decreased<br />
concentration and poor executive functions<br />
may lead to an increased number of errors and<br />
accidents. Together with increased amounts of<br />
sick leave, these consequences of insomnia have<br />
negative economic consequences.<br />
Ageing is an important risk factor for the<br />
development of insomnia with the prevalence of<br />
poor sleep increasing from 36% in middle-aged<br />
adults to 50% in the elderly. Specific changes in the<br />
sleep stages, such as a loss of slow wave sleep, more<br />
awakenings and shorter overall length of sleep<br />
may be related to a gradual drop in the amount<br />
of melatonin produced after young adulthood. Of<br />
the people affected by insomnia, at least two thirds<br />
will be women. Women are more prone to insomnia<br />
possibly due to loss of hormones after menopause,<br />
although sleep is lighter in women even at younger<br />
ages. Patients who have insomnia request relief<br />
from their most troublesome symptoms. They may<br />
request help to reduce their sleep latency (so<br />
that they fall asleep easier/faster), to reduce their<br />
number of awakenings during the night, to lengthen<br />
their hours of sleep, to improve the quality of their<br />
sleep, or to reverse their daytime symptoms without<br />
causing other side effects.<br />
Natural sleep remedies, such as chamomile and<br />
valerian teas and over-the-counter tablets, are often<br />
tried first by patients, but they are not usually effective.<br />
Apart from specific treatment for particular disorders,<br />
such as dopamine for RLS, the most studied and<br />
approved treatments are either CBT or hypnotics.<br />
CBT involves a process using sleep restriction<br />
(reducing sleep by 2-3 hours every night), stimulus<br />
control (which prevents long periods spent in<br />
bed trying to sleep) and keeping a sleep diary<br />
to gradually improve sleep over a period of a few<br />
weeks. CBT works very well but requires patient<br />
cooperation and commitment. Hypnotics improve<br />
sleep by decreasing sleep onset and decreasing<br />
awakenings but they are associated with the<br />
problems of dependence and adverse side<br />
effects. Patients often find it very hard to stop taking<br />
hypnotics due to psychological dependence,<br />
even when taking the less physically dependent<br />
Z-drugs. Significant side effects include memory<br />
lapses and increased body sway (particularly<br />
with benzodiazepines), which could lead to falls,<br />
especially if the patient has to get up in the middle<br />
of the night. The two treatment methods can be<br />
combined by using hypnotics infrequently e.g.<br />
every third night to assist in keeping patients on the<br />
CBT programme.<br />
As the nocturnal melatonin levels decrease<br />
progressively with age the elderly have the lowest<br />
melatonin levels. Replacing melatonin in these<br />
patients therefore provides a more natural solution.<br />
Immediate-release melatonin, while offering a small<br />
hypnotic effect and shortened sleep latency, has<br />
a short duration of action and may not improve<br />
symptoms occurring during the night. A prolongedrelease<br />
melatonin (such as Circadin ® ), which more<br />
closely mimics the natural melatonin levels in early<br />
adulthood, is preferred. Prolonged-release melatonin<br />
has been shown to shorten sleep onset latency,<br />
reduce wakefulness and improve both quality of<br />
sleep and daytime functioning without necessarily<br />
increasing total sleep time. The side effect profile of<br />
both types of melatonin is similar to that of placebo<br />
with, particularly, no increase in body sway.<br />
Despite these positive effects on sleep in patients<br />
who have reduced melatonin levels, it is important<br />
to realise that melatonin does not have the global<br />
effect on sleep that hypnotics do. Taking melatonin<br />
can only return sleep to the natural state and will not<br />
replace a hypnotic in patients who have high levels<br />
of anxiety. Therefore, careful selection of patients<br />
is important. Circadin ® is registered for patients<br />
over the age of 55 years with insomnia. The 2 mg<br />
tablet should be taken once a day, about 2 hours<br />
before the desired bedtime, to allow for an increase<br />
in melatonin plasma levels and the subsequent<br />
drop in body temperature. The extended release of<br />
melatonin throughout the night contributes to good<br />
quality sleep.<br />
Dr Alison Bentley is the Medical Director for AHC and<br />
SleepMD. Correspondence: dralisonbentley@gmail.com<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 39
REPORT<br />
THE PROVISION OF<br />
EXPERT OPINION<br />
AND EVIDENCE AS<br />
A HEALTH PROFESSIONAL<br />
Kathy Malherbe<br />
THERE IS NO DOUBT THAT ‘EXPERT’<br />
WITNESSES, PARTICULARLY THOSE IN THE<br />
MEDICAL FRATERNITY, HAVE COME UNDER<br />
THE SPOTLIGHT RECENTLY – FOR THE WRONG<br />
REASONS. EXPERT MEDICAL WITNESSES<br />
ARE NOT BORN THAT WAY, NOR DO YEARS<br />
OF CLINICAL EXPERIENCE IN THE FIELD<br />
QUALIFY THEM TO TESTIFY. IT IS A FIELD WHERE<br />
THE STATUS IS ACHIEVED ONLY THROUGH<br />
EXPERIENCE, HARD WORK AND SKILLS<br />
TRAINING. IT ALSO REQUIRES KNOWLEDGE<br />
OF THE CONSTITUTION, THE LAW IN OUR<br />
COUNTRY, THE COURT PROCEDURES, REPORT<br />
WRITING AND LEGAL PROCEDURES.<br />
The identified need for expert witness training<br />
as a health professional was what led to the<br />
inaugural course on the Provision of Expert<br />
Opinion as a Health Professional that took<br />
place in November 2017. The week-long program was<br />
designed by Burns-Hoffman Consulting, accredited<br />
by and presented at UCT medical school. A number<br />
of health professionals completed the course,<br />
which judging by their feedback was a resounding<br />
success. The professionals who attended the course<br />
evaluated the content and level of presentation as<br />
being excellent, noting that the practical sessions<br />
were invaluable.<br />
The course was the brain-child of Elise Burns-<br />
Hoffman, owner of Burns-Hoffman Consulting. Burns-<br />
Hoffman is an Occupational Therapist (OT) with<br />
30 years’ experience who actively engaged in the<br />
development of the program at the start of 2016,<br />
commenced discussions with UCT Health Sciences<br />
Faculty in late 2016 and from early 2017 onwards has<br />
been working with and alongside the UCT Faculty of<br />
Health Sciences’ Continuing Education Unit in order<br />
to roll it out last month.<br />
The course program was designed to ensure that<br />
health professionals gain proper understanding of<br />
their professional role in the non-clinical contexts,<br />
such as business and law, alongside providing<br />
practical guidance and advice on running one’s own<br />
business. It included the following topics: business<br />
principles and strategic planning; an understanding<br />
of the Constitution as a health professional; the law<br />
of contract; the law of delict; an overview of the civil<br />
and criminal legal procedure; expert witness training<br />
via a ‘court day’ and professional report writing.<br />
Burns-Hoffman says that, added to her own<br />
professional experience in this line of work, her<br />
research included discussions with various<br />
professionals and investigations into what other<br />
suitable courses are on offer. In her discussions she<br />
spoke to numerous attorneys; health professionals;<br />
advocates; risk companies and related disciplines.<br />
She says that the course is unique in a number of<br />
ways, the most pertinent of which is the hands on,<br />
practical approach taken, with the specific intention<br />
of imparting skills – not attained by merely listening,<br />
but rather via interaction and roleplay. To quote<br />
40 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
REPORT<br />
Benjamin Franklin: “Tell me and I forget, teach me<br />
and I may remember, involve me and I learn” –<br />
quoted on the course.<br />
The lecturers engaged in this course have all<br />
enjoyed extensive exposure to the provision of expert<br />
opinion and evidence in their particular professional<br />
environment(s) and included a highly respected<br />
retired judge of the SCA; senior and junior counsel;<br />
independent business practitioners and others.<br />
ALTHOUGH THE VISION FOR THIS COURSE WAS<br />
INITIALLY TAKEN TO THE UCT OCCUPATIONAL<br />
THERAPY DEPARTMENT FOR THE SPECIFIC<br />
PURPOSE OF PROVIDING RELEVANT TRAINING<br />
FOR OTS (BURNS-HOFFMAN’S PROFESSIONAL<br />
AREA OF DISCIPLINE) THERE WAS SUCH<br />
SUPPORT FOR THE PROPOSAL THAT IT WAS<br />
DECIDED TO MAKE IT AVAILABLE TO ALL HEALTH<br />
PROFESSIONALS WHO WISH TO BECOME AND<br />
OR ARE ALREADY INVOLVED IN THE PROVISION<br />
OF EXPERT OPINION AND EVIDENCE TO SOCIETY,<br />
GOVERNMENT, BUSINESS AND THE COURTS.<br />
Health professionals working in the areas of medical<br />
negligence, MVAs, employee incapacity, relevant<br />
contractual and incapacity / disability claims<br />
assessments are encouraged to attend the course.<br />
The course is suited to all claims and other life<br />
insurance personnel who have a heath professional<br />
qualification. Burns-Hoffman says, ‘it is by no means<br />
limited to those in independent practice and<br />
business.’<br />
The request for follow up courses from the delegates<br />
is testimony to the need for the continuing<br />
education of health professionals in a domain that<br />
is not necessarily discipline based, but draws on the<br />
experience of such disciplines in the resolution of<br />
conflict and attainment of justice.<br />
FOR MORE INFORMATION CONTACT:<br />
Elise Burns-Hoffman<br />
e: elise@b-h.co.za<br />
t: +27 21 785-2878<br />
c: 083-627-5584<br />
w: www.b-h.co.za<br />
Kathy Malherbe is a Freelance Writer for Du Maurier Communications, Rondebosch, Cape Town, <strong>South</strong> Africa.<br />
Correspondence: Kathy@iafrica.com Website: www.kathymalherbe.co.za<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 41
NEWS<br />
STERKFONTEIN HOSPITAL OPENS FAMILY RELATIONS UNIT<br />
Lebogang Legobye , Amanda Edge & Prudence Baloyi<br />
Children under 12 years whose mothers are patients<br />
in the hospital are set to benefit significantly from the<br />
Family Relations Unit (FRU) called Wendy House that<br />
was launched at Sterkfontein Psychiatric Hospital on<br />
7 November 2017. Because children under the age<br />
of 12 are not allowed in the wards, the purpose of<br />
the unit is to allow the children of state patients to<br />
visit their mothers and this is where they can meet<br />
and bond together.<br />
Professor Subramaney officially opened the occasion<br />
and welcomed all saying “I am excited to in troduce<br />
you briefly to how this unit and Programme came<br />
into being and what we as Ward 3 Multi-Disciplinary<br />
Team (MDT) hope it will offer. Building Wendy House<br />
has been exciting for all of us who have been<br />
involved and are happy with this achievement. She<br />
extended her gratitude to all the sponsors for giving<br />
the hospital resources to assist in constructing the<br />
new structure.<br />
With a smile the CEO said “I am glad to have<br />
witnessed and be part of this opening, this is truly the<br />
first of its kind”. He emphasised and encouraged the<br />
crowd about the culture of change, “you can not<br />
do the same thing every day and expect different<br />
results, let this be the beginning of good things to<br />
come” added Mapunya. He then declared the<br />
house officially open.<br />
Social worker Yandisa Xundu, psychologist Amanda Edge and Ugash<br />
Subramaney inside the family relations unit.<br />
An in-house psychologist Amanda Edge mentioned<br />
that because of the physical distance that the<br />
women experience from their families, and not taking<br />
enough measure to facilitate the enhancement of<br />
family bonds is an injustice to the patients as they<br />
are separated from their previous roles.<br />
Thus a need arose to establish a programme<br />
including a space that would involve most<br />
members of the Multi Disciplinary Team (MDT) to<br />
formally psycho-educate families on the process of<br />
being declared a state patient, facilitate the family<br />
adjustment process, provide mothers with mothering<br />
skills and help with mother-child attachment.<br />
