South African Psychiatry - November 2018

ISSN 2409-5699 

ABOUT the discipline FOR FOR the the discipline discipline issue 17 • NOVEMBER 2018 

CLINICAL & SOCIAL ASPECTS OF 

PERINATAL 

DEPRESSION 

THE GENOCIDE 

OF PSYCHIATRIC 

PATIENTS 

DEADLY 

MEDICINE 

PUBLISHED IN ASSOCIATION WITH THE SOUTH AFRICAN SOCIETY OF PSYCHIATRISTS 

MINISTERIAL 

MENTAL HEALTH 

S U M M I T 

EQUINE ASSISTED 

PSYCHOTHERAPY 

www.southafricanpsychiatry.co.za

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M1617 Dec-17.

Features 


7 

PSYCHOTHERAPY 

CLINICAL AND SOCIAL 

ASPECTS OF 

18 

PERINATAL DEPRESSION 

THE GENOCIDE OF 

PSYCHIATRIC PATIENTS 

24 

DEADLY 

30 

MEDICINE 

MINISTERIAL MENTAL HEALTH 

SUMMIT 

35 

IN LONDON 

NOTE: “instructions to authors” are available at www.southafricanpsychiatry.co.za 

SOUTH AFRICAN PSYCHIATRY ISSUE 17 2018 * 3

CONTENTS 

CONTENTSNOVEMBER 2018 

5 FROM THE EDITOR 

16 GLOBAL PSYCHIATRY 

21 SHOOTING WAR 

35 MINISTERIAL MENTAL HEALTH SUMMIT IN LONDON 

39 THE 4 TH ANNUAL AFCNP CONGRESS 

40 NEW HORIZONS 

42 THE LUNDBECK FOCUS DAY 

44 LUNDBECK BREAKFAST SYMPOSIUM 

46 DEPARTMENTS OF PSYCHIATRY NEWS 

52 MENTAL HEALTH FUN WALK – TARA HOSPITAL 

56 BUTTERFLIES & MOUNTAIN VIEWS 

59 CULINARY CORNER 

65 MOVIE REVIEW: THE DRESSMAKER 

68 TRAIN-THE-TRAINEE WORKSHOP 

71 THE ABC OF CBT FOR ADHD 

72 NATIONAL HEALTH INSURANCE BILL, 2018 

86 RESPONSE TO THE POLICY GUIDELINES 

7 EQUINE ASSISTED PSYCHOTHERAPY IN A SOUTH AFRICAN 

FORENSIC SETTING: A DESCRIPTIVE REPORT 

18 CLINICAL AND SOCIAL ASPECTS OF PERINATAL DEPRESSION IN 

SOUTH AFRICA 

22 JANSSEN PROUDLY CELEBRATES 60 YEARS IN MENTAL HEALTH 

24 THE GENOCIDE OF PSYCHIATRIC PATIENTS THROUGH 

THOUGHTLESSNESS & EVIL COMPLIANCE 

30 DEADLY MEDICINE THE MARK OF THE LIFE ESIDIMENI DECANTING 

37 WORLD PSYCHIATRIC ASSOCIATION’S EPIDEMIOLOGY MEETING 

2018 

51 OVER 700 PEOPLE UNITED FOR MENTAL HEALTH WALK 

63 WINE FORUM: / HANNUWA / – PIPE-DREAM, OR POSSIBILITY? 

69 GOLDILOCKS & THE BEAR FOUNDATION CBT WORKSHOP 

80 1 IN 6 TEENAGERS WHO USE CANNABIS WILL BECOME ADDICTED 

83 SASOP MEDIA STATEMENT: ‘MY NAME MAY BE TOWER HOSPITAL...’ 

90 SASOP HEADLINE 

100 SASOP CONGRESS 2018 EXHIBITOR STANDS 

* PLEASE NOTE: Each item is available as full text electronically and as an individual pdf online. 

Disclaimer: No responsibility will be accepted for any statement made or opinion expressed in the publication. 

Consequently, nobody connected with the publication including directors, employees or editorial team will be held liable for any 

opinion, loss or damage sustained by a reader as a result of an action or reliance upon any statement or opinion expressed. 

© South African Psychiatry This magazine is copyright under the Berne Convention. In terms of the South African 

Copyright Act No. 98 of 1978, no part of this magazine may be reproduced or transmitted in any form or by any means, 

electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, 

without the permission of the publisher and, if applicable, the author. 

COVER PHOTOGRAPH: Shutterstock Image 

Design and layout: The Source * Printers: Imagine It Print It 

4 * SOUTH AFRICAN PSYCHIATRY ISSUE 17 2018

FROM THE EDITOR 

Dear Reader, welcome to our final issue...for 2018. 

It is a bumper issue totalling over 100 pages. There is 

much worthy of writing about and reporting on. The 

issue has an Original article detailing equine assisted 

psychotherapy. A novel intervention, and one worthy of 

further exploration. It is great to have the opportunity to 

publish content related to innovative South African work. 

The Feature articles are quite different, one dealing with 

death (the Life Esidimeni Tragedy) and the other related 

to new life - and potential complications. A related 

Report on an event dedicated to the memory of the Life Esidimeni Tragedy 

serves to provide a further perspective. No doubt the consequences will 

unfold beyond the arbitration hearings, with the subsequent counselling 

for and financial compensation to families. We must never forget. There 

are numerous Reports involving a range of events both local and 

international. The scope of activity is varied and extensive. South Africans 

are everywhere. As always we have pieces from regular contributors (Wine 

Forum, Movie Review, Culinary Corner and Perspective). A special thank 

you to the authors- David, Franco, Ethelwyn and Claudia - for providing 

interesting content throughout the year... on time. A specific thank you to 

Ian Westmore as outgoing Headline editor - a job well done. Welcome to 

Bernard Janse van Rensburg who has stepped into the hot seat. As always 

a big thanks to industry for their continuous and enthusiastic support 

for South African Psychiatry as well as their contributions. I wish all of the 

readership a peaceful year end and look forward to seeing you in 2019... 

as well as receiving your contributions. 

Louw Roos - Department of Psychiatry, University of Pretoria 

Zuki Zingela - Head, Department of Psychiatry, Walter Sisulu University 

Bonga Chiliza - Head Department of Psychiatry UKZN; President South African Society of Psychiatrists 

Headline Editor: Ian Westmore (outgoing)/Brenard Janse van Rensburg (incoming) 

Acknowledgement: Thanks to Lisa Selwood for assistance with proof reading 

Design and Layout: Rigel Andreoli Printer: Imagine It Print It 


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ORIGINAL 


PSYCHOTHERAPY 

IN A SOUTH AFRICAN 

FORENSIC SETTING: 

A DESCRIPTIVE REPORT 

Marc Roffey a , Sarah Garland b , Fiona C. Bromfield c , 

Nafisa Abdulla d , Rowdah Hawtrey e , Theoca Moodley f , Noeline Nune g 

a,d,e,f,g 

Valkenberg Hospital 

b,c 

The Equinox Trust 

ABSTRACT 

Equine Assisted Psychotherapy (EAP) is gaining much popularity as an intervention for a range of mental health 

problems. Although evidence for its efficacy has to date been low, this may largely be due to poorly conducted 

research. This article examines the evidence for EAP, and the indications for its use. It also explores its theoretical 

foundations and discusses an EAP project that has been conducted for four years at Valkenberg Hospital’s 

Forensic Mental Health Unit. 

The gracefulness, strength and agility of horses have long enthralled the human imagination, and the worlds 

of story-telling, myth and legend are richly populated with them. Although amongst the most beloved of 

domesticated animals, for millennia horses have been used as ‘beasts of burden’, and it has only been since the 

later years of the twentieth century that the therapeutic potential of working with horses has been formulated, 

explored, and researched. This article provides an overview of the discipline of equine assisted psychotherapy 

(EAP), which is emerging globally as an increasingly popular intervention for a range of mental health problems. 

It also describes an EAP project, now in its fourth year, which has been conducted at the forensic unit at 

Valkenberg Psychiatric Hospital, Cape Town. 

ANIMAL ASSISTED THERAPY 

By way of introduction, EAP can be understood within the larger construct of animal assisted therapy (AAT). 

Many people, especially pet-owners and animal-lovers, have an intuitive understanding of the potential benefits 

of being in the presence of, and interacting with, domesticated animals. AAT is the intentional inclusion of an 

animal into a therapeutic setting or intervention. Probably the best-known example is the therapy or service dog 

that is often used by people with physical disabilities. Other animals that are used in AAT include cats, guinea 

pigs, rabbits, fish, horses and birds, and typical settings include nursing, rehabilitation and elderly care facilities, 

hospices, correctional facilities, psychiatric and paediatric wards, homeless shelters and, on occasion, disaster 

scenes. 1 


ORIGINAL 

Beneficial effects that are thought to arise from 

AAT include displacing attention from symptoms 

of physical illness; companionship, including 

the enhancement of engagement and rapport; 

reductions in anxiety, hopelessness and despair; and 

increases in mood, energy and optimism. 1,2 Several 

studies have attempted to measure these effects 

empirically, by studying how various physiological 

parameters change during interactions with animals 

in such settings. 1,2 Proposed mechanisms for the 

benefits of AAT include the following: animals can 

facilitate social engagement; they assume symbolic 

and metaphoric significance; they become sources 

of attachment and social support; and they can act 

as agents of learning through, for example, providing 

immediate feedback to types of different behaviours 

shown to them, and by the empowerment which is 

enabled by training and nurturing them. 3 

Highly structured AAT interventions, such as equine 

assisted psychotherapy, have unique features 

that are absent in traditional dualistic therapeutic 

settings. As an animal is present, a therapeutic 

triangle is formed which, it has been suggested, 

can potentially enhance traditional client-therapist 

therapy models. 4 Physical interactions with the 

animal provide opportunities for experiencing and 

establishing physical attachment. 4 

THE NOVELTY AND SETTINGS OF AAT 

INTERVENTIONS MAY APPEAL TO CLIENTS 

WHO ARE RESISTANT TO, OR THREATENED 

BY, TRADITIONAL PSYCHOLOGICAL 

THERAPY, AND THE ANIMAL’S PRESENCE 

AND BEHAVIOUR MAY FACILITATE 

DISCUSSION BETWEEN CLIENT AND 

THERAPIST, OR BETWEEN CLIENTS WITHIN 

A GROUP SETTING. 4,5 

The work of Boris Levinson, in the United States in the 

1960s and 70s, is of particular psychiatric interest, 

writing as a child psychiatrist of his experiences with 

canine assisted therapy with his clients; his books, 

‘Pet-Oriented Child Psychotherapy’ and ‘Pets and 

Human Development’, although anecdotal and 

case-study orientated, marked the first modern 

professional writings on the subject of AAT. 2 

EQUINE ASSISTED THERAPY 

The specific use of horses in animal assisted 

therapy falls under the broad category of ‘equine 

assisted therapy’. When the term refers primarily to 

a psychological intervention, it is differentiated from 

‘hippotherapy’, or ‘therapeutic horse-riding’. This is 

an intervention primarily aimed at, but not limited 

to, people with physical disabilities, and is defined 

as horse-riding “to improve posture, balance and 

mobility while developing a therapeutic bond 

between the patient and horse”. 6 The terms equine 

facilitated psychotherapy (EFP) and equine assisted 

psychotherapy (EAP) are commonly used, by 

practitioners, and in the literature, to describe the use 

of horses in psychologically therapeutic interventions 

and are essentially interchangeable. Equine assisted 

learning (EAL) is a closely related field which differs 

in that it uses similar methods to achieve learning 

goals, rather than purely therapeutic ones. 7 

While there seems to be no standard definitions of 

these various terms, common features appear to 

be the use of horses, within a stable or paddock 

environment, in structured sessions which are 

facilitated by two professionals, an equine specialist 

and a registered mental health practitioner. The 

model utilised in the programme to be described, 

and in which the EAP-facilitator co-authors are 

trained, is the EAGALA (Equine Assisted Growth and 

Learning Association) model. EAGALA, founded in 

1999, is an international equine therapy non-profit 

organisation (NPO), and therapists registered with it 

are required to undergo a training and certification 

programme, with ongoing professional development 

and two-yearly registration renewal being requisites 

for continued certification. 8 As its name suggests, 

the model combines elements of therapy and 

learning, and EAGALA defines EAP as follows: 

“Equine assisted psychotherapy incorporates horses 

experientially for emotional growth and learning. It 

is a collaborative effort between a mental health 

professional and a horse specialist working with 

clients and horses to address treatment goals”. 7 This 

definition emphasizes that a team approach is used, 

in which two professionally trained facilitators are 

present: the focus of the equine facilitator is on the 

responses of the horses and physical safety of the 

participants, while the mental health worker focuses 

attention on the emotional safety and non-verbal 

communication of the clients. 

THE MODEL IS A VERSATILE ONE, AND IS 

UTILISED IN A RANGE OF SETTINGS, FROM 

THERAPEUTIC SETTINGS WITH INDIVIDUALS 

AND GROUPS, TO CORPORATE TEAM 

BUILDING PROGRAMMES AND SKILLS 

DEVELOPMENT PROGRAMMES. THE 

NUMBER OF HORSES USED IN SESSIONS 

VARIES DEPENDING ON THE GROUP SIZE, 

HOWEVER IT IS PREFERABLE TO HAVE A 

HERD OF AT LEAST TWO TO THREE HORSES 

PER SESSION. THE HORSE SPECIALIST 

MUST HAVE A GOOD KNOWLEDGE 

OF THE HORSES BEING UTILISED, AS 

PHYSICAL AND EMOTIONAL SAFETY OF 

BOTH HORSE AND CLIENT IS OF UTMOST 

IMPORTANCE. THE GROUPS ARE USUALLY 

SMALL IN NUMBER, AND RANGE FROM 

FIVE TO FIFTEEN PARTICIPANTS. 

During the sessions, participants engage in groundbased 

activities, in a suitable open environment. 

No horse riding occurs, and no prior experience 

of working with, or being with horses, is required. 

Typically, sessions open with greeting and grooming 

the horses; this is followed by structured activities 

which involve interactions between the participants 


ORIGINAL 

and horses, and which usually increase in complexity 

as the session progresses. The activities are usually 

centred on problem-solving tasks, in a novel 

setting, where task performance by clients enables 

observation of behaviour by the facilitators, instead 

of a reliance only on what is said. 9 

A core aspect of the EAGALA therapeutic process is 

the use of metaphors, which can arise from at least 

three sources generated by the therapy sessions: the 

behaviour of the horses, the props (such as halters, 

ropes and buckets), and lessons learned within 

sessions that are analogous to life experiences. 10 

Examples of both session activities and metaphors 

which occurred in the project will be described later. 

The above illustrates that there are important 

differences between a typical AAT setting (for 

example, the presence of pets in nursing homes), 

and EAP. These include the presence of structured 

sessions and facilitators; the deliberate entering 

of the participants into the physical environment 

of the animal (which in effect means that, from 

the perspective of the horses, the participants 

temporarily become incorporated into the herd); 

and the much larger size of horses compared to 

other animals usually found in AAT settings. 

EAP HAS BEEN UTILISED FOR A 

RANGE OF MENTAL HEALTH PROBLEMS, 

INCLUDING AUTISM SPECTRUM 

DISORDERS, BEHAVIOURAL PROBLEMS 

IN CHILDHOOD AND ADOLESCENCE, 

SUBSTANCE ABUSE, SCHIZOPHRENIA, 

MOOD DISORDERS AND 

POSTTRAUMATIC STRESS DISORDER. 11 

EQUINE THERAPY PROGRAMMES 

HAVE ALSO BEEN USED IN LEADERSHIP 

AND BUSINESS PROGRAMMES. IN 

THESE LATTER CONTEXTS, AND OTHERS 

WHERE PARTICIPANTS DO NOT HAVE 

DIAGNOSED MENTAL HEALTH PROBLEMS, 

IT IS PROPOSED THAT ENHANCED SELF- 

AWARENESS AND WELL-BEING 11 , AS 

WELL AS SKILLS DEVELOPMENT, ARE 

EXPERIENCED BY PARTICIPANTS. 

Although there is no well-established theoretical 

framework for EAP, various models have been cited 

by practitioners and researchers as contributing 

to a theoretical formulation of the therapeutic 

potential of EAP: these include CBT, experiential 

therapy, Gestalt therapy, object relations theory and 

attachment theory. 12 Other, more specific ideas have 

been proposed suggesting why horses should be 

particularly suitable for therapeutic work. Principal 

among these is that horses are recognised as being 

extremely sensitive to human emotion, and to subtle 

expressions of emotions. 4,11 Several studies, using 

empirical behavioural and physiological markers 

of horses, support this 11 ; a recent study, for example, 

revealed that horses are able to spontaneously 

discriminate between positive (happy) and negative 

(angry) human facial expressions in photographs 13 . 

A corollary is that horses are able to mirror or 

reflect these emotional states, through interactional 

responses, and in this way provide feedback, which 

is central to the therapeutic aspect of the process. 4,11 

Such responses and interactions are spontaneous, 

and impartial (or non-judgemental), and are 

therefore authentic, and this is a further defining 

feature of EAP. 4 As stated by Frewin and Gardiner: 

“Horses are not judgemental; they don’t have 

expectations or prejudices. 

THEY DON’T CARE WHAT YOU LOOK LIKE; 

ARE NOT INFLUENCED BY YOUR STATION 

IN LIFE; ARE BLISSFULLY UNAWARE OF 

WHETHER YOU HAVE FRIENDS OR NOT. 

HIGH QUALIFICATIONS DO NOT IMPACT 

UPON THE RESPONSE OF THE HORSE TO 

YOUR PRESENCE. THE HORSE RESPONDS 

TO THE IMMEDIACY OF YOUR INTENT 

AND YOUR BEHAVIOUR, AND DOES SO 

WITHOUT ASSUMPTION OR CRITICISM”. 14 

The sensitivity of horses to their surroundings is in part 

due to the fact that they are prey (as opposed to 

predator) animals. They are naturally hyper-vigilant 

to danger, will flee from it, and will communicate 

their fear instantly to the rest of the herd. 14 This fact, 

that they are herd animals, and possess both social 

structure, and sensitivity to herd dynamics, constitutes 

a further proposed theoretical underpinning of EAP. 

In addition, horses have become domesticated over 

the course of several thousand years 14 , and during 

this process have come to view humans as part of 

the herd. There are important implications of this 

process: their sensitivity to people, and their ability to 

communicate this, non-verbally, has become more 

sophisticated over time 14 and, importantly, they look 

to humans for leadership. 4 As previously mentioned, 

when newcomers enter an equine assisted therapy 

milieu, they temporarily become part of the herd, and 

the horses will respond to the changed dynamics 

of the group/herd. For the participants, there 

are opportunities to observe the herd dynamics 

and processes of the horses, including themes of 

hierarchy and relationship 4 , and these in turn provide 

material for metaphoric exploration. 

An additional and highly significant proposed 

theoretical factor in understanding the therapeutic 

value of working with horses is their size - they are 

large and powerful animals, and may appear as 

imposing, intimidating and even frightening to 

clients (this in itself can provide rich metaphorical 

material). As a result, participants enter sessions 

with immediate and increased sensitivity to their 

environment, and heightened awareness of their 

safety. 14 Successful completion of tasks with the 

horses leads to increased confidence, and an 

overcoming of fear. 11 

Because of their size, horses cannot be physically 

coerced to act in predetermined ways during 

therapeutic sessions, and other strategies have to 


ORIGINAL 

be utilised in order to enable their cooperation. 11 

Several apparent contradictions emerge from the 

juxtaposition of horses as large and powerful animals 

on the one hand, and as therapeutic facilitators on 

the other. Clients are amply aware, for example, 

during interactions with them therapeutically, that 

horses are animals that have the potential to cause 

physical harm, and yet their behaviour during 

sessions can be gentle. 15 It has been suggested that 

this may possibly encourage participants to model 

non-violent behavioural strategies. 16 Furthermore, as 

prey animals they are, although large and potentially 

dangerous, non-predatory, which might contribute 

to their above-described ability to reflect, rather than 

direct, human responses to them. 15 This, in turn, could 

confer therapeutic advantages over more predatory 

species used in other forms of AAT, which may be 

seen as more threatening to some clients. 15 

Although horses are powerful themselves, their 

strength is managed and directed by people, 

through leadership, and gaining this realisation 

through relationship building, rather than domination, 

affords positive therapeutic opportunities. Aggressive 

tendencies can be brought to bear to a situation 

in a “sublimated, creative and positive manner” 4 , 

and nonviolent behavioural strategies can 

lead to altered tolerances of, and responses to, 

interpersonal provocation. 15 Frewin and Gardiner 

quote an example of this, in which shifts occurred 

in adolescent gang members’ attitudes to the 

perceived threat that was represented by the horse: 

unable to physically dominate or control it, they 

learned that “openness and vulnerability are more 

likely to elicit positive behaviour than displays of 

defiance and aggression”. 14 

THE EVIDENCE FOR EAP 

The evidence for EAP is particularly relevant given that 

it is a highly resource-intensive intervention: horses, 

a suitable outdoor environment, and two trained 

therapists are required, and these are resources that 

are not readily available in the majority of mental 

health-care settings. 

THERE IS A PROLIFERATING LITERATURE 

ON EAP, IN THE FORM OF CASE-STUDIES, 

ANECDOTAL REPORTS, POST-GRADUATE 

STUDIES, AND FORMAL RESEARCH 

STUDIES. THESE HAVE FOCUSED 

ON NUMEROUS MENTAL HEALTH 

PROBLEMS, IN A VARIETY OF SETTINGS, 

INCLUDING YOUTH CENTRES, HOSPITALS, 

CORRECTIONAL FACILITIES, AND, IN THE 

UNITED STATES, ARMED FORCES VETERAN 

SETTINGS. IS THERE ANY EVIDENCE FOR 

ITS EFFECTIVENESS AS A THERAPEUTIC 

INTERVENTION? 

In 2012 Selby and Smith-Osborne published a 

systematic review of studies in which equine 

related therapies (including EAP and therapeutic 

horse-riding), were used as complementary and 

adjunct therapies in a variety of mental conditions, 

including bereavement, PTSD, ‘at-risk’ adolescents, 

and unspecified emotional and behavioural 

disturbances. They concluded that the interventions 

showed “promising” results in these trials. 9 

Anestis et al., in a systematic review written in 2014, 

concluded that there was insufficient evidence 

to justify the recommendation of equine related 

treatments (meaning that the interventions included 

other equine therapies in addition to EAP) as a 

standalone treatment for mental disorders. The 

review identified fourteen studies, and the mental 

disorders included children with ADHD and autistic 

spectrum disorder, ‘at-risk’ children, women with 

eating disorders, and a large number of unspecified 

diagnoses. One small study included six adult 

outpatients, diagnosed with schizophrenia or 

schizoaffective disorder. 17 

THE AUTHORS IDENTIFIED SIGNIFICANT 

PROBLEMS WITH STUDIES THAT HAD 

BEEN DONE UP TILL THAT POINT: THESE 

INCLUDED THREATS TO VALIDITY; 

VIOLATIONS WITH RESPECT TO PROPER 

EXPERIMENTAL CONTROL AND 

PROCEDURES, AND UNBIASED RATERS; 

HIGH VARIABILITY WITH RESPECT TO 

THE STRUCTURE AND CONTENT OF 

INTERVENTIONS; LACK OF RANDOM 

ASSIGNMENT; AND FAILURE TO INDICATE 

HOW PSYCHIATRIC DIAGNOSES WERE 

ESTABLISHED. 17 

Additional identified problems with published EAP 

trials include small sample sizes, lack of control groups, 

and the lack of an overall and unified EAP theoretical 

framework. 12 

A subsequent review, published in 2015, identified four 

studies with children and adolescents that in part 

overcame some of the problems identified above. 

There were two groupings of study participants – 

children with autism spectrum disorder and ‘at-risk’ 

youths, and positive changes in several outcomes, 

including anxiety, depression, inattention, empathy 

and self-regulation were demonstrated 18 . 

One well-designed study, published in 2016, warrants 

particular mention as it included ninety hospital 

in-patients with severe mental illness (including 

schizophrenia, schizoaffective disorder and mood 

disorders), and examined the effectiveness of EAP in 

reducing aggressive behaviour. EAP was contrasted 

with CAP (canine assisted psychotherapy), and the 

study design included two control groups (enhanced 

social skills psychotherapy and regular hospital 

care). Results indicated improvements in both 

animal assisted therapy groups, with, at three-month 

follow-up, a reduction in aggression in the EAP group 

only. Results were specific for violence, and there 

was no effect on other psychiatric symptoms. 15 This 

study was referenced in another 2016 review, which 


ORIGINAL 

focused on the efficacy of non-pharmacological 

interventions for reducing aggression in severe 

mental illness: the best interventions were cognitive 

behavioural therapy (CBT) and modified reasoning 

and rehabilitation (R&R), a cognitive skills programme 

which aims to reduce recidivism in offenders. The 

positive results which resulted from the EAP study 

were acknowledged, with the comment that it is an 

impractical choice for most psychiatric units 16 . 

In conclusion, despite a burgeoning literature, there 

is currently little evidence for the effectiveness of 

EAP in broad psychiatric populations, and this is 

because of poorly designed studies which lack 

methodological rigour. While there is also scant 

evidence for its effectiveness in severe mental illness 

specifically, there are suggestions that it may be 

effective in reducing aggression and violence. This, 

together with findings supportive of behavioural 

changes in children and adolescents, suggests 

that EAP may have unique benefits for a forensic 

psychiatric population, in which aggression and 

violence are recurring problems. 

THE VALKENBERG HOSPITAL EAP 

FORENSIC PROJECT 

Four EAP programmes have taken place at 

Valkenberg Hospital’s forensic unit since 2015, each 

occurring annually. The first three were each of eight 

weeks duration, and at the time of writing a fourth 

and longer, twelve-week programme had just been 

completed at the unit. 

THE FORENSIC MENTAL HEALTH UNIT AT 

VALKENBERG HOSPITAL (VBH) TREATS 

AND REHABILITATES PEOPLE WHO HAVE 

COMMITTED OFFENCES AND WHO 

HAVE BEEN ASSESSED AS NOT HAVING 

CRIMINAL CAPACITY FOR THEIR ACTIONS, 

AS THEY WERE MENTALLY ILL AT THE TIME 

OF COMMITTING THESE OFFENCES. 

Under South African law they are required, by the 

justice system, to undergo rehabilitation as inpatients 

in psychiatric hospitals. The illnesses that are mostly 

diagnosed in these patients (who are classified 

under South African law as ‘state patients’) include 

severe psychiatric illnesses such as schizophrenia 

and mood disorders, and there are often comorbid 

conditions present, including personality disorders 

and substance abuse. Only male state patients are 

accommodated at Valkenberg Hospital; female 

state patients, who are far fewer in number, are 

rehabilitated at Lentegeur Hospital. 

State patients are treated for extended periods 

of time (months to years) and are thus ideally 

suited to benefit from prolonged interventions, 

including equine assisted therapy programmes. 

The patients are actively treated for psychosis 

during the early phase of their rehabilitation, after 

which they are provided opportunities to engage 

in more psychologically and occupationally based 

rehabilitative work. 

Over and above pure mental illness, the 

psychopathological problems that are present in a 

forensic population, and the treatment interventions 

that are required to address them, are complex. As 

mentioned, disorders of personality, especially of 

the cluster B type, and including psychopathy, are 

frequently present. In addition, some patients have 

varying degrees of intellectual disability. Aggressive 

and recurrent behavioural disturbances are 

habitually present in forensic environments and are 

worsened by a high prevalence of substance abuse, 

which also causes relapse of mental illness. 