Before the programme could kick start, hurdles had<br />
to be overcome. Initially, the hospital regulations<br />
stipulated that children under the age of 12 are not<br />
allowed in the ward and many of the women have<br />
young children. However, the Chief Executive Officer<br />
Mr. Jimmy Mapunya granted the permission to have<br />
this changed for those [patients] participating in<br />
the programme.<br />
Management realised the importance of a family<br />
friendly space and that is how Wendy House a family<br />
relations unit was birthed. The FRU is fully set up with<br />
furniture, second hand toys, therapeutic books and<br />
resources.<br />
Dr Niki Eklektos (senior registrar in the unit at the time and budding forensic<br />
psychiatrist; Ugash Subramaney (Consultant in charge of the female forensic<br />
unit); Yandisa Xundu (social worker in the unit); Dr Dani Hoffman (principle<br />
psychologist in the ward and HOD(Psychology) at STKN); Ms Alicia Myburgh<br />
(OT attached to the unit) and Amanda Edge (psychologist in the unit and<br />
head of the project)<br />
Dr K Moloi, clinical manager; Ms M Sono, nursing manager; Ms Amanda<br />
Edge, psychologist, Mr Jimmy Mapunya, CEO and Mr H Shuping, Corporate<br />
manager of STKN hospital inside the family relations unit.<br />
GRADUATIONS<br />
PhD<br />
MMed<br />
Ethelwyn Rebelo graduated on the 7th December 2017. The title of<br />
her PhD was: An investigation of parental attachment relationships;<br />
perceived parental gender attitudes; and respondents’ gender-role<br />
behaviour in the formation of gender attitudes.<br />
Dr A Anic graduated with the MMed degree, 7 th December<br />
2017, entitled: “Prevalence and Patterns of Substance Use<br />
amongst Psychiatric Inpatients at Helen Joseph Hospital”.<br />
42 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
NEWS<br />
EUROPEAN EATING DISORDERS CONFERENCE- VILNIUS, LITHUANIA<br />
Drs Nkokone Tema and Thebe Madigoe (Eating<br />
disorders unit, Tara Hospital) were invited to present<br />
an overview of the eating disorders landscape in<br />
<strong>South</strong> Africa as part of a symposium entitled “Eating<br />
Disorders in a Multicultural Setting” at The European<br />
Council of Eating Disorders conference held in<br />
Vilnius, Lithuania 7 th to 9 th September 2017. There<br />
were presentations from Mexico, UAE and Egypt.<br />
It was very encouraging to see that local services<br />
compare favourably despite the limited resources.<br />
Dr Tema<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 43
NEWS<br />
CPMH CELEBRATES GRADUATES<br />
A key gap in current mental health professional<br />
training in Africa and globally is an orientation to<br />
public mental health. This means an orientation to<br />
the mental health needs of populations, and the<br />
policies, laws and services that are required to meet<br />
those needs. The WHO has highlighted this critical<br />
shortage and has put out an urgent call to improve<br />
and strengthen professional mental health capacity<br />
in Africa. The Alan J Flisher Centre for Public Mental<br />
Health has heeded this call and has produced a<br />
steady stream of graduates over the last few years.<br />
This year has been no different with 5 MPhil and 1<br />
PhD graduates.<br />
Japhet Myaba from Malawi focused his MPhil on<br />
the prevalence and predictors of antipsychotic<br />
medication non-adherence among clients with<br />
psychotic disorders in Mzimba, Malawi. Megan<br />
Malan from <strong>South</strong> Africa studied the prevalence<br />
and predictors of intimate partner violence among<br />
women attending a midwife and obstetrics unit<br />
in the Western Cape. Hailing from Ethiopia, Tigist<br />
Zerihun, conducted a qualitative study on family<br />
planning for women with severe mental illness<br />
in rural Ethiopia. Prasansa Subba from Nepal<br />
conducted a formative study on the adaptation of<br />
mental health promotion programmes for perinatal<br />
depression in West Chitwan. Also conducting a<br />
qualitative study, Winifred Nalukenge from Uganda,<br />
focused on mental health explanatory models,<br />
and the perceived impact of life experiences on<br />
mental health, in HIV-infected adolescents in rural<br />
and urban Uganda. Maxine Spedding from <strong>South</strong><br />
Africa made the CPMH proud by obtaining her<br />
PhD. She focused her doctorate on the prevalence<br />
and predictors of intimate partner violence among<br />
women attending a midwife and obstetrics unit in<br />
the Western Cape.<br />
CPMH’s MPhil students attend a two week workshop to secure basic research<br />
knowledge.<br />
Graduates from all over Africa attend the workshop to hone their research<br />
skills and to learn from the Centre’s celebrated researchers.<br />
THE HIV MENTAL HEALTH RESEARCH UNIT BRAND LAUNCH AND REVIEW<br />
The HIV Mental Health Research Unit (HIVMHRU)<br />
brought its research project leaders together for an<br />
annual review process and launch of its new brand.<br />
The event was chaired by Prof John Joska who<br />
opened with a brief background of the unit and the<br />
vision for the future. He highlighted the importance<br />
of using these review meetings to share ideas and<br />
establish advisory committees to shed light, and assist<br />
in addressing challenges experienced by the various<br />
projects. The unit was established in response to the<br />
growing recognition of the burden of mental disorders<br />
in people living with HIV – including depressive, anxiety,<br />
substance abuse and neurocognitive disorders.<br />
The rebranding process is part of the vision to<br />
maintain this position and to become a good<br />
contender for current mental health research. There’s<br />
growing interest and investment to increase mental<br />
health awareness across the country, therefore with<br />
more visibility and presence, this opens a window<br />
of opportunity for collaboration and the unit to<br />
become a carrier of this message through scientific<br />
research. This requires collective effort and where<br />
possible sharing resources and time. Through reports<br />
presented by the project managers, it is evident that<br />
the unit has had quite a productive year and the<br />
possibilities for the future are endless.<br />
Prof John Joska and Assoc. Prof Jackie Hoare with the team<br />
after presentations.<br />
Goodman Sibeko, a doctoral<br />
student in the Dept, has been<br />
appointed co-Director of the<br />
newly formed Addictions<br />
Technology and Transfer<br />
Centre, a new SAMHSA and<br />
PEPFAR initiative focused on the<br />
training of frontline clinicians<br />
in the area of addictions<br />
psychiatry. He will bring his<br />
experience as a clinician and<br />
researcher to bear in leading this venture forwards.<br />
44 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
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SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 45
UCLA/<strong>South</strong> <strong>African</strong> Trauma<br />
Training Research (Phodiso) Scholars<br />
Programme<br />
Project Narrative:<br />
The UCLA/<strong>South</strong> <strong>African</strong> Trauma Training Research (Phodiso) Programme has received 5<br />
additional years of funding to prepare future investigators to conduct research on<br />
psychological trauma and injury exposure in the context of <strong>South</strong> Africa’s high levels of<br />
interpersonal and community violence and intentional injuries. As an international<br />
collaboration between UCLA and the <strong>South</strong> <strong>African</strong> Research Consortium (SARC), which<br />
includes the Human Sciences Research Council (HSRC), North-West University (NWU),<br />
and University of Cape Town (UCT), Phodiso’s public health mission is to: 1) Increase the<br />
number of well-trained <strong>South</strong> <strong>African</strong> trauma researchers; 2) Translate research findings to<br />
culturally congruent trauma and injury prevention and treatment programmes and; 3)<br />
Facilitate building of community capacity and infrastructure that benefit the people of<br />
<strong>South</strong> Africa.<br />
We will be recruiting every year for 1 candidate for a 2 year post-doctoral Scholar position.<br />
The Scholar will train at the University of California in Los Angeles for 3 months, be<br />
mentored by Phodiso faculty in both <strong>South</strong> Africa and USA, conduct their own research in<br />
<strong>South</strong> Africa with supervision, collect data, and publish their data. The selected Scholar<br />
will receive a stipend for research and full time salary support. Upon completion of the<br />
program, the candidate will be encouraged to work in areas related to research.<br />
Minimum Requirements:<br />
Ph.D. degree or MB ChB degree and a <strong>South</strong> <strong>African</strong> citizen or permanent resident<br />
Deadline for Applications: May 15, <strong>2018</strong><br />
Programme begins: September <strong>2018</strong><br />
Please send any questions or a summary of your research experience, CV, and a two<br />
page research concept paper that has to do with trauma and health or mental health<br />
that you would want to pursue to Ms. Amber Smith via email<br />
(Ambersmith@mednet.ucla.edu). Interviews will be scheduled for June 22nd and 23rd in<br />
Durban, <strong>South</strong> Africa and transportation will be provided, if required.<br />
46 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
REPORT<br />
WPA WHO AFRICAN MENTAL HEALTH FORUM:<br />
“CONTINENTAL ALLIANCE FOR INTEGRATED<br />
MENTAL HEALTH CARE IN AFRICA”<br />
DURING THE WPA INTERNATIONAL CONGRESS IN CAPE TOWN, 18-22 NOVEMBER 2016<br />
EXECUTIVE SUMMARY<br />
Roof Terrace CTICC, Friday, 18 November 2016 08h15-15h00<br />
Bernard J van Rensburg Chair - Local Organizing Committee WPA<br />
International Congress in Cape Town 2016<br />
The WPA-WHO Africa Mental Health Forum was<br />
organized as a round table discussion on the<br />
18th November 2016 in Cape Town, with plenary<br />
presentations, as well as four break away panel<br />
discussions.<br />
The panels were set up in terms of the four objectives<br />
of the WHO MENTAL HEALTH ACTION PLAN 2013-<br />
2020: 1 (1) PANEL I. Leadership and governance;<br />
(2) PANEL II. Health and social services; (3) PANEL<br />
III. Prevention and promotion; and (4) PANEL IV.<br />
Information, evidence and research.<br />
The participants in this round table discussion<br />
included WPA Executive Committee and Board<br />
Members, Psychiatric Associations in Africa and<br />
elsewhere, National Directors of Mental Health<br />
Programs and Mental Health Advocacy Groups.<br />
The three background policy documents for the<br />
Forum were: (1) The WHO MH Care Action Plan 2013-<br />
2020; 1 (2) The Africa Health Transformation Program<br />
2015-2020; 2 and (3) WPA Action Plan 2014-2017. 3<br />
Chairs and Panel Leaders were encouraged to liaise<br />
with the proposed panel members beforehand,<br />
but also to consider and advise on any other<br />
participants which they thought would be able to<br />
contribute to these discussions. Panel Leaders were<br />
invited to coordinate and prepare in advance a brief<br />
background section on each subtheme of about 1-2<br />
pages, including 2-3 potential recommendations.<br />
They were also invited to forward any documentation<br />
for the meeting that should be considered as<br />
context. (Both the leaders’ background documents<br />
and submitted documents are included/listed in<br />
the Addenda to the “Documentation” document for<br />
the forum.)<br />
The round table program consisted of three plenary<br />
sessions and four breakaway sessions. The session<br />
on the report back session by the four breakaway<br />
panels was audio-recorded and transcribed. (The<br />
1<br />
http://www.who.int/mental_health/publications/action_plan/en/<br />
2<br />
http://www.afro.who.int/en/rdo/reports/4928-the-africa-health-transformation-programme-2015-2020-a-vision-foruniversal-health-coverage.html<br />
3<br />
http://www.wpanet.org/detail.php?section_id=25&content_id=1132<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 47
REPORT<br />
EXECUTIVE<br />
transcription has been included as an Addendum<br />
to the “Documentation” document for the forum.)<br />
Presentations. The plenary presentations were<br />
delivered under the program headings of: (1)<br />