STATE PATIENTS FREQUENTLY FEEL 

MARGINALISED AND STIGMATISED BY 

THEIR FAMILIES AND COMMUNITIES, 

AND BY SOCIETY AT LARGE, NOT ONLY 

BECAUSE THEY HAVE MENTAL ILLNESSES, 

BUT ALSO BECAUSE THEY HAVE 

COMMITTED OFFENCES. SHAME, GUILT 

AND REMORSE, WHEN THEY DO OCCUR, 

ARE SELDOM ARTICULATED. MOST STATE 

PATIENTS STRUGGLE TO EXPRESS THESE 

FEELINGS, LET ALONE WORK THROUGH 

THEM WITH ANY DEGREE OF SUCCESS, 

AND DEFENSIVE MECHANISMS, 

INCLUDING DENIAL AND AVOIDANCE, 

ARE COMMON. 

Despite these therapeutic obstacles, the forensic 

unit’s therapeutic ethos is aligned with the 

principles of the recovery model, and it constantly 

strives to engender within state patients the 

model’s four domains of hope, positive self-identity, 

meaning in life and personal responsibility 19 . In 

addition to conventional pharmacological and 

psychotherapeutic interventions, and extensive 

occupational therapy programmes, the unit 

offers additional interventions such as pottery, art 

and music sessions. All of these interventions are 

creative and innovative, facilitate participation in 

group therapeutic activities, engage clients in a 

physical manner, and potentially enable access to 

psychological material in non-verbal ways. When 

the opportunity to work with equines presented 

itself to the unit, it was welcomed as an additional 

intervention which shared these characteristics. 

In addition, and very fortunately for Valkenberg 

Hospital, the intervention was considered to be a 

practical and accessible one, as the hospital is 

immediately adjacent to the Oude Molen Eco- 

Village, where there is a stable and horses. The 

horses that are accommodated and cared for at 

the stable are mostly rescued horses, and take part 

in community equestrian events, including horseriding 

lessons. The owner of the horses is supportive 

of equine assisted therapy and has readily allowed 

the unit to make use of the stable’s horses. 


ORIGINAL 

The two facilitators who have run the sessions since 

the project’s inception, and who are co-authors of 

this paper, are founding members of The Equinox 

Trust, a Cape Town based EAGALA-certified nonprofit 

organisation. This project was a landmark 

event for the Trust as it provided its facilitators with 

an opportunity to work for the first time with a purely 

psychiatric population. 

THE PROGRAMMES 

on the experiences, and possible metaphorical links, 

with the facilitators. 

AT THE END OF EACH SESSION, 

THE FACILITATORS WOULD PROVIDE 

IMMEDIATE VERBAL FEEDBACK TO 

THE MDT AND WOULD SUBSEQUENTLY 

PROVIDE A WRITTEN REPORT. THE 

FEEDBACK INCLUDED INPUT FROM THE 

EQUINE FACILITATOR, WHO OBSERVED 

THE BEHAVIOUR OF THE HORSES, 

AND FROM THE MENTAL HEALTH 

PRACTITIONER, WHO COMMENTED ON 

THE BEHAVIOUR OF THE PARTICIPANTS. 

Some observations, features and themes drawn 

from the sessions and programmes are as follows: 

Participants with certificates of completion 

The tasks with the horses that the participants were 

requested to engage with would generally increase 

in complexity over the course of each programme. 

This would occur as the individual participants grew 

more comfortable and confident with the horses, 

and also with each other and with the process. 

Examples of less complex tasks included simply 

walking individually around a horse, in this way 

becoming familiar with the animal and sensing its 

boundaries and walking individually with a horse 

around the field. 

Six new male state patients were selected for each 

of the three eight-week programmes that were held 

from 2015 – 2017. Each session took place on a Friday 

morning, on a field attached to one of the forensic 

wards. The patients, two equine assisted therapy 

facilitators and either two or three horses participated 

in each session. No participants dropped out of any 

of the programmes, and mostly the same horses 

were used throughout each individual programme, 

depending on their availability and suitability for work 

with this population, as discussed in consultation 

with staff at the Oude Molen stables. 

Various objects that were brought by the therapists, 

and which included buckets, traffic cones and 

rubber ‘noodles’, were placed on the field and were 

available for the various tasks and activities that 

would take place in the session. Members of the 

multi-disciplinary team (MDT) involved in the care of 

the patients observed from the periphery of the field. 

Each session lasted for up to an hour and would 

start with the patients grooming the horses. During 

each session patients would engage with activities, 

after which there would be opportunities to reflect 

Participants leading a horse through a cone excercise with lead rope 

More complex tasks included leading horses 

through pathways and over obstacles that the group 

constructed with the items on the field, as well as 

getting the horses to move into spaces demarcated 

by objects placed on the field. Variations of the latter 

exercise would be the permissible use of aids such 

as halters and lead-ropes, not being allowed to use 

these aids, not being allowed to touch the horse at 

all, and getting the horse to remain in the space 

for a short duration of time. During one exercise 

some of the patients were ‘handicapped’ by being 

blindfolded or tied by the arms to other patients, 

before the commencement of the activity. 


ORIGINAL 

AS EACH PROGRAMME DEVELOPED IN 

COHESION AND COMPLEXITY, THE ABILITY 

OF THE MEMBERS TO DEMONSTRATE 

LEADERSHIP AND TEAMWORK, AND TO 

EXERCISE ABSTRACT THINKING AND 

PROBLEM-SOLVING SKILLS, WAS TESTED 

AND ENCOURAGED. 

During the exercise in which participants had to 

lead a horse into an enclosed rectangular space 

on the ground, without touching it or leading it 

with a halter or lead-rope, various solutions were 

attempted. These included coaxing the horse with 

handfuls of grass, and forming a human ‘tunnel’, 

with raised hands, through which the horse was 

encouraged to walk. In another exercise, a patient 

successfully kept the horse, which was moving 

slightly, within an enclosed space by moving the 

boundary, instead of attempting to keep the horse 

still, thereby demonstrating an interesting and 

creative use of problem-solving abilities. Participants 

who attempted to physically drag or push horses into 

spaces or along paths quickly realised that this was 

a mostly unsuccessful strategy, as reflected back to 

them by the horse’s unwillingness to move. 

WHEN THE EXERCISES PROVED 

CHALLENGING AND PARTICIPANTS 

WERE UNSUCCESSFUL IN ACHIEVING 

THEM, FRUSTRATION AND GROUP 

FRAGMENTATION OFTEN FOLLOWED. 

WHEN THIS OCCURRED, OR WHEN 

IT HAPPENED SPONTANEOUSLY, THE 

HORSES REFLECTED THIS BY BECOMING 

‘SKITTISH’ AND DIFFICULT TO WORK WITH. 

The groups were increasingly aware of this, and 

realised that calm cooperation often resulted 

in better outcomes. In general, the participants 

became more attuned to the characters and needs 

of the horses, and this was evidenced by more 

attentive and careful grooming as the programmes 

progressed, and by approaching horses differently 

– for example, during one session a particularly 

engaged and aware patient learned that 

approaching a temperamental horse from the side, 

rather than the front, led to a better engagement 

with that horse. In addition, one particular patient, 

who in the first sessions consistently behaved in a 

provocative manner towards the horses, by slapping 

them on their hind-quarters, was able to receive 

a clear message from them that this was not 

acceptable and was able to change his behaviour 

accordingly. 

Metaphors were introduced into the sessions early on 

and depending on the make-up of the groups were 

comprehended and worked with by the participants 

at various times within the programmes. Examples of 

these included: 

• What do the horses remind you of? 

• If you approach people differently would 

they react differently, in the same way that 

the horses do? 

• When you are feeling frustrated by not being 

able to achieve something, how do you 

cope? 

• How does one know when a horse/person 

is calm? 

• What does it feel like to have a handicap? 

• The male and female horses continue to 

keep separate from each other – does this 

reflect what happens in your life? 

• What does it feel like to have a reliable horse 

around? 

• Can you think of a situation in your life where 

you might need ‘lead-ropes’ and someone 

to give you direction? 

An example of a metaphor being successfully and 

spontaneously grasped and understood occurred 

towards the end of a programme, when the group 

took down an obstacle that the horse was not 

walking over and used the materials instead to create 

a path which the horse successfully negotiated. As 

well as providing metaphorical material which they 

were able to engage with and discuss, none of 

the rules which had been set for the exercise were 

contravened; the outcome was therefore also a 

success in terms of the group’s problem-solving skills, 

and it provided them with a sense of empowerment. 

As a further example, during two of the exercises 

each participant was requested to write down goals, 

values, and something they needed to protect in 

their lives. The lists were then used in exercises with 

the horses. The participants could identify that the 

horses were being supportive during the exercises 

and were able to link this to the need for support 

systems in their own lives. 

The participants themselves tended to form subgroups 

and alliances that endured throughout the sessions. 

There were also consistent and interesting pairings 

of dominant and quiet members within the groups. 

Generally, the participants of each programme got 

along well, and were willing to help each other. There 

were no displays of hostility or aggression towards 

each other, nor towards the facilitators. 

The selection process for each programme was done 

by the occupational therapists and psychiatrists 

working in the unit. Overt psychosis was an exclusion 

criterion. Generally, in each successive year, as The 

Equinox Trust and Valkenberg teams gained more 

experience with working with EAP in a psychiatric 

population, higher functioning patients tended 

to be selected for each group. This resulted in the 

participants working more rapidly with metaphors, 

which appeared to lead to greater cohesion and 

support within the groups. 

For the 2018 group, participants were primarily 

selected on the basis of challenging behaviours, 

including intrusiveness, physical and verbal 

aggression and hostility, as the literature currently 


ORIGINAL 

appears to support EAP as a promising intervention 

for such behaviours. For all of the programme’s broad 

themes of social/group awareness, interaction and 

communication, and regulation of emotion and 

behaviour, were chosen as desirable outcomes. 

OUTCOMES 

Simple scoring instruments, developed by The 

Equinox Trust, were administered to each participant 

at the beginning and end of each programme. 

These demonstrated positive shifts with respect 

to improving interpersonal and social skills and 

reducing aggressive and irritable behaviours. 

The patients appeared to enjoy the intervention, 

especially as it was held outdoors, and it was 

consistently noted, at the start of each session, that 

they expressed keen and enthusiastic interest in 

remaining involved in the project. Teamwork and 

group cohesion were increasingly observed as the 

sessions progressed. Some of the participants also 

appeared to develop a genuine affection towards 

the horses and were at times seen spontaneously 

hugging them during the later sessions. 

In the weeks following the third programme, 

participants were interviewed about their 

impressions of the programme. Some were able to 

make useful metaphorical links to family and social 

relationships, while others expressed a recognition 

that horses have feelings, and that this helped 

them to understand their own emotional worlds, 

as well as those of others. The problem-solving 

tasks that occurred during the sessions were also 

referenced, as reminders that their own problems 

that the participants encountered in their daily lives 

were able to be solved. These findings suggest that 

the therapeutic effects of the intervention have the 

potential to be sustained, and it can be hypothesised 

that this effect will be greater if the intervention is for 

a longer period; this was indeed the rationale for 

designing a longer twelve-week programme. 

AN UNEXPECTED EFFECT OF THE FIRST 

PILOT PROGRAMME, HELD IN 2015, WAS 

THAT IT DREW MUCH INTEREST FROM THE 

PUBLIC. 

The project was covered by several mainstream and 

community newspapers in Cape Town, and was 

featured in a national radio programme, in which 

several of the authors were interviewed. The attention 

that the project raised in these ways raised public 

awareness of the hospital, the forensic unit, and EAP 

as an intervention. 

THE WAY FORWARD 

Although positive outcomes were measured, 

they were done so using scales that do not have 

proven validity and reliability. The intervention would 

require more rigorous measurements, perhaps 

using a combination of clinical assessments 

and instruments, to make more meaningful 

pronouncements on positive findings. With this in 

mind the current programme has introduced a preand 

post-intervention 39-item Life Skill Profile (LSP) 

instrument rating score. 

The long-term vision for the project is to access 

ongoing funding, so that equine therapy can 

be a permanent intervention that is available to 

the forensic unit’s patients. To date, funding for 

the programmes has mostly been provided by 

The Equinox Trust’s own donor funding, with minor 

contributions from the Schonberg Trust and the 

Valkenberg Facility Board, both of which provide 

funding for patient activities at Valkenberg Hospital. 

CONCLUSION 

Equine assisted psychotherapy has gained 

enormous popularity across the world as an 

intervention for a diverse range of mental health 

problems. It is based on the intriguing and appealing 

premise that equines, as gentle yet powerful animals, 

can act as important therapeutic facilitators. Good 

evidence for the intervention has until recently been 

lacking, and this has been due to poorly designed 

studies. This shortcoming has been increasingly 

emphasised in the literature, and it is to be hoped 

that future studies, with improved methodological 

design, will demonstrate positive therapeutic effects 

in behavioural problems that are associated with 

mentally ill populations. 

Valkenberg Hospital is extremely fortunate to have 

access to a neighbouring stable and horses, and to 

have partnered with The Equinox Trust, an EAGALA 

affiliated NPO. The equine assisted therapy project 

has been successful in that it has been well received 

by participants and staff, with tentative positive 

therapeutic results being found. This is the first 

time that an equine assisted therapy programme 

has occurred in a forensic unit in South Africa. It is 

envisaged that the project will continue, and that 

it will in the future offer an opportunity for muchneeded 

research in this field. 

ACKNOWLEDGEMENTS 

Thank you to the following: The Equinox Trust; the multidisciplinary 

forensic staff at Valkenberg Hospital, for 

their enthusiastic support of the project, the owner 

and staff of the Oude Molen stable, for use and care 

of the horses, and the following funders who have 

made the project possible: The Rice Foundation Trust, 

the L&S Chiappini Trust, The GCG Werdmuller Trust, 

The FC Carter Trust, Allister Rogan, the Schonberg 

Trust, and the Valkenberg Hospital Facility Board. 

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knowledge and future research directions. 

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24(3): 225–246. 

8. http://www.eagala.org/certification. 

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of Effectiveness of Complementary and Adjunct 

Therapies and Interventions Involving Equines. 

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10. Kakacek SL. An Arena for Success: Metaphor 

Utilization in Equine-Assisted Psychotherapy. 

Paper based on a programme presented at the 

2007 Association for Counselor Education and 

Supervision Conference, Columbus, Ohio. 

11. Gibbons JL, Cunningham C.A, Paiz L, Poelker 

KE, Chajón A. ‘Now, he will be the leader of 

the house’: An equine intervention with at-risk 

Guatemalan youth. International Journal of 

Adolescence and Youth 2016; 1 – 15. 

12. Bachi K. Equine-Facilitated Psychotherapy: The 

Gap between Practice and Knowledge. Society 

& Animals 2012; 364-380. 

13. Smith AV, Proops L, Grounds K, Wathan J, 

McComb K. Functionally relevant responses 

to human facial expressions of emotion in the 

domestic horse (Equus caballus). Biology Letters 

2016; 12: 20150907. 

14. Frewin K, Gardiner B. New Age or Old Sage? A 

review of Equine Assisted Psychotherapy. The 

Australian Journal of Counselling Psychology 

2005; 6: 13-17. 

15. Nurenberg JR, Schleifer SJ, Shaffer TM, Yellin MJ, 

Desai PJ, Amin R, et al. Animal-Assisted Therapy 

with Chronic Psychiatric Inpatients: Equine- 

Assisted Psychotherapy and Aggressive Behavior. 

Psychiatric Services 2015; 66:1 

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Lucca G, Livanou M, et al.Non-pharmacological 

interventions for reducing aggression and 

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TA, Lilienfeld SO. Equine-Related Treatments for 

Mental Disorders Lack Empirical Support: A 

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1115–1132. 

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Psychotherapy with Children and Adolescents: 

An Update and Literature Review. Journal of 

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19. Slade M. One hundred ways to support recovery. 

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ways_to_support_recovery_2nd_edition.pdf 

Marc Roffey, holds a consultant post in Forensic Psychiatry at Valkenberg Psychiatric Hospital and University of Cape Town, 

Cape Town, South Africa. Correspondence: marc.roffey@uct.ac.za 

Sarah Garland, is an EAGALA Certified Equine Assisted Therapy Facilitator, is a Founding Trustee and the Public Relations 

and Programme Manager of The Equinox Trust, an equine therapy non-profit organisation in Cape Town, South Africa. 

Correspondence: sarah@equinoxtrust.org 

Fiona C. Bromfield, is an EAGALA Certified Equine Assisted Therapy Facilitator, is a Founding Trustee and the Financial and 

Operations Manager of The Equinox Trust. Correspondence: fiona@equinoxtrust.org 

Nafisa Abdulla, is the Chief Occupational Therapist at the Forensic Unit at Valkenberg Hospital. Correspondence: 

Nafisa.Abdulla@westerncape.gov.za 

Rowdah Hawtrey, is an Occupational Therapist at the Forensic Unit at Valkenberg Hospital. Correspondence: 

Rowdah.Hawtrey@westerncape.gov.za 

Theoca Moodley, is an Occupational Therapist at the Forensic Unit at Valkenberg Hospital. Correspondence: 

Theoca.Moodley@westerncape.gov.za 

Noeline Nune, is an Occupational Therapy Technician at the Forensic Unit at Valkenberg Hospital. Correspondence: 

Nolene.Nune@westerncape.gov.za 


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FEATURE 

CLINICAL AND SOCIAL ASPECTS 

OF PERINATAL 

DEPRESSION 

IN SOUTH AFRICA 

Carina Marsay 

The term perinatal depression is used to refer to 

both major and minor depression occurring 

at any time between conception and the 

baby’s first birthday. Much of the focus until 

recently has been on postnatal depression, but 

the prevalence and the importance of antenatal 

depression, as the greatest predictor of postnatal 

depression, is being increasingly recognized. 

IN ADDITION TO THIS MANY CASES 

OF POSTPARTUM DEPRESSION BEGIN 

ANTENATALLY WITH FEATURES OF 

ANXIETY. RECENT LITERATURE SUGGESTS 

THAT POSTNATAL ANXIETY IS AS 

COMMON AS POSTNATAL DEPRESSION, 

AND THAT ANTENATAL DEPRESSION IS AS 

COMMON AS POSTNATAL DEPRESSION. 

THIS HAS LED TO THE EMERGENCE OF A 

DEFINITION OF PERINATAL DEPRESSION 

THAT INCLUDES BOTH DEPRESSION AND 

ANXIETY SYMPTOMS IN THE PERINATAL 

PERIOD. 

Postpartum psychosis is relatively rare, with an 

incidence of 1.1 – 4 per 1000 deliveries, and usually 

occurs in women with a personal or family history of 

bipolar or schizoaffective disorder. 

CLINICAL PRESENTATION 

Perinatal depression and anxiety occur on a 

continuum and therefore, there are a wide range of 

clinical presentations. Core symptoms of depression 

include: 

• A depressed mood most of the 

day and nearly every day 

• Loss of interest in pleasurable 

activities 

• Feeling down and hopeless or 

worthless 

• Trouble sleeping, especially 

early morning awakening or 

hypersomnia 

• Decreased appetite or weight 

loss, or increased appetite and weight gain 

• Inability to concentrate and impaired thinking 

and decision making 

• Psychomotor agitation or retardation 

• Fatigue and decreased energy 

• Feelings of guilt 

• Suicidal and recurrent morbid thoughts 

Carina Marsay 

These symptoms need to be present for two or more 

weeks and cause impairment in functioning. Anxiety 

can be part of and separate to perinatal depression, 

and there is a very high comorbidity. Not all women 

meet the diagnostic criteria for a mood or anxiety 

disorder, but their levels of distress are significant 

and clinically relevant. Other commonly reported 

symptoms include: 

• Sadness, weepiness, low mood, irritability, 

impaired concentration and feeling 

overwhelmed 

• Anxiety and agitation, ruminating or obsessional 

thoughts about the pregnancy or baby 

• Severe hypervigilance of the baby, including 

inability to sleep at night when the baby is 

sleeping 


FEATURE 

• Feeling detached from the infant 

• Lack of interest in holding or caring for the baby 

• Guilt that they are not able to enjoy the baby. 

PREVALENCE AND RISK FACTORS 

Rates of depression in women during the perinatal 

period are reported to be around 10-15% in highincome 

countries. In other low and middle-income 

countries rates are 16-20%. In South Africa however, 

the rates of perinatal depression are significantly 

higher, ranging from 22-47%. The high rates of 

perinatal depression in South Africa may be related 

to the compounding nature of multiple economic, 

social and psychosocial stressors. 

THESE INCLUDING POVERTY AND 

UNEMPLOYMENT, INTIMATE PARTNER 

VIOLENCE, LACK OF PARTNER SUPPORT, 

UNPLANNED PREGNANCY, AND 

THE HIGH PREVALENCE OF HIV IN 

PREGNANT WOMEN (39-45%), INCLUDING 

DIAGNOSIS OF HIV INFECTION IN THE 

COURSE OF ANTENATAL CARE. SIMILAR 

ASSOCIATIONS HAVE BEEN FOUND 

IN OTHER LOW AND MIDDLE-INCOME 

COUNTRIES, WHERE SOCIO-ECONOMIC 

DISADVANTAGES COMPRISING OF 

FOOD INSECURITY, FINANCIAL DIFFICULTIES, 

UNEMPLOYED PARTNERS AND LOW 

INCOME WERE ASSOCIATED WITH 

PERINATAL DEPRESSION. 

In addition, social disadvantage comprising of 

poor emotional support and lack of empathy from 

partners, having hostile in-laws and having insufficient 

practical and emotional support, contributed to the 

risk of perinatal depression. From this, it is clear that 

maternal depression has multiple etiologies, and 

cannot be solely explained by women’s biological 

and psychological vulnerability. Rather, social and 

environmental factors are important contributing 

factors and determinants of risk and socio-cultural 

context impacts both prevalence and presentation 

of perinatal depression. Protective factors include; 

having more education, permanent job, a kind and 

trustworthy intimate partner, as well as support from 

friends and family. 

CONSEQUENCES 

Infants and children of depressed mothers have 

poorer physical, cognitive and emotional outcomes. 

Among women living in relative poverty, poor 

maternal mental health during the antenatal period 

is a risk factor for low birth weight and preterm 

delivery. Postnatally, malnutrition, poor infant growth, 

and increased frequency of infant diarrheal illness 

are prevalent, which may be related to the early 

cessation of breastfeeding in depressed mothers 

living in poverty. This can lead to an increase in 

child mortality. The emotional development of 

infants is compromised because of a disturbed 

mother-infant relationship, where mothers are less 

sensitive towards their infants and infants are less 

responsive towards mothers. This in turn leads to 

poorer quality attachment, resulting in behavioural 

and psychological difficulties that can last into 

adolescence and adulthood. Compromised 

cognitive functioning and delayed development 

also affect infants and children of depressed 

mothers, impacting on their scholastic achievement. 

In the context of chronic social and economic 

adversity, poor quality parenting as a result of 

maternal depression is especially harmful. 

THESE ADVERSE OUTCOMES FURTHER 

PERPETUATE SOCIAL AND ECONOMIC 

INEQUALITY IN THE NEXT GENERATION. 

DEPRESSED MOTHERS ARE ALSO AT 

RISK OF LOSING THEIR INCOME AND 

ECONOMIC POTENTIAL AS A RESULT 

OF THEIR IMPAIRED MENTAL STATE. 

THESE WOMEN ALSO HAVE HIGHER 

RISKS OF INTIMATE PARTNER VIOLENCE, 

SUBSTANCE ABUSE AND SUICIDE. 

Possible mechanisms for the above mentioned 

consequences may include; poor uptake of 

health and social services by depressed mothers; 

increased stress hormones in utero impacting on 

the developing fetus as well as a co-occurrence with 

worse physical health, poor nutrition and substance 

abuse. Luckily, some of the factors contributing to 

these adverse consequences are modifiable and 

we can prevent some of these devastating effects. 

SCREENING FOR PERINATAL 

MENTAL DISORDERS 

Given the high rates and compounding associated 

risk factors for maternal depression, its early 

identification and management is vital. Screening 

with referral is a valuable, strategy for mitigating the 

devastating consequences of the illness on mothers 

and their families. Secondary prevention consists 

of early identification and treatment of a disease 

to prevent potential future complications and 

disabilities from the disease. 

TRADITIONALLY, SCREENING PROGRAMMES 

ARE A GOOD EXAMPLE OF SECONDARY 

PREVENTION IN MEDICINE. THE PERINATAL 

PERIOD IS AN IDEAL TIME AS PREGNANT 

WOMEN ARE LIKELY TO HAVE ACCESS TO 

HEALTH CARE AND THE PERINATAL PERIOD 

PROVIDES MULTIPLE OPPORTUNITIES FOR 

EDUCATION, PREVENTION, DETECTION 

AND TREATMENT OF COMMON PERINATAL 

MENTAL DISORDERS. 


FEATURE 

Screening can generate controversy, however 

sufficient data exists to support the introduction 

of screening for perinatal depression and anxiety. 

Perinatal depression meets most of the criteria for 

the implementation of a screening program. 

THE CONDITION IS SERIOUS, PREVALENT, 

TREATABLE AND ACCEPTABLE TESTS OF 

KNOWN ACCURACY ARE AVAILABLE. 

THERE ARE MULTIPLE TOOLS FOR USE 

INCLUDING GENERIC SELF-REPORT 

TOOLS FOR DEPRESSION SCREENING 

AND PERINATAL-SPECIFIC SELF-REPORT 

TOOLS. 

Some widely used screening tests that have been 

validated in perinatal populations including 

women in South Africa, include the Edinburgh 

Postnatal Depression Scale (EPDS), Patient Health 

Questionnaire–9 (PHQ-9) and case finding 

questions such as the Whooley questions. The 

PHQ-9 is a commonly used generic self-report 

four-point Likert-type scale questionnaire used 

in primary health care settings. The EPDS is a 

perinatal-specific self-report 10-item 4-point Likert 

scale. It is brief, and the most widely used tool used 

for both antenatal and postnatal depression. The 

Whooley questions are two case-finding questions 

that require only a yes or no response. They can 

identify anxiety and depression with reasonable 

accuracy. 

THEY ARE SHORT AND DO NOT 

REQUIRE LITERACY, OR SCORING AND 

INTERPRETATION LIKE PENCIL AND 

PAPER TESTS, AND SO ARE MORE TIME- 

EFFECTIVE. THESE TWO QUESTIONS 

ADDRESS SYMPTOMS OF DEPRESSION 

THAT ARE NECESSARY BUT NOT 

SUFFICIENT TO MAKE A DIAGNOSIS OF 

DEPRESSION: “DURING THE PAST MONTH, 

HAVE YOU OFTEN BEEN BOTHERED 

BY FEELING DOWN, DEPRESSED OR 

HOPELESS?” AND “DURING THE PAST 

MONTH, HAVE YOU OFTEN BEEN 

BOTHERED BY LITTLE INTEREST OR 

PLEASURE IN DOING THINGS?” 

General clinical recommendation suggest that: 

• Screening should be conducted in order 

to increase identification of cases, which 

subsequently should improve outcomes. 

• The screening should ideally be completed in 

the presence of a health care professional. 

• Ask about and assess psychosocial risk factors 

such as unemployment, and lack of partner 

support. 

• Short, simple screening tools with high sensitivity 

should be used and followed-up with tools with 

high specificity ie: The Whooley case finding 

questions first and then the EPDS. 

• Screening can occur anytime pre- or postnatally. 

Recommendations are that postnatal screening 

be conducted between 4 and 12 weeks 

postnatally. 

• Screening should take place in settings that 

are acceptable to women. Ensure the women’s 

privacy and a non-judgmental environment 

and explain why you are doing the screening; 

and what the results mean. 

• Once screening is implemented it is vital to have 

a plan and resource for diagnosis, management 

and follow-up and referral if needed. Be prepare 

to address suicidality and have an emergency 

plan in place to assist suicidal women. 