“Overview of Mental Health Care Policy in Africa”;<br />
(2) “Service delivery, training and research”; and<br />
(3) “Alliance of stake holders for integrated care”<br />
The different presentations were either included in<br />
the Addenda to the “Documentation” document for<br />
the forum, or a short summary was included in the<br />
text of the document:<br />
1. Dr Shekhar Saxena – “The Global Mental Health<br />
Action Plan”<br />
2. Dr Matshidiso Moeti – “The Transformation<br />
Agenda and the Global Mental Health Action<br />
Plan: Policies and targets for Africa”<br />
3. Prof Dinesh Bhugra – “WPA Action Plan 2014-<br />
2017”<br />
4. Prof Dinesh Bhugra – “Social contracting of<br />
<strong>Psychiatry</strong> and psychiatrists for mental Health in<br />
Africa”<br />
5. WPA <strong>African</strong> Regions overview: Northern Africa –<br />
Zone 11; Central and Western Africa – Zone 13;<br />
Eastern and <strong>South</strong>ern Africa – Zone 14<br />
Prof David Ndetei (Kenya) - Eastern & <strong>South</strong>ern<br />
Africa (Zone 14)<br />
6 Dr Mvuyiso Talatala – “WPA and an <strong>African</strong><br />
Federation of Psychiatric Associations”<br />
7. Prof Dinesh Bhugra and Panel – “Continental<br />
alliance for integrated mental health care in<br />
Africa - WHO, WPA, professional societies”<br />
THE OUTCOME OF THE MEETING<br />
WAS FORESEEN TO BE A REPORT<br />
ON THE FOUR PANELS’ INPUTS WITH<br />
PARTICULAR RECOMMENDATIONS<br />
ON THE IDENTIFIED FOUR AREAS,<br />
WHILE ALSO TO INCORPORATE<br />
AND CONSOLIDATE A POSITION<br />
STATEMENT ON A CONTINENTAL<br />
ALLIANCE FOR INTEGRATED MENTAL<br />
HEALTH CARE IN AFRICA.<br />
Recommendations by four panels. The following 25<br />
recommendations were made by the four panels:<br />
1. PANEL I.Leadership and governance<br />
1. To involve all stake holders in all (planning)<br />
meetings at all levels, including consumers,<br />
while enabling and supporting consumers to<br />
participate meaningfully<br />
2. To achieve a systematized approach in mental<br />
health leadership and governance, so that not<br />
all effort and support depends on one individual<br />
in a particular Ministry - the approach should<br />
include different departmental officials from the<br />
chief medical officer to administrative staff, but<br />
also reach beyond and across departments and<br />
governments<br />
3. To obtain comprehensive data on all aspects in<br />
order to have information and provide evidence<br />
for the financing required for different mental<br />
health programs<br />
4. To retain the “bigger picture” with regard to CRPD, 4<br />
namely to achieve humane mental health care,<br />
and not to be side-tracked in the debate while<br />
considering applicable options for mental health<br />
in a step-by-step way<br />
5. To mobilize resources for training in public mental<br />
health from national to district level; in order to<br />
have understanding that resources must be<br />
identified and systems created beyond hospital<br />
care, e.g. not only to advocate for hospitals, but<br />
for systems of care<br />
6. To utilize “Mental Health Innovations - Africa” as<br />
a platform for role players to continue discussion<br />
and communication between role players in<br />
Africa<br />
2. PANEL II. Health and social services<br />
7. To reorganize and reform the whole mental health<br />
care system by integrating available resources<br />
(e.g. psychiatrists in private practice with other<br />
role players), while clearly identifying the roles of<br />
mental health care workers involved<br />
8. To achieve integration and role identity through<br />
training of current and future practitioners and<br />
students - all need to know more about each<br />
other; an integrated model of practice must be<br />
promoted e.g. <strong>Psychiatry</strong> and other disciplines,<br />
mental and physical health care.<br />
9. To broaden the treatment pyramid base<br />
through self-care and getting people to be able<br />
to care for themselves - at least, with regard<br />
to minor problems, while people with severe<br />
neuropsychiatric problems per se should still be<br />
further treated in specialized centers<br />
10. To clarify the roles of the different role players in the<br />
field in a specific catchment area, while people<br />
in a certain catchment area must also be aware<br />
of what the referral route is for emergencies, or<br />
the correct way to address problems<br />
11. To address this communication and logistical<br />
aspects will require leadership, while these<br />
basics may have to be addressed to achieve<br />
a reorganization and reformation of the mental<br />
health care system<br />
3. PANEL III. Prevention and promotion<br />
12. To incorporate the interests of service users,<br />
which must be at the heart of all mental health<br />
care, including promotion and prevention - their<br />
voice must be recognized in order to bring the<br />
richness and strength of their experience to the<br />
table; particular areas of concern include:<br />
- that a holistic approach is adopted when<br />
addressing comorbid physical illnesses of users<br />
in view of the known increased risk of morbidity<br />
4<br />
Convention on the Rights of Persons with Disabilities<br />
48 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
REPORT<br />
SUMMARY<br />
and mortality associated with being a mental<br />
health care user<br />
- involvement in the evaluation of service provision<br />
in order to achieve services that care and<br />
support, rather than stigmatize<br />
13. To achieve different competencies, such as<br />
cultural, (health) educational, service delivery<br />
and policy competency<br />
14. To involve the media to address stigma, e.g.<br />
through advertisement, while also addressing<br />
cultural aspects of stigma and constantly<br />
recognizing the voices of service users<br />
15. To revise training curricula of under and post<br />
graduate programs to ensure inclusion of the<br />
minimum required content on mental health,<br />
including on promotion and prevention<br />
4. PANEL IV. Information, evidence and research<br />
16. To acknowledge the critical importance of<br />
collaboration and networks<br />
17. To share information and experiences<br />
18. To address stigma, including stigma in mental<br />
health workers and the systems in which they<br />
work<br />
19. To incorporate the use of technology in screening<br />
and intervention delivery<br />
20. To consider cultural idioms of distress and<br />
appropriate interventions<br />
21. To accommodate the qualification of new cadres<br />
of mental health workers through creating posts<br />
and career paths<br />
22. To teach research methods and dispel myths<br />
about research, while refocusing the emphasis<br />
on scientific curiosity to answer questions<br />
23. To embrace a range of research methods<br />
in mental health from quantitative, systems,<br />
mixed to qualitative; from basic neuroscience<br />
to implementation research; also, to develop<br />
“clinician researchers”<br />
24. To conduct further epidemiological research, as<br />
there are relatively few data for example on the<br />
prevalence and associations of mental disorders<br />
in primary care settings in the <strong>African</strong> context<br />
25. To conduct research on the effectiveness<br />
and cost-efficiency of integrated care and<br />
collaborative care in the <strong>African</strong> context, as well<br />
as for further work on moderating and mediating<br />
factors<br />
HEALTH FOR ALL AND INTEGRATED MENTAL<br />
HEALTH CARE IN AFRICA, WE WILL NEED<br />
TO WORK TOGETHER WITH COLLECTIVE<br />
STRENGTH AND ACTIVE COLLABORATION.<br />
SUCH AN ALLIANCE FOR INTEGRATED<br />
MENTAL HEALTH CARE IN AFRICA, WITH<br />
EMPHASIS ON PUBLIC MENTAL HEALTH,<br />
INCLUDES: INDIVIDUAL AND COLLECTIVE<br />
PSYCHIATRISTS, AS WELL AS ALL MEMBERS<br />
OF THE MULTIDISCIPLINARY MENTAL HEALTH<br />
TEAM (PSYCHOLOGISTS, NURSES, SOCIAL<br />
WORKERS, OCCUPATIONAL THERAPISTS),<br />
OTHER HEALTH PROFESSIONALS IN PRIMARY<br />
AND SPECIALIST HEALTH CARE, COMMUNITY<br />
MENTAL HEALTH WORKERS AND SELF-HELP<br />
RESOURCES, OUR PATIENTS OR SERVICE<br />
USERS AND THEIR FAMILIES, THE PUBLIC AT<br />
LARGE THROUGH THE MEDIA, TRAINING<br />
INSTITUTIONS, AS WELL AS GOVERNMENTS’<br />
MINISTRIES OF HEALTH AND PRIVATE SERVICE<br />
PROVIDERS OF MENTAL HEALTH CARE<br />
SERVICES. WHILE DIFFERENT COUNTRIES<br />
AND GROUPS MAY HAVE DIFFERENT ENTRY<br />
POINTS, STRENGTHENING OF THIS ALLIANCE<br />
MUST BE SOUGHT WITHIN COUNTRIES<br />
NATIONALLY, PROVINCIALLY AND LOCALLY,<br />
BUT ALSO ON SUBCONTINENTAL AND<br />
CONTINENTAL LEVELS.<br />
Bernard Janse van Rensburg<br />
Johannesburg<br />
April 2017<br />
Position statement on a continental alliance for<br />
integrated mental health care in Africa<br />
IN ORDER TO ACHIEVE THE COMMUNICATED<br />
VISION, OBJECTIVES AND TARGETS FOR<br />
ACHIEVING THE POTENTIAL OF MENTAL<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 49
CULINARY CORNER<br />
A MEANINGFUL MEAL<br />
OF PSYCHIATRIC AND<br />
PSYCHOLOGICAL<br />
INFORMATION<br />
Our meal today is themed around the<br />
notions that we humans need to<br />
construct a sense of belonging and that<br />
we also construct our realities, even our<br />
physical realities. These constructions may interfere<br />
with the way we cope with our world and the way<br />
we understand it.<br />
We start with some thoughts regarding lingering PTSD<br />
and depression. The main meal consists of research<br />
which highlights the importance of belonging and<br />
enjoying being part of a group. An essay by Oliver<br />
Sacks, published posthumously, reflecting on his<br />
‘mishearings’ will provide a refresher. This will be<br />
accompanied by another essay by Sacks which<br />
touches on a possible consequence of being on<br />
the outside - if one is a scientist. Dessert will consist of<br />
Nicholas Humphrey’s Illusionist view of consciousness<br />
as art and Martin Rees’ question regarding whether,<br />
given our cognitive limitations, we will ever be able<br />
to totally comprehend the universe.<br />
STARTER<br />
PTSD AND TRIBE<br />
Sebastion Junger, a prize-winning<br />
journalist and author, published<br />
a book in 2017 called ‘Tribe’. In<br />
this work, Junger makes some<br />
use of psychological, sociological, political and<br />
anthropological data to develop his argument that<br />
long-term PTSD in American war veterans is more<br />
associated with a loss of the connectedness and<br />
purpose they enjoyed as soldiers - than the injuries<br />
of battle.<br />
Junger notes that for millions of years, our hominid<br />
ancestors functioned within tribes and it remains<br />
part of human nature to desire the interpersonal links,<br />
rituals and economic equality that characterised<br />
these types of societies. For this reason, in the early<br />
years of the European occupation of America, there<br />
were multitudes of examples of Europeans fleeing to<br />
live with the Native American or First People, but very<br />
few examples of the latter willingly joining the settlers.<br />
He points out that while modern civilisation has<br />
50 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
CULINARY CORNER<br />
much to recommend it in terms of increased<br />
autonomy and wealth, it deprives us of a sense of<br />
community and interdependence. It is only during<br />
times of adversity or war that we recreate that lost<br />
sense of fellowship with others in our society. Junger<br />
argues that lingering PTSD in American War Veterans<br />
is thus more the result of problems with re-entry into<br />
society than trauma. In essence, it is associated with<br />
the break up of the ‘band of brothers’ that existed in<br />
the war zone.<br />
Junger recommends that soldiers rejoin a society<br />
with reasonably equal and decent opportunities<br />
for everyone. All veterans need to be made to feel<br />
that they are just as necessary and productive<br />
in society as on the battlefield. It is important that<br />
people remember that they are warriors and are<br />
not defined solely as victims. Veterans need to rejoin<br />
a society which possesses a collectively greater<br />
understanding of what they have been through<br />
and what they have lost - in their homecoming -<br />
regarding their sense of belonging.<br />
Junger’s argument is convincing. He himself has<br />
covered several wars as a war correspondent.<br />
However the links between the claims he makes and<br />
the evidence which may bolster these claims is not<br />
always evident. It is also possible that in analysing<br />
the ongoing trauma of returning soldiers he neglects<br />
an important intervening variable, namely resilience.<br />
PTSD AND RESILIENCE<br />
Wingo et al (2017) assessed resilience in 264<br />
American war veterans suffering from PTSD<br />
or Depression using the Connors-Davidson<br />
Resilience Scale. The authors found that childhood<br />
maltreatment, gender, marital status, education<br />
and employment did not predict social functioning.<br />
However, resilience, which includes the capacity<br />
to manage stress, bounce back from adversity<br />
and adapt to new circumstances, was positively<br />
associated with a more intact engagement with<br />
the world - regardless of the severity of the PTSD or<br />
depression.<br />
MAIN MEAL<br />
POSITIVE RELATIONSHIPS AND<br />
SEMANTIC MEMORY<br />
An experimental group of thirty-one superagers<br />
and a control group of individuals with averagefor-their<br />
age semantic memories completed the<br />
Ryff 42-item Psychological Well-Being Questionnaire.<br />
This inventory comprises six subscales measuring:<br />
Autonomy, Positive Relations With Others,<br />
Environmental Mastery, Personal Growth, Purpose<br />
in Life and Self-Acceptance. Both groups were<br />
matched for demographic factors and estimated<br />
premorbid intelligence.<br />
Results revealed that the superagers endorsed<br />
greater levels of positive relations with others. There<br />
were, however, no other significant differences. The<br />
authors conclude by questioning whether this<br />
psychological feature impacts on the development<br />
of a thicker anterior cingulate gyrus and on the<br />
denser levels of von Economo neurons which<br />
characterise the brains of superagers (associated<br />
also with empathy, social awareness and selfcontrol).<br />
Maher et al (2017) have been involved with a<br />
‘SuperAging’ programme at Northwestern University<br />
studying a cohort of individuals who are over eighty<br />
years old and whose episodic memory ability is<br />
equal to or superior to those of normal middle-age<br />
adults. It is known that psychological well-being is<br />
positively correlated with cognitive performance in<br />
older adults. The present study therefore sought to<br />
further explore the psychological factors associated<br />
with the participants’ contentment.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 51
CULINARY CORNER<br />
OSTRACISM AND BREAKING RULES<br />
Following social rules are important if one is to<br />
gain social acceptance. It appears that once a<br />
person is ostracised, their desire to follow rules may<br />
be even more weakened. Poon and Teng (2017)<br />
carried out three studies, making use of a multimethod<br />
approach, to determine whether ostracism<br />
was positively associated with rule negligence and<br />
aggression. Their motivation for the research lay in<br />
prior studies which had revealed a causal effect<br />
between ostracism and aggression. The authors<br />
accordingly wondered whether rule negligence<br />
might be a psychological mechanism mediating<br />
the relationship between ostracism and aggression.<br />
Results confirmed their hypothesis. However they<br />
found that priming ostracised people with the<br />
importance of social rules weakened the effect of<br />
ostracism on aggression.<br />
the brain’s processing of music is more robust than<br />
that of spoken language. Playing or hearing music<br />
involves not only the analysis of tone and rhythm, but<br />
also an engagement with the emotional centres of<br />
the brain and with procedural memory. Speech too<br />
relies on these areas of the brain. It is also dependant<br />
on systems for semantic memory and syntax. More<br />
significantly, however, speech is open, inventive,<br />
improvised and rich in ambiguity and meaning.<br />
He refers to Freud’s explanation that slips of<br />
the tongue and mishearings are moulded by<br />
unconscious motivations. While he does not<br />
disagree that wishes, fears, motives and conflicts may<br />
play a part on occasion, he cautions that Freud’s<br />
understanding underestimates the power of neural<br />
mechanisms. The open and unpredictable nature of<br />
language furthermore causes it to be susceptible<br />
to a sabotage of meaning and a generation of<br />
mishearings that are irrelevant both to context and<br />
subconscious motivation.<br />
One can easily attribute the uncertainty surrounding<br />
spoken language to his substitution of ‘choir practice’<br />
for ‘chiropractor’ and ‘cuttlefish’ for ‘publicist’,<br />
although one imagines that Professor Freud might<br />
have enjoyed his substitution of ‘Christmas Eve’ with<br />
‘Kiss my feet’ and may have wanted to know more...<br />
SCIENTIFIC JUMPS AND FALLS<br />
REFRESHER<br />
MISHEARINGS<br />
Ever the scientific observer, even in his last days,<br />
the well-known neurologist and writer, Oliver Sacks,<br />
noted his responses to the world. In a chapter of<br />
his posthumous book: ‘The River of Consciousness’<br />
(2017), he leaves us with his thoughts around<br />
‘mishearings’ to which his growing deafness made<br />
him more and more susceptible. When a friend<br />
told him she was going to a ‘chiropractor’, Sacks<br />
understood her to say she was going to ‘choir<br />
practice’. A ‘big-time publicist’ was heard as a ‘bigtime<br />
cuttlefish’, ‘Christmas Eve’ as ‘Kiss my feet’.<br />
Sacks observed that while he often misheard words,<br />
he rarely misheard music. The reason for this is that<br />
In the same book, Sacks also writes about how<br />
there have been discoveries in science which<br />
have been forgotten or neglected and then later<br />
recreated. For example, oxygen was discovered in<br />
the 1670s by John Mayow a century before Scheele<br />
and Priestley identified it. John Frederick Herschel<br />
identified hallucinatory patterns accompanying<br />
visual migraines in 1858, long before the concepts<br />
he attempted to elucidate re-emerged in the 1970s<br />
and 1980s with chaos theory. Gilles de la Tourette<br />
identified the syndrome which takes his name in 1885<br />
and 1886, it was later written about again by Henry<br />
Meige and E Feindel in 1907. However awareness of<br />
the syndrome was largely lost until the 1970s.<br />
Sacks cites many other instances of the loss of<br />
scientific conclusions. One of the most astounding<br />
is that Galileo’s ‘revolutionary’ picture of the solar<br />
system was, in fact, identified by Aristarchus in the<br />
third century BC. His heliocentric view was not only<br />
well understood but also accepted by the Greeks<br />
until it was rejected by Ptolemy five centuries later.<br />
Why are there these sorts of scotoma in science?<br />
Based on the numerous such incidents he has<br />
noted, he summarises that they appear to be due<br />
to the following possible factors: a resistance to new<br />
ideas which might constitute a threat to cherished<br />
belief systems; an absence of a requisite level of<br />
technology; and insufficient funding, opportunity,<br />
health or social support.<br />
Sacks, termed ‘the poet laureate of medicine’ by<br />
the New York Times, wrote this essay when he was<br />
52 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
CULINARY CORNER<br />
old and sick. One suspects that in healthier days<br />
he might have referred to certain philosophers of<br />
science such as Thomas Kuhn (see‘The Structure<br />
of Scientific Revolutions’, first published in 1962) in<br />
elaborating on his discussion of these regressions<br />
and neglects.<br />
DESSERT<br />
CONSTRUCTING REALITY<br />
It is well known that jumping spiders and pigeons<br />
are able to see broader spectrum of colours than<br />
human beings. Spiders, in particular, can identify<br />
greater detail in the world around them. Dragonflies<br />
see movement as if in slow motion. The world is<br />
experienced differently depending on anatomy and<br />
sense modalities.<br />
As Beau Lotto (2017) puts it, we are unable to<br />
experience the world as it is because our brains did<br />
not evolve to do so. Our brains give us the impression<br />
that our perceptions are objectively real, but our<br />
sensory processes separate us from ever accessing<br />
that reality directly. There has been much writing in<br />
psychology on the sorts of perceptual tricks that<br />
our brain plays on us and the illusions created (see<br />
Macknik and Martinez-Conde, 2015). For example,<br />
the brain can be fooled into seeing the wrong<br />
colour, perceiving motion in stationary objects and<br />
misjudging length and perspective.<br />
These findings have influenced certain theorists<br />
of consciousness, who fall into two camps. The first<br />
camp believes that the contents of our subjective<br />
experience, the special qualities of our sensations or<br />
qualia, are inherent in the fabric of the universe. The<br />
second camp, the Illusionists, are more suspicious.<br />
They argue that consciousness may be more like<br />
a conjuring show in which our brains trick us into<br />
believing in qualities that do not exist. One such<br />
Illusionist, Nicholas Humphreys, has written an article<br />
in the Summer 2017 edition of the Scientific American<br />
in which he presents the notion of consciousness<br />
as art - in which we are both the artist and the<br />
recipient. Humphrey hopes that if we try to view our<br />
perceptions as artistic constructs, it may be easier to<br />
come to terms with the fact that reality is not entirely<br />
as we perceive it to be. The function of our particular<br />
human qualia may be that they create in us a sense<br />
of self and self-attachment.<br />
WILL WE EVER BE ABLE TO<br />
UNDERSTAND THE UNIVERSE?<br />
Martin Rees, the Astronomer Royal and an emeritus<br />
professor of cosmology and astrophysics at<br />
Cambridge has written an article in the online<br />
newsletter ‘Aeon’ on his concerns regarding the<br />
limits of scientific understanding. His concern is that<br />
while human brains have evolved to be adaptable,<br />
our neural architecture has barely changed since<br />
our ancestors roamed the savannah. There is thus<br />
the possibility that we may reach the limits of what<br />
our brains are able to grasp.<br />
Scientific understanding has been envisaged as a<br />
building, the base of which is mathematics. Moving<br />
upwards from mathematics are sciences based<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 53
CULINARY CORNER<br />
on increasingly complex systems, with the social<br />
sciences at the top. Rees argues that the analogy<br />
between science and a building is a poor one.<br />
Comprehension of the more complex systems is not<br />
curtailed by deficiencies in understanding of the<br />
more simple systems such as subnuclear physics.<br />
Each layer is limited by a lack of understanding<br />
of the particular system involved and has its own<br />
distinct explanations. Different phenomena with<br />
varying levels of complexity have to be understood<br />
in terms of associated, irreducible concepts.<br />
This does not mean that we may not be able to<br />
compute processes with the help of electronic<br />
machines. Rees predicts that the future may be<br />
dominated by intellects formed via the intelligent<br />
design of computers. However computing is not the<br />
same as having an insightful comprehension and it<br />
may be unduly anthropocentric to believe that a full<br />
understanding of physical reality is within humanity’s<br />
grasp. He may have a point. Many of us already<br />
struggle to truly understand how gravity may be the<br />
curving of the fabric of spacetime.<br />
On the other hand his words also remind one of, and<br />
are perhaps contradicted by, Einstein’s explanation<br />
of his achievement to his son, Eduard:<br />
WHEN A BLIND BEETLE CRAWLS OVER THE<br />
SURFACE OF A CURVED BRANCH, IT DOESN’T<br />
NOTICE THAT THE TRACK IT HAS COVERED IS<br />
INDEED CURVED. I WAS LUCKY ENOUGH TO<br />
NOTICE WHAT THE BEETLE DIDN’T NOTICE<br />
(ISAACSON, 2015).<br />
One suspects and hopes that our species will<br />