• A screening test must never replace clinical 

judgment 

CONCLUSION 

Currently there are few routine mental health 

programmes; or even guidelines for screening 

perinatal women in South Africa in the public sector, 

despite evidence showing that these programmes 

can be effectively introduced to a primary health 

care setting. 

AS A RESULT, PERINATAL MENTAL HEALTH 

PROBLEMS REMAIN UNDER DIAGNOSED 

AND ARE LEFT UNTREATED IN THE MAJORITY 

OF CASES. WHAT IS NEEDED IS THE 

DEVELOPMENT AND IMPLEMENTATION 

OF EFFECTIVE PERINATAL MENTAL 

HEALTH POLICIES, WHICH WILL HELP 

PROTECT AGAINST ADVERSE AFFECTS OF 

PERINATAL DEPRESSION AND ANXIETY 

IN A SIGNIFICANT NUMBER OF SOUTH 

AFRICAN WOMEN. 

In the meantime however, it is up to the individual 

health care provider to be aware of the severity of 

the problem and to make it a habit to screen all 

perinatal women for depression and anxiety. 

References available from the author 

Carina Marsay is a specialist psychiatrist. She obtained 

her FC Psych (SA) in 2009 and her MMed (Psych) in 2010. 

Dr Marsay has a PhD from the University of Witwatersrand 

related to her work in perinatal psychiatry and is an honorary 

appointee in the Department of Psychiatry at Wits. She is 

a recipient of the MRC Clinician Researcher Programme 

Scholarship. Dr Marsay has an interest in perinatal psychiatry 

and is a member of the International Marcé Society, 

an organisation dedicated to perinatal mental health. 

Correspondence: carinamarsay@gmail.com 

If you would like to know more, please have a look at 

what the Perinatal Mental Health Project are doing 

for women in South Africa: https://pmhp.za.org/ 


BOOK 

SHOOTING 

WAR 

Title: SHOOTING WAR 

Publisher: Glitterati Editions 

Author: Anthony Feinstein 

Forward: Sir Harold Evans 

Conflict photographers are visual historians, bearing 

witness to stories that must be told. The images they 

produce seize our attention and, moved by what 

we see, troubling questions come to mind. What 

has become of these victims of war whose plight 

has been so memorably captured on camera? 

How did human behaviour turn so dark? SHOOTING 

WAR builds on this narrative by asking a different set 

of questions that to date has received little, if any, 

attention. What of the person taking the photograph? 

What might they have experienced? 

Neuropsychiatrist Anthony Feinstein provides the 

answers in a series of essays, one each for 18 of 

the world’s preeminent conflict photographers. 

Complementing each essay is a single, iconic 

photograph around which the text is built. The 

essays, derived from face-to-face interviews with the 

photojournalists, relatives, and close friends, give new 

and revealing insights into those factors, professional 

and psychological, that motivate photographers 

to enter zones of conflict repeatedly and the 

consequences that come from exposure to grave 

danger. These may include grievous physical injury, 

PTSD, moral injury, and prolonged bereavement for 

colleagues lost. While the text lays bare the traumas 

endured, the images speak to the resilience and 

creativity of the photographer in shaping our 

understanding of war and conflict. 

In addition to opening a new line of investigation into 

photographers and conflict, SHOOTING WAR includes 

a definitive foreword by Sir Harold Evans, himself a worldrenowned 

commentator on conflict and photography. 

A comprehensive index of photographer biographies 

and the wars and conflicts they have photographed 

is cited. This ground-breaking book will stir interest 

in the essential work of the men and women who, 

armed with only a camera, venture into the world’s 

most dangerous places. 

From Shooting War by Anthony Feinstein, copyright © 2018, 

Published by Glitterati Editions 

ANTHONY FEINSTEIN is a professor of Psychiatry at 

the University of Toronto, a Guggenheim Fellow, and 

a Peabody winner for his documentary Under Fire: 

Journalists in Combat. He has published a series of 

seminal studies exploring the psychological effects 

of conflict on journalists covering the Balkans, Iraq, 

Syria, Kenya, Iran, and the refugee crisis in Europe. He 

lives in Toronto, Canada. 

SIR HAROLD EVANS is a British-born journalist and 

bestselling author of The American Century. He 

was knighted by Queen Elizabeth in 2004 and is the 

recipient of an International Center of Photography 

Lifetime Achievement Award, two honors among 

many he has garnered over the course of a 

celebrated career. He lives in New York City and East 

Hampton, New York 

CONFLICT PHOTOGRAPHERS INCLUDE: 

• YANNIS BEHRAKIS 

• ALEXANDRA BOULAT 

• LAURENCE GEAI 

• ASHLEY GILBERTSON 

• DAVID GUTTENFELDER 

• CAROL GUZY 

• ROBIN HAMMOND 

• RON HAVIV 

• TIM HETHERINGTON 

• SANTIAGO LYON 

• PETER MAGUBANE 

• DON MCCULLIN 

• TIM PAGE 

• CHARLES PORTER 

• SEBASTIAO SALGADO 

• CHIM SEYMOUR 

• JOAO SILVA 

• CORINNE DUFKA 


ANNOUNCEMENT 

CELEBRATES 

60 YEARS IN MENTAL HEALTH 

In 2018, we proudly mark the 60th year of 

Janssen’s continued dedication to the area 

of mental health. Our journey began in 1958, 

with Dr Paul Janssen’s discovery of a pioneering 

antipsychotic drug, haloperidol, challenging the 

tradition of institutionalisation. Since then, we 

have continued our mission to reduce the burden, 

disability and devastation caused by mental 

health disorders, by understanding and producing 

treatments that address the most serious unmet 

medical needs. We recognise the importance of 

continuous treatment and that non-adherence is a 

consistent feature of schizophrenia, which is why we 

consistently pursue the development of long acting 

formulations of our most prominent antipsychotic 

treatments. 

medicines 2 – which have collectively helped to 

shape the care of neuropsychiatric diseases. 

Mental health affects us all – one in four people 

in the world will be affected by mental health or 

mood disorders at some point in their lives 3 – and 

we celebrate this legacy in the knowledge that we 

remain steadfast in our commitment to transforming 

and improving individual lives. 

Over the last 60 years we have produced more than 

20 medications and innovations 1 – two of which are 

on the World Health Organization’s list of essential 

1 Awouters F.H.L., Lewi P.J. Forty Years of Antipsychotic Drug Research – from Haloperidol to Paliperidone – with Dr. Paul Janssen. Antipsychotic 

drug research 2007;57(10):625–632 

2 World Health Organization. Model Lists of Essential Medicines. Available at: http://www.who.int/selection_medicines/committees/expert/20/ 

EML_2015_FINAL_amended_AUG2015.pdf?ua=1. Accessed May 2018. 

3 World Health Organization. http://www.who.int/whr/2001/media_centre/press_release/en/ 

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jschres.2017.12.010. 2. Decuypere F, Serman J, Geerts P, et al. Treatment continuation of four long-acting antipsychotics medications in the Netherlands and Belgium: A retrospective database study. PLoS ONE 

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FEATURE 

THE GENOCIDE 

OF PSYCHIATRIC PATIENTS 

THROUGH THOUGHTLESSNESS 

& EVIL COMPLIANCE 

Zamo Mbele 

“Government, even in its best state, is but a necessary evil; in its worst state, an intolerable 

one.” - Thomas Paine 

“To ignore evil is to become an accomplice to it.” - Martn Luther King, Jr. 

Ayoung South African democracy faces a 

dark hour in the wake of what is generally 

referred to as the ‘Life Esidimeni tragedy’, 

where following a series of neglectful and 

devastating oversights hundreds of psychiatric 

patients have lost their lives, many more remain 

missing and unaccounted for, a countless number 

of families find themselves in grief, and the extent 

of neglect and callousness in the healthcare 

systems has been uncovered. In the case of the 

deaths of said psychiatric patients much has been 

written, published and publicized in the media 1,2,3 , 

academically 4,5,6,7 and as this paper is being 

written an official alternative dispute resolution 

process is underway with judgment from retired 

Judge Moseneke pending 1a . This tragedy – which 

is one of many such in contemporary South Africa, 

is iconic in bringing into sharp focus the ill-health 

and criminality towards psychiatry in the public 

health sphere and of the public health sentiment 

respectively in South Africa. Yet, it 

is the opinion of the author, that 

while public discourse in reflection 

of this tragedy continues, public 

hearings and arbitrations are held 

to account for this tragedy, that two 

‘running truths’ deserve comment. 

Zamo Mbele 

FIRSTLY, THAT THIS IS 

ONE OF MANY SUCH 

DISASTERS WHICH KNOWINGLY OR 

UNWITTINGLY ROB MILLIONS OF THEIR 

CONSTITUTIONAL RIGHT TO DIGNITY 

THROUGH CONDITIONS FACED BY MANY 

MORE PEOPLE LIVING WITH PSYCHIATRIC 

CONDITIONS (DIAGNOSED OR NOT) IN 

SOUTH AFRICA. 

1a 

Since authoring the article the said process has concluded with Judge Moseneke finding that top officials in 

the Gauteng health department had skirted their responsibilities resulting in the death of at least 144 psychiatric 

patients and neglect of others. He likened the treatment of the patients moved between facilities to torture and 

abuse that lead to death in many cases. He added that the South African government had breached several 

constitutional rights in the mistreatment of the patients in question. Further, Moseneke’s report ordered that the 

government pay each claimant a sum of money in compensation and damages. 


FEATURE 

Secondly, that where psychiatry and public 

health converge, we find gross neglect from state 

institutions in ethos and action. While this inhumane 

disaster is a monumental catastrophe deserved of 

global outcry and presidential attention, it remains 

an example of the lived experience of millions 

past, present and future when the humanity of the 

psychiatric patient is discounted and completely 

undermined by national and social structures. While 

this incident is incomparable, this near genocide 

must be appreciated in similar relevance to those 

seen elsewhere historically in Africa, Europe, South 

America inter alia. In this regard, it is important 

perhaps to briefly contextualize genocides in 

psychiatry historically and discursively, and further to 

have a brief consideration of the known mechanics 

of supporting the most vulnerable persons in society 

by active social participation. Specifically, this paper 

will offer and discuss a particular and brief account 

of relevant psychiatric deaths that occurred in the 

neglectful and cruel authority of the state. Mostly 

through historical accounts and further proposing 

a succinct theoretical concept, the paper aims 

humbly to add nuance to the important discussion 

on mental health neglect and the accountability 

of society and relevant social authority. This paper 

is neither a comprehensive historical archive by 

any stretch with regards to the former, nor a policy 

driven attempt to complementary social service 

with regards to the latter. Instead the paper aims to 

highlight in brief specific considerations. 

THE DEVELOPMENT AND HISTORY 

OF STATE PSYCHIATRIC INTUITIONS 

FOR INTERMEDIATE AND LONG-TERM 

INPATIENT CARE AND TREATMENT IS 

WELL DOCUMENTED AND ARCHIVED 

IN MULTIMEDIA AND JOURNALS 

RESPECTIVELY. THE PARTICULAR ADVENT 

AND PROLIFERATION OF PSYCHIATRIC 

ASYLUMS TOO ENJOYS MUCH WRITTEN 

ATTENTION HISTORICALLY AND CURRENTLY. 

Where the deposition of mental health care has 

been mostly restricted to asylums and related 

self-contained live-in institutions, the results have 

often been seen to be in contempt of the initially 

imagined intention to look after those most 

vulnerable of society. 8 Instead, it is well researched 

that such institutions often result in severe abuse 

and torture of admitted users at the worst of times, 

and profound neglect at best. 9 These research 

results have unfortunately been replicated with little 

variance historically and globally for many centuries 

now. From Europe 8,10 , North America 11,12 , South 

America 11 , Africa 13 , and Asia 14 , the asylum has often 

and to the detriment of many psychiatric patients 

deteriorated into abduction, disposal and abuse to 

the extent of gross human rights abuse. 8 The latter 

body of research has been shown even with variable 

variance between children and adults 15 , gender 16,17 , 

race and class. 17 The debate remains whether the 

cruelty experienced in said institutions cascades 

bottom-up from a social stigma and common 

practice into such institutions, or rather vice versa 

from institutional practice and knowledge which 

is then inculcated into social norms. Nevertheless, 

histories of such torture are abundant and worth 

consideration here. 

In postmodern and contemporary Africa, the 

institutionalization of care of psychiatric patients 

has followed a global trend in line with socioeconomic 

divisions of labour, industrialization, 

and modernization. Here too, the momentum to 

institutionalize, marginalize and specialize care 

to and by state institutions has culminated, by 

and large, in disastrous results when coupled 

with maladministration, corruption, illegality and 

negligence - often driven by individual self-interests, 

stigma related to psychiatry, and improper state 

psychiatric commitments. 13,18 For South Africa, Sukeri, 

Betancourt & Emsley (2014) 19 give an accurate 

account of the former opinion with special interest 

to the Eastern Cape region and its inseparable 

relationship with the socio-political marriage of 

colonial and apartheid South Africa (and Southern 

Africa). Gberie (2017) 20 discusses the plight of 

neglect of psychiatric patients by African social 

systems, public statutes and governing states, both 

by the lack of resources and access to resources in 

society outside of stipulated institutions as well as in 

institutions for those identified for admissions. Gberie 

(2017) 20 and others 18,21 add complexity and highlight 

the failed responsibility of African states in providing 

adequate, necessary and humane psychiatric 

healthcare. The former authors adequately frame the 

historical inheritance of this neglect and highlight 

the contemporary psychiatric genocide resulting 

in an inadequate response in the social need for 

psychiatric services. 

IT BECOMES CLEAR THAT THE ARGUMENT 

AGAINST ‘BURDEN TO THE STATE’ OFTEN 

WAGED AGAINST PROPER RESOURCING 

OF PSYCHIATRIC CARE AND INSTITUTION 

IS DIM WHEN CONSIDERING THE BURDEN 

TO PERSONS AND THE AFRICAN STATE 

AS A WHOLE IN THE CARELESSNESS 

AND PARSIMONIOUS ATTENTION 

AND RESOURCING TO THIS MATTER. 

French philosopher, Michel Foucault, offers us great 

insights into the possibility (and probability) of 

venality and perversion of society and the psychiatric 

complex for patient and persons. On aggregate, 

Foucault argues the probability of a corruption 

of social authority and social consciousness inter 

alia. He specifically offers Madness and Civilization 

(1961), The Birth of a Clinic (1963) and Discipline and 

Punish (1975) for the interrogation of the former. 22-24 

Foucault (1961; 1963; 1975) 22-24 cautions against 

the propensity for society to incarcerate, punish 

and dehumanize the psychiatric patient through 

the civil installation and ratification of asylums. 

The former academic’s thesis is ingrained in the 

historical context of interwar Europe and specifically 

the damage and destruction experienced by the 


FEATURE 

discipline of medicine and psychiatry as a result. 

He directs our attention to the mass violence 

suffered by the most vulnerable in society – in this 

regard psychiatric patients and how the death of a 

patient is often undignified by its dilution as a lesser 

comparison to the death of a person. A difficult 

substrate to find evidence for the former assertion is 

as previously referred too; interwar Europe and their 

‘psychiatric genocide’. 

The context of World War I and World War II are too 

vast to capture here, and rather, the author would 

like to better focus on the less accounted for and 

less discussed deaths of psychiatric patients during 

this tempestuous period. Torrey and Yolken (2009) 25 

succinctly and concisely assert “The Nazi genocide 

of psychiatric patients was the greatest criminal act 

in the history of psychiatry”. 

WHILE THE VERACITY OF THE DEATH TOLL 

WILL ALWAYS REMAIN CONTENTIOUS AND 

VARY DEPENDENT ON PUBLICATIONS AND 

SOURCES, IT IS ESTIMATED THAT BETWEEN 

220 000 AND 269 500 INDIVIDUALS WITH 

SCHIZOPHRENIA ALONE WERE STERILIZED 

AND KILLED DURING WORLD WAR II. 25 

THESE MURDERS WERE IN THE CONTEXT 

OF THE THEN STATE’S (OFFICIAL) INITIATIVE 

TO REDUCE THE COSTS AND BURDEN TO 

STATE EXPERIENCED BY INSTITUTIONAL 

CARE FOR PSYCHIATRIC PATIENTS. 

The idea of killing the patients in psychiatric hospitals 

first surfaced prominently in 1920 in a publication by 

Karl Binding, a lawyer, and Alfred Hoche, a psychiatrist. 

Entitled Permission for the Destruction of Life Unworthy 

of Life, the tract posed the question: “Is there human 

life which has so far forfeited the character of 

something entitled to enjoy the protection of the 

law, that its prolongation represents a perpetual 

loss of value, both for its bearer and for society as a 

whole?” The authors’ answer was clearly affirmative 

and described such individuals as being “mentally 

dead” and “on an intellectual level which we only 

encounter way down in the animal kingdom.” The 

authors emphasized the economic burden of such 

individuals to Germany. The economic argument 

was repeated in subsequent discussions of this issue, 

such as in a 1932 article entitled “The Eradication of 

the Less Valuable from Society,” in which the author, 

psychiatrist Berthold Kihn, estimated that mentally 

ill individuals were costing Germany 150 million 

Reichsmarks per year. 

The consequence of this legitimized motion later 

pervasively proliferated through Europe, seeing 

for example that “Tens of thousands of mentallyill 

patients died of starvation in French psychiatric 

hospitals between 1940 and 1945” 26 , and many 

others demise in European states from neglect 

(Robertson, Light, Lipworth, Walter, 2017). 27 The 

hallmark in this regard -which we must find relevant 

and resonant in modern day South Africa- was the 

legitimization of a psychiatric genocide, which we as 

a contemporary South African society have and are 

experiencing even in a modern day democracy with 

a robust constitution which hails itself as protective 

of all who live in it and those most vulnerable. It is 

striking then that decades later, with the benefit of 

advantage in hindsight, we as a society would find 

ourselves in a similarly precarious and perpetrator 

role through a repeated ethos. It is remarkable that 

the highest custodian of citizens and citizenship, 

vested with power to protect and sanctify life, would 

be found to be the direct executor of death and 

murder. Where the former institutions use asylum 

institutions as quasi death camps, this failure and 

perversion must be interrogated with urgency and 

constitutionally. Additionally, the question addressed 

to processes that in failure to protect and serve, 

allow such heinous actions and consequences 

are due much interrogation, hopefully for the civil 

protection of future persons and patients, globally 

and indigenously. 

IT IS NOT UNCOMMON FOR (ACTIVE AND 

PASSIVE) PARTICIPATORY PERPETRATORS 

OR INDIVIDUALS IN INSTITUTIONS TO 

CLAIM IGNORANCE THROUGH BEING 

ILL-INFORMED, UNAWARE OR MISLED 

WHEN BEING HELD TO ACCOUNT FOR 

ABOVE MENTIONED CRIMES AGAINST 

HUMANITY, AND HISTORY IS RIFE WITH 

ACQUAINTING EXAMPLES. 

During the aftermath and the proceeding hearings 

into the ‘Life Esidimeni tragedy’, almost all the top 

officials in the Department of Health of Gauteng 

have recused themselves from any accountability 

and absolved themselves of responsibility for the 

actions leading to the disastrous project. Dhai 

(2017) 5 notes for example; “According to the 

ombud’s report, the MEC was not aware of the 

total number of patients who had died in a project 

that she had authorised during the ‘conscientious’ 

performance of a function of her office”, a sentiment 

echoed by her colleagues, including the Ministry of 

Health with high frequency. 

HOWEVER THE ‘I DID NOT KNOW’ 

ARGUMENT APPRECIATES CONSIDERATION 

IN ARENDT’S WORK, WHERE SHE 

EXAMINES COMPLICITY IN IGNORANCE, 

PARTICULARLY WHEN THE IGNORANCE IS 

IN THE GULF OF ACTIVE PARTICIPATION 

AND ACTION WITHOUT THOUGHT. 

ARDENT SHIFTS THE ARGUMENT SLIGHTLY 

FOR ANALYSIS BETWEEN ‘I DID NOT 

KNOW’ TO ‘I REFUSED TO KNOW’ OR ‘I DID 

NOT THINK’. 

Hannah Arendt’s notion of the “banality of evil” is 

relevant here, a phrase she coined in her 1963 book, 

Eichmann in Jerusalem: A Report on the Banality 


FEATURE 

of Evil, about the trial of Adolph Eichmann, a top 

administrator in the machinery of the Nazi death 

camps, in an Israeli courtroom. 27 Ardent argues 

that if someone carries out unspeakable crimes 

often enough, he or she comes to accept them as 

“normal.” 

TO ARENDT’S MIND, EICHMANN WILLINGLY 

DID HIS PART TO ORGANIZE THE 

HOLOCAUST — AND AN INSTRUMENTAL 

PART IT WAS — OUT OF NEITHER ANTI- 

SEMITISM NOR PURE MALICE, BUT OUT OF 

A NON-IDEOLOGICAL, ENTIRELY MORE 

PROSAIC COMBINATION OF CAREERISM 

AND OBEDIENCE. 

The “banality of evil” also applies to an entire society. 

We as a society can get used to outrageous things 

— slavery, Jim Crow segregation laws, massive 

homelessness, widespread malnutrition, the frequent 

killing of black men by police — until we are provoked 

to view them as unjust. “The Israeli court psychiatrist 

who examined Eichmann found him a “completely 

normal man, more normal, at any rate, than I am 

after examining him,” the implication being that the 

coexistence of normality and bottomless cruelty 

explodes our ordinary conceptions and present the 

true enigma of the trial” . 28 Suffice to engage briefly 

with Hanna Arendt’s arguments and conversations 

on the banality of evil. The thesis of the banality of evil 

is strongly contested and controversial. However as a 

segway it affords a useful understanding of socially 

inhumane acts – such as psychiatric genocides, by 

engaging the perpetrator. A succinct explanation is 

shared by Banhabib (1996) 28 . 

“IN USING THE PHRASE “BANALITY 

OF EVIL” AND IN EXPLORING THE 

MORAL EQUALITY OF EICHMANN’S 

DEEDS NOT IN TERMS OF 

MONSTROUS OR DEMONIC NATURE 

OF THE DOER, ARENDT BECAME 

AWARE OF GOING COUNTER TO THE 

TRADITION OF WESTERN THOUGHT 

WHICH SAW EVIL IN METAPHYSICAL 

TERMS AS ULTIMATE DEPRAVITY, 

CORRUPTION OR SINFULNESS. THE 

MOST STRIKING QUALITY OF 

EICHMANN, SHE CLAIMED, WAS 

NOT STUPIDITY, WICKEDNESS OR 

DEPRAVITY BUT ONE SHE DESCRIBED 

AS ‘THOUGHTLESSNESS’”. 

For Arendt, evil acts can become of banal 

compliance, which is the near direct condition where 

thought and thinking are devoid. While disputed, 

Arendt does not seem to want to absolve the evil 

of the process and act, rather caution against 

thoughtlessness and the accompanying evil. It is 

therefore not difficult to imagine that the thoughtless 

veiled by ignorance – as argued by top state official’s 

in the arbitrations and hearings for the Life Esidimeni 

cases, is a repetition of the enactment of banal evil 

resulting in mass deaths. Careerism and obedience 

are often found at the foundation of such acts 

that were too referred to in defense and mitigation 

against prosecution or accountability where the 

said arbitrations have taken place. However these 

latter two practices, Arendt argues are not enough 

of an excuse for absolution of criminality. A further 

complication of the argument emerges when we 

hold an entire society accountable for ignorance – 

passive and active. 

The argument made by Arendt is compelling and it 

is astute to conclude that the psychiatric genocides 

mentioned above and elsewhere in histories 

are evidence partially of the thoughtlessness 

of individuals, governments and societies. A 

thoughtlessness that is not without deliberation or 

evil intent, though thoughtlessness that is without 

compassion, empathy and consideration of the 

person in the patient. 

THE SOUTH AFRICAN GOVERNMENT 

AND ALL COMPLICIT INDIVIDUALS IN 

THE NATIONAL AND PROVISIONAL 

DEPARTMENTS OF HEALTH RESPONSIBLE 

FOR THE DEATHS OF PATIENTS, ABUSE 

OF PATIENTS AND CRUELTY THROUGH 

NEGLECT HAVE REPEATED A GENOCIDE, 

AND THE CLAIMS OF IGNORANCE 

ARE RATHER INDICATIVE OF A 

MORE PERVASIVE IGNORANCE AND 

THOUGHTLESSNESS WHICH LEADS TO EVIL. 

Respectively, this ignorance is an ignorance 

perpetuated through and by stigma surrounding 

mental health and psychiatric illness. It is an 

ignorance which results in the above discussed 

tragedy and many other micro tragedies 

experienced by individuals living with psychiatric 

conditions on a daily basis. An ignorance that is 

also socially rife and struggles to penetrate broad 

social discourse enough for its demystification and 

contention. The thoughtlessness is as suggested – 

a thoughtlessness of behaviour without cognition, 

agency and creativity, a thoughtlessness of 

compliance that is accompanied by complicities. 

However it is additionally a thoughtlessness that is 

devoid of the dignity required in the care of those 

most vulnerable in society, a thoughtlessness 

of callous character, of a society and certainly 

individuals devoid of beneficence, mindfulness and 

humanity. It is evil. 

REFERENCES 

1. Rahlaga M. Moseneke likens treatment of 

Esidimeni patients to Slave Trade, ewn.co.za, 

February 2018, accessed 12 May 2018, http:// 

ewn.co.za/2018/02/09/moseneke-likenstreatment-of-esidimeni-patients-to-slave-trade. 


FEATURE 

2. Nicolson G. Life Esidimeni: Former Health MEC 

Qedani Mahlangu spins a web of confusion 

and deceit to shift the blame, Daily Maverick, 

23 January 2018, accessed 12 May 2018, < 

https://www.dailymaverick.co.za/article/2018- 

01-23-life-esidimeni-former-health-mec-qedanimahlangu-spins-a-web-of-confusion-anddeceit-to-shift-the-blame/>. 

3. 62 Life Esidimeni patients are missing, Times Live, 

26 January 2018, accessed 12 May 2018,. 

4. Dhai A. After Life Esidimeni: True human rights 

protections or lip service to the Constitution? 

South African Journal of Bioethics Law 

2017;10(1):2-3. 

5. Dhai A. The Life Esidimeni tragedy: Constitutional 

oath betrayed. South African Journal of Bioethics 

Law 2017;10(2):40-41. 

6. Janse van Rensburg B. Life Esidimeni psychiatric 

patients in Gauteng Province, South Africa: 

Clinicians’ voices and activism – an ongoing, 

but submerged narrative. South African Journal 

of Bioethics Law 2017;10(2):44-47. 

7. Stein DJ, Chambers C, Daniels I, Patel B, 

Sunkel C, White J, Wilson Z, Lund C. Death by 

maladministration: An important category of 

patient mortality. South African Medical Journal 

2017; 1;107(4):280. doi: 10.7196/SAMJ.2017. 

v107i4.12389. 

8. Shorter E. History of psychiatry. Current Opinion in 

Psychiatry 2008; 21(6):593–597. 

9. Philo C. Across the water: Reviewing geographical 

studies of asylums and other mental health 

facilities. Health and Place 1997; 3(2):73-89. 

10. Kelly D. The Mental Treatment Act 1945 in Ireland: 

an historical enquiry. History of Psychiatry 2008; 

19 (1); 47-67. 

11. Grob GN. The mad among us: A history of the 

care of America’s mentally ill. New York, NY, United 

States of America: Free Press, 1994. 

12. Trent Jr JW. Inventing the Feeble Mind: A History 

of Mental Retardation in the United States. 

California, United States of America: University of 

California Press, 1994. 

13. Keller RC. Colonial Madness: Psychiatry in French 

North Africa. United States of America: The 

University of Chicago, 2007 . 