continue to produce those who can see what the<br />
rest of us cannot see.<br />
INGREDIENTS<br />
Cook Maher, A., Kielb, S., Loyer, E., Connelley, M., Rademaker,<br />
M-M., et al. (2017). Psychological well-being in elderly adults with<br />
extraordinary episodic memory. PLos ONE, 12(10): e0186413.<br />
https://doi.org/10.1371/journal.pone.0186413.<br />
Humphreys, N. (2017) Consciousness as Art. Scientific American,<br />
26(3), pp 5-9.<br />
Isaacson, W. (2015). How Einstein Reinvented Reality. Scientific<br />
American, 313(3), pp 28-34.<br />
Junger, S. (2017). Tribe, On Homecoming and Belonging, 4th Estate,<br />
London.<br />
Kuhn, T.S. (1996). The Structure of Scientific Revolutions, University of<br />
Chicago Press, Chicago.<br />
Lotto, B. (2017). Deviate, The Science of Seeing Differently, Weidenfeld<br />
& Nicolson, London.<br />
Macnik, S.L., & Martinez-Conde, S. (2015). Scientific American Mind,<br />
26(3), pp 20-22.<br />
Poon, K., & Teng, F. (2017). Feeling unrestricted by rules: ostracism<br />
promotes aggressive responses. Aggressive Behavior, 43(6), pp. 558-567.<br />
Rees, M. (2017). Is There a Limit to Scientific Understanding?<br />
Aeon - in association with the Centre for the Study of Existential Risk,<br />
https://aeon.co/ideas/black-holes-are-simpler-than-forests-andscience-has-its-limits.<br />
Sacks, O. (2017). Scotoma: Forgetting and Neglect in Science, in The<br />
River of Consciousness. Picador, New York, pp 185-217.<br />
Sacks, O. (2017). Mishearings, in The River of Consciousness. Picador,<br />
New York, pp 123-127.<br />
Wingo, A., Briscione, M., Norrhelm, S.D., Jovanovic, T., Mc Cullough,<br />
S.A., et al. (2017). Psychological Resilience is associated with more<br />
intact social functioning in veterans with post-traumatic stress<br />
disorder and depression, <strong>Psychiatry</strong> Research, (249)1, pp 206-211.<br />
Ethelwyn Rebelo is a clinical psychologist working in private practice and has recently completed a PhD<br />
through the Department of <strong>Psychiatry</strong>, Faculty of Health Sciences, University of the Witwatersrand. She has spent<br />
a good part of her professional life based in psychiatric wards and psychiatric clinics. A full reference list is<br />
available from the author Correspondence: ethelwyn@live.co.za<br />
54 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
WINE FORUM<br />
Le Riche<br />
DECADES OF QUALITY,<br />
CONSISTENCY & ELEGANCE<br />
We were on the wagon in the bleachers<br />
at the New Year Newlands cricket test,<br />
my friend and me. Not that we’d overindulged<br />
during the festivities mind (well,<br />
not really…), but we’re not partial to the sponsor’s<br />
brew, and the wine on offer in the public bar was,<br />
well, unpotable. It was simple plonk from the<br />
country’s biggest volume brand which, considering<br />
we’re not wine snobs, was not the problem, but all<br />
three variants – white, pink and red – were sweet. Very<br />
sweet. Not for quenching a thirty-degree thirst…<br />
So, we sipped expensive, reverse-osmosis (‘pure’)<br />
water as we chewed the cud. Conversation turned to<br />
wine, as it does. My guest, who heads a well-known,<br />
top-end wine estate, mused that the journalistic<br />
space had been captured by the Young Guns, of<br />
whom I’ve written here before. Swartland grapes<br />
from ‘rediscovered’ old vineyards made into wine<br />
‘naturally’ with minimal intervention and without<br />
the addition of any of the multitude of permissible<br />
additives that can shape wine flavours, aged in old<br />
oak if any, and sold in minute tranches with usually<br />
heavy swing tickets. And attitude. Don’t forget the<br />
attitude…<br />
Well, it’s easy to sell small quantities of handreared<br />
wine at premium prices, suggested my<br />
guest in between overs, but producing and selling<br />
larger, economic volumes of high quality wine,<br />
consistently over time, is, well, more demanding. And<br />
to do it at an industry-sustaining premium – witness<br />
Boekenhoutskloof The Chocolate Block or Waterford’s<br />
The Jem – is quite astonishing.<br />
Which got me thinking of Etienne Le Riche. Now<br />
in the twilight of his cellar days, Le Riche has long<br />
advocated for both Cabernet Sauvignon and its<br />
home in Stellenbosch, regardless of contemporary<br />
fad or fashion. His mantra of ‘Quality, Consistency and<br />
Elegance’ has carried him through four decades of<br />
quality wine making.<br />
Le Riche spent twenty years<br />
as winemaker at the historic<br />
Rustenberg Estate, where he<br />
crafted the legendary 1982<br />
Cabernet Sauvignon and the<br />
famous, now erstwhile, Dry Red<br />
(a pre-crush blend of Cabernet<br />
Sauvignon and Cinsaut, if memory<br />
serves), and during which time he<br />
was named Wine Man of the Year<br />
by John Platter in his 1990 SA Wine Guide. But the<br />
winds of change blew through the property in the<br />
mid-Nineties, and Etienne went solo. Many felt at<br />
the time he was unfairly ‘pinged’ for the problems<br />
at Rustenberg and, whatever may have gone on<br />
behind the scenes, what followed showed it had<br />
nothing to do with his vintner’s expertise.<br />
Le Riche Wines has just celebrated its 21 st year.<br />
Etienne and long-time assistant winemaker Mark<br />
Daniels set up shop at a modest cellar in the<br />
Jonkershoek Valley named Leef op Hoop – Live on<br />
Hope – which was most appropriate considering<br />
their financial context! They needn’t have worried;<br />
accolades flowed for the wines they made from<br />
bought-in grapes – classic Stellenbosch Cabernet<br />
Sauvignon, quiet and retiring, even somewhat<br />
austere, but never obvious or fruity. A series of Platter<br />
5-stars commenced with the maiden 1997 Reserve,<br />
and the 2005 Reserve was Platter’s Red Wine of the<br />
Year.<br />
Duly qualified with both local and international<br />
cellar experience under the belt, son Christo joined<br />
dad as winemaker in 2010. Sister Yvonne, herself a<br />
Cape Wine Master who graduated in politics and<br />
economics and who had valuable experience in<br />
the cutting-edge British wine market, boarded the<br />
ship to look after marketing, sales and exports. All<br />
the while long-time cellarman Mark Daniels kept a<br />
meticulous eye on the tiller…<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 55
WINE FORUM<br />
In 2013 the Le Riche family built a winery at Raithby<br />
on the lower slopes of the Helderberg between<br />
Stellenbosch and Somerset West. There are no cabernet<br />
vines on the property; grapes continue to be sourced<br />
through now well-established relationships with growers<br />
in Jonkershoek, Firgrove and the Simonsberg. Le Riche<br />
likes the established model; each parcel is made into<br />
wine with care, respect and minimal intervention so that<br />
it can add its own personality to the final blend that is<br />
the better for the complexity multi-source grapes bring.<br />
Never sweet in the mouth, a bone-dry finish is taken as<br />
read.<br />
The Le Riches produce a creditable (and good<br />
value) Chardonnay (R130) because sometimes<br />
one needs a white wine, and then a brace of<br />
cabernets. Richesse (R140) is a lighter styled<br />
cabernet-led blend offering refreshment, while<br />
the more serious Cabernet Sauvignon (R210)<br />
and top-of-the-pile Cabernet Sauvignon Reserve<br />
(R500) reward cellaring. Indeed, there is currently<br />
a mature 2008 Reserve available at the cellar<br />
door for R950. Etienne is a founder member of the<br />
Cape Winemakers Guild and his CWG bottling<br />
of cabernet is highly contested at auction,<br />
averaging around R1000 in youth.<br />
Reams have been written about inter-generational<br />
farming and its succession planning. How do the<br />
Le Riche family manage it? ‘We have discussions,<br />
not arguments,’ offers Etienne. Christo – due to<br />
marry his New Yorker bride Whitney Ross before<br />
the <strong>2018</strong> harvest – is sage for his years: ‘A lot has<br />
changed over the past twenty years, but nothing<br />
is new…’<br />
LE RICHE WINES<br />
Address: 8 Raithby-Annandale Road,<br />
Raithby, 7130<br />
Email: wine@leriche.co.za<br />
Telephone: 021 842 3472<br />
Open for tastings and sales:<br />
Monday to Friday: 9:00 – 16:30 (Closed<br />
12:30 – 14:00)<br />
Saturday: By appointment<br />
www.leriche.co.za<br />
Left: Le Riche Cabernet Sauvignon 2014<br />
Right: Le Riche Cabernet Sauvignon Reserve 2014<br />
Christo, Etienne and Yvonne Le Riche<br />
Le Riche Wine Cellar, built in 2013 on the lower slopes of the Helderberg Mountain<br />
David Swingler is a writer and taster for Platter’s <strong>South</strong> <strong>African</strong> Wine Guide for 21 years to date.<br />
Dave Swingler has over the years consulted to restaurants, game lodges and convention<br />
centres, taught wine courses and contributed to radio, print and other media. A psychiatrist<br />
by day, he’s intrigued by language in general, and its application to wine in particular.<br />
Correspondence: swingler@telkomsa.net<br />
56 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
MOVIE REVIEW<br />
Victoria & Abdul<br />
a review by Franco P. Visser<br />
A BBC Films / Cross Street Films /<br />
Perfect World Pictures Presentation<br />
Lee Hall Screenplay<br />
Stephen Frears Director<br />
For almost 15 years Queen Victoria enjoyed<br />
an exceptionally close, platonic relationship<br />
with an Indian attendant named Abdul<br />
Karim. This caused such a great upheaval<br />
in the conservative and regimental structure, that<br />
characterised her household in the late 1800s, that<br />
many historians today regard the behaviour of the<br />
Queen’s household and family members towards<br />
Abdul as being racist and socially prejudiced.<br />
Not since Queen Victoria’s close relationship with<br />
another servant by the name<br />
of John Brown, that followed the<br />
untimely death of her husband<br />
Prince Albert on 14 December<br />
1861, have any of the Queen’s<br />
relations caused such a big stir.<br />
As the nearly 80 year-old<br />
monarch approached her<br />
golden jubilee in 1887, she<br />
showed a particular interest<br />
in the Indian subcontinent of<br />
which she was Queen Empress<br />
at the time. She requested<br />
that Indian servants attend to<br />
her and her guests at official<br />
state banquets, and it was<br />
during this time that Abdul<br />
along with a fellow compatriot<br />
found their way to England.<br />
Chosen to present a golden<br />
medal to Queen Victoria on<br />
the occasion of her golden<br />
jubilee, Abdul quickly found<br />
himself being in favour with the<br />
aging monarch. Such was the<br />
spark in their relationship that<br />
the Queen elevated Abdul from a mere servant in<br />
the royal household to the position of ‘Munshi and<br />
Indian Clerk to the Queen Empress’.<br />
This did not go down well with<br />
Queen Victoria’s Court, and family<br />
members and household staff<br />
alike made every attempt to thwart<br />
their growing relationship. Born the<br />
son of a lowly hospital assistant,<br />
Abdul hailed from a very humble<br />
background in Agra, too humble<br />
for the likes of the Queen’s eldest<br />
son and the senior household command. The film<br />
Victoria & Abdul is a portrayal of Abdul’s fascinating<br />
life at Court, a life that was not at all easy for him<br />
most of the time. Queen Victoria (played by Judi<br />
Dench) felt Prince Albert’s death all too keenly, and<br />
her grief and persistent mourning for her husband<br />
are well documented. It was<br />
clear that the prince Consort’s<br />
death left a huge gap in Queen<br />
Victoria’s life, leaving her feeling<br />
very lonely and isolated, even<br />
though she was surrounded by<br />
family members and a large<br />
Court contingent. She sought<br />
solace in the company of those<br />
who were removed from what<br />
she was used to on a daily<br />
basis, and the film portrays this<br />
vulnerable side of the formidable<br />
old Queen quite well. Abdul<br />
(played by Ali Fazal) on his part<br />
took on an almost paternal role<br />
towards the Queen and he was<br />
highly protective of her. Queen<br />
Victoria showered Abdul with<br />
praise and honours, bestowing<br />
upon him the Order of the Indian<br />
Empire and the Royal Victorian<br />
Order. She also provided servants<br />
for him, a private carriage,<br />
personal gifts in addition to<br />
commissioning several portraits<br />
of Abdul, all much to the chagrin of her family and<br />
household. Abdul taught the Queen the Urdu (then<br />
Hindustani) language. She kept meticulous notes in<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 57
MOVIE REVIEW<br />
special diaries that she kept on the instructions of<br />
her beloved Munshi.<br />
Playing the role of Queen Victoria is not Judi Dench’s<br />
first portrayal of the Queen, as she also played the<br />
role of the monarch in a film made about the Queen<br />
Victoria’s relationship with her Scottish servant John<br />
Brown. Titled ‘Mrs. Brown’, the film was released back<br />
in 1997. Historically speaking, one of the biggest<br />
injustices occurred shortly following the death of<br />
Queen Victoria, as her son, with the assistance of his<br />
family and senior courtiers, immediately set about<br />
erasing all traces of Abdul’s existence from court life.<br />
Queen Victoria’s own daughter, Princess Beatrice for<br />
example proceeded to re-write all of the Queen’s<br />
daily journals, some 121 volumes in total. In so doing,<br />
a wealth of information about the Queen was forever<br />
lost to history.<br />
IT IS INTERESTING TO NOTE THAT THE<br />
NEW KING ALSO ENGAGED IN THE SAME<br />
BEHAVIOUR AS HEIR APPARENT SHORTLY<br />
FOLLOWING THE DEATH OF JOHN BROWN IN<br />
1883. IN HIS MIND BOTH JOHN AND ABDUL<br />
POSED SERIOUS THREATS TO HIS POSITION<br />
AS THE HIGHEST-RANKING MALE IN THE<br />
LAND AND IT IS WELL KNOWN THAT QUEEN<br />
VICTORIA’S RELATIONSHIP WITH HER ELDEST<br />
SON WAS STRAINED AT BEST. EDWARD VII DID<br />
ALLOW ABDUL TO BE THE LAST PERSON TO<br />
SEE THE QUEEN’S BODY BEFORE THE CASKET<br />
WAS CLOSED. HE ALSO ALLOWED HIM TO<br />
FORM PART OF THE GROUP OF PRINCIPAL<br />
MOURNERS AND THE FUNERAL PROCESSION,<br />
ALTHOUGH THE REQUESTS FOR THESE<br />
CONCESSIONS CAME FROM HIS MOTHER<br />
BEFORE HER DEMISE AND WERE NO KIND<br />
GESTURES ON HIS PART TOWARDS ABDUL.<br />
Victoria & Abdul is mainly set in the beautiful<br />
surroundings of Osborne House on the Isle of<br />
Wight, the Italianate summer residence designed<br />
by Prince Albert and built between 1845 and 1851.<br />
It is at Osborne House that Queen Victoria died in<br />
January 1901, and it was here that a little more than<br />
a hundred years following her death a journalist<br />
started uncovering clues as to their special<br />
relationship. These clues ultimately led to the story of<br />
Queen Victoria and Abdul Karim being written into<br />
its rightful place in history – and obviously the basis<br />
of this film, one well worth viewing.<br />
Franco Visser is a psychologist and lecturer in Neuro-<br />
& Forensic Psychology at UNISA, Pretoria, <strong>South</strong> Africa.<br />
Correspondence: Visserp@unisa.co.za<br />
Victoria & Abdul<br />
58 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
SASOP MEDIA STATEMENT<br />
<strong>South</strong> <strong>African</strong> Society of Psychiatrists<br />
RECOVERY PLAN FOR THE<br />
GAUTENG<br />
DEPARTMENT OF HEALTH<br />
The <strong>South</strong> <strong>African</strong> Society of Psychiatrists<br />
(SASOP) welcomes the announcement on the<br />
26 th November 2017 by the Gauteng Premier,<br />
Mr David Makhura, together with National<br />
Minister of Health, the Honorable Dr Aaron Motsoaledi<br />
and Gauteng MEC of Health, Dr Gwen Ramakgopa,<br />
of the high-level intervention team to coordinate a<br />
recovery plan for the Gauteng Department of Health.<br />
Especially in view of the SASOP’s own calls in <strong>February</strong><br />
2017 and again in June 2017, for the complete<br />
overhaul of health and mental health care systems in<br />
Gauteng, but also in other provinces, such as Eastern<br />
Cape, Limpopo, Free State and Kwazulu-Natal. These<br />
calls, at the time, was based on Recommendation<br />
16 of the Health Ombud’s report into the Life<br />
Esidimeni (LE) deaths, which recommended<br />
that deinstitutionalization should occur with the<br />
integration, strengthening and resourcing of both the<br />
primary and specialist multidisciplinary mental health<br />
teams in districts and hospitals. 1<br />
The SASOP’s June statement on the state of mental<br />
health services in <strong>South</strong> Africa, based on reports from<br />
SASOP’s regional Subgroups at our Public Sector<br />
Group’s annual strategic meeting, attempted to also<br />
provide information on the state of affairs in other<br />
provinces and not only in Gauteng, as the first phase<br />
of completing the move of the surviving LE patients<br />
back to safe placements, were still in process. This<br />
statement was, however, unusually heavily criticized<br />
by the National Minister, both for the accuracy of the<br />
information it referred to, as well as for the fact that a<br />
professional body such as SASOP has communicated<br />
this information publicly. 2 The Honorable Minister also<br />
alluded to the challenges in recruiting and retaining<br />
specialists, in this case psychiatrists to, in particular,<br />
more rural provinces such as Limpopo Province.<br />
In response to this criticism, the SASOP was<br />
subsequently able to meet with the national Ministerial<br />
Advisory Committee in August 2017, as well as with the<br />
MEC’s and Departments of Health of Mpumalanga<br />
and Eastern Cape, after requesting meetings with<br />
the Minister’s office as well as with MECs of Health of<br />
five provinces. On these occasions, it was confirmed<br />
that the information from the provinces reported on<br />
by the SASOP, actually concurred not only with these<br />
visited provinces’ own assessments, but also with<br />
the report on the audit of provincial mental health<br />
services, conducted by the National Department of<br />
Health itself. Similar information was also released by<br />
the provincial departments of health who all made<br />
submissions and presentations to the <strong>South</strong> <strong>African</strong><br />
Human Rights Commission earlier in November 2017,<br />
during its recent national hearing held on the status<br />
of mental health in <strong>South</strong> Africa.<br />
As the collective professional body representing<br />
more than 90% of the about 700 psychiatrists and<br />
psychiatric registrars in the country, the SASOP has<br />
been reporting on mental health care conditions<br />
in the rest of the country, in lieu of its incorporated<br />
objectives and responsibility to monitor, evaluate and<br />
advise on policies related to the delivery of clinical<br />
services and the protection of patients’ rights; and to<br />
promote and uphold the principles of human rights,<br />
dignity and ethics in the practice of <strong>Psychiatry</strong>. While<br />
the SASOP understands and uphold the principle of<br />
1<br />
Office of Health Standard Compliance. Health ombudsperson report into the ‘Circumstances surrounding the death<br />
of mentally ill patients: Gauteng Province’. http://ohsc.org.za/wp-content/uploads/2017/09/FINALREPORT.pdf<br />
p 55. This investigation has clearly shown that for deinstitutionalisation to be undertaken properly, the primary and specialist<br />
multidisciplinary teams that are community based mental health care services must be focused upon, must be resourced and must<br />
be developed before the process is started. It will most probably require more financial and human resource investment initially for<br />
deinstitutionalisation to take root. Sufficient budget should be allocated for the implementation<br />
2<br />
Minister Aaron Motsoaledi: Media briefing on matters of National importance in Health. 29 Jun 2017 Statement by<br />
Minister of Health, Dr Aaron Motsoaledi on matters of National Importance in Health. https://www.gov.za/speeches/<br />
minister-aaron-motsoaledi-media-briefing-national-health-insurance-white-paper-29-jun-2017<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 59
SASOP MEDIA STATEMENT<br />
available “internal mechanisms” in terms of which its<br />
individual state employed members will attempt to<br />
resolve issues and report problems, the SASOP as a<br />
national professional organization, is also expected<br />
to resort to “external mechanisms” to address issues.<br />
It is therefore compelled to provide direct support for<br />
health professionals in high-risk situations under the<br />
auspices of the professional association; to establish<br />
an independent oversight and reporting structure to<br />
play a monitoring role, as well as engage publicly to<br />
raise awareness in the profession and the public of<br />
possible dual-loyalty problems, and to advocate for<br />
legal, administrative and social changes that will<br />
enable professionals and service providers to respect,<br />
protect and fulfil the human rights of their patients.<br />
The SASOP further concurs with the notion that not<br />
enough psychiatrists are currently available or trained<br />
and that an urgent review of the number of psychiatrists<br />
needed in the country should be undertaken. The<br />
current estimated about 1 psychiatrist per 100,000<br />
of the <strong>South</strong> <strong>African</strong> population, and even less, 0.4<br />
(state sector psychiatrists) per 100,000 according to<br />
the WHO Global Health Observatory data, seemed<br />
to be grossly inadequate. 3 To train more psychiatrists<br />
than the average number of 35 who currently qualify<br />
annually in order to achieve a modestly improved<br />
ratio of 1.5/100,000, the current training capacity and<br />
number of available registrar training posts at the<br />
eight medical schools country-wide, may have to be<br />
increased drastically.<br />
The SASOP also supports the development of new<br />
business models for delivering integrated care<br />
by available public and private practitioners in<br />
innovative public-private partnership projects where<br />
uniform baskets of care have been determined, in the<br />
context of realistic and fair remuneration of services<br />
rendered on different levels of care.<br />
The SASOP therefore also recently strongly supported<br />
and participated in the Gauteng MEC of Health, Dr<br />
Gwen Ramakgopa’s initiatives to further develop<br />
the narrative on mental health care in Gauteng<br />
following the LE disaster, through the Gauteng Mental<br />
Health Summit held on the 31 st October 2017. A new<br />
declaration was adopted and a renewed pledge<br />
was undertaken at this occasion to prioritize mental<br />
health care and to put it firmly onto the health<br />
agenda, to eradicate the stigma still associated with<br />
mental health illness and care, to recognize that<br />
mental health is the cornerstone of people’s health<br />
and also, importantly, to break the silence about<br />
mental health issues and about issues in the mental<br />
health care delivery system.<br />
SASOP Board<br />
Johannesburg<br />
3<br />
WHO. Global Health Observatory (GHO) data. Updated 2015. http://apps.who.int/gho/data/node.main.<br />
MHHR?lang=en<br />
JOIN OUR TEAM<br />
NELSPRUIT<br />
The Akeso Group has a national footprint<br />
of psychiatric hospitals. Its newest<br />
hospital, based in Nelspruit, is seeking to<br />
expand its team by inviting all interested<br />
SA-registered psychiatrists to consider<br />
setting up a practice within the hospital,<br />
enjoying full admission rights. The team is<br />
still small, and there is a great opportunity<br />
to grow a practice in this medically underresourced<br />
but fast-growing area. There<br />
are just a few psychiatrists covering an<br />
extensive region, and there is a great<br />
opportunity to establish a practice in the<br />
area, especially now that there is a 75<br />
bedded specialist psychiatric hospital offering<br />
comprehensive treatment.<br />
60 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong><br />
For all enquiries, please contact the Hospital Manager,<br />
Maggie Oberholzer on maggie.o@akeso.co.za or +27 (0) 87 098 0460
SASOP ANNOUNCEMENT<br />
SOUTH AFRICAN SOCIETY OF PSYCHIATISTS<br />
SASOP POSITION<br />
STATEMENT ON<br />
CANNABIS<br />
Compiled by the Addictions SIG<br />
<strong>South</strong> Africa, like many other countries, has<br />
recently found itself having to re-assess<br />