14. Higginbotham N, Marsella AJ. . International 

consultation and the homogenization of 

psychiatry in Southeast Asia. Social Science & 

Medicine 1988; 27(5):553-561. 

15. Rivlin LG, Wolfe M. The Early History of a Psychiatric 

Hospital for Children: Expectations and Reality. 

Environment and Behavior 1972; 4(1): 33-72. 

16. Pouba K, Tianen A.. Lunacy in the 19th Century: 

Women’s Admission to Asylums in United States 

of America. Oshkosh Scholar 2006; 1: 95-103. 

17. Swartz S. IV. Lost Lives: Gender, History and 

Mental Illness in the Cape, 1891-1910. Feminism 

& Psychology 1999; 9(2): 152-158. 

18. McCulloch J. Colonial Psychiatry and the African 

Mind. Great Britain: Cambridge University Press , 

1995. 

19. Sukeri K, Betancourt OA, Emsley R, Nagdee M, 

Erlacher H. . Forensic mental health services: 

Current service provision and planning for a 

prison mental health service in the Eastern 

Cape. South African Journal of Psychiatry 2014; 

22(1): 1-8. 

20. Gberie L. Mental illness: Invisible but devastating. 

Africa Renewal online December 2016 - March 

2017, accessed 12May 2018, < https://www. 

un.org/africarenewal/magazine/december- 

2016-march-2017/mental-illness-invisibledevastating>. 

21. Akyeampong E, Hill AG, Kleinman A M. The 

Culture of Mental Illness and Psychiatric Practice 

in Africa. Indiana, United States of America: 

Indiana University Press, 2015. 

22. Foucault M. Madness and civilization: a history 

of insanity in the Age of Reason. New York, NY: 

Vintage Books, 1961. 

23. Foucault M. The Birth of the Clinic: An Archaeology 

of Medical Perception. Vintage Books, 1963. 

24. Foucault M. Discipline and punish: the birth of 

the prison. New York: Pantheon Books, 1975. 

25. Torrey E F, Yolken R H. Psychiatric Genocide: 

Nazi Attempts to Eradicate Schizophrenia. 

Schizophrenia Bulletin 2009; 36(1): 26–32. 

26. on Bueltzingsloewen I. The Mentally-ill who Died 

of Starvation in French Psychiatric Hospitals 

during the German Occupation in World War 

II. Vingtième Siècle Revue d’histoire 2002; 76(4): 

99-115. 

27. Arendt H. Eichmann in Jerusalem, A Report on 

the banality of evil 5 th edition. New York: Penguin 

Books, 2006. 

28. Banhabib S. Identity, Perspective and Narrative 

in Hannah Arendt’s “Eichmann in Jerusalem”. 

History and Memory 1996; 8 (2): 35-59. 

Zamo Mbele is a clinical psychologist at Tara Hospital and 

jointly appointed in the Department of Psychiatry, University 

of the Witwatersrand, Johannesburg, South Africa. He also 

serves as a board member of the South African Anxiety 

and Depression Group (SADAG). Correspondence: 

zamombele@gmail.com 


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REPORT 

DEADLY 

MEDICINE 

THE MARK OF THE LIFE ESIDIMENI DECANTING 

Megan Jones 

The two-day “Deadly Medicine: The Mark of 

the Life Esidimeni Decanting” conference 

was held on 10 and 11 August 2018 at the 

Johannesburg Holocaust & Genocide Centre 

(JHGC) in Forest Town. The event was organized 

under the auspices of GRASP (Groups for Reading 

and Study of Psychoanalysis) by GRASP members, 

together with the clinical team that participated in 

the Life Esidimeni (LE) Alternative Dispute Resolution 

(ADR) process. (This team had interviewed some 

of the families of the mental health care users who 

had died during the Marathon Project and had 

contributed to the psychoanalytical expert testimony 

report). 

Opening: Coralie Trotter (conference organizer), Jabulile Hlatswayo (a family 

member of the deceased), and members of the Mzansi Youth Choir during 

the memorial ceremony. (Photographer: Louise Gubb) 

The conference was opened during the memorial 

ceremony held the preceding evening – a 

paradoxically but appropriately rejuvenating 

gathering for the families of the surviving, deceased, 

and missing LE victims. Through poetry, photography, 

song, ritual, and dialogue, an attempt was made 

to create further bridges among 

the conscious experience of the 

trauma, the evidence led during 

the ADR, Judge Moseneke’s 

resulting arbitration report, and the 

still unknown aspects of what really 

transpired over the past few years. 

THE EMOTIONAL AND 

Megan Jones 

PSYCHOLOGICAL AIM WAS 

TO HONOUR THOSE WHO HAD LOST 

THEIR DIGNITY AND HUMANITY DURING 

THE DECANTING AND TO CONTINUE 

OPENING UP A SPACE IN WHICH FURTHER 

INTEGRATION OF THE MARATHON 

PROJECT’S DEVASTATION COULD TAKE 

PLACE. 

The JHGC was a fitting home for the memorial 

ceremony and conference given that the centre’s 

broad mandate is to “teach the consequences 

of prejudice, racism, antisemitism, homophobia 

and xenophobia and the dangers of indifference, 

apathy, and silence to freedom and democracy” 

(“Johannesburg Holocaust & Genocide 

Centre; About”, n.d., para. 3; my italics). Mounted 

prominently on a wall in the foyer is a quote by 

Italian Jew, writer, and chemist Primo Levi, reminding 

us of our all too human propensity to recurringly 

abandon our humanity and disavow plentiful 

evidence of our parallel potential for othering and 

cruelty. Following Levi’s release from the Auschwitz 

concentration camp, he wrote prolifically about his 

experiences; writings which seven decades later 

have perspicacious bearing on the LE tragedy. 


REPORT 

FOR LEVI, THE WORST VILLAINS IN THE 

HOLOCAUST WERE NOT NECESSARILY 

THE PEOPLE WHO PHYSICALLY KILLED 

THEIR VICTIMS, BUT THOSE WHO 

DEGRADED THOSE HUMANS DEEMED BY 

THEM UNDESIRABLE TO “THINGS”. 1 LEVI 

CONSIDERED THE “DESTRUCTION OF THE 

VICTIM’S HUMANITY AND DIGNITY” – A 

FORM OF PSYCHIC MURDER – AS AN 

EQUAL OR EVEN GREATER ATROCITY TO 

PHYSICAL MURDER, A SLAUGHTER WHICH 

IS THEN ALL TOO EASILY RATIONALISED 

ONCE VICTIMS HAVE BEEN STRIPPED OF 

THEIR HUMAN STATUS. 1 

Levi’s intellectual genius allowed him to write 

extensively about aspects of the dehumanization, 

torture, and cruelty of Auschwitz and the Holocaust. 

However, by 1986, depressed and burdened by the 

cumulative weight of his persistent witnessing of 

human-induced devastation, he penned the quote 

now displayed in the JHGC’s entrance: “It happened, 

therefore it can happen again … and it can happen 

everywhere” (Levi, 1989). One year later, Levi 

committed suicide. Fellow Holocaust survivor and 

1986 Nobel Peace Prize laureate Elie Wiesel astutely 

diagnosed the aetiology of Levi’s tragic death in 

his penetrating observation: “Levi died at Auschwitz 

forty years later, crushed by a sadness from which he 

could no longer escape, not even with the incredible 

strength of reason, with which he had cast light for 

everyone [on the Holocaust experience]”. 2 I would 

tentatively hypothesise that whilst Levi could hold 

in mind, symbolise, and narrate many facets of his 

own and his society’s harrowing experiences, other 

fragments of this trauma had been banished from 

his conscious mind and buried in the unconscious 

aspects of his psyche-soma. Thus dissociated from 

awareness, these unbound and unintegrated 

residues of horror would have been inaccessible 

to the psychic work which proffers the potential of 

metamorphosing “ghostly deformed horror[s]” into 

something with “shape and meaning”. 3 

milieu in which the Marathon Project emerged also 

impinges upon our capacity – as individuals and as a 

society – to engage in the prerequisite psychological 

work to transform and then represent the Decanting’s 

insufferable and ineffable pain: the wreckage from 

this event is strewn across the landscape of our 

country’s still festering apartheid and colonial past: 

24 years into democracy, the inequities and terrors of 

our socio-political history continue to impinge on the 

availability of requisite resources to process trauma. 

These deficits manifest in both the external physical 

world (e.g. lack of access to resources to meet basic 

biological and human needs; absence of adequate 

health and mental health services; continuing 

threats to physical and psychic safety), as well as 

within each person’s intrapsychic landscape (e.g. 

absence of secure attachments; compromised 

capacities to mentalise and symbolise). 

During the later stages of the arbitration, Judge 

Moseneke, struggling with the incomprehensibility 

of the gratuitous devastation, imploringly asked: 

‘What was this about? You know I sat here for weeks 

and I still deeply worry and wonder what was this 

Marathon Project about. What were you trying 

to do? Why did you go along with that plan that 

was bound to prove murderous?’. 4 Psychoanalytic 

thinking’s transition from couch to courtroom, 

and the attendant redirection of gaze from the 

intrapsychic to the nation’s psyche and the realm of 

human rights and social justice, demonstrated this 

discipline’s arguably unique value in “understanding 

the human mind” and its potential to explicate “a 

trail of events that [otherwise would have defied] 

comprehension”. 5 

For the South Africans who survived or witnessed 

what is considered to be the worst human rights 

crime in our nascent post-apartheid society, the 

imperative redress is not solely financial. Redress 

necessitates the provision of safe opportunities for 

the sensorial, unbound, and unbearable shards 

of horror to be shared, witnessed, and potentially 

rendered available for conscious consideration and 

integration. For the fortunate, the possibility may also 

then emerge for mourning, meaning-making, and 

the re-establishment of a continuity of being. 

The above described necessary psychic redress is a 

prodigious ask for a number of reasons, two of which 

link to constituent features of the LE tragedy: (1) it 

having been an entirely avoidable human induced 

disaster, and (2) the obfuscating and perverse 

absence of full disclosure and lack of coherent 

explanation for its reckless inception. Sadly, the 

Candle Lighting Ceremony accompanied by the Mzansi Youth Choir. (Photographer: 

Louise Gubb) 


REPORT 

The psychoanalytical approach to the memorial 

ceremony and conference invited attendees to 

embark on the momentous psychic journey to 

salvage psychic life from the devastating debris of 

the decanting. The red thread of psychoanalysis 

wove itself through the LE team’s initial interviews with 

the affected families; the preparation, presentation, 

and cross examination of the LE team’s expert 

testimony report during the ADR (a ground-breaking 

forensic application for psychoanalysis in South 

Africa); and the culminating memorial ceremony 

and conference. Where persistent and repeated 

legal questioning of conscious motives and 

knowledge was unable to provide clarity, the 2017 

psychoanalytical testimony at the ADR and this 

year’s dialogue at the Deadly Medicine Conference 

offered tentative explanations for the emergence of 

this tragedy. By engaging with deeper, unconscious 

motives and driving forces within individuals and 

society, aspects of the LE decanting have started to 

be metabolised and rendered less ineffable and at 

least partially comprehensible. 

The keynote address at the conference was delivered 

by Professor Leslie Swartz, who initiated a critical 

dialogue around the disenfranchised locus of the 

disabled and of mental healthcare users in our 

society, and the fraught politics of identity in relation 

to our psychoanalytic work. He also highlighted how, 

as in the LE Decanting, death makes neglect visible, 

but that “the Esidimeni tragedy is … not unique in its 

betrayal and neglect of disabled people”. 6 Swartz’s 

emphasis on LE not being an isolated event was 

reiterated throughout the conference: abundant 

examples were named of the abject disintegration 

or absence of physical resources and of systemic 

deficits to tolerate and symbolise unbearable 

horror. The LE disaster is, unnervingly, simply one 

instantiation of a far more pervasive and insidious 

disregard for human life and dignity; simply one of 

many – admittedly less public – concrete expressions 

of the organisational and societal dysfunction within 

the Gauteng Health Department and broader state 

and societal structures. 

THE PANEL PRESENTATIONS AND PAPERS 

WHICH FOLLOWED SWARTZ’S KEYNOTE 

ADDRESS EXTENDED DISCUSSION OF THE 

ESSENTIAL PROCESS OF CONTAINING 

AND SYMBOLISING SUFFERING; THE 

ROLE OF COUNTERTRANSFERENCE 

IN RELATION TO TRAUMA; AND THE 

DECONSTRUCTION OF THE PERVERSE, 

PSYCHOTIC, AND ANARCHIC STATE OF 

MENTAL HEALTH SERVICES IN GAUTENG 

AND SOUTH AFRICA AS A WHOLE. 

Van der Walt’s paper, which critically examined and 

contrasted the Truth and Reconciliation Commission’s 

(TRC) approach to achieving reparation and redress 

with that of the ADR, also serendipitously provided an 

additional perspective on Primo Levi’s suicide. Whilst 

the TRC’s unofficial preoccupation appeared to be 

omnipotent healing and forgiveness – possibly at 

the cost of acknowledging the unbearable truth 

of boundless and unbound suffering and rage – 

the ADR process seemed to be less susceptible to 

the compelling urge to retreat from “the raw and 

destabilizing power of trauma”. 7 As a result, the ADR 

could introduce into an official record a “metabolized 

version of trauma narrative” 7 , a potential starting 

point for confronting the emotional – and not 

simply cognitive – truth of unthinkable human 

suffering. This then in turn introduces the hope of 

safeguarding the psychic life of individuals and 

social structures in the aftermath of trauma – unlike 

for Primo Levi whose conscious ‘reason’ afforded 

others a rich understanding of the Holocaust, but 

whose unbound residues of horror never achieved 

representation and expression, thus ultimately killing 

him. 

In 1958, Primo Levi initially wrote that “if there is 

one thing sure in this world, it is certainly this: that 

it will not happen to us a second time”. This may 

well be the desired rhetoric in the aftermath of the 

LE tragedy (and perhaps may have also been the 

Upon request of the families of the victims of the Marathon Project, memorial ceremony attendees dressed in black and affixed differently coloured flowers to their 

clothing. Family members of the deceased wore red flowers; family members of the survivors, white flowers; and other attendees, yellow flowers. From left to right: 

memorial ceremony attendee Bokang Mpeta; poet and conference presenter Makhosazana Xaba; and member of the LE clinical team and conference presenter 

Zamakhanya Makhanya. (Photographer for “Flowers for Memorial”: Louise Gubb; Photographer for “Flowers”: Michael Benn) 


REPORT 

wish during the TRC). Yet it is Levi’s 1986 terrible and 

tragic but truthful realisation that must be retained 

in consciousness: “It happened, therefore it can 

happen again … and it can happen everywhere”. 

2. Colombo, F. (1987, 14 April). Elie Wiesel: Con 

l’incubo che tutto sia accaduto invano. La 

Stampa. Translated by E. Mecco. Retrieved from: 

http://www.archiviolastampa.it/component/ 

option,com_lastampa/task,search/ 

mod,libera/action,viewer/Itemid,3/page,3/ 

articleid,0972_01_1987_0087_0003_13356602/. 

3. Johannesburg Holocaust & Genocide Centre; 

About, n.d.. Retrieved from http://jhbholocaust. 

co.za/about-us/. 

4. Laing, B. (2018, 11 August). When the scream 

becomes a word: The maternal function in the 

Life Esidimeni Arbitration. Paper presented at 

the conference: Deadly Medicine: The Mark of 

the Life Esidimeni Decanting, Johannesburg. 

5. Levi, P. (1987) [1958]. If This is a Man, translated 

by S. Woolf, London, Abacus. 

Primo Levi quote on a wall in the Johannesburg Holocaust & Genocide Centre’s 

foyer. (Photographer: Michael Benn) 

Metabolising the trauma of the Marathon Project, 

and slowly and painfully translating its horror into the 

symbolic realm, is a crucial start to individual and 

societal recovery. However, the symbolised memory 

of LE must then become the prelude to continued 

action in addressing the manifold substantive 

issues which pervasively and perversely continue 

to threaten basic human rights and dignity (e.g. 

the freezing of critical health posts; the proposed 

National Health Insurance (NHI)). As Trotter wrote 

in her closing address at the conference: “We 

cannot gain the high ground of a truth insulated 

from violence and unreason, destruction and selfdestructiveness, 

madness and sin. … Psychoanalysis 

at its best is thoughtful and anarchic in that it aims 

to deconstruct rather than collude with normative 

paradigms [and] this demands not remaining silent 

in the face of inhumanity and abuse”. 4 

AS WE SOAK IN THE LINGERING HORROR. 

WE WONDER, WORRY, WIGGLE AND ASK: 

IN WHOM SHALL WE TRUST THIS COUNTRY, 

WHERE HOPE LANDS THEN CRASHES, 

AND ITS SHARDS RUIN EVERYTHING 

AROUND IT, 

AND THE PRESENT TASTES LIKE THE PAST? 

Extract from the poem “Alive” by Makhosazana Xaba 

ACKNOWLEDGMENTS 

Appreciative thanks for collaborative and helpful 

suggestions, insights, and edits from Coralie Trotter, 

Lis Jones, Anne-Marie Lydall, Elisa Mecco, and the “LE 

Deadly Medicine” Whatsapp group community. 

REFERENCES 

1. Angier, C. (2002, 9 March). The secret life of Primo 

Levi. The Guardian. Retrieved from https:// 

www.theguardian.com/books/2002/mar/09/ 

biography.artsandhumanities. 

6. Levi, P. (1989) [1986]. The Drowned and the 

Saved, translated by R. Rosenthal, New York, 

Vintage. 

7. Rahlaga, M. (2017, n.m.). Moseneke: moving 

of Esidimeni patients a murderous project. Eye 

Witness News (EWN). Retrieved from https:// 

ewn.co.za/2017/11/24/moseneke-moving-ofesidimeni-patients-a-murderous-project. 

8. Trotter, C. (2018b, 11 August). Deadly medicine: 

another brick in the wall. Paper presented at the 

conference: Deadly Medicine: The Mark of the 

Life Esidimeni Decanting, Johannesburg. 

9. Swartz, L. (2018, 10 August). Who counts 

as a person? Disability and the violence 

of concealment. Paper presented at the 



10. Trotter, C. (2018a). The Feminine: The Role of the 

‘Brick Mother’ and Maternal Function in the Life 

Esidimeni Catastrophe and Arbitration, South 

Africa. Proposal for the IPA Congress, London, 

2019. 

11. Van der Walt, C. (2018, 11 August). The 

metonymic spectacle versus emotionally 

informed law: some comparative notes on the 

Truth and Reconciliation Commission and the 

Esidimeni proceedings. Paper presented at the 



Megan Jones has a Master of Science in Clinical 

Psychology from the University of Johannesburg and a 

PhD in Zoology and a Postgraduate Diploma in Applied 

Ethics from the University of the Witwatersrand. She works 

for the Gauteng Department of Health in the Eating 

Disorders and Adolescent Units at Tara Hospital. She 

runs a small part-time private practice, primarily seeing 

children for play therapy or psychological assessment. 

Megan is a member of GRASP as well as the IPCP (Institute 

for Psychodynamic Child Psychotherapy). Megan has 

published and presented at international conferences 

on the effects of early experience on brain development, 

emotions, and behaviour in animals which she now 

applies to her clinical thinking and work. Correspondence: 

megan.jones@icon.co.za 


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REPORT 

MINISTERS GATHER TO ADDRESS 

MENTAL HEALTH 

AT THE GLOBAL 

MINISTERIAL MENTAL 

HEALTH SUMMIT IN LONDON 

Chantelle Booysen 

In the wake of being woke to the wellness ‘trend’, 

there has been much needed focus on mental 

wellness and mental health, specifically, and its 

impact in relation to physical health. A focus that 

is long overdue, and certainly welcomed, as age old 

efforts of the medical fraternities, academics, nonprofit 

organisations and civil society seems to be 

gathering traction on this issue, on a global scale. 

AS MENTAL HEALTH BECOMES THE FASTEST 

GROWING GLOBAL HEALTH CHALLENGE 

OF OUR TIME, IT FORMED THE BASIS OF 

THE FIRST GLOBAL MINISTERIAL MENTAL 

HEALTH SUMMIT HELD IN LONDON ON 

THE 9 TH AND 10 TH OCTOBER 2018. 

The theme of this summit focused on the Equality 

for Mental Health in the 21st Century, endorsed and 

promoted by the UK Government in partnership 

with the Organisation for Economic Co-Operation 

and Development (OECD) and the World Health 

Organisation (WHO). 

The summit organisers reported the attendance of 

586 delegates from 61 countries with 47 countries 

sending 106 official delegates. 15 of these national 

delegations were led by respective country Ministers, 

engaging in the discussions and declarations for 

achieving equality for mental health. 

The summit highlighted the inclusion of the Lived 

Experience voice in addressing legislation, services 

and approaches to mental health care. There is also 

a big drive to involve young people 

in these global discussions and 

implementations as a key element 

to address adolescent mental 

health issues. 

As part of Youth Leaders for The 

Lancet Commission for Global 

Mental Health, this summit was 

particularly important as it created Chantelle Booysen 

a platform for the launch of this fresh 

approach to the prioritisation of mental health care. 

The Commission creates a guideline to a global 

approach in addressing mental health approaches 

and assesses the global mental health agenda 

in the context of the Sustainable Development 

Guidelines as set out by the United Nations General 

Assembly. 

THE YOUTH CAMPAIGN FOR THE LANCET 

COMMISSION FOR GLOBAL MENTAL 

HEALTH WAS SPECIFICALLY CREATED 

TO DISSEMINATE AND TRANSLATE THE 

KEY MESSAGES OF THE COMMISSION 

IN ORDER TO CREATE EFFECTIVE 

PLATFORMS FOR COMMUNICATING 

THESE MESSAGES IN A WAY THAT YOUNG 

PEOPLE CAN GRASP AND ASSOCIATE 

WITH. A BIG PART OF THIS YOUTH 

CAMPAIGN IS FOCUSED ON CREATING 

CONVERSATION THROUGH ADVOCACY 

EFFORTS ON A MULTI-TIERED APPROACH. 


REPORT 

The conversations are initiated through social media 

activation, where information and resources are 

relayed through visual media content, to create an 

accessible and relatable narrative. The second tier 

is based on youth-led event activations in various 

communities around the world with further on-theground 

strategies being implemented throughout 

the course of the campaign. 

THE KEY FOCUS AREAS OF THIS 

CAMPAIGN ARE: TO REDUCE STIGMA, 

TO PROMOTE MENTAL HEALTH AS A 

FUNDAMENTAL PART OF BEING HUMAN, 

TO INTEGRATE YOUNG PEOPLE’S VOICES, 

VALUES AND EXPERIENCES INTO PUBLIC 

DEBATE IN GLOBAL MENTAL HEALTH AND 

TO EDUCATE YOUNG PEOPLE TO TAKE 

ACTION TO PROMOTE WELL-BEING IN 

THEIR COMMUNITIES. 

This Youth Campaign is led by researchers at the 

University of Oxford as part of the Wellcome Trustfunded 

project, BeGOOD. It is co-designed with The 

Young Leaders for The Lancet Global Mental Health 

Commission who is an international group of young 

people who share a passion for mental health. 

Further collaborators are: NCD Child, Sangath, and 

CitiesRise. 

The Duke and Duchess of Cambridge also attended 

the event in support of Global Mental Health, as 

an extension of their existing public efforts, as in 

the case of their organisation Heads Together. Their 

attendance at this event created a lot of media 

attention that will hopefully translate into further 

awareness in global communities. 

In conclusion, this event attempted to engage 

government stakeholders, to confirm a level of 

commitment to implement and move forward on 

the issue of mental health policies and infrastructure 

in their respective environments. The event saw 

key documents emerge i.e. Global Declaration 

on Achieving Equality for Mental Health and 

Recommendations to Ministers in workstreams. 

These documents were signed by various country 

representatives in the hope of application and 

implementation. 

The next summit is due to be hosted by the 

Netherlands and we will certainly be monitoring the 

effect of a gathering of this nature. 

Chantelle Booysen is a Mental Health Advocate and Youth 

Leader. Correspondence: cbooysen2@gmail.com 

The summit hosted various work streams and 

focused presentations that included Children, Young 

People and the Now Generation, Caring Societies: 

creating the conditions for inclusion, prevention 

and wellbeing, The Economics of, and Investment 

in, Mental Health Finance, A Just Society: supporting 

societal shifts, tackling stigma and discrimination, 

creating inclusive societies, Mental Health Services 

around the World as well as Research and the Future 

of Mental Health. These break away sessions sought 

debate amongst both attendees and presenters. 

IN A VERY PROGRESSIVE MOVE, THE UK 

PRIME MINISTER APPOINTED THE VERY 

FIRST MINISTER IN SUICIDE PREVENTION 

FOCUSING ON CREATING STRUCTURAL 

PLANS TO REDUCE OR STOP PREVENTABLE 

DEATHS. THIS APPOINTMENT WAS MADE 

DURING THIS MINISTERIAL SUMMIT WHICH 

FURTHER EMPHASISED THE URGENCY 

OF GOVERNMENTS TAKING A RIGHTS 

BASED APPROACH TO ENSURE THOSE 

STRUGGLING WITH MENTAL HEALTH 

ISSUES GET THE ACCESS, ATTENTION 

AND SUPPORT THEY NEED. THIS IS 

HOWEVER JUST THE VERY TIP OF THE 

ICEBERG IN TERMS OF WHAT IS NEEDED 

BUT CERTAINLY A STEP IN THE RIGHT 

DIRECTION. 

Youth Leaders and representatives from the Youth Campaign for The Lancet 

Commission for Global Mental Health on the Friendship Bench, a concept 

originating from Zimbabwe 

Group photo of The Lancet Commission for Global Mental Health including 

the Youth Leaders 


REPORT 

WORLD PSYCHIATRIC ASSOCIATION’S 

EPIDEMIOLOGY 

MEETING 2018 

Sumaya Mall 

Psychiatric epidemiology is a discipline that 

seeks to understand the distribution and 

causes of mental illness. The discipline’s origins 

are contested but it is generally agreed that the 

field has followed many contours including a recent 

integration of psychiatric genetics 1 . The discipline 

has historically benefited from collaborations with 

psychiatrists, psychologists and sociologists all of 

whom have an interest in the influence of social 

conditions on health 2 . The discipline strengthens 

over time with the integration of new statistical 

techniques to map causal pathways for psychiatric 

disorders. 

IT IS THEREFORE APPROPRIATE THAT THE 

WORLD PSYCHIATRIC ASSOCIATION 

(WPA) HAS AN EPIDEMIOLOGY SECTION 

HEADED BY LEADING PSYCHIATRIC 

EPIDEMIOLOGISTS WITH INTERNATIONAL 

STANDING. 

The WPA held their epidemiology 

meeting at the Joseph Mailman 

School of Public Health, Columbia 

University, New York, United States 

of America (USA) from the 2 nd – 4 th 

May 2018. The meeting was cochaired 

by Professors Eli Karam 

and Katherine Keyes of Balamand 

University (Lebanon) and 

Columbia University respectively. 

Sumaya Mall 

The host, Columbia University has 

had a thriving psychiatric epidemiology training 

programme (PET) since 1972 and has graduated 

many doctoral and post-doctoral trainees. The 

core components of PET, that have evolved with 

the discipline of psychiatric epidemiology were 

reflected in the conference programme notably 

measurement of prevalence and incidence of 

psychiatric disorders 3,4 as well as integration of the 

principles of the broader discipline of epidemiology 

to examine causality 5 . There is an argument that 

while the field of psychiatric epidemiology has given 

attention to observational epidemiology i.e. the 

design of cross-sectional, case control and cohort 

studies to examine prevalence, incidence and 

causes of psychiatric disorders, the discipline has 

given sparse attention to interventions or randomized 

controlled trials (RCTs) 6 . The conference did have a 

presentation on interventions of which further detail 

is given in this article. 