current laws pertaining to the availability and<br />
safety of the cannabis plant and its products.<br />
SASOP notes with concern a growing public<br />
perception of cannabis as a ‘harmless’ plant, and that<br />
few measures have been instituted to address this.<br />
The Global Burden of Diseases Study (2010)<br />
estimates that 2 million years lived with disability<br />
were attributed to cannabis (Degenhardt et al,<br />
2013). The <strong>South</strong> <strong>African</strong> Community Epidemiology<br />
Network on Drug Use (SACENDU) reports that, during<br />
the 2 nd half of 2016, cannabis was the most common<br />
primary substance of abuse for persons younger<br />
than 20 years presenting to treatment facilities in all<br />
areas across <strong>South</strong> Africa, except for the Free State,<br />
Northern Cape and North West. It is estimated that<br />
1 in 6 teenagers who experiment with cannabis will<br />
become addicted to it (Volkow et al, 2014).<br />
Human brain development and maturation is a<br />
process that is guided by the body’s endogenous<br />
cannabinoid system and occurs until the early 20’s.<br />
Exposure to phyto-cannabinoids (cannabinoids<br />
obtained from the cannabis plant) during this<br />
vulnerable period may disrupt the process of brain<br />
maturation and affect aspects of memory, attention,<br />
processing speed and overall intelligence (WHO,<br />
2016). Cannabis use during the adolescent period<br />
may cause lasting cognitive deficits, even after<br />
sustained abstinence (Meier et al, 2012).<br />
A review article by the WHO (2016) concluded that<br />
current evidence points to a modest contributory<br />
causal role for cannabis in schizophrenia and<br />
that a consistent dose-response relationship exists<br />
between cannabis use in adolescence and the risk<br />
of developing psychotic symptoms or schizophrenia.<br />
RECOMMENDATIONS<br />
1. Any change to the legislation regulating<br />
cannabis use should be undertaken in<br />
consultation with all the relevant stakeholders,<br />
be based on good quality scientific evidence<br />
and take into consideration the availability and<br />
accessibility of current drug addiction treatment<br />
resources in <strong>South</strong> Africa.<br />
2. SASOP concurs with the Executive Committee<br />
of the Central Drug Authority (CDA) of <strong>South</strong><br />
Africa that the approaches to combat the use<br />
and abuse of psychoactive substances should<br />
include harm reduction (interventions aimed at<br />
reducing the harmful consequences associated<br />
with substance use), supply reduction and<br />
demand reduction/preventative strategies<br />
(Stein, 2016).<br />
3. SASOP agrees with the Executive Committee<br />
of the CDA that there is currently insufficient<br />
evidence to predict the long-term<br />
consequences of the legalization of cannabis.<br />
The ease of accessing an intoxicating substance<br />
may have an underestimated impact on the<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 61
SASOP ANNOUNCEMENT<br />
SOUTH AFRICAN SOCIETY OF<br />
PSYCHIATRISTS<br />
initiation, frequency and amount of use, and<br />
the subsequent risk of developing a substance<br />
use disorder (Budney et al, 2017). Legalization<br />
should therefore not be considered at this point.<br />
4. The decriminalisation of cannabis removes the<br />
criminal penalty related to the use of cannabis; it<br />
allows for a distinction between a drug dealer and<br />
an individual experimenting with or addicted to<br />
a drug. While SASOP supports the human rights<br />
of all individuals, we argue that a decision to<br />
protect those addicted to substances should not<br />
be viewed as a simple binary decision based on<br />
criminal penalties. In 2001 Portugal augmented<br />
the decriminalization of illicit substances with<br />
drug dissuasion commissions, increased the<br />
number of facilities offering detoxification and<br />
therapeutic admissions, increased the number<br />
of drug education campaigns and refocused<br />
policing efforts on large scale trafficking<br />
operations. The decriminalization of cannabis<br />
must be preceded by and augmented with<br />
similar socially responsible strategies for it to be<br />
successful in <strong>South</strong> Africa.<br />
5. Available evidence does not support the<br />
strong positive public opinion and anecdotal<br />
reports favouring medicinal cannabis, except<br />
for its demonstrated benefits for chronic pain,<br />
spasticity due to Multiple Sclerosis and weight<br />
loss associated with HIV (Whiting et al, 2015).<br />
Good quality evidence does however exist<br />
regarding the frequently occurring side effects of<br />
cannabis such as confusion, dizziness, diarrhea,<br />
euphoria, fatigue and hallucinations (Whiting et<br />
al, 2015).<br />
Any potential benefit obtained from cannabis<br />
must therefore be weighed against its risk<br />
of causing addiction, psychosis, cognitive<br />
impairments and a 2.6 times greater likelihood<br />
of motor vehicle accidents (Li et al, 2012). SASOP<br />
further notes with concern the growing evidence<br />
linking cannabis use with an increased risk of an<br />
acute myocardial infarction (Mittleman et al,<br />
2001; Goya et al, 2017) as well as an ischaemic<br />
stroke (Wolff et al, 2011; Hackam et al, 2015;<br />
Rumalla et al, 2016).<br />
6. SASOP commends the Medicine Control<br />
Council decision to limit the use of cannabis<br />
for medicinal purposes to registered prescribers<br />
and for individuals in which an acceptable<br />
justification is provided.<br />
7. SASOP supports ongoing research on the use<br />
of cannabis for medicinal purposes to ensure<br />
that its purported and potential benefits can<br />
be scientifically measured against medical and<br />
societal risks.<br />
December 2017<br />
REFERENCES:<br />
Budney, A.J., Borodovsky, J.T., The potential impact<br />
of cannabis legalization on the development of<br />
cannabis use disorders, Prev. Med. (2017), http://<br />
dx.doi.org/10.1016/j.ypmed.2017.06.034<br />
Degenhardt L, Ferrari AJ, Calabria B, et al. The<br />
global epidemiology and contribution of cannabis<br />
use and dependence to the global burden of<br />
disease: results from the GBD 2010 study. PLoS One.<br />
2013;8(10):e76635.<br />
Goyal H, Awad HH, Ghali JK. Role of cannabis<br />
in cardiovascular disorders. Journal of Thoracic<br />
Disease 2017;3(2).<br />
Hall W, Renström M, Poznyak V. The health and social<br />
effects of nonmedical cannabis use.: World Health<br />
Organization; 2016.<br />
Hackam DG. Cannabis and stroke: systematic<br />
appraisal of case reports. Stroke 2015;46:852-6<br />
http://www.mrc.ac.za/adarg/sacendu/<br />
SACENDUBriefJuly2017.pdf<br />
Li MC, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li<br />
G (2012). Marijuana use and motor vehicle crashes.<br />
Epidemiol Rev. 34(1):65–72<br />
Meier MH, Caspi A, Ambler A, Harrington H, Houts<br />
R, Keefe RS, et al. (2012). Persistent cannabis users<br />
show neuropsychological decline from childhood to<br />
midlife. Proc Natl Acad Sci U S A. 109(40):E2657–64.<br />
Mittleman MA, Lewis RA, Maclure M, et al. Triggering<br />
myocardial infarction by marijuana. Circulation<br />
2001;103:2805-9<br />
Rumalla K, Reddy AY, Mittal MK. Recreational<br />
marijuana use and acute ischemic stroke: A<br />
population-based analysis of hospitalized patients<br />
in the United States. J Neurol Sci 2016;364:191-6<br />
Stein DJ. Position statement on cannabis. SAMJ:<br />
<strong>South</strong> <strong>African</strong> Medical Journal 2016;106(6):569-570.<br />
Volkow ND, Baler RD, Compton WM, Weiss SR.<br />
Adverse health effects of marijuana use. N Engl J<br />
Med. 2014;370(23):2219-2227.<br />
Whiting PF, Wolff RF, Deshpande S, Di Nisio M, Duffy<br />
S, Hernandez AV, et al. Cannabinoids for medical<br />
use: a systematic review and meta-analysis. JAMA<br />
2015;313(24):2456-2473.<br />
Wolff V, Lauer V, Rouyer O, et al. Cannabis use,<br />
ischemic stroke, and multifocal intracranial<br />
vasoconstriction: a prospective study in 48<br />
consecutive young patients. Stroke 2011;42:1778-<br />
80.<br />
62 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
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SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 63
SASOP REPORT<br />
ON THE 17 th AND 18 th FEBRUARY, THE<br />
SASOP<br />
S P E C I A L<br />
INTEREST GROUP<br />
FOR ADULT ADHD<br />
HOSTED A TRAIN-THE-TRAINER WORKSHOP AT<br />
THE EVERTSDAL GUEST HOUSE, DURBANVILLE.<br />
The purpose of the Train-the-trainer workshop<br />
was to provide training to members of<br />
the SASOP adult ADHD SIG, and a few<br />
colleagues with a special interest in<br />
ADHD, to ensure alignment in diagnostic and<br />
management aspects of adult ADHD. Attendance<br />
and participation in this workshop provided<br />
endorsement to individual SIG members to act<br />
as trainers. This enables the SIG to decentralise<br />
training of other health care providers<br />
(psychiatrists, registrars, general practitioners,<br />
and other health care professionals).<br />
The venue and refreshments were kindly provided<br />
by Shire.<br />
Congratulations to the newly<br />
endorsed adult ADHD trainers!<br />
Presentations included:<br />
Dr Renata Schoeman (co-convenor of the<br />
SIG): the neurobiology of ADHD, the diagnosis<br />
of adult ADHD, pharmacological and nonpharmacological<br />
interventions for ADHD,<br />
workplace interventions for ADHD<br />
Dr Eleanor Holzapfel: neuropsychology of ADHD,<br />
adult ADHD and substance use disorders, and<br />
psychotherapeutic interventions for adult ADHD<br />
Dr Rykie Liebenberg (convenor of the SIG):<br />
comorbidity in adult ADHD, lifestyle intervention<br />
for adult ADHD and ethical considerations in<br />
adult ADHD<br />
Front (from left to right): Drs Rudolph Hiemstra, Ralph Gilbert, Rykie Liebenberg,<br />
Chanakya Jonnalagadda, Renata Schoeman<br />
Back (from left to right): Drs Annelise Groenewoud, Suntheren Pillay, Eleanor<br />
Holzapfel, Anton Kruger, Michelle King, Michael Reid, Chris Verster<br />
64 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
SASOP HEADLINE<br />
FEBRUARY<strong>2018</strong><br />
As I write, people all over the<br />
country are returning from their<br />
annual summer break and are<br />
preparing for a new year. I trust<br />
that most of you have had a<br />
good break and wish you all<br />
the best for <strong>2018</strong>.<br />
The month of January derives<br />
its name from the Latin word<br />
Januarius (mensis) ‘(month)<br />
of Janus’, the Roman god who<br />
presided over doors and beginnings. He is typically<br />
depicted with two faces – one looking back, and the<br />
other looking forward. As a Society of Psychiatrists,<br />
we look back on a year that was eventful for various<br />
reasons, and one that saw many of our colleagues<br />
addressing issues specifically in the media (e.g.<br />
regarding the Life Esidimeni tragedy). We can<br />
expect to see much more of this work as we look<br />
forward to <strong>2018</strong>, and continue with our mandate<br />
to “promote, maintain and protect the honour and<br />
interests of members, the discipline of <strong>Psychiatry</strong> as<br />
a medical speciality and to serve the community”.<br />
Our “outbound communication” has certainly been<br />
stepped up.<br />
This SASOP newsletter, Headline, that is published<br />
four times a year forms part of our “inbound<br />
communication”. Its purpose is to keep members<br />
informed about what SASOP is doing as an<br />
organization. A great deal of important work is<br />
undertaken by members at various levels, and<br />
communication amongst ourselves is vital if we are<br />
to present a co-ordinated approach to the issues<br />
that concern us and our patients. In <strong>2018</strong>, I hope<br />
to present a modified (and hopefully more relevant)<br />
Headline to you, so that SASOP will benefit from the<br />
interaction of its diverse membership. I look forward<br />
to receiving your comments and input.<br />
Dr Ian Westmore (Editor)<br />
January <strong>2018</strong><br />
BEST WISHES FOR <strong>2018</strong> ON BEHALF OF THE<br />
SASOP BOARD AND MYSELF.<br />
Looking back on 2017, we had quite an eventful<br />
year with the Life Esidimeni tragedy still dominating<br />
the news throughout until November, when the<br />