A number of plenary sessions and symposia took 

place over the three days. There was an introductory 

plenary session given by Professor Ron Kessler 

on methodological challenges in psychiatric 

epidemiology in the 21 st Century. 

PROFESSOR KESSLER WHO HAS A 

WEALTH OF EXPERIENCE IN DESIGNING 

AND IMPLEMENTING CROSS SECTIONAL 

STUDIES TO ESTIMATE THE PREVALENCE 

AND CORRELATES OF PSYCHIATRIC 

DISORDERS IN HIS ROLE AS PRINCIPAL 


REPORT 

INVESTIGATOR OF THE WORLD MENTAL 

HEALTH SURVEY IDENTIFIED THE 

FOLLOWING CHALLENGES FOR THE 

FIELD OF PSYCHIATRIC EPIDEMIOLOGY: 

LACK OF RESPONSE OF PARTICIPANTS 

AND COST OF THESE SURVEYS, FOCUS 

ON PRIMARY DATA COLLECTION AND 

POOR ATTENTION TO REPRESENTATIVE 

SAMPLING. 

Additional plenary sessions covered a range of 

causal factors of psychiatric disorders including 

genetic and social risk factors. These sessions were: 

social determinants of psychiatric disorders (Dr 

Joanna Maselko), a session on a public health 

approach for the prevention of psychosis (Professor 

Robin Murray), psychiatric epidemiology and mental 

health challenges in Mexico (Dr Corina Benjet) and 

challenges in designing neuropsychiatric genetic 

research in Africa (Professor Lukoye Atwoli). This 

session focused specifically on the NeuroGAP Moi 

project. The plenary given by Professor Murray on 

psychosis highlighted the limitations of identifying 

individuals attending prodromal health services 

in identifying cases with psychosis as well as latest 

research on childhood adversity in psychosis. 

In addition to these plenary sessions there were 

also symposia held. The symposia mirrored the 

themes of the plenary sessions with the majority 

focusing on psychosis and schizophrenia. They 

included a symposium on variation in incidence, an 

umbrella under which there was a session given by 

Professor Terry Brugha on Autism Spectrum Disorder. 

Additional symposia were given on children’s 

mental health (Dr Viviane Kovess-Masfety), psychosis 

(Professor Craig Morgan), perspectives of the World 

Health Organizations epidemiological studies of 

schizophrenia (Professor Normon Sartorius) and 

suicide (Michael Phillips). 

OVERALL THE SYMPOSIA GAVE 

ATTENTION TO EPIDEMIOLOGICAL 

CHALLENGES OF CASE ASCERTAINMENT 

AND CONSISTENCY IN MEASUREMENT 

OF PSYCHIATRIC DISORDERS IN DIVERSE 

SETTINGS ACROSS THE GLOBE AS 

WELL AS CURRENT CHALLENGES OF 

LINKING EPIDEMIOLOGY TO PRECISION 

MEDICINE, GLOBAL MENTAL HEALTH AND 

INTERVENTIONAL EPIDEMIOLOGY (I.E. 

RANDOMIZED CONTROLLED TRIALS). 

As mentioned above psychiatric epidemiology 

as a discipline has lagged behind with regard to 

designing and implementing interventions. Professor 

Milton Wainberg tacked this challenge by presenting 

perspectives of global mental health. Professors 

Bibilola Oladeji presented the results of depression 

interventions in Nigeria where lay health workers are 

used. 

Overall the oral presentations and posters 

highlighted the use of existing cohorts to examine 

novel mediators and causal pathways to physical 

and mental health. A presentation given by Dr Alison 

Merikangas examined the relationship between 

parental age, children’s psychopathology and 

cognition in an existing cohort in Philadelphia 

while another given by Norbert Schmitz focused on 

depression as a pathway between cardiovascular 

disease and cognition. These presentations highlight 

the importance of using existing secondary data to 

employ novel statistical techniques. 

The conference programme was comprehensive 

and no doubt future WPA psychiatric epidemiology 

meetings will take on debates that are central to 

the discipline focusing on high, low and middle 

income countries. Of interest for future meetings will 

be how psychiatric epidemiologists integrate with 

neuroscientists given the ongoing challenges of 

mental disorders. 

REFERENCES 

1. Keyes KM, Susser E. The expanding scope of 

psychiatric epidemiology in the 21st century. Soc. 

Psychiatry Psychiatr Epidemiol 2014. 49:1521– 

1524 

2. Lovell AM, Susser E. What might be a history of 

psychiatric epidemiology? Towards a social 

history and conceptual account. Int J Epidemiol 

2014. 43:i1–i5 . doi: 10.1093/ije/dyu147 

3. Dohrenwend BP. “The problem of validity in field 

studies of psychological disorders” revisited. 

Psychol Med 1990. 20:195–208. doi: 10.1037/ 

h0020301 

4. Dohrenwend BP, Dohrenwend BS. Perspectives on 

the past and future of psychiatric epidemiology. 

The 1981 Rema Lapouse Lecture. Am J Public 

Health 1982. 72:1271–1279 . doi: 10.2105/ 

AJPH.72.11.1271 

5. Susser E, Schwartz S, Morabia A, Bromet E 

Psychiatric epidemiology: Searching for the 

causes of mental disorders. New York: Oxford 

University Press, 2006 

6. Kessler RC. Psychiatric epidemiology: challenges 

and opportunities. Int Rev Psychiatry 2007. 

19:509–521 . doi: 10.1080/09540260701564914 

Left to right: Oye Gureje, Vania Martinez, Paula Ravitz, Milton Wainberg, Bibilola 

Oladeji 

Sumaya Mall (PhD) is a Senior Lecturer, Division of 

Epidemiology and Biostatistics, School of Public Health, 

University of the Witwatersrand, Johannesburg, South 

Africa Correspondence: sumaya.mall@gmail.com / 

sumaya.mall@wits.ac.za. 


REPORT 

THE 4 TH ANNUAL 

AFRICAN COLLEGE OF 

NEUROPSYCHOPHARMACOLOGY 

( A F C N P ) 

CONGRESS 

Roxanne James 

The 4 th Annual African College of 

Neuropsychopharmacology congress was 

held in Cape Town, South Africa over the 

weekend of 28 th and 29 th July 2018. The 

congress was organised and hosted in collaboration 

with the University of Cape Town’s Department of 

Psychiatry and Mental Health and showcased the 

ongoing research of a variety of specialists and 

academics drawn from both local and international 

faculties. 

The congress was well attended by mental health 

professionals from various parts of the globe, 

including Uganda, Kenya, Ethiopia, the Netherlands, 

USA, UK, Denmark and Australia. The weekend held 

a great deal of sadness with the revelation of the 

untimely death of Professor Bongani Mayosi, a 

renowned cardiologist and the Dean of the Faculty 

of Health Sciences in the University of Cape Town. It 

provided a great opportunity for various professionals 

in the field of Mental Health to re-connect, network 

and reflect. 

THE FOCUS OF THE VARIOUS 

PRESENTATIONS REVOLVED 

AROUND CUTTING EDGE 

RESEARCH IN THE FIELDS OF 

PSYCHOPHARMACOLOGY, 

NEUROLOGY, ADDICTION STUDIES, 

THE EFFECTIVENESS OF VARIOUS 

TREATMENT MODALITIES AND 

Roxanne James 

GENETIC RESEARCH. A PARALLEL 

YOUNG RESEARCHERS SYMPOSIUM AND 

WORKSHOP WAS ALSO HELD, WHICH 

ALLOWED YOUNG RESEARCHERS THE 

OPPORTUNITY TO PRESENT THEIR RESEARCH 

AND RECEIVE CONSTRUCTIVE FEEDBACK. 

RESEARCHERS WERE ALSO ABLE TO PRESENT 

POSTERS TO PROVIDE GREATER EXPOSURE 

TO THEIR RESEARCH QUESTIONS. 

Roxanne James is the Project Manager (Neuro-Gap) in the Department of Psychiatry&Mental Health Faculty of 

Health Sciences, University of Cape Town Education Centre, Valkenberg Hospital, Observatory, Cape Town, South Africa. 

Correspondence: Roxanne.James@uct.ac.za 


REPORT 

FEEDBACK FROM THE ROYAL COLLEGE OF PSYCHIATRISTS 

INTERNATIONAL CONFERENCE, JUNE 2018: 

NEW 

HORIZONS 

Lesley Robertson 

I 

represented the South African Society of 

Psychiatrists (SASOP) at the Royal College 

of Psychiatrists (RCPsych) 2018 international 

conference. A “tripartite” agreement exists 

between the South African College of Psychiatrists, 

the SASOP, and the RCPsych. Unlike South Africa, 

where the College is responsible for conducting 

national examinations and the SASOP furthers other 

objectives of the profession, the RCPsych combines 

both functions in one organisation. With its mission 

statement of “Improving the lives of people with 

mental illness”, the RCPsych is governed by a board 

of ten trustees, which includes three lay people. At 

present the lay trustees include a retired businessman, 

a lawyer and a person with experience as a nonexecutive 

director and strategic management. The 

Board is supported and advised by the Council, 

which has overall responsibility for education and 

training, policy, professional practice, professional 

standards, public engagement, quality improvement 

and research. A far larger body, the Council includes 

a patient and a carer representative as well as four 

members of the Board, academic and divisional 

representatives. 

THE THEME OF THE CONGRESS WAS “NEW 

HORIZONS”, AND THE FIRST NEW HORIZON 

DISCUSSED WAS A NEW MENTAL HEALTH 

ACT, TO BE ALIGNED WITH THE UNITED 

NATIONS CONVENTION ON THE RIGHTS 

OF PERSONS WITH DISABILITIES (CRPD). 

Baroness Hale, the president 

of the supreme court, outlined 

the complexities around the 

comment on article 12 of the 

CRPD, legal capacity, involuntary 

mental health care and insanity 

defence. The difficulties she 

raised were like those raised by 

Freeman et al (2015), 1 and are 

highly relevant to South Africa, Lesley Robertson 

also signatory to the CRPD. I believe 

we could gain by closely watching the processes 

followed by the UK in drafting their new legislation. 

In view of the Essential Medicines List, I opted to 

attend presentations by the British Association 

of Psychopharmacology (BAP), which publishes 

evidence-informed treatment guidelines. They 

presented on the management of the aggressive 

patient, on schizophrenia, and on the use of 

valproate. 

THEIR APPROACH DIFFERS FROM THE 

NICE GUIDELINES IN THEIR INCLUSION OF 

OBSERVATIONAL STUDIES. OF NOTE, RCTS 

MAY NOT RECRUIT SEVERELY ILL PEOPLE, 

LEADING TO SMALL EFFECT SIZES AND A 

LACK OF GENERALISABILITY. 

So, to inform the BAP guidelines, observational 

studies with hard, patient-oriented outcomes (e.g. 


REPORT 

NEW HORIZONS 

readmission or repeat offending) may be upgraded, 

and RCTs downgraded, for strength of evidence. 

Their updated schizophrenia guidelines should be 

published soon. 

I attended an NHS Trust audit of psychiatric care, 

something which, in theory at least, NHI would 

introduce in South Africa. The audit was mainly 

around prescribing patterns; reflecting on the 

varying proportions of medicines used and changes 

over time. 

THERE WAS SOME DISCUSSION AROUND 

THE PRESENCE OF AND PRESCRIBING 

FOR PHYSICAL COMORBIDITIES. HOWEVER, 

THERE WAS LITTLE RELATION OF 

PRESCRIBING PATTERNS TO CARE 

OUTCOMES. THIS I THINK MAY BE 

RELATED TO A GLOBAL UNCERTAINTY 

REGARDING OUTCOME MEASURES IN 

PSYCHIATRIC CARE, BUT NEVERTHELESS IT 

RENDERS A CLINICAL AUDIT SOMEWHAT 

LACKING IN MEANING. 

Physical health in people with severe mental illness 

also featured in a session in which results of the HOME, 

STEPWISE and PRIMROSE trials were presented. These 

trials are well worth looking out for and will probably 

reinforce the need for health systems which promote 

collaborative and integrated care. 

Deinstitutionalisation also featured, with symposiums 

on residential facilities and community-based 

mental health care. Although highly pertinent to 

South Africa, I was unfortunately unable to attend 

these. I did however speak to members of the 

National Collaborating Centre for Mental Health, the 

organisation presenting on community psychiatry. 

Interestingly, they are having to re-examine their 

mental health system as those with severe illness are 

falling through the cracks. 

THIS WAS EVIDENT IN THE NUMBERS OF 

HOMELESS PEOPLE IN BOTH LONDON 

AND BIRMINGHAM, SOME OF WHOM 

WERE CLEARLY UNWELL. WITH A 

COMPREHENSIVE WELFARE SYSTEM 

AND AMPLE SHELTERS IN THE CITIES, IT’S 

POSSIBLE THAT MENTAL ILLNESS AND 

PERSONALITY FACTORS PERPETUATE THE 

HOMELESSNESS. 

One of the plenary sessions was given by a journalist, 

Sathnam Sanghera, author of “The Boy with the Top 

Knot and Marriage Material”. He spoke of how, in 

his early twenties, he realised his father and sister 

had schizophrenia. He termed schizophrenia as 

the leprosy of today and described great difficulty 

in accessing appropriate care for his father within the 

National Health System, which he felt neglected severe 

mental illness except during periods of aggression. His 

words of wisdom conveyed caution regarding: 

• awareness campaigns which have 

inadvertently led to the prioritisation of mild 

to moderate common mental illnesses; 

• a recovery orientated approach which may 

cause false expectations and a sense of 

personal failure among people with severe 

illness and their carers; 

• the reluctance to use the risk of violence 

as a lobbying tool for better mental health 

services and preventative care. 

A MEETING OF THE RCPSYCH AFRICA 

DIVISION INCLUDED REPRESENTATIVES 

FROM KENYA AND GHANA. DISCUSSION 

REVOLVED MAINLY AROUND UK TRAINING 

OPPORTUNITIES FOR PSYCHIATRY 

REGISTRARS. AT THE GALA DINNER, I 

HAD THE PLEASURE OF MEETING DR 

ALTHA STEWART, THE APA CHAIR, WHO 

REMEMBERED ALL THE SOUTH AFRICANS 

SHE HAD MET AT THE APA CONGRESS IN 

MAY. I SAT WITH THE RCPSYCH TREASURER 

AND ONE OF THE LAY TRUSTEES, AND 

LEARNT MORE ABOUT THE RCPSYCH, AND 

OF THE GAPS IN MENTAL HEALTH CARE 

IN THE UK, WHICH ARE VERY SIMILAR TO 

MANY OF OUR ISSUES. 

Overall, the congress was excellent and very 

enlightening. I am grateful to my SASOP colleagues 

for the sponsorship. Among all the lessons I learnt is 

the certainty that we will also become, in the words 

of Professor Sir Simon Wessely of the RCPsych for 

the UK, the “calm, trusted, and authoritative voice in 

mental health” for South Africa. 

REFERENCE 

1. Freeman MC, Kolappa K, de Almeida JM, Kleinman 

A, Makhashvili N, Phakathi S, et al. Reversing hard 

won victories in the name of human rights: a 

critique of the General Comment on Article 12 of 

the UN Convention on the Rights of Persons with 

Disabilities. Lancet Psychiatry. 2015;2(9):844-50. 

Lesley Robertson is a psychiatrist working in the Sedibeng 

District and jointly appointed in the Department of Psychiatry, 

University of the Witwatersrand, Johannesburg, South Africa. 

Correspondence : Lesley.Robertson@wits.ac.za 


REPORT 

THE LUNDBECK 

FOCUS DAY 

- 18 TH AUGUST 2018 

Duncan Rodseth 

The Lundbeck Focus day has established itself 

as an important event in the calendar for 

psychiatrists in South Africa. Lundbeck has 

a long tradition of commitment to medical 

education and the Focus Day truly reflects this. 

This year the event was held at several venues 

throughout South Africa. In Johannesburg, Lundbeck 

hosted a large group of psychiatrists at the Maslow 

Hotel on 18 th August. 

Wendy Cupido, Marketing Manager from Lundbeck 

said “We have decided for this meeting to expand 

the horizons of psychiatrists and present the latest 

advances in several other fields of medicine. 

Psychiatrists are often called upon to evaluate 

and treat patients that are under the care of other 

specialists and we felt it would be particularly helpful 

for them to understand what is happening in other 

areas of medicine”. 

The meeting began with a presentation by Professor 

Eugenio Panieri who is a General Specialist Head at 

the Department of General Surgery Groote Schuur 

Hospital and an Associate Professor at the Faculty 

of Health Sciences at the University of Cape Town. 

His areas of clinical interest and research are in 

the field of endocrine surgery, breast cancer and 

soft tissue sarcoma. Prof Panieri gave a fascinating 

presentation entitled “Understanding Breast Cancer 

from Superstition to Science Fiction”. He began 

with the history of St Agatha of Catania, the patron 

saint of breast cancer sufferers and then went on 

to describe the treatments for breast cancer from 

cauterization in ancient Egypt through to the first 

successful interventions of W S Halstead, who made 

radical mastectomy the gold standard in the early 

1900s. 

the clinical picture risk factors and evidence 

associated with a decline in cognitive function after 

surgery. Dr van Niekerk pointed out that this decline is 

not necessarily associated with general anesthesia 

but may be seen after surgery with regional 

anesthesia. She also discussed the possibility that 

there could be post-operative improvement in 

cognition in certain patients. Finally, she presented 

the risk factors for dementia and showed evidence 

to support that up to 35 % of dementia can be 

prevented by eliminating risk factors. 

The final presentation was by Dr Willie Koen, 

Cardiothoracic Surgeon, Vincent Pallotti Hospital in 

Cape Town. Dr Koen presented “New Challenges is 

Modern Cardiac Surgery”. 

During the past decade, cardiac surgery has 

changed into a highly technological specialty. 

Mechanical cardiac support has become an 

everyday treatment and is used much more 

commonly than cardiac transplantation. Dr Koen 

also mentioned the incredible developments in 

battery technology, and particularly advances in 

recharging power supplies, that are on the horizon. 

The Focus meeting was very well received and 

finished with an opportunity for the audience to 

discuss the topics with the presenters. 

Duncan Rodseth is in private psychiatric practice 

at the WITS Donald Gordon Medical Centre. He is an 

honorary lecturer at WITS. He also consults as a medical 

advisor for Lundbeck on a part time basis. He has 

recently started up a ketamine clinic for treating resistant 

depression, one of the few ketamine clinics in South Africa 

Correspondence: drodseth@icon.co.za 

He then discussed chemotherapy, radiation therapy, 

estrogen blockade, vaccine treatments and the 

evidence of efficacy for these treatments. Professor 

Panieri explained that there was considerable 

variability in patient responses to the available 

treatment and we are now entering the era of gene 

profiling to select the best treatment for individual 

patients. 

Dr Mariët van Niekerk is Neurologist in Private Practice 

in Pretoria and has a special interest in Alzheimer’s 

dementia. Her talk was entitled “Milk of Amnesia” 

Postoperative Cognitive Dysfunction. She discussed 

The Lundbeck team from left to right are: Erica Palin, Wendy Cupido, Marelize 

Bosch, Chantall Hayes, Julie Howarth, Charmaine Thomas, Christel Malherbe. 

The lady kneeling in front is Charline Pelzer. 


Depression can 

make keeping 

on top of daily 

tasks a struggle 

Brintellix can help with her mood, 

concentration and fatigue, so she is able 

to organise her day again 

10 mg once daily 

Lundbeck South Africa (Pty) Ltd. Unit 9, Blueberry Office Park, Apple Street, Randpark Ridge Extension 114 Tel: +27 11 699 1600 S5 Brintellix 10 mg film-coated tablets. 

Each tablet contains vortioxetine hydrobromide equivalent to 10 mg vortioxetine. Reg No. 48/1.2/0430 Namibia: NS 3:15/1.2/0071 Botswana: S2: BOT 1502705 MO 08/17

REPORT 

LUNDBECK 

BREAKFAST 

SYMPOSIUM 

@ SASOP 2018 – STEPHEN STAHL 

Lisa Selwood 

The first breakfast symposium of the 2018 

congress was sponsored by Lundbeck, 

with Professor Stephen Stahl as the keynote 

speaker. Having such a big name was a 

huge drawcard - the number of attendees was 

so overwhelming, that the venue had to change 

before the start to accommodate everyone who 

wanted to attend! Prof Stahl is an Adjunct Professor 

of Psychiatry at the University of California, San 

Diego, an Honorary Visiting Senior Fellow at the 

University of Cambridge and the Director of 

Psychopharmacology in the California Department 

of State Hospitals. He is arguably the father of 

psychopharmacology, having published over 

500 scientific papers, edited 12 textbooks and 

personally authored 35 textbooks relating to various 

topics within the discipline. 

INTRODUCTION 

The topic of the symposium was ‘Combining 

pharmacologic mechanisms of action to target 

residual symptoms in major depressive disorder’. 

Prof Stahl opened the session by stating that 

depression is not just a mood disorder, but it is also 

a cognitive disorder. This is of particular importance, 

as cognitive symptoms do not necessarily remit with 

treatment as most antidepressants are not robust in 

treating residual cognitive symptoms. 

‘THE FAB FOUR’ 

Just like the original ‘fab four’, the Beatles, there are 

four domains in cognition, outlined in Table 1 below: 

Table 1 

Domain Beatle Role Description 

Consequences resulting 

from a deficit in each 

domain 

Attention 

John Lennon 

Always received the attention, 

and is noted as ‘The Most 

Famous Beatle’ 

Trouble concentrating, 

multitasking and maintaining 

a response over time 

Executive function 

Paul McCartney 

As the lead singer, he was 

known to be the ring-leader of 

the group 

Indecisiveness and difficulty 

with planning 

Speed of processing 

Ringo Starr 

As the lead drummer, he had 

to ensure the right tempo 

was maintained. If this was 

not done, there would be 

a problem with the songs 

produced 

Slowed thinking 

Learning and memory 

George Harrison 

As the lead guitarist, he had 

to possess the memory to play 

the songs correctly 

Difficulty acquiring, 

retaining and manipulating 

information 


REPORT 

Cognitive complaints are common in patients 

with MDD, yet fewer than half of all psychiatrists 

evaluate cognitive function, with some believing 

it is irrelevant. However, studies have shown that 

these symptoms are equivalent to acute sleep 

deprivation or taking 2mg of lorazepam. 

This is likely due to the five mechanisms of action 

which this antidepressant has. At the end of the 

day, it is not about the drugs themselves, but it is 

about the mechanisms of action. 

The consequences of untreated, or inadequately 

treated, MDD are severe. It has been shown that 

this can cause a decrease in total hippocampal 

volume. 

IN THE FIRST FEW EPISODES, THIS CAN 

BE REVERSED BUT AFTER SEVERAL 

DEPRESSIVE EPISODES, THE VOLUME 

REMAINS DECREASED, LEADING 

TO POOR CLINICAL OUTCOMES, 

REDUCED MEMORY AND PROCESSING 

SPEED, LOWER RATES OF SUSTAINED 

RESPONSE AND REMISSION AND AN 

INCREASE IN DEPRESSION RELATED 

DISABILITY. 

P R O - C O G N I T I V E 

NEUROTRANSMITTERS 

The pro-cognitive neurotransmitters include 

acetylcholine, dopamine, norepinephrine and 

histamine. These neurotransmitters can be 

regulated by a variety of mechanisms, including 

5HT1A agonism, 5HT1B/D antagonism and 5HT3 

antagonism. Previously, multi-modal use of more 

than one antidepressant, each with a different 

mechanism of action, was necessary to attain 

the synergy needed to improve cognition. 

ALTHOUGH THERE ARE VERY FEW 

PLACEBO CONTROLLED STUDIES ON 

THE EFFECTS OF ANTIDEPRESSANTS 

ON COGNITION, THREE STUDIES HAVE 

BEEN DONE WHICH COMPARED 

VORTIOXETINE TO AN SNRI, NAMELY 

DULOXETINE. IN ALL THREE STUDIES 

VORTIOXETINE, BUT NOT DULOXETINE, 

IMPROVED COGNITIVE SYMPTOMS IN 

PATIENTS WITH MDD. 

IN SUMMARY: 

• Cognitive symptoms are common in MDD 

both before and after antidepressant 

treatment, as well as during and between 

episodes 

• The number of episodes, and not necessarily 

the severity of the episodes, leads to 

increased cognitive dysfunction, and poorer 

clinical outcomes. 

• Most current antidepressants do not have 

robust effects on cognition, and combining 

pharmacologic mechanisms of action may 

be required 

• Vortioxetine has five mechanisms of action, 

and improves cognition when compared to 

duloxetine, which is an SNRI 

As always, Prof Stahl was hugely entertaining, 

eliciting a lot of laughs and questions from the 

audience. His manner of teaching ensured all 

delegates left with an increased awareness of 

cognition in MDD, and most importantly, how to 

treat it, in order to ensure their patients receive 

optimal care. 

Lisa Selwood is a pharmacist and medical writer 

Correspondence: lisaannselwood@gmail.com 

Prof Stephen Stahl addresses the attendees of the Lundbeck Breakfast 

Symposium 

Front seat from left to right: Fatima Davids, Lynda Lawrenson and Wendy Cupido 

Back row from left to right: Chantall Hayes, Magda van der Merwe, Julie 

Howarth, Itzelle Jonker, Prof Stahl, Charmaine Thomas and Ben Christen 


NEWS 

DSc 

Christopher Paul Szabo (Professor and academic 

head), was awarded a DSc (15 th October 2018) 

for a thesis entitled: Eating disorders, risk and 

management: a South African and African 

perspective. The DSc represents 47 publications, 

related to eating disorders, covering a period of 

over 20 years (1995-2016) - influenced by clinical 

work and focusing on the areas of risk and 

management. The publications have provided 

both a South African and African perspective 

that has contributed to clinician knowledge 

and practice. Professor Szabo was mentored by 

Emeritus Professor Peter Cleaton-Jones in the 

School of Clinical Medicine. 

VISITING PROFESSOR 

He was appointed as a Visiting Professor at 

the University of Belgrade, School of Medicine, 

Belgrade, Serbia. His inaugural lecture (3 rd 

October 2018) was entitled Leadership, Public 

Mental Health and clinical advocacy 

INVITED SPEAKER: 

Prof. Ugash Subramaney was an invited 

speaker to the 3 rd International Conference 

on Forensic Psychology and Criminology 

held in Stockholm, Sweden on the 16-17 

August 2018. 

Her talk was entitled “Filicidal Women: 

a SA perspective” and was based on 

her experiences of working with women 

charged with the murder of their child/ 

children at Sterkfontein Hospital 


NEWS 

WORLD PSYCHIATRIC ASSOCIATION – OCTOBER 2018, MEXICO CITY, MEXICO 

Christopher Paul Szabo was an Invited speaker – Presidential Symposium - on the topic of URBANIZATION 

AND MENTAL HEALTH - AN AFRICAN PERSPECTIVE 

L-R : David Ndetei, Christopher Paul Szabo 

L-R: David Ndetei (Kenya), Afzal Javed (WPA President elect), Christopher Paul Szabo, Laura Andrade (Brazil) 

ACADEMIC DOCTORS ASSOCIATION OF 

SOUTH AFRICA (ADASA) CHAIRPERSON 

PhD – AWARDED: 

Bernard Janse van Rensburg was appointed as Chairperson 

at the ADASA Elective AGM (25 th July 2018) 

Carina Marsay: “Antenatal depression 

screening and perinatal depression among 

women at Rahima Moosa Hospital” 

INTERNATIONAL AWARD – MARCE SOCIETY PRESENTED TO CARINA MARSAY 


NEWS 

CMSA SUBSPECIALIST QUALIFICATIONS 

– 2 ND SEMESTER 2018 : 

FORENSIC PSYCHIATRY 

NEUROPSYCHIATRY 

Dr P Maharaj Dr I Chetty Dr M Sibandze (on left) 

IN MEMORIAM: BONGANI MAYOSI 

1967–2018 

BRITISH FEDERATION OF WOMEN GRADUATES AWARD 

The University of Cape Town mourns the passing of Professor 

Bongani Mayosi, Dean of the Faculty of Health Sciences, who left 

us on the morning of Friday, 27 July. While this is a very difficult 

time for both students and staff, particularly those in the Faculty 

of Health Sciences, it is also a time to reflect on and celebrate 

the incredible life of one of the university’s finest academics and 

researchers. 

Catherine Wedderburn (pictured) has been awarded 

the Johnstone & Florence Stoney Studentship from 

the British Federation of Women Graduates for her 

research on the ‘Neurodevelopmental effects of 

HIV and ART exposure: a prospective neuroimaging 

study of uninfected children born to HIV-infected 

mothers’. Her research is a sub-study of the 

Drakenstein Child Health Study, a population-based 

birth cohort study in Paarl, Western Cape, South 

Africa investigating the early life determinants of 

child health. Her PhD involves magnetic resonance 

imaging of children aged 2-3 years and measuring 

their clinical neurodevelopment, and is supervised by 

Prof Kirsty Donald. This work is funded by a Wellcome 

Trust Research Training 

Fellowship through the London 

School of Hygiene & Tropical 

Medicine (LSHTM) and the 

University of Cape Town, and 

focuses on understanding the 

effects of in utero exposure to 

HIV and antiretroviral treatment 

in order to improve global child 

health. 

For more information see http://www.psychiatry.uct. 

ac.za/news/british-federation-women-graduatesaward-0 


NEWS 

GROUND-BREAKING NEUROSCIENCE CENTRE 

A breaking-ground ceremony was held on 12 th June 

2018 for the new Neuroscience Centre. The centre 

will be an interdisciplinary research and clinical 

space to study and treat mental and neurological 

disorders in South Africa. The centre will be the 

physical home of the newly established UCT 

Neuroscience Institute, as well as the Groote 

Schuur Hospital Clinical Neuroscience Centre, 

where researchers and clinicians will work together 

to treat brain and nervous system disorders that 

burden South Africa. 

The institute will encompass key neuroscience 

disciplines, a neurosurgical innovation and skills 

laboratory, a human tissues repository and attached 

laboratory, a state-of-the-art lecture theatre and 

other communal spaces, as well as direct access to 

the Cape University Body Imaging Centre (CUBIC). 

Construction of the Neuroscience Centre will be 

completed in September 2019. 

(From Right): Prof John Joska, Dr Fleur Howells, Dr Ian Lewis, Prof Dan Stein Prof 

Sharon Kleintjes at the ceremony. 

The department has played a key role in establishing 

multi-disciplinary clinics and research in the brainbehaviour 

arena at Groote Schuur Hospital and 

elsewhere, and the NI represents an exciting 

opportunity to further this work. 

Source article: http://www.psychiatry.uct.ac.za/ 

news/ground-breaking-neuroscience-centre 

VICE CHANCELLOR’S INAUGURAL LECTURE 

Congratulations to Prof Crick Lund on his Vice 

Chancellor’s Inaugural Lecture on 23 May 2018. 

Prof and his collaborators’ work has played a key 

role in thinking through not only our local clinical 

services, but also those in many other countries. 

These lectures are truly wonderful occasions; they 

provide a snapshot of a lifetime of work, and they 

celebrate an individual and his/her team. Our 

Division of Public Mental Health is proud to have 

had Prof Lund at its helm 

For more see http://www.psychiatry.uct.ac.za/ 

news/making-case-investing-mental-health-0 

DIVISIONS OF INTELLECTUAL DISABILITY MENTAL HEALTH AND DISABILITY STUDIES 

The Division of Intellectual Disability coconvened 

a one day seminar with UCT’s 

Division of Disability Studies, hosting a 

delegation from the American Association 

on Intellectual and Developmental 

Disabilities (AAIDD) at a symposium on 

2 nd October 2018. The theme “Changing 

the paradigm: Enabling Participation 

and meaningful lives for people with 

Intellectual Disability” was highlighted 

through presentations from a wide 

array of stakeholders, including selfadvocates 

and caregivers, NGOs, health 

practitioners, managers and academics. 

Conceptualised through a framework of 

empowerment, each session’s presenters 

spoke to the ideas of social transformation, 

Session presenters engaging in discussions with audience. Left to Right: Prof Colleen Adnams, 

Prof Judith McKenzie, Prof Sharon Kleintjes, Dr Charlotte Capri, Joachim Busch, Bernd Frauendorf, 

Ulrich Nieholl (behind), Carol Bosch and Shavonne Samaai. 

citizen support and agency in community. The symposium discussions generated key points to consider 

in research and practice aimed at advancing the full inclusion of persons with Intellectual Disability in all 

aspects of society. 


REPORT 

OVER 700 

PEOPLE 

UNITED FOR 

MENTAL HEALTH WALK 

Suvira Ramlall 

Ahead of World Mental Health Day on 

October 10th 2018, over 700 people from 

around KZN met early on a sunny Sunday 

morning to call for improved services in 

the province. Durban’s north beach amphitheatre 

became a hive of activity on October 7 th as the 

KZN Mental Health Advocacy Group hosted its third 

annual Advocacy Walk to raise awareness about 

the neglected issues of mental health and illnesses, 

substance abuse, and their impact on wellbeing. 

Psychology students from UKZN were the main 

volunteers at the event. Shwetha Singaram, 

President of the Student Society of Psychology at 

UKZN, said volunteering for the walk was a fulfilling 

experience. 

“At such a beautiful location, I not only felt Durban’s 

warm atmosphere but the warmth of its people. It 

was so encouraging to see people from all walks 

and colours of life coming together to send an 

important message. I am grateful to the mental 

health advocacy group for organizing this significant 

event” said Singaram. 

Dr Suvira Ramlall, a specialist psychiatrist and 

academic leader at UKZN’s College of Health 

Sciences, says that mental illness is a topic shrouded 

in misconceptions even though “it is not unlike other 

medical disorders and has recognised and effective 

treatments, which include both pharmacological 

and psychosocial therapies.” 

“MENTAL HEALTH IS EVERYBODY’S 

BUSINESS, FROM THE HOME, SCHOOLS, 

TERTIARY INSTITUTIONS AND THE 

WORKPLACE. MENTAL HEALTH AND 

ILLNESS HAVE FAR REACHING AND 

SERIOUS IMPLICATIONS FOR THE 

HEALTH, ECONOMY AND SUCCESS OF A 

NATION,” SAYS RAMLALL, WHO INITIATED 

THIS EVENT THREE YEARS AGO. 

This year’s global theme for World Mental Health 

Day centred on young people in a changing world. 

Suntosh Pillay, a clinical psychologist and co-founder 


REPORT 

of the Advocacy Group, says that the youth are 

especially vulnerable to mental health problems in 

a country like South Africa. 

“Suicide and depression are increasing in young 

people, and are made worse by poverty, inequality 

and unemployment in South Africa. The larger sociopolitical 

climate has direct effects on psychosocial 

wellbeing and mental health, so it’s our moral duty 

to be activists in an area that is largely fragmented 

and consistently side-lined by local, provincial and 

national government” says Pillay. 

DURING THE WALK TO USHAKA AND BACK, 

PATIENTS, FAMILIES, PROFESSIONALS, 

AND THE PUBLIC SPREAD MESSAGES 

OF HOPE CARRYING PLACARDS THAT 

CALLED FOR AN END TO STIGMA AND 

SILENCE AROUND MENTAL HEALTH, 

WITH SOME URGING THAT VACANT 

PUBLIC SECTOR POSTS BE FILLED. 

The morning included free health screenings, HIV 

testing, aerobics classes by Virgin Active, and free 

advice from local organisations, such as Alzheimer’s 

KZN, Nurture, Alcoholics Anonymous, Advice Desk 

for the Abused, the Ethekwini Mental Health Review 

Board, Ikhwezi Welfare Organization, HIV Addiction 

Technology Transfer Centre, and the Mum’s Support 

Network. Staff and mental health care users from 

various government hospitals were also present, 

including Ekuhlengeni, Townhill, RK Khan and King 

Dinuzulu. 

Lynn Norton, the manager of Durban’s new SADAG 

office, said the response was inspiring. “The South 

African Depression and Anxiety Group (SADAG) 

KZN was a proud partner in this event, and we 

had almost 100 people sign up at our stall to be a 

volunteer, showing the great interest and need for 

open dialogue about mental health” said Norton. 

LIVASHLIN NAIDOO, A UKZN ALUMNUS 

WHO PARTICIPATED IN THE WALK, 

SAID HE WAS “PROUD” TO BE THERE. 

“IT WAS A WELL-COORDINATED 

AND COMMENDABLE EVENT. I WILL 

DEFINITELY BE THERE TO SUPPORT ANY 

FUTURE ENDEAVOURS TO HELP RAISE 

AWARENESS FOR MENTAL HEALTH” SAID 

NAIDOO. 

Pillay urged all mental health stakeholders to join 

forces to advocate for mental health. “The positive 

response from the public highlights the need for a 

common platform to drive services and support. This 

event was made possible purely through donations 

and sponsorships, with a wide range of corporate 

and non-profit partners coming on board to pledge 

their commitment to making a difference. Together 

we can do more.” 

To get involved, partner, donate, or volunteer, email 

MHadvocacygroup@gmail.com 

Suvira Ramlall Correspondence: Ramlalls4@ukzn.ac.za 


REPORT 

MENTAL HEALTH 

FUN WALK 

– TARA HOSPITAL 

Vuledzani Munzhelele, 

with contribution from Ronelle Price-Hughes 

Sandton came to a standstill on the 17 th October 

2018 when Tara hospital in collaboration with 

SASOP – Southern Gauteng region hosted 

the 2018 Mental Health Fun walk. Around 200 

people participated in the walk which included staff, 

members of the public and various stakeholders 

involved in mental health services across the 

Gauteng Province. The purpose of the walk was to 

reach all Tara staff, various stakeholders involved in 

mental health care and the broader community to 

ensure increased awareness within and outside the 

hospital. The event was aimed at making information 

and awareness of mental health more accessible 

and inclusive. Mental health day is celebrated 

across the world on the 10 th of October. 

afforded an opportunity to engage with various 

organizations that specialises in mental health 

conditions -SADAG, Talisman, SANCA and Forest Farm 

were amongst the many that availed themselves to 

provide more information on mental health. 

A big thank you to Sanlam, Old Mutual, SASOP 

and Randburg Fruit and Veg for their generous 

sponsorship. The event was a great success because 

of your contribution - Tara Team. 

Vuledzani Munzhelele is the Communications Officer, 

Department Of Health: Tara The H.Moross Hospital. 

Correspondence: Munzhelele.vuledzani@gauteng.gov.za 

“Everyone, everywhere walk for Mental Health” was 

the theme for the event which was honored by the 

presence of Miss World South Africa 2018, Thulisa 

Keyi. She, with the assistance of the hospital CEO, 

Dr Florence Otieno cut the ribbon at the start of the 

walk (see photo). 

THULISA HAS IDENTIFIED MENTAL HEALTH 

IN POST-TRAUMATIC DISORDER AS 

ONE OF HER KEY AREAS OF SOCIAL 

RESPONSIBILITY. BEFORE THE WALK, TARA 

HOSPITAL EXECUTIVE MANAGERS LED 

BY THE CEO TOOK THULISA ON A WALK 

TO THE WARDS WHERE SHE GREETED 

THE PATIENTS AND FOUND OUT THE 

WORK THAT TARA HOSPITAL ENGAGES 

IN TO CHANGE THE LIVES OF THE MOST 

VULNERABLE. 

Stigma and discrimination attached to mental 

health remains the powerful negative attribute to 

social relations the walk was to encourage those 

with mental health conditions to come forward to 

seek help. At the end of the walk participants were 


REPORT 

MENTAL HEALTH FUN WALK – TARA HOSPITAL 


PERSPECTIVE 

BUTTERFLIES & 

MOUNTAIN 

VIEWS 

Claudia Campbell 

Quite a while back I had a conversation with 

my psychiatrist that continues to resonate 

within me – a conversation my mind often 

returns to when navigating the twists and 

turns mental illness and mental health care presents, 

for myself and for those whose journeys I now have 

the privilege to witness. My doctor spoke candidly 

about how it’s not often that as a psychiatrist he is 

able to experience what it is like ‘on the other side’, 

the true reality of his patient’s world. In that moment 

I realized it is also not often we as patients are able 

to understand what it is like in our psychiatrist’s world. 

I’m not referring to their personal lives, but rather the 

experience that is created with us, their patients. 

Sometimes it’s easy to presume that the stories told 

in my psychiatrist’s consulting room, because they 

emanate from me – the patient, only affect me. I 

suppose there is sometimes a chance they affect 

him too? 

It was many, many years ago that I wrote the 

passage below, but I remember with such clarity 

the frustration with which I attacked my keyboard. It 

was my first hospitalization under my long-standing 

psychiatrist. I had not realized the state I was in, and 

I didn’t know if I believed my psychiatrist’s version of 

my situation either. My personal point of reference 

for psychiatric admissions was a ruinous and aching 

memory from the year before. Up until that point, my 

experience with psychiatrists was one of mental and 

physiological devastation, frightening, something I 

avoided at all cost. However, my husband supported 

my psychiatrist’s advice to be hospitalized. I was 

not convinced. After all I did not really know my 

psychiatrist yet, nor had I had the time to develop 

trust in him either. And so I wrote: 

I’M TRYING AGAIN TO 

ASSIMILATE THE WORDS 

‘I DON’T WANT YOU TO 

BE NERVOUS FOR THESE 

SESSIONS’. THE REALITY? 

I AM TRYING TO GET 

THOUSANDS OF BUTTERFLIES 

IN MY STOMACH TO SIMPLY 

FLY IN FORMATION, NOT TO 

MENTION DISAPPEAR COMPLETELY. 

Claudia Campbell 

However, how do you not be nervous, be just fine, 

be valiant when you know that facing you are 

conversations about the deepest, most personal, 

intimate, terrifying, confusing moments in your life? 

Yes fine, the details are going to be given over to a 

‘professional’, ‘excellently skilled’ in dealing with these 

kinds of ‘situations’. But does this imply that by virtue 

of a profession you shouldn’t view the professional 

in front of you as an ordinary person? No it doesn’t. 

And in every relationship, with any person one meets, 

a level of trust is involved. Trust built over time and 

generally not because of impressive certificates and 

an occupation description on a business card. One 

needs to be able to trust that your integrity, emotions 

and reactions will be handled with care and not 

scribbled down on a patient file for reference 

purposes only. Trust is feeling that you are more 

than a few pages of notes. How can I trust someone 

when I am a ‘case’, with a ‘file’, a set of ‘symptoms’, 

needing a ‘diagnosis’? Does the fact that I have 

the label of ‘patient’ mean that I lose my status of 

‘person’, something or perhaps someone beyond 


PERSPECTIVE 

a yellow file, with next-of-kin details, and alternative 

contact numbers? I struggle to place my hurt and 

heartache into the category of another’s commodity. 

I STRUGGLE TO TRUST SOMEONE WHEN 

I FEEL THAT MY MOST INTIMATE DETAILS 

NEED TO BE HANDED OVER AS SIMPLY 

PART OF A ‘JOB’. IT MAKES ME FEEL 

DEFENSIVE AND GUARDED” 

I realize now that on day two or three of that 

admission my psychiatrist had tried to prepare me 

for the dreaded conversation he wanted to have 

with me the following day. He needed to know more 

detail about my story in order to treat me effectively, 

and he explained this to me – warning me that the 

next night we were going to ‘go there’. In some ways 

I felt pushed and I was angry, but more than anything 

else I was terrified. Today I know with certainty that 

my psychiatrist was acutely aware of my terror and 

that is why he had attempted to forewarn me about 

what was to come. 

REFLECTING BACK NOW I HAVE TO 

WONDER IF, IN A WAY, HE WAS PREPARING 

HIMSELF TOO. IT IS FAIRLY OBVIOUS HOW 

I FELT IN MY HOSPITAL BED DIATRIBE, 

BUT AT THAT STAGE I NEVER STOPPED 

TO CONSIDER HOW HE FELT. I KNOW IT 

WASN’T MY JOB OR DUTY – AFTER ALL I 

WAS THE PATIENT. BUT, I HAVE TO WONDER 

IF THIS TYPE OF SCENARIO ISN’T PERHAPS 

TOUGH FOR PSYCHIATRISTS TOO. 

How tough is it to be the one who has the responsibility 

to decide that a patient’s fear, instability and distress 

are so acute that the best place for them to be is the 

confines of a hospital bed? 

My psychiatrist has watched and listened to me as 

I’ve traversed every up and down along my journey. 

He has seen everything from pulsating nausea and 

shivers to insomnia and terror, elation, laughter, 

panic, dizziness, desperation, confusion, terror and 

migraines. He has witnessed it all. He has listened 

to my stories of bewilderment, love, dread, elation, 

travel, bikes, textbooks, graduations, mother, brother, 

friends, excitement and disappointment – so the list 

continues. I don’t know how he does it. When I leave 

my psychiatrist’s consulting room I often wonder how, 

day after day, he manages to listen, with such care 

to the complex and deep intricacies of so many 

people’s lives. Where does he find the reserves to 

perpetually assimilate the delicate nuances of every 

patient? Not all psychiatrists get this right, but what 

sustains those who do? 

I can’t imagine that being diagnosed with mental 

illness is great for anyone. It’s not something that 

comes coupled with a statement from your doctor of: 

“… but don’t worry we can cure this with a strong dose 

of penicillin”. I think about the fact that psychiatrists 

have a duty to regularly hand over diagnoses of 

these illnesses. Not only are they often incurable, but 

frequently they are tricky to treat – a tedious path 

of medication trial and error for both patient and 

doctor. In addition, these diagnoses psychiatrists 

pass over to us come loaded with societal stigma. 

Caring for us seems an overwhelmingly weighty 

responsibility. Does that weight ever feel too much 

to carry? 

Being on the receiving end of diagnoses and 

psychiatric treatment is far removed from Flake ice 

creams. I remember when I received my diagnosis; 

on the one hand I felt relieved – relieved that there 

was an explanation other than a lack of self-control 

for my erratic, unreasonable thinking and behaviour. 

BUT I ALSO FELT AS IF I HAD BEEN LEFT- 

HOOKED IN THE SOLAR PLEXUS. IN 

THOSE FIRST MOMENTS I DIDN’T FIND 

MYSELF DEALING WITH THE STIGMA OF 

THE OUTSIDE WORLD, BUT THAT, WHICH 

LIVED INSIDE MY OWN MIND. I HAD 

ALWAYS FELT A DEEP EMPATHY, OR 

PERHAPS SYMPATHY, TOWARDS THOSE 

WITH MENTAL ILLNESS. HOWEVER, IT WAS 

SOMETHING THAT BELONGED TO ‘THEM’ 

NOT ME, SOMETHING WORTHY OF PITY. 

I was horrified at myself. After I faced myself I did 

have to deal with the reactions of the outside world. 

I find it so fascinating to watch the responses of many 

when I disclose my diagnosis. Even those who have 

known me for extended periods make comments 

such as: “No! But you’re so normal!” What pray-tell 

is that meant to mean? Do they expect me to be 

walking around wild-eyed and snarling? Or another 

choice reaction is when it seems as if the wind 

has been knocked out of them, and they scrabble 

desperately for a way to change the subject. If you 

let it, these reactions can make you believe that your 

‘abnormality’ renders you unworthy of consideration 

– renders you a failure on the most basic human 

level, shameful, and useless. 

Often, it has been the time spent sitting across from my 

psychiatrist that has helped me regain perspective 

and figure out how to navigate the hurdles of 

stigma. Amidst my own doubts and uncertainty my 

psychiatrist seemed to have consistent, granite belief 

in me – my abilities and potential, belief beyond 

what I could fathom. His belief fed my husband’s 

belief, and eventually this helped me believe that I 

shouldn’t give up, even when I fell. The combined, 

unwavering support I have received has often 

shored up my crumbling walls. 

I question how often it is that psychiatrists notice lifechanging 

moments that happen across from them. 

Moments that in their brevity might seem little, but in 


PERSPECTIVE 

their effect are very large. My first such experience 

happened during my initial appointment with my 

psychiatrist. I felt intense shame when I explained 

my self-harming behaviour. It made me feel 

embarrassed and despicable. I don’t know why he 

chose the words he did in response to my disclosure, 

but they have always stayed with me: “Claudia, 

every time you cut yourself, you cut away a piece of 

yourself you will never get back”. 

It was the most painful thing to hear, but it made 

such sense. I felt ‘less’ of a person’ already and 

I didn’t want to cut the rest of myself away. To this 

day those words motivate me to not give into that 

insidious craving. My psychiatrist’s response when I 

recounted this experience recently was that he did 

not really remember that particular occasion and 

so he did not realise how big its impact was on me. 

He told me that it was a sobering, yet encouraging, 

reminder of how powerful words can be. 

I cherish the fact that in my psychiatrist’s office 

laughter is allowed, and that he will often be the one 

to see the funny side of things - without forgetting 

their seriousness. I appreciate that I’ve not only 

been able to share the diagnosis-related parts of my 

life with him but my dreams and musings too. Even 

though sometimes it’s been uncomfortable and my 

husband and I have felt that we couldn’t move any 

further, my psychiatrist was part of the team that 

never gave up, doggedly trudging this path with us. 

AS MY PSYCHOLOGIST NOTED, MAYBE 

WE NEVER REACH THE IMAGINED SUMMIT 

OF OUR MOUNTAINS; PERHAPS FROM 

TIME TO TIME WE JUST NEED TO TAKE A 

MOMENT TO APPRECIATE THE VIEWS OF 

PROGRESS ALONG THE WAY. 

I deeply appreciate my psychiatrist for so patiently 

helping me see how to get to where I am today, and 

I know that without doubt my husband feels the 

most profound gratitude to him too. Our view right 

now is quite lovely indeed. 

Claudia Campbell holds a post-graduate degree in psychology and has 10 years experience in the field of corporate 

transformation strategy. Claudia works in a voluntary capacity as a psychosocial facilitator, public speaker, and strategic 

consultant. Claudia is currently undertaking a psychology research master’s degree focused on the implementation of the 

National Mental Health Policy Framework 2013-2020 and the role of registered counsellor, through Stellenbosch University. Due 

to various health concerns, Claudia’s personal life includes many experiences from the patient’s side of the consultation table. 

Correspondence: claudia@redbench.co.za 

Sustaining 

Development: 

Investing in Child and 

Adolescent Mental Health 

South African Association for Child and Adolescent 

Psychiatry and Allied Professions 

SA-ACAPAP 

Congress 2019 

In partnership with PANDA-SA and SAISI 

MISTY HILLS HOTEL AND CONFERENCE CENTRE | MULDERSDRIFT, GAUTENG | 23-25 MAY 2019 

SAVE THE DATE 

58 * SOUTH AFRICAN PSYCHIATRY ISSUE 17 2018 Congress website www.saacapap.co.za

CULINARY CORNER 

A MEANINGFUL MEAL 

OF PSYCHIATRIC AND 

PSYCHOLOGICAL 

INFORMATION 

Our menu today starts with a delicious little 

titbit of how Freud may have obtained, 

what he thought was confirmation, for his 

theory of penis envy. 

Our main meal begins with an account of the 

“data thugs” who are terrorising social psychology 

researchers. These “thugs”are freelance scientists 

and fringe academics who review the statistics in 

published research. Among other things they make 

use of computer programs developed to identify 

miscalculated p-values. The final article of the main 

course presents an illustration of the biases that may 

emerge in science. 

The refresher consists of two palate-cooling articles 

regarding our growth of scientific understanding 

with regard to females on the autism spectrum; 

and dessert identifies some of the other factors 

hampering the progress of science. 

STARTER 

ANNA FREUD’S PENIS ENVY 

Coffey (2017), a science and 

psychology journalist and novelist, 

questions why Freud took on 

the analysis of Anna, given his 

awareness that analysis could be 

erotically charged? 

Anna had never married and she 

may have been struggling with 

questions of sexual preference. 

Was Freud concerned about his personal reputation 

should it emerge that Anna was not heterosexual? 

In terms of his theories, if Anna had been a lesbian, 

this would have been due to mistakes he had made 

as a father. Indeed, in 1924 she had met Dorothy 

Burlingham with whom she became very close. Not 

only did the two vacation together, they bought a 

small home in the country and eventually Dorothy 

was referring to Anna as her children’s second 

mother. 

From the age of six, Anna had been masturbating to 

beating fantasies. In adulthood, she would imagine 

herself being a young man held captive and 

beaten by a knight who tried to force her to betray 

family secrets. Freud considered masturbation to be 

masculine in nature and dangerously inappropriate 

for women. 

COFFEY (2017) DOES NOT CONSIDER 

THE POSSIBILITY THAT ANNA MAY HAVE 

SUFFERED FROM GENDER DYSPHORIA, 

BUT GIVEN THE NATURE OF HER SEXUAL 

FANTASIES IN WHICH SHE IMAGINES 

HERSELF TO BE A MAN, IT IS HARD NOT 

TO SPECULATE WHETHER, IN A DIFFERENT 

AGE, SHE MIGHT NOT HAVE SOUGHT TO 

IDENTIFY HERSELF AS MALE. 



More to the point, from a theoretical point of view, in 

1925 Freud published an elaboration of his original 

theory of penis envy. In his view, the moment at which 

a girl discovers her lack of a penis is a moment of 

immense psychic trauma. From that moment on, the 

girl will want a penis and as she matures, will hope 

for second best: her father’s penis. As incest is taboo, 

this will inspire feelings of shame in her and she will 

ultimately sublimate her desire for her father’s penis 

into a desire for a child. 

As Coffey (2017) notes, Freud’s theory of penis envy 

may be less based on observable phenomena 

in girls and young women in general, than on his 

daughter’s specific issues. 

MAIN MEAL 

DATA THUGS 

applications. They may process survey results through 

a computer application known as SPRITE (Sample 

Parameter Reconstruction via Interactive Technique). 

This can be used to determine whether survey results 

on paper appear to have been fabricated. They 

also have the aptly named GRIM, which stands for 

Granularity-Related Inconsistency of Means. This 

program tests to see whether certain figures reported 

in an article are mathematically possible. If they’re 

not, then the authors either miscalculated or they 

made it up (Bartlett, 2018). 

In his essay, “I Want to Burn Things to the Ground” 

Bartlett (2018) notes that the problem is exacerbated 

by the unwillingness of researchers to share their 

data freely (often to protect the anonymity of 

respondents). 

UNFORTUNATELY, CONCEALING DATA 

MAKES IT EASIER TO FUDGE WHAT IS 

FOUND. RESEARCHERS OFTEN DO 

NOT STATE WHAT THEY ARE TRYING 

TO DISCOVER BEFORE THEY ATTEMPT 

TO DISCOVER IT. THE FREEDOM TO 

ALTER HYPOTHESES THEN FACILITATES 

P-HACKING - WHICH REFERS TO WHEN 

A RESEARCHER GOES SEARCHING FOR 

PATTERNS IN STATISTICAL NOISE. 

REPORTING P-VALUES 

It gets worse - or better. In the early 2010s a computer 

program known as Statcheck was developed by 

psychologists at the University of Amsterdam. This 

program is used to detect instances in reported 

research where the p-value does not correspond to 

the value of the reported statistic, whether this be x², 

F, r, t or z. 

Social psychology studies have been going through 

something of a crisis related to high levels of poor 

replication. To add to this growing sense of insecurity, 

a group of research investigators consisting of 

freelance scientists and fringe academics have 

sprung up. They make it their business to challenge 

the statistical findings in published research. 

These individuals belong to a body called the Society 

for the Improvement of Psychological Science and 

are often portrayed as “data thugs”. While they are 

to be welcomed on the one hand for contributing 

to discussions regarding the quality of data, their 

dissection of studies are also stifling new research 

projects as potential researchers experience 

growing fear that their findings may not withstand 

their withering scrutiny (Bartlett, 2018). 

“Data thugs” are able to contribute to their researchassaulting 

activities by means of computer 

USING STATCHECK, CANADIAN 

RESEARCHERS, GREEN ET AL (2018), 

SURVEYED ARTICLES IN SEVERAL 

PRESTIGIOUS EUROPEAN AND AMERICAN 

PSYCHOLOGY JOURNALS. THEY FOUND 

THAT THERE WAS A HIGH LEVEL OF 

INCOHERENCE BETWEEN THE P-VALUE 

AND THE RELEVANT TEST STATISTICS IN 

THE RESEARCH INVESTIGATED. NEARLY 

HALF OF ALL THE PAPERS CONTAINED 

AT LEAST ONE SUCH ERROR, AS DID 10% 

OF ALL NULL HYPOTHESIS SIGNIFICANCE 

TESTS. 

The researchers then turned their attention to 

Canadian journals and discovered similar rates of 

p-value errors. The authors recommend that in the 

future, journals include explicit checks of statistics in 

their editorial process. 



RESEARCH AS A SOCIAL PROCESS 

P-hackers and other statistical cheats are not the 

only people hampering the development of science. 

Another problem relates to the social context in 

which research finds are disseminated. 

REFRESHER 

AUTISTIC FEMALES ARE DIFFERENT 

TO AUTISTIC MALES 

Daniel Kahneman, the author of the well-received 

book “Thinking Fast and Slow” (2011), argued that 

the concept of loss aversion was the most significant 

contribution to the psychology of behavioural 

economics. Not so, argues David Gal (2018), a 

professor of marketing at the University of Illinois 

at Chicago. He, together with Derek Rucker of 

Northwestern University carried out a critical review 

of loss aversion and concluded that there is, in fact, 

no global loss aversion bias. 

Contexts in which people are motivated by a fear of 

loss are associated with rational thought processes, 

as are contexts where people are not motivated by 

a fear of loss. These incidents are associated with 

specific explanations rather than with an inborn 

cognitive tendency. 

FOR EXAMPLE, MESSAGES THAT FRAME 

AN APPEAL IN TERMS OF LOSS ARE NO 

MORE PERSUASIVE THAN MESSAGES THAT 

FRAME AN APPEAL IN TERMS OF GAIN. 

In his essay, “Why the Most Important Idea in 

Behavioural Decision Making is a Fallacy” Gal 

(2018) goes on explain why a belief in loss aversion 

has persisted so strongly. He notes that science is a 

social process in which advocates of a theory need 

to convince other scientists by means of logic and 

argument that the evidence is best explained by 

that particular theory. 

ONCE MANY PEOPLE ARE CONVINCED, 

THE INCUMBENT THEORY IS 

ADVANTAGED OVER CHALLENGES TO 

IT. GAL (2018) POINTS OUT THAT THE 

STATUS QUO IS MAINTAINED THROUGH 

CONFIRMATION BIAS, SOCIAL PROOF, 

IDEOLOGICAL COMPLACENCY, AND THE 

VESTED INTERESTS OF SCIENTISTS WHOSE 

REPUTATIONS ARE CONNECTED TO 

EXISTING THEORIES. IN THE CASE OF LOSS 

AVERSION, CONTRADICTORY EVIDENCE 

HAD BEEN IGNORED, DISMISSED 

OR EXPLAINED AWAY. FURTHERMORE, 

AMBIGUOUS EVIDENCE HAD TENDED TO 

BE INTERPRETED AS CONFIRMING LOSS 

AVERSION. 

Gal (2018) concludes that one should be neither 

too accepting in relation to institutional consensus of 

theories nor too wary of criticising accepted beliefs. 

Of late there has been much criticising of accepted 

beliefs in autism studies. The challenged wisdom has 

been that autism is found in boys more than girls 

and that when it is found in girls it is very severe. 

However it is emerging that many females who are 

less extremely based on the spectrum are often 

not diagnosed because they present differently 

(Szalavitz, 2016). Behavioural and neuroimaging 

studies suggest that females with autism are closer 

to developing males in their social abilities than 

typical girls or boys with autism. 

Autistic girls show more of a desire to connect, they 

exhibit less repetitive behaviour than boys, their 

preferences and pastimes are more similar to other 

girls and, unlike their male counterparts, they may 

indulge in pretence play. Their tendency towards 

rigidity, focus on detail and distress with change 

may lead them to be misdiagnosed as suffering 

from obsessive compulsive disorder, attention deficit 

disorder or anorexia nervosa (Szalavitz, 2016). 

AUTISM AND ANOREXIA NERVOSA 

Individuals with anorexia nervosa and those 

with an autism spectrum condition both exhibit 

perfectionism, a preference for symmetry and 

exactness, obsessiveness, impaired social cognition 

and social skills. Preliminary studies have suggested 

that in both disorders there is decreased neural 

activity in the superior temporal cortex and temperoparietal 

junction (involved with social cognition and 

social skills), as well as a decrease in grey matter in 

the temporal lobes (Bjornsdotter et al, 2018). 

Bjornsdotter et al (2018) investigated whether there 

was less grey matter in areas associated with a 

theory of mind in anorexic girls aged 16 to 25 who 

presented also with autistic traits. It emerged that 

elevated autistic traits in young women with anorexia 

nervosa were indeed associated with morphometric 

alterations of brain areas linked to social cognition. 



This study provides confirmation for a behavioural link 

between anorexia nervosa and autism. It poses the 

question regarding whether neurological risk factors 

linked to autistic traits in adolescent girls contribute 

to their developing anorexia nervosa. As such, the 

possibility is raised that patients with anorexia who 

exhibit a high level of autistic traits may benefit from 

therapeutic programmes which acknowledge their 

autistic characteristics. 

DESSERT 

THE PROGRESS OF SCIENCE 

of the “h-index”. This index then becomes a kind 

of currency which is convertible into salaries and 

research grants. The same researchers, producing 

the same types of research then get rewarded 

disproportionately, leaving less room for those with 

less quantifiable value. 

Instead of intensifying conformity, the scientific 

community needs to encourage the diversity of 

funding mechanisms and research approaches. 

Baumberg (2018) argues that citations should 

be complemented by a more comprehensive, 

multifaceted assessment of scientific work. 

INGREDIENTS 

Bartlett, T. (11 September 2018). ‘I Want to Burn Things 

to the Ground’, The Chronicle of Higher Education. 

https://www.chronicle.com/article/1-want-to-Burn- 

Things-to/244488 

Jeremy Baumberg (2018), a nano-scientist at the 

University of Cambridge and the author of several 

books on science, argues that globalization, the 

digitization of knowledge and the growing number 

of scientists in the world suggest that science is 

progressing. Unfortunately these supposed positive 

trends have a negative side to them. According to 

Baumberg they also encourage a hyper-competitive, 

trend-driven and herd-like approach to scientific 

research. 

Globalization increases competition. However it also 

reinforces narratives relating to the research areas 

which are considered to be the most deserving of 

funding. 

A GREAT DEAL OF WORK THEN 

PROLIFERATES IN THESE AREAS, 

REDUCING THE EFFICACY OF FUNDING IN 

OTHER AREAS. THIS IS NOT CONDUCIVE 

TO SCIENTIFIC PROGRESS. THE HISTORY 

OF SCIENCE HAS SHOWN THAT THE 

MOST SIGNIFICANT ADVANCES HAVE 

OFTEN COME ABOUT AS A RESULT 

OF A COMBINATION OF SEEMINGLY 

UNRELATED RESEARCH. 

The digitization of knowledge amplifies this problem. 

Scientists are ranked in terms of citations by means 

Bjornsdotter, M., Davidovic, M., Karjalainen, L., Starck, 

G., Olausson, H., & Wentz, E. (March 2018). Grey matter 

correlates of autistic traits in women with anorexia 

nervosa, Journal of Psychiatry and Neuroscience, 

43(2), 79-86. 

Coffey, R. (2017). The Erotic Psychoanalysis of Anna 

Freud by her father, Sigmund, and Other Skeletons in 

the Freud Family Closet, Beck and Branch, LL Online 

Literary Studio and Micro Press. 

Gal, D. (Nov/Dec 2018). Why the Most Important Idea 

in Behavioural Decision Making is a Fallacy, Scientific 

American Mind, 52-54. 

Green, C.D., Abbas, S., Belliveau, A., Beribisky, N., 

Davidson, I.J., DiGiovanni, J., Herdari, C., Martin, S.M., 

Oosenbrug, E., & Warnewright, L.M. (2018). 

Statcheck in Canada: What Proportion of CPA 

Journal Articles Contain Errors in the Reporting 

of p-values, Canadian Psychology/Psychologie 

Canadienne, 59(3), 203-210. 

https://dx.doi.org/10.1037/cap0000139 

Kahneman, D. (2018). Thinking Fast and Slow, Farrar, 

Strauss and Giroux, New York. 

Szalavitz, M. (March 2016). Autism - It’s Different in 

Girls, Scientific American 

https://www.scientificamerican.com/article/ 

autism- it-s-different-in-girls/ 

Ethelwyn Rebelo (PhD) is a clinical psychologist working in private practice. She has spent a good part of her 

professional life working in psychiatric wards and psychiatric clinics. Correspondence: ee.vajdakova@outlook.com 


WINE FORUM 

/ HANNUWA / 

– PIPE-DREAM, OR POSSIBILITY? 

12 th to 14 th September saw your scribe shake off 

the dust of the clinic and don his journo hat 

as a media delegate to CapeWine 2018, the 

triennial international trade show that is core 

to the mandate of WOSA – Wines of South Africa; 

promoting the export of South African wines in key 

international markets. 

WOSA is an inclusive, not-for-profit body representing 

all South African wine producers which export their 

products. Established in its current form in 1999, 

it has over 500 producers on its database and is 

independent of any single producer or wholesaling 

company, or any government department. It is, 

however, recognised by government as an Export 

Council. WOSA is funded by a per litre statutory levy 

on all natural and sparkling wines exported. 

This year a total of 2,414 delegates from 66 countries 

– 1345 local and 1069 international trade and media 

guests – registered for this showcase of wines from 

352 producers under one roof at the Cape Town 

International Convention Centre. The theme was 

/Hannuwa/, which alludes to the 200,000 year old 

Khoi-San word that describes the harmony between 

man and the land from which we harvest. The focus 

was on creating a sustainable future for the people, 

vineyards and an industry that employs roughly 

290,000 people in South Africa. 

Carina Gous, who took over the WOSA Chair from 

ex-FNB chief Michael Jordaan in November 2017, 

painted a disarmingly frank and gloomy picture 

of SA wine in the big league during the Opening 

Seminar. South Africa, which exports some 52% of 

wine production, well over half in bulk (sadly), is a 

minnow. France commands the space with both 

volume and price – it exports some 1 500 million litres 

(L) at just over 6 €/L. Italy and Spain may export more 

– over 2 billion L each – but at a lower price, 1.24 

€/L in the latter case. New Zealand is also a small 

exporter (255 million L) but at an admirable average 

€ 4.15/L. And South Africa? We export around half 

a million litres, but at a paltry 1.24 

€/L. That’s the same price achieved 

as Spain, but on about a fifth of 

the volume. The whole point of this 

three-day expo was to sell more 

wine to foreign buyers, at hopefully 

higher prices. 

APART FROM THE EXHIBITION 

– THE CORE OF THE MEETING WHERE 

NEW BUYERS WERE WOOED AND DEALS 

DONE – THERE WAS A HOST OF ALLIED 

EVENTS OF INTEREST. THESE INCLUDED 

BI-DAILY SEMINARS, THRICE DAILY 

SPEAKER’S CORNER PRESENTATIONS, 

FREE-POUR TASTING SESSIONS BOTH 

MORNING AND AFTERNOON, AND EVEN 

A WINE PROFESSIONALS BLIND TASTING 

COMPETITION. 

The seminars explored mores serious matters, based 

on an illustrative tasting, such as The Old Vine 

Project (grist for a future Wine Focus mill), the ageability 

of SA white wines, the new wave Young Gun 

winemakers, and Climate Change in the vineyard. Dr 

Tara Southey presented her fascinating climate data 

that track ‘Growing Degree Days’ which reflect the 

area’s heat profile. This suggests there are hosts of 

potential vineyard sites in non-traditional places that 

may well be cooler (more desirable at our latitude) 

than thought. Eschew Stellenbosch at over R1 million 

to procure a hectare of virgin earth, the answer may 

be tucked up in hills beyond the Huguenot Tunnel… 

The Amorim Speaker’s Corner was less formal and 

more personal, but still backed up with a tasting. 

The new designation ‘Wine of Origin Cape Town’, 

organic and biodynamic wine farming, new or 

trendy grape varieties, sweet wine, bottle-fermented 

wine and progress of the transformation of SA wine, 

were amongst the itinerary. 


WINE FORUM 

Delegates in discussion 

Business 

Rock stars Peter-Allan Finlayson (Crystallum) 

& Chris Alheit co-marketing as the Zoo Cru 

The Bridge of Hope empowerment 

project 

WAS IT A SUCCESS? BY ALL ACCOUNTS, 

‘YES’. DISPLAYING PRODUCERS SEEMED 

WELL PLEASED WITH NEW CONTACTS 

AND POTENTIAL BUSINESS, THE JOURNOS 

GENERALLY OOHED AND AAHED, AND 

HIGH-PROFILE VISITORS MADE THE RIGHT 

NOISES. 

Wine buyer and partner for UK retailer, Waitrose, 

Victoria Mason said: ‘I was completely blown away 

by CapeWine 2018 – the quality and diversity of 

wines on show, the passion of the people behind 

the wines, the level of excitement all week from 

all the guests and exhibitors, the “extra-curricular” 

programme of events and tastings, and the optimism 

and determination of the industry as a whole in the 

face of some significant external challenges.’ 

Gripes? I have but a few. With the focus on 

sustainability, there were blind spots. Neither I nor 

WOSA know how many glasses were washed as 

we went about the three days, but it was plenty, 

for sure. While the process may have been water-, 

heat- and phosphate-friendly, it would have been 

nice to have been assured that. And the stark irony, 

viewing the stage at the Opening Seminar, of plastic 

water bottles littering the tables at the launch of a 

sustainability-based event, could only have been 

lost on those asleep at the time. That the CTICC has 

not yet found an alternative to plastic water bottles 

is astonishing. 

Was it worth it? Well, apart from an uptick in exports 

that could be due to a multitude of other reasons, 

we’ll never know. As WOSA is not the sole funder 

of the jamboree and there is plenty of marketing 

around the main event, I doubt absolute costs are 

quantified and, if they are, they’re not disclosed. 

Considering that WOSA’s prime business is rooted in 

the Western Cape, one would have thought it would 

be interested in tracking the economic impact of its 

premier event on the local economy, much like the 

Cape Town Cycle Tour Trust does. Alas, apparently 

not. 

Raymond Ndlovu REMGRO & 

Black Elephant Vintners 

Wine Professional blind tasting competition 

Seminar time 

Niels Verburg 

Johnathon Grieve (Avondale) discusses Biodynamic 

Wines 

Wine Wizard Michael Fridjhon and De Morgenzon’s 

Wendy Applebaum 

A regional stand 

Free-pour tasting station 

David Swingler is a writer and taster for Platter’s South African Wine Guide for 21 years to date. 

Dave Swingler has over the years consulted to restaurants, game lodges and convention 

centres, taught wine courses and contributed to radio, print and other media. A psychiatrist 

by day, he’s intrigued by language in general, and its application to wine in particular. 

Correspondence: swingler@telkomsa.net 


MOVIE REVIEW 

THE 

DRESSMAKER 

a review by Franco P. Visser 

A Screen Australia / Universal Pictures 

International / Ingenious Senior Film Fund & 

Embankment Films Presentation 

A Film Art Media Production 

Directed by Jocelyn Moorhouse 

Produced by Sue Maslin 

If ever there was a tasteful feel-good revenge 

movie for those affected by a traumatic school 

career, it is this one. The Dressmaker (a 2015 

release), a film based on the novel by Rosalie 

Ham, tells the story of Myrtle ‘Tilly’ Dunnage (played 

by Kate Winslet) whose return to the town where she 

grew up more than ruffles a few feathers. A grown 

up Tilly, an accomplished dressmaker, returns to the 

Australian Outback town of Dungatar after years 

of absence and banishment. As a young girl Tilly 

was accused of causing the death of a local boy, 

Stewart Pettyman (played by Rory Porter), the son 

of Evan Pettyman (played by Shane Bourne), the 

adulterous town councillor – a murder that she 

cannot remember. 

Upon Tilly’s return she finds her mentally ill mother 

Molly (played by Judy Davis) living in squalid 

conditions. Tilly sets about changing things at home 

and in town, and boy does she ever! 

Tilly turns up at the final of a local ‘footy’ match 

wearing a drop-dead gorgeous red couture 

dress of her own making, naturally to the shock 

and astonishment of the locals, not to mention 

the disastrous effects that she and her revealing 

apparel have on the concentration of the men 

playing in the game. It is at this football match that 

Tilly crosses paths with Gertrude Pratt (played by 

Sarah Snook), the dull daughter 

of Dungatar’s local General Store 

owner. It is not long after the match 

that some of the town’s ladies start 

knocking on Tilly’s door in order 

to be transformed by her and her 

dressmaking skills. 

Naturally Tilly has her strong 

detractors in town, not least of 

which being Evan Pettyman whose son’s death 

she allegedly caused. Evan recruits Una Pleasance 

(played by Sacha Horler), a dress maker with far less 

skills than Tilly posses to establish a rival dressmaking 

business in town. It goes without saying that Una’s 

attempted rivalry causes some hilarious moments 

in the film, mostly due to the fact that Una is not 

nearly in Tilly’s league when it comes to the art of 

dressmaking. 

TILLY’S DRESSMAKING SKILLS TRANSFORM 

THE DULL GERTRUDE PRATT INTO A RATHER 

HANDSOME AND ALLURING BEAUTY, AND 

AT THE FOOTBALL DANCE SHE CATCHES 

THE EYE OF WILLIAM BEAUMONT 

(PLAYED BY JAMES MACKAY). WILLIAM’S 

MOTHER IS ONE OF EVAN PETTYMAN’S 

STAUNCHEST SUPPORTERS AGAINST TILLY, 

AND HER SON’S CLEAR INFATUATION 

WITH A TRANSFORMED GERTRUDE DOES 

NOT GO DOWN WELL. WILLIAM SOON 

ASKS GERTRUDE FOR HER HAND IN 

MARRIAGE TO THE DELIGHTFUL HORROR 

OF HIS SNOBBISH MOTHER ELSBETH 

(PLAYED BY CAROLINE GOODALL). 


MOVIE REVIEW 

As is expected it does not take long for Evan 

Pettyman’s eye to wonder towards Una, and the 

two are caught ‘in the act’ by Evan’s wife Marigold 

(played by Alison Whyte). Evan had drugged his 

wife for years following their son’s death, mostly as 

a means of satisfying his own sexual needs and 

to cover up his various indiscretions. How Marigold 

reacts I will leave to you the viewer to discover. 

TILLY LEARNS THE TRUTH OF WHAT 

ACTUALLY HAPPENED ON THE DAY THAT 

STEWART PETTYMAN DIED IN ADDITION 

TO BEING TOLD BY GERTRUDE THAT 

STEWART HAD SEVERELY BULLIED HER, A 

FACT THAT TILLY HAD BLOCKED FROM 

HER MEMORY. 

Not only was Tilly a favourite target of Stewart’s 

bullying propensities, but she was also picked upon 

by their nasty school teacher, Beulah Harridiene 

(played by Kerry Fox). It was Beaulah’s false affidavit 

following Stewart’s death that caused the young 

Tilly’s removal from her mother and her banishment 

from Dungatar. Tilly also finds love in Dungatar albeit 

with heartbreaking consequences for her. 

Naturally there are many twists and turns that I 

have not mentioned in this review. The Dressmaker 

succeeds in taking the viewer through a range 

of emotions and the film is a delightful piece of 

cinematography to view. 

IT IS NOT YOUR AVERAGE RUN OF THE MILL 

MOVIE, AND ALTHOUGH IT MIGHT NOT 

APPEAL TO EVERYONE, THE DRESSMAKER 

SURELY RANKS AS ONE OF MY FAVOURITE 

FILMS OF ALL TIME. 

Seeing Tilly avenge the wrongs that were done to her 

as a child is highly enjoyable, and the artistic flair of 

the film makes it extra special. The film comes highly 

recommended. Enjoy! 

Franco Visser is a psychologist and former lecturer in Neuro- & Forensic Psychology at UNISA, Pretoria, South Africa and 

currently in private practice Correspondence: francopierrevisser@gmail.com 


Adult ADHD is debilitating... 

Change that, 

make every 

moment 

a lightbulb 

moment. 

ALLOW ADULTS WITH ADHD TO PERFORM AT THEIR BEST. 

Approximately 2 out of 3 ADHD children grow up to be ADHD adults 1 

Ritalin ® 

• Reduced inattention 2* 

• Reduced impulsive behaviour 2* 

• Improved response inhibition 3† 

• Well tolerated 2* 

RitalinLA 

Unleashing potential 2 

*Compared to placebo in a randomized, 6-week, placebo-controlled, parallel study of methylphenidate in 146 adult patients with DSM-IV ADHD 2 . † Response inhibition was assessed with the “tracking” stop-signal test in 13 adults with a diagnosis of ADHD, both while taking and while not taking medication, and 

13 healthy, unmedicated, age- and intelligence quotient-matched control subjects 3 . 

References: 1. Faraone SV, Biederman J, Mick E. The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychological Medicine 2006; 36(2): 159-165.. 2. Spencer T, Biederman J, Wilens T, et al. A Large, Double-Blind, Randomized Clinical Trial of Methylphenidate in 

the Treatment of Adults with Attention-Deficit/Hyperactivity Disorder. Biol Phsychiatry 2005;57:456-463. 3. Aron AR, Dowson JH, Sahakian BJ, Robbins TW. Methylphenidate Improves Response Inhibition in Adults with Attention-Deficit/Hyperactivity Disorder. Soc Biol Psychiatry 2003;54:1465-1468. 

S6 RITALIN ® 10: B/1.2/1610. RITALIN ® LA 10: 44/1.2/0594. RITALIN ® LA 20: 36/1.2/0186. RITALIN ® LA 30: 36/1.2/0187. RITALIN ® LA 40: 36/1.2/0188. Composition: Tablets containing 10 mg methylphenidate hydrochloride. Modified-release capsules (RITALIN ® LA) containing 10 mg, 20 mg, 30 mg and 40 mg 

methylphenidate hydrochloride respectively. Pharmacological Classification: A 1.2 Psychoanaleptics (antidepressants). Indications: Attention deficit hyperactivity disorder (ADHD). The diagnosis should be made according to current DSM criteria or the guidance from International Classification of Diseases (ICD). 

RITALIN ® 10 only: narcolepsy in adults. Contraindications: Hypersensitivity to methylphenidate or to any of the excipients, anxiety, tension, agitation, hyperthyroidism, pre-existing cardiovascular disorders including hypertension, angina, arterial occlusive disease, heart failure, haemodynamically significant congenital 

heart disease, cardiomyopathies, myocardial infarction, potentially life-threatening dysrhythmias and channelopathies (disorders caused by dysfunction of ion channels), QT prolongation either congenital, familial or caused by medication; during treatment with monoamine oxidase (MAO) inhibitors, or within a minimum 

of 2 weeks of discontinuing those medicines due to risk of hypertensive crisis; glaucoma, phaeochromocytoma, diagnosis or family history of Tourette’s syndrome. Pregnancy and lactation. Warnings and Special Precautions: Treatment with RITALIN ® is not indicated in all cases of Attention-Deficit/Hyperactivity disorder 

and should be considered only after detailed history-taking and evaluation. Generally should not be used in patients with structural cardiac abnormalities or other serious cardiac disorders that may increase the risk of sudden death. Preexisting cardiovascular disorders, a family history of sudden death and ventricular 

arrhythmia should be assessed before initiating treatment. RITALIN ® increases heart rate and systolic and diastolic blood pressure. Therefore, caution is indicated in treating patients whose underlying medical conditions might be compromised by increases in blood pressure or heart rate, e.g. those with pre-existing 

hypertension and severe cardiovascular disorders. Blood pressure should be monitored at appropriate intervals in all patients taking RITALIN ® . Patients who develop symptoms suggestive of cardiac disease should undergo prompt cardiac evaluation. Misuse may be associated with sudden death and other serious 

cardiovascular adverse events. Patients with pre-existing cerebrovascular abnormalities should not be treated with RITALIN ® . Patients with additional risk factors (history of cardiovascular disease, concomitant medications that elevate blood pressure) should be assessed regularly for neurological/psychiatric signs and 

symptoms. Pre-existing psychiatric disorders and a family history of psychiatric disorders should be assessed before initiating treatment. Should not be initiated in patients with acute psychosis, acute mania or acute suicidality. Consider treatment discontinuation in patients who experience psychotic symptoms, including 

visual and tactile hallucinations or mania. In case of emergent psychiatric symptoms or exacerbation of preexisting psychiatric symptoms, RITALIN ® should not be given to patients unless the benefit outweighs the potential risk. Evaluate the need for adjustment of treatment regimen in patients experiencing behavioural 

changes such as aggressive behaviour. Treatment interruption can be considered. Family history should be assessed and clinical evaluation for tics or Tourette’s syndrome in children should precede ADHD treatment. Patients should be regularly monitored for the emergence or worsening of tics during treatment initiation. 

Growth and weight should be monitored during treatment and treatment may need to be interrupted and adjusted. Caution in patients with epilepsy. Chronic abuse can lead to marked tolerance and psychological dependence. Caution in emotionally unstable patients. Careful supervision during withdrawal. Blood 

count monitoring during long-term treatment. Consider appropriate medical intervention in the event of haematological disorders. Not indicated for children under 6 years of age. Refrain from driving and using machinery if dizziness, drowsiness, blurred vision, hallucination or other CNS side effects occur. Tablets not 

to be taken by patients with lactose intolerance and capsules not to be taken by patients with fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency. RITALIN ® 10 (containing lactose) and RITALIN ® LA (containing sucrose) may have an effect on the glycaemic control of patients with 

diabetes mellitus. Interactions: Concomitant use contraindicated: MAO inhibitors (currently or within the preceding 2 weeks). Caution when used concomitantly with drugs that elevate blood pressure, coumarin anticoagulants, anticonvulsants, centrally acting alpha-2 agonists (e.g. clonidine or dexmedetomidine), 

direct and indirect dopaminergic drugs (e.g. tricyclic antidepressants, DOPA, dopamine agonists (antipsychotics, e.g. haloperidol). Alcohol: patients should abstain from alcohol during treatment. Ritalin should not be taken on the day of a planned surgery due to risk of sudden blood pressure increase during surgery. 

Dosage: Dosage should be individualised according to the patient’s clinical needs and responses. Maximum daily dose is 60 mg for narcolepsy in adults and ADHD in children. Maximum daily dose is 80 mg for treatment of ADHD in adults. If improvement is not observed after appropriate dosage adjustment 

over a one-month period, RITALIN ® should be discontinued.Narcolepsy in adults: Average dose (tablets only) is 20 – 30 mg daily given in 2 – 3 divided doses. ADHD in children and adolescents (6 years and older): Tablets: start with 5 mg once or twice daily and increase in increments of 5 to 10 mg weekly. 

Capsules: recommended starting dose of RITALIN ® LA is 20 mg. Can begin treatment with RITALIN ® LA 10 when a lower initial dose is appropriate. ADHD in adults: Only the RITALIN ® LA formulation to be used. Starting dose is 20 mg in patients new to methylphenidate. In patients currently using methylphenidate, 

treatment to be continued with the same daily dose. Refer to the package insert for full dosing information. RITALIN ® LA is for once daily administration. Side effects: Very common: nervousness, insomnia, nasopharyngitis, decreased appetite, nervousness, insomnia. Common: Anxiety, restlessness, sleep disorder, 

agitation, headache, drowsiness, dizziness, dyskinesia, tremor, tachycardia, palpitation, dysrhythmias, changes in blood pressure and heart rate (usually an increase), abdominal pain, nausea, vomiting, dry mouth, rash, pruritus, urticaria, fever, scalp hair loss, hyperhidrosis, arthralgia, feeling jittery, weight decreased. 

Rare: difficulties in visual accommodation, blurred vision, angina pectoris, reduced weight gain and growth retardation during prolonged use in children. Very rare: leucopenia, thrombocytopenia, anaemia, hypersensitivity reactions, hyperactivity, psychosis (sometimes with visual and tactile hallucinations), transient 

depressed mood, convulsions, choreoathetoid movements, tics or exacerbation of existing tics and Tourette’s syndrome, cerebrovascular disorders including vasculitis, cerebral haemorrhages and cerebrovascular accidents, thrombocytopenic purpura, exfoliative dermatitis, erythema multiforme, muscle cramps. Other 

possible adverse reactions: pancytopenia, hypersensitivity reactions, such as auricular swelling, including angioedema and anaphylaxis, anxiety, irritability, aggression, affect lability, agitation, abnormal behaviour or thinking, anger, suicidal ideation or attempt (including completed suicide), mood altered, mood swings, 

hypervigilance, mania, disorientation, libido disorder, apathy, repetitive behaviours, over-focussing, confusional state, cases of abuse and dependence have been described, tremor, reversible ischaemic neurological deficit, migraine, diplopia, mydriasis, visual disturbance, cardiac arrest, myocardial infarction, peripheral 

coldness, Raynaud’s phenomenon, cough, pharyngolaryngeal pain, dyspnoea, diarrhoea, constipation, angioedema, hyperhidrosis, erythema, fixed drug eruption, myalgia, muscle twitching, haematuria, gynaecomastia, chest pain, fatigue, sudden cardiac death, cardiac murmur, neuroleptic malignant syndrome. Packs: 

RITALIN ® 10 is supplied in blister packs of 30. RITALIN ® LA range is available in HDPE bottles containing 30 modified-release capsules. This BSS is for use on promotional material linked to MCC approved package insert dated 29 September 2017. 

Novartis South Africa (Pty) Ltd. Magwa Crescent West, Waterfall City, Jukskei View, 2090. Tel +27 11 3476600. Company Reg No: 1946/020671/07. Kindly report all adverse events and quality complaints occurring with Novartis 

product within 24hrs. • Email: patientsafety.sacg@novartis.com • Tel: 0861 929 929 • Fax: +27 11 929 2262 • Or report adverse events directly through our website: https://psi.novartis.com/. To report Quality Complaints email: 

qa.phzais@novartis.com. ZA1812935525

REPORT 

On the 8 th September 2018, the SASOP Special Interest Group for adult ADHD hosted a 

TRAIN-THE-TRAINEE 

WORKSHOP 

at Novartis building, Midrand. 

The purpose of Train-the-trainee workshop is to 

provide a training to registrars and prepare 

them for their examinations and clinical 

practice. We also try to ensure alignment 

in diagnostic and management aspects of adult 

ADHD. This full-day workshop, covering topics such 

as the neurobiology of ADHD, pharmacology, 

comorbidity, psychosocial interventions, and ethics, 

was presented by Dr Rykie Liebenberg and Prof 

Renata Schoeman, who have also compiled a 

copyrighted booklet with summaries of all of the 

talks. We were astounded by the attendance, and 

participation of 36 registrars/consultants from Wits 

and Tuks. The feedback received was very positive. 

“The training was very insightful and enhanced our 

knowledge” 

“IT WILL DEFINITELY HELP THEM WITH OUR 

PREPARATIONS FOR THE EXAMS” 

“IT WILL BE APPRECIATED IF SOMETHING 

LIKE THIS CAN BE DONE EVERY YEAR” 

The venue and refreshments were kindly provided by 

Novartis. 

Dr Rykie Liebenberg 

Three training workshops for registrars are planned 

for 2019. Details will be communicated in due 

course 

Registrars and consultants from Wits and Tuks 


REPORT 

GOLDILOCKS & THE BEAR 

FOUNDATION CBT WORKSHOP 

On the 13 th and 14 th September, the Goldilocks and The Bear Foundation hosted 

a Cognitive Behavioural Therapy for treating children with ADHD workshop at the 

Evertsdal Guest House, Durbanville. 

This two-day training event, led by Professor 

Susan Young, introduced staff and volunteers 

of the Goldilocks and The Bear Foundation, as 

well as some other healthcare professionals 

and educators, to an individual and group 

intervention program for children with ADHD and 

associated problems. 

Day 1 drew on the Skilled Thinking And Reasoning 

(STAR) programme, which is a cognitive behavioural 

group intervention delivered to children that includes 

individual coaching sessions for use with families. 

Using the metaphor of a detective to understand 

personal emotions, children learn skills of selfregulation, 

concentration and problem solving. It 

is based on policing skills techniques used by New 

Scotland Yard which promote problem-solving 

procedures of Scanning the environment, Analysing 

information, Responding in an appropriate way 

and Assessing the outcome (SARA). The technique 

has been adapted for use by children in a fun and 

imaginative way and draws on the appeal of them 

developing real life detective skills. 

During day 2, the Young-Smith program for Helping 

Children with ADHD, was introduced to the attendees. 

This program provides a complete intervention 

strategy for healthcare professionals and parents, 

allowing them to flexibly deliver individual behavioural 

and cognitive interventions to children with ADHD 

and associated problems. The focus throughout is on 

practical techniques to address symptoms, problem 

behaviours and emotional difficulties. 

IN ORDER TO ENSURE THE ENGAGEMENT 

OF YOUNG PEOPLE, CORE CONCEPTS 

ARE PRESENTED IN AN INNOVATIVE WAY 

THROUGH THE EYES OF BUZZ, A YOUNG 

BOY. THE VARIED ADVENTURES OF BUZZ 

PROVIDE THE INTERVENTION WITH A 

STRUCTURAL NARRATIVE, WHILE ALSO 

TEACHING CHILDREN SKILLS THAT THEY 

CAN SUBSEQUENTLY APPLY THEMSELVES 

IN KEY AREAS SUCH AS KEEPING CALM, 

PLANNING, MANAGING IMPULSIVITY 

AND DEALING WITH ANXIETY. 

It was a fun-filled and inspirational two days, which 

left all energized for the work being done in the 

Foundation, and in their own private practices or 

schools 

From Left to right: 

Front: Sarah Jervis, Cornelia 

Vermeulen, Susan Young, 

Renata Schoeman, Jena 

Enbright 

Middle: Sanet Schoeman, 

Lorinda Botha, Elna Otter, Ray 

Anne Cook 

Back: Linda Schoeman, 

Xandria Louw, Hanlie Snyman, 

Kayleigh Hansen, Nicolet 

Bedeker, Nic de Beer, Marike 

Badenhorst, Marinda Brink 


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OROS ® * TECHNOLOGY 

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S6 Concerta ® 18, 27, 36 or 54 mg extended release tablets containing 18 mg, 27 mg, 36 mg or 

54 mg of methylphenidate hydrochloride respectively. Reg. Nos. 37/1.2/0322; 42/1.2/0282; 37/1.2/0323 and 37/1.2/0324. For full prescribing information, refer to the latest package 

insert (April 2013). JANSSEN PHARMACEUTICA (PTY) LTD, (Reg. No. 1980/011122/07), Building 6, Country Club Estate, 21 Woodlands Drive, Woodmead, 2191. www.janssen.co.za. Medical Info 

Line: 0860 11 11 17. PHZA/CONC/1117/0013

REPORT 

THE ABC OF 

CBT FOR ADHD 

On the 21 st September 2018, the SASOP Special Interest Group for adult ADHD 

hosted a Cognitive Behavioural Therapy workshop at the CSIR, Pretoria. 

The purpose of the ABC of CBT for ADHD 

workshop was to provide understanding 

of the place and practice of CBT in the 

management of ADHD to psychiatrists and 

psychologists with a special interest in ADHD and 

CBT. 

The workshop was chaired by Dr Rykie Liebenberg, 

with presentations by Prof Renata Schoeman (An 

update on the evidence for CBT in the management 

of ADHD), Mr Anthony Townsend (Executive (Dys) 

function in Adult ADHD: Trapped in the Revolving 

Door of Consciousness), Dr Anton Kruger (A third 

wave CBT perspective on adult ADHD) and Ms 

Marlene Wells (Emotional Regulation in Adult ADHD: 

Neurobiological underpinnings, and intervention 

strategies using CBT and MCBT). 

Attendees at the CBT workshop 

Left to Right: Anthony Townsend, Anton Kruger, Rykie Liebenberg, Renata Schoeman, Marlene Wells 


SASOP 

SOUTH AFRICAN SOCIETY OF PSYCHIATISTS 

NATIONAL HEALTH 

INSURANCE BILL, 2018 

- COMMENT BY THE NATIONAL MENTAL 

HEALTH ALLIANCE PARTNERSHIP 

The National Mental Health Alliance Partnership (NMHAP) is a coalition of individuals 

and groups dedicated to the realization of access to quality mental health care in 

South Africa. As such, the NMHAP appreciates the opportunity to comment on the 

NHI Bill, published for public comment in Government Gazette No.41725 in June 

2018. There are two parts to this comment, the first pertaining to mental health care 

services, and the second to issues in leadership and governance. Here you will find 

the final version of the comment, compiled by Dr. L J. Robertson and set on the 21 st 

of September 2018. 

The National Mental Health Alliance Partnership 

(NMHAP) is a coalition of individuals and groups 

dedicated to the realization of access to quality 

mental health care in South Africa. As such, the 

NMHAP appreciates the opportunity to comment 

on the National Health Insurance (NHI) Bill, as 

published in Government Gazette No.41725, June 

2018. The NMHAP commend the Honourable 

Minister of Health, Dr Motsoaledi, in his endeavours 

to achieve equal access to quality care for all South 

Africans and hopes that Universal Health Coverage 

(UHC) will include people with serious mental illness 

and/or psychosocial and intellectual disability 

in equity with others. There are two parts to this 

comment, the first pertaining to mental health care 

services, and the second to issues in leadership 

and governance. 

EXECUTIVE SUMMARY 

A Mental Health Care Services 

The NHI Act must ensure that anything that applies 

to any area of health also applies to mental health. 

It also must ensure equitable distribution of funds 

according to need and to desired health outcomes. 

Thus, the NMHAP has four key requests regarding NHI 

and UHC of people living with mental illness and/or 

intellectual disability (PLWMI &/or ID). 

These are as follows: 

1. DEFINITIONS 

The following two definitions to be included in the NHI Act: 


SASOP 

SOUTH AFRICAN SOCIETY OF 

PSYCHIATRISTS 

• ‘Health’ to be defined in a manner which 

ensures mental health is included in parity with 

physical health, such as in the World Health 

Organisation (WHO) definition of health as a 

“State of complete physical, mental, and social 

wellbeing, and not merely the absence of 

disease or infirmity”, would be an example. 

• ‘Comprehensive Health Services’, to be 

defined as by the WHO, as “health services 

that are managed so as to ensure that people 

receive a continuum of health promotion, 

disease prevention, diagnosis, treatment and 

management, rehabilitation and palliative care 

services, through the different levels and sites of 

care within the health system, and according to 

their needs throughout the life course.” 

2. APPLICATION OF THE ACT 

It is essential that the Act also applies to nonprofit 

health establishments, as defined in the 

National Health Act No.61 of 2001 

3. OBJECTIVE OF THE ACT 

The objective of the Act must be “to establish 

a fund that aims to achieve sustainable and 

affordable universal access to comprehensive 

health care services …” 

4. PROVISION FOR COMMUNITY-BASED 

PSYCHIATRIC SERVICES WITHIN THE 

HEALTH SYSTEM REFERRAL NETWORK 

Section 39(2) and Section 54(4)(f) and (g) 

imply that all specialist health care will be 

hospital-based, including all psychiatry. This will 

perpetuate excessive hospitalisation and poor 

coverage of mental illness. While communitybased 

specialist care is relevant for several 

specialties, it is essential for psychiatry. Without it, 

serious mental illness and behavioural problems 

will continue to remain inaccessible. This is 

particularly for children, adolescents, women, 

and the elderly, who struggle to access hospitalbased 

psychiatric care, which is dominated by 

extended and repeated admissions of adult 

users with aggressive and disruptive behaviour. 

Community-based psychiatry is integral to 

comprehensive health care services for PLWMI & ID 

as it: 

• facilitates integrated primary mental health care 

of PLWMI & ID through task-sharing by providing 

accessible, context relevant support. 

• reduces hospital admissions by a) providing 

accessible ambulatory assessments of new 

patients with severe illness (who would otherwise 

require expensive inpatient assessments even 

when hospitalisation is not required clinically); 

b) preventing relapse in those with chronic, 

severe illness; c) supporting rehabilitative and 

palliative care within the community 

• facilitates non-health sector care of PLWMI & ID 

through local inter-sectoral collaboration 

B LEADERSHIP AND GOVERNANCE 

While we support the goal of UHC, we are seriously 

concerned that NHI will be unable to achieve this. 

We have three major recommendations: 

1. The Board of the Fund is directly accountable to 

the public. There must be full transparency of all 

procedures, with oversight of the appointment 

process of Board members by an external 

juristic body with no political connections, and 

all governance, operational and financial 

information must be accessible to the public. 

2. Provincial Departments of Health to be involved 

in development of policy, strategic plans and 

implementation guidelines, to ensure that these 

are relevant and implementable at provincial 

and district level. 

3. Health care providers to be represented on 

the Health Benefits Pricing Committee and the 

Stakeholder Advisory Committee. In addition, a 

properly structured forum for consultation and 

negotiation with health care providers must be 

established. 

NATIONAL HEALTH INSURANCE 

BILL, 2018 - COMMENT BY THE 

NATIONAL MENTAL HEALTH 

ALLIANCE PARTNERSHIP 

The National Mental Health Alliance Partnership 

(NMHAP) appreciates the opportunity to comment 

on the National Health Insurance (NHI) Bill, as 

published in Government Gazette No.41725, June 

2018. There are two parts to this comment, the first 

pertaining to mental health care services, and the 

second to issues in leadership and governance. 

A MENTAL HEALTH CARE SERVICES 

The NMHAP commend the Honourable Minister of 

Health, Dr Motsoaledi, in his endeavours to achieve 


SASOP 


PSYCHIATRISTS 

equal access to quality care for all South Africans 

and hopes that Universal Health Coverage (UHC) 

will include people with serious mental illness and/ 

or psychosocial and intellectual disability in equity 

with others. To this end, we are fully supportive of the 

inclusion of mental health care already evident in 

the NDOH Essential Medicines List and Standard 

Treatment Guidelines. 1 Regarding the NHI Bill, we are 

pleased to note that, in Section 54(2)(b)(iv), mental 

health disorders and people with disabilities are 

included as a vulnerable population group requiring 

an “interim purchasing of health care services.” 

However, we are still concerned that mental health 

is not recognised in parity with general health by the 

Bill. This concern is derived from the following: 

• Mental health is only recognised in parity with 

general health in the preamble in relation to 

Article 12 of the United Nations Covenant on 

Economic, Social and Cultural Rights, 1966 and 

Article 16 of the African Charter on Human and 

People’s Rights, 1981. There is no other mention 

of the needs of people with mental illness or 

intellectual disability until Section 54, where 

they are mentioned only in the context of a 

vulnerable population group. 

• The Bill does not acknowledge the United 

Nations Convention on the Rights of Persons 

with Disabilities and Optional Protocol (CRPD), 

which came into force in 2008, 2 and to which 

South Africa is signatory. 

• The Bill does not acknowledge the Mental 

Health Care Act No.17 of 2002 (MHCA) other 

than as a piece of legislation which will require 

amendment for NHI. The MHCA differs from the 

other health-related legislation listed in that it 

regulates mental health care services, which 

should be funded by NHI in parity with all other 

health care services. Although the MHCA is to 

be amended for the purposes of NHI, it must still 

be observed by NHI, as is the National Health 

Act No.61 of 2003 (NHA), which also requires 

amendment. 

• These omissions (the term “mental health”, the 

CRPD, acknowledgment of the MHCA) imply that 

mental health, and the care of PLWMI &/or ID, 

may not be funded equitably under NHI. While 

one does not want to emphasise a separation 

between “mental health” and “health,” it is 

necessary to have an inclusive definition in the 

Act to ensure that anything that applies to any 

area of health also applies to mental health. 

Such a definition would be consistent with the 

CRPD and the Sustainable Development Goals 

(SDGs), which include mental health in parity 

with general health in the “Declaration” and in 

health goal 3. 

In addition, the health service should address the 

needs of all people for all types of illness according 

to disease burden, with necessary adjustments 

made to the health system to accommodate all 

disabilities. 

Therefore, we recommend the following alterations 

to the Bill: 

• Definitions 

‘Health’ to be defined in a manner which 

ensures mental health is included in parity 

with physical health, such as in the World 

Health Organisation (WHO) definition of 

health as a “State of complete physical, 

mental, and social wellbeing, and not merely 

the absence of disease or infirmity”, would be 

an example. 

‘Comprehensive Health Services’, to be 

defined as by the WHO, as “health services 

that are managed so as to ensure that people 

receive a continuum of health promotion, 

disease prevention, diagnosis, treatment and 

management, rehabilitation and palliative 

care services, through the different levels and 

sites of care within the health system, and 

according to their needs throughout the life 

course.” 

• Application of the Fund 

Section 2(1) – to include “non-profit health 

establishments”, as in the definition of health 

establishment in Section 1 of the NHA. Nonprofit 

health establishments are essential for 

comprehensive health care services, including 

those which are within the community. 

1 

NATIONAL DEPARTMENT OF HEALTH. 2018. Standard Treatment Guidelines and Essential Medicines List [Online]. 

Pretoria, Republic of South Africa. Available: http://www.health.gov.za/index.php/standard-treatmentguidelines-and-essential-medicines-list 

[Accessed 16 September 2018]. 

2 

UN Convention on the Rights of Persons with Disabilities and Optional Protocol, available from http://www. 

un.org/disabilities/documents/convention/convoptprot-e.pdf [accessed 13 September 2018] 


SASOP 


PSYCHIATRISTS 

• Objective of the Act 

Section 4 – to refer to “comprehensive health 

care services.” 

Thus, “to establish a Fund that aims to achieve 

sustainable and affordable universal access to 

comprehensive health care services …” 

• Duties of the Fund 

Section 5(3) – To amend as follows in italics: The 

Fund must support the Minister in fulfilling his 

or her obligation to protect, promote, improve 

and maintain the health and mental health of 

the population as provided in section 3 of the 

National Health Act and section 4 of the MHCA. 

• Eligibility as beneficiaries of the Fund 

Section 7 – This section does not appear to uphold 

Section 27 of the Constitution, which does not 

differentiate between persons. We believe that 

excluding any individual from needed health 

care services, particularly if they suffer from a 

mental illness which impairs psychosocial and 

cognitive function, is inhumane. 

The requirements raise serious concerns for 

PLWMI &/or ID, such as: 

o PLWMI &/or ID often have severe childhood 

adversity; biological parents and relatives 

may not be traceable, and the psychosocial 

and/or intellectual disability may be such that 

they have difficulty accessing government 

social and home affairs services. Provision 

must be made that they are not refused 

treatment because they are not registered 

with a primary health care facility or have no 

South African Identity Document. 

o Migrants, refugees and asylum seekers are all 

at higher risk of mental illness than the general 

population. Serious mental illness tends to be 

chronic and relapsing and causes severe 

functional impairment. The Bill excludes 

them from mental health care services other 

than emergency care, notwithstanding their 

extreme vulnerability. 

o Mental illness worsens maternal and foetal 

outcomes of pregnancy. However, migrants 

to South Africa are only entitled to maternal 

care at primary health service level, even if 

the pregnancy is high risk. 

o Many travel insurance policies exclude 

cover of any mental illness, including index 

presentations. 

• Rights of users 

Section 9(m) to include a clause referring to the 

ethical obligation to breach confidentiality if a 

risk to public health is identified, as in the NHA 

Section 14(2)(c), or if there is a risk of harm to 

the user or others, as in the MHCA Section13. 

• Reimbursement for services rendered and 

referral to specialists 

Section 10(2)(c) – To add a proviso that the 

user’s complaint is adequately addressed at the 

initial health establishment. This must include a 

proviso that people with difficulty in expressing 

themselves, explaining their needs, or containing 

their behaviour, are accommodated with 

additional time and attention so that the health 

or mental health need is addressed appropriate 

to the level of severity of the condition. 

o Such individuals must not be penalised for 

seeking health care at a more specialised 

service level if the primary health care provider 

has not identified or treated the health or 

mental health problem appropriately or has 

not recognised the need to refer the user. 

o Psychosocial and intellectual disability of 

PLWMI &/or ID places them at risk of having 

delayed or inadequate health care. 

• Health service benefits coverage 

Section 11(2)(a) and (b) – Must include 

intersectoral referral pathways, with entry into the 

health system by referral from non-health sectors 

such as Social Development, Justice, Correctional 

Services, and Education. Such referral into the 

health system must be appropriate to the severity 

of illness and level of health need, particularly 

for PLWMI &/or ID, who often present first to nonhealth 

sector services. Severe illness may not be 

recognised as an emergency if not disruptive or 

acute, but still requires urgent specialist rather 

than PHC attention. 

Section 11(4) – The Benefits Advisory Committee 

must consider burden of disease and population 

needs, not only the potential funds available. 

Recommendations must be in proportion to 

desired health care outcomes, not to funding. Funds, 

and their judicious use, must then be allocated 

according to the desired health outcomes. 

o Making recommendations based on 

available funds without considering health 

outcomes places vulnerable people at high 

risk of neglect. 


SASOP 


PSYCHIATRISTS 

• Benefits Advisory Committee 

Section 25(1) – To change “may” to “must” 

Section 25(2) – To also include: 

- a member seconded by the WHO Department 

of Mental Health and Substance Abuse 

- two health care providers recognised 

nationally for clinical expertise, one of whom has 

expertise in psychosocial and/or occupational 

intervention and rehabilitation. 

o The Benefits Advisory Committee is to 

determine the health service benefits 

and types of services to be reimbursed 

at each level of care, and to determine 

the detailed and cost-effective treatment 

guidelines, by which the services of all 

health care providers will be evaluated. 

o The scope of the health benefits and 

guidelines to be determined requires 

a perspective on health care provision, 

scope of practice, and service delivery 

which may not be in the purview of heads 

of medical schools and other members 

of the Benefits Advisory Committee 

• Stakeholder Advisory Committee 

Section 27(1) – To change “may” to “must” and 

to include two user-representatives of persons 

with disabilities. 

• Payment of Service Providers 

Section 39(2) – To include specialist level mental 

health services from the district setting, i.e. 

Community-based psychiatry. 

o Providing accessible, community-based 

psychiatric services is a necessary health 

system adjustment to accommodate 

psychosocial or intellectual disability. 

o Community-based psychiatry allows for 

accessible ambulatory assessments of new 

patients with severe illness, which would 

otherwise require expensive hospitalisation. 

It prevents relapse and readmission of 

people with chronic, severe illness by 

providing assertive maintenance care. 

o Positioning a specialist level service in the 

district setting provides greater opportunity 

for upskilling of and collaboration 

with PHC practitioners and other 

health workers, as well as inter-sectoral 

collaboration with local non-health and 

non-governmental sectors, supporting 

rehabilitative and palliative care within the 

community with a task-sharing approach. 

o Persisting with a solely hospicentric model of 

psychiatric care will not only deny accessible 

comprehensive health care services to the 

user, it will have costly negative effects on 

the health system and society. There is no 

evidence to support effective PHC care of 

severe mental illness without accessible 

specialist support and collaboration, and 

scant evidence for collaborative care. 3,4,5 

• Transitional arrangement 

Section 54(2)(b)(iv) – although an interim 

arrangement is welcome, the care of PLWMI 

&/or ID cannot just be an interim measure. 

Because most serious mental illness is chronic 

and relapsing, starting usually in youth and 

often persisting throughout life, interim measures 

will not clear backlogs. Proper development of 

mental health care services, with appropriate 

human resource organisation and suitable 

infrastructure, is needed to ensure adequate 

promotive, preventative, curative, rehabilitative 

and palliative mental health care. 

Section 54(4)(f) and (g) – To add a category 

of community-based specialist level services, at 

least for psychiatry if not for other specialties. 

This should include provision for multidisciplinary 

team assessment, care, treatment and 

rehabilitation of index presentations and of 

maintenance care of PLWMI &/or ID from the 

community platform. A flexible approach to 

the human resources should be incorporated 

so that task-sharing within the specialist level 

service, with PHC practitioners, and with relevant 

members of the community is enabled. 

o The implications of the current arrangement 

3 

Reilly, S. 2013 Collaborative care approaches for people with severe mental illness. Cochrane Library 

4 

Hviding, K. et al. 2007. Collaborative Care Initiatives for Patients with Serious Mental Disorders Treated in Primary 

Care Setting. Oslo, Norway. 

5 

Hanlon, C. et al. 2014. Challenges and opportunities for implementing integrated mental health care: a district 

level situation analysis from five low- and middle-income countries. PLoS One, 9, e88437. 


SASOP 


PSYCHIATRISTS 

are that all ambulatory mental health 

care is within the scope of practice of PHC 

practitioners, and that any need for specialist 

level assessment or treatment must require 

hospital care. This is not realistic. Additionally, 

there is no provision for ambulatory, 

accessible, specialist mental health care 

which may prevent hospitalisation, and may 

result in better psychosocial functioning 

and quality of life of the individual. 

o The tendency of hospital-based mental health 

care is to focus on relief of acute psychiatric 

symptoms rather than improvement of longterm 

function and prevention of relapse, 

which should occur in the context of the 

user’s daily life. In addition, hospital based 

psychiatric care is poorly accessible to 

children, adolescents, women, the elderly, 

and anyone with severe psychosocial 

disability who is not aggressive or disruptive. 

o There is no reason why psychiatry, including 

tertiary level care, must be restricted to 

hospitals, as hospital-based equipment 

and infrastructure is not required. What is 

required for community-based psychiatry 

is qualified personnel, physical space, 

and simple equipment for psychological 

assessments and occupational therapy. 

o Outreach, either in person or via telemedicine, 

from hospital to district services may be the 

only option in certain, mainly rural, areas. 

However, it does not replace communitybased 

psychiatry which should become 

integral to the district health service 

although not PHC themselves. Furthermore, 

outreach would itself require additional 

staff for this purpose at the hospital level. 

B LEADERSHIP AND GOVERNANCE 

The entire health system depends on ethical 

leadership and governance with the appropriate 

expertise. This is especially as NHI proposes a singlepayer 

system. 

We have the following serious concerns and 

recommendations: 

• The Board of the Fund 

That the Board is recommended by the Minister 

and appointed by Cabinet, following interviews by 

a Cabinet appointed committee raises questions 

about its independence. From the appointment 

process described, there could be a high risk that 

the Board members may be political appointees. 

In addition, there