arbitration hearings - chaired by retired deputy<br />
chief-justice Digkang Moseneki, went into recess.<br />
Mvuyiso Talatala did an excellent job in his testimony<br />
to the arbitration tribunal, highlighting the pertinent<br />
issues preceding the decision by the Gauteng<br />
Department of Health officials to terminate the care<br />
contract of more than 1700 long-term service users.<br />
Through his and others’ evidence it was possible<br />
to show how the Department continued to dismiss<br />
all warnings, despite being engaged by SASOP,<br />
Section 27, SADAG and the SAMHF in legal action to<br />
appoint a curator and subsequently an interdict to<br />
prevent the move. These hearings will recommence<br />
later in January <strong>2018</strong>, with the much anticipated<br />
testimony of the previous MEC for Health, Ms Qedani<br />
Mahlangu.<br />
THE SASOP BOARD ALSO CONTINUED<br />
WITH OUR ATTEMPTS TO ENGAGE HEALTH<br />
DEPARTMENTS OF OTHER PROVINCES,<br />
AFTER THE SASOP PRESS RELEASE IN JUNE<br />
2017 ON THE APPALLING STATE OF MENTAL<br />
HEALTH SERVICES ACROSS THE COUNTRY.<br />
AS A RESULT, DISCUSSIONS WERE HELD WITH<br />
THE MINISTERIAL ADVISORY COMMITTEE IN<br />
AUGUST, AS WELL AS WITH THE PROVINCIAL<br />
MECS FOR HEALTH OF MPUMALANGA AND<br />
THE EASTERN CAPE. WE RECEIVED A RATHER<br />
STANDARD WRITTEN RESPONSE FROM THE<br />
WESTERN CAPE DEPARTMENT OF HEALTH,<br />
WHILE SASOP BOARD MEMBERS WERE ALSO<br />
INVITED TO MEET WITH THE NEW GAUTENG<br />
MEC OF HEALTH, DR GWEN RAMAKGOPA IN<br />
DECEMBER 2017.<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 65
SASOP HEADLINE<br />
Since the Biological Congress in September, there<br />
was another very successful Registrar Finishing<br />
School in November 2017 - as before, very well<br />
organized and overseen by Ian Westmore, Chair of<br />
the Mentorship Division. While we had another Board<br />
meeting on the 4th November, a new initiative to<br />
explore closer collaboration between SASOP’s public<br />
and private sector groups has also been started. This<br />
happened by means of a joint meeting between<br />
the SASOP and the PsychMG Boards, facilitated by<br />
Prof Arnold Smit from the University of Stellenbosch<br />
Business School. The meeting explored the future<br />
of public-private collaboration in psychiatric and<br />
mental healthcare in <strong>South</strong> Africa. The conversation<br />
was set against the background of the changing<br />
national healthcare landscape on the one hand<br />
and existing SASOP and PsychMG structures and<br />
processes on the other. In these communications,<br />
a number of parallel processes concurrently<br />
happening in both sectors were recognized and it<br />
is being argued that, if such common streams can<br />
be identified, both the SASOP vocational groups will<br />
eventually be better positioned towards and within<br />
the context of implementing the NHI, as well as in<br />
the different respective efforts to engage with public<br />
sector employer(s) and private sector funders.<br />
A DECISION WAS THUS MADE BY THE<br />
COMBINED BOARDS TO FORM A SASOP<br />
PUBSEC-PSYCHMG WORKING GROUP<br />
(SASOP PP-WG) ON PROMOTING ACCESS<br />
TO APPROPRIATE PSYCHIATRIC AND<br />
MENTAL HEALTH CARE IN SOUTH AFRICA.<br />
THIS WORKING GROUP WILL CONTINUE<br />
ITS DISCUSSIONS DURING <strong>2018</strong> AND WILL<br />
REPORT TO THE SASOP MEMBERSHIP DURING<br />
THE NATIONAL SASOP CONGRESS IN<br />
SEPTEMBER <strong>2018</strong>.<br />
A final press statement for 2017 was released on the<br />
1 st December, following the Gauteng Department<br />
of Health’s high-level intervention team appointed<br />
to coordinate a recovery plan for the Department.<br />
Although the initiative was welcomed, it was noted<br />
that the Department should also not lose sight of<br />
the overall inadequate number of psychiatrists<br />
nationwide and the issues arising as a result on a<br />
provincial level across the country. On average,<br />
there is currently only 1 psychiatrist per 100,000 of<br />
the <strong>South</strong> <strong>African</strong> population, and in the state sector<br />
even less - according to the WHO Global Health<br />
Observatory data of 2015. To train more psychiatrists<br />
than the average about 35 who currently qualify<br />
annually in order to achieve a modestly improved<br />
ratio of 1.5/100,000, the current training capacity<br />
and number of available registrar training posts<br />
at the eight medical schools country-wide, would<br />
probably have to be increased drastically.<br />
THIS BRINGS US TO THIS YEAR, THE SECOND<br />
PART OF THE CURRENT 2016-<strong>2018</strong> TERM OF<br />
OFFICE, WITH THE FOLLOWING ITEMS ON THE<br />
AGENDA:<br />
• SASOP and the Rural Health Advocacy Project joint<br />
CPD meetings in different provinces to improve<br />
knowledge and awareness on how to advocate<br />
for mental health.<br />
• SASOP partnering to host a travelling exhibition<br />
raising awareness about abuse of the human<br />
rights of mental health care users.<br />
• SASOP governance and service delivery.<br />
• SASOP’s continued media activity.<br />
• SASOP fundraising and sponsorship.<br />
• Participation in the 5 th Global Mental Health<br />
Summit in <strong>February</strong> <strong>2018</strong>.<br />
• Participating with the College of <strong>Psychiatry</strong> in a<br />
study on the need for, and training of psychiatrists<br />
in SA.<br />
• A SASOP position statement on cannabis.<br />
• A SASOP endorsed guide on disability assessment.<br />
• A review of the SASOP Strategic Business Overview<br />
for 2014-<strong>2018</strong>.<br />
We wish you a very prosperous and<br />
productive year ahead.<br />
Bernard Janse van Rensburg<br />
SASOP President 2016-<strong>2018</strong><br />
66 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
SASOP HEADLINE<br />
3. THE REGISTRAR<br />
FINISHING SCHOOL 2017<br />
In November 2017, the fifth annual Registrar Finishing<br />
School (RFS) was held in Johannesburg. This year,<br />
the event was sponsored by Lundbeck and Adcock-<br />
Ingram, as well as SASOP/PsychMG. (This was the<br />
first time that the Society has not only been part<br />
of the organizing and presenting team, but also a<br />
sponsor). We had 27 enthusiastic registrars attending<br />
from various provinces.<br />
THE RFS HAS BECOME AN IMPORTANT EVENT<br />
IN THE SASOP MENTORSHIP PROGRAM, AND<br />
IN 2017 THE PROGRAM WAS ADJUSTED<br />
TO MAKE IT EVEN MORE RELEVANT TO THE<br />
NEEDS OF THE ATTENDEES. ITS AIM IS TO<br />
PROVIDE REGISTRARS IN THEIR FINAL YEAR<br />
WITH A “SNAPSHOT” OF WHAT TO EXPECT<br />
IN BOTH THE PUBLIC AND PRIVATE SECTORS<br />
UPON QUALIFYING AS PSYCHIATRISTS, AND<br />
TO PREPARE THEM FOR THE ROLES THAT<br />
THEY WILL BE UNDERTAKING IN BOTH. IT WAS<br />
A CONSIDERABLE CHALLENGE FOR THE<br />
ORGANIZERS IN THAT THE PROGRAM WAS<br />
CONDENSED TO 1.5 DAYS AND THERE WAS<br />
A MOVE BACK TO MORE GROUP ORIENTED<br />
WORK AND LESS DIDACTIC TEACHING. IN<br />
THE GROUP WORK SPECIFICALLY THERE WAS<br />
LIVELY DEBATE AROUND THREE SPECIFIC<br />
THEMES: RELATIONSHIPS (PERSONAL AND<br />
PROFESSIONAL); THE WORK-LIFE BALANCE,<br />
AND THE FUTURE OF SOUTH AFRICAN<br />
PSYCHIATRY.<br />
A highlight for both the presenters and the registrars<br />
this year, was a presentation by Dr Hoepie Howell<br />
at the Friday night dinner. Dr Howell was the coordinator<br />
of the RFS until 2016 and is an experienced<br />
psychiatrist who has worked in both the private<br />
and public sectors, the military, overseas and in<br />
the pharmaceutical industry. She reflected on her<br />
“dance” with <strong>Psychiatry</strong> over the decades and her<br />
talk was typically unique, moving and inspirational.<br />
We hope to share this with a broader audience in<br />
the next issue of <strong>South</strong> <strong>African</strong> <strong>Psychiatry</strong>.<br />
Every year, we are reminded of the need for such an<br />
event, as the feedback is overwhelmingly positive,<br />
and 2017 was no exception. We will be commencing<br />
with the planning for RFS <strong>2018</strong> shortly – this year we<br />
hope to offer an additional training event for newly<br />
qualified psychiatrists who enter private practice,<br />
and that follows on from the introductions of the RFS.<br />
A “Manual for Private Practice” will be compiled and<br />
be used as reference point in these workshops.<br />
Dr I Westmore<br />
FACILITATED JOINT MEETING OF SASOP<br />
AND PSYCHMG BOARDS ON A SASOP<br />
PUBLIC-PRIVATE ALLIANCE.<br />
A facilitated joint meeting of the combined Boards<br />
of Directors of SASOP and PsychMG was held on<br />
the 4 th November 2017, at the Intercontinental<br />
Hotel, O.R. Tambo International Airport. The meeting<br />
was facilitated by Prof Arnold Smit, from the USB<br />
(University of Stellenbosch Business School) and<br />
explored the future of public-private collaboration in<br />
psychiatric and mental healthcare in <strong>South</strong> Africa.<br />
The conversation was set against the background<br />
of the changing national healthcare landscape on<br />
the one hand and existing SASOP and PsychMG<br />
structures and processes on the other. The<br />
facilitation of the meeting was guided by themes<br />
and questions such as the historic SASOP/PsychMG<br />
relationship, the current service delivery environment<br />
and envisioning the future.<br />
Bernard J/V Rensburg, 1,2 Indhrin Chetty, 1 Ian Westmore, 2 Peet Kotze (HM),<br />
Eugene Allers, 2 Amos Poto, 2 Thabo Rangaka, 2 Prof Arnold Smit (USB), Kali<br />
Tricoridis, 2 Mvuyiso Talatala, 1,2 Mpho Mhlongo, 2 Renata Schoeman, 2 Lerato<br />
Dikobe, 2 Bonga Chiliza, 1 Anusha Lachman, 1 Johann Serfontein (HM), Sebo<br />
Seape, 1,2 Lesley Robertson 1 ;<br />
HM – Healthman; 1 - SASOP Board ; 2 - PsychMG Board<br />
Prof Arnold Smit<br />
Joint SASOP and PsychMG Board meeting<br />
SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong> * 67
68 * SOUTH AFRICAN PSYCHIATRY ISSUE 14 <strong>2018</strong>
The fine art of mental health treatment<br />
HOLDING onto MEMORIES<br />
Ebitine<br />
MEMANTINE HYDROCHLORIDE<br />
S4 Ebitine 10 mg. Each film-coated tablet contains memantine hydrochloride 10 mg. Reg. No. 45/32.16/0496.<br />
For full prescribing information, refer to the package insert approved by the medicines regulatory authority.<br />
1046988 08/2017 Adcock Ingram Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021. Tel.<br />
+27 11 635 0000 www.adcock.com
Restored Sleep<br />
The<br />
Definition:<br />
• An effective hypnotic 1<br />
• ‘Intermediate’ half-life (6 - 8 hours) 1,2<br />
• Unaltered REM sleep 1,3<br />
• Rapid sleep onset and maintenance of sleep 1,2<br />
• Refreshed morning awakening 1<br />
• Helps reduce anxiety symptoms associated<br />
with insomnia 1,4,5<br />
- Caution should be exercised in patients suffering from anxiety<br />
accompanied by an underlying depressive disorder<br />
References: 1. Clark BG, Jue SG, Dawson GW, et al. Loprazolam - A Preliminary Review of its Pharmacodynamic Properties and Therapeutic Efficacy in Insomnia. Drugs. 1986:31(6):500-516. 2. Dormonoct ®<br />
2 mg package insert. 3. Salkind MR, Silverstone T. The Clinical and Psychometric Evaluation of a new Hypnotic Drug, Loprazolam, in General Practice. Curr Med Res Opin. 1983;8(5):368-374. 4. McInnes GT,<br />
Bunting EA, Ings RMJ, et al. Pharmacokinetics and Pharmacodynamics Following Single and Repeated Nightly Administrations of Loprazolam, a new Benzodiazepine Hypnotic. Br J Clin Pharmac.1985:<br />
19:649-656. 5. Botter PA. A comparative Double-blind Study of Loprazolam, 1 mg and 2 mg, Versus Placebo in Anxiety-induced Insomnia. Curr Med Res Opin. 183;8(9):626-630.<br />
For full prescribing information refer to the package insert approved by the medicines regulatory authority.<br />
SCHEDULING STATUS: S5 PROPRIETARY NAME (AND DOSAGE FORM): Dormonoct ® 2 mg. COMPOSITION: Dormonoct ® 2 mg: Each tablet contains 2,49 mg loprazolam mesylate, equivalent to 2 mg loprazolam.<br />
PHARMACOLOGICAL CLASSIFICATION: A 2.2. Sedatives, hypnotics. REGISTRATION NUMBER: Dormonoct ® 2 mg: Q/2.2/355. NAME AND ADDRESS OF THE HOLDER OF THE CERTIFICATE OF REGISTRATION:<br />
sanofi-aventis south africa (pty) ltd., Reg. No. 1996/010381/07, 2 Bond Street, Midrand, 1685, <strong>South</strong> Africa. Tel + 27 (0)11 256 3700, Fax +27 (0)11 256 3707. www.sanofi-aventis.com SAZA.LOME.16.11.0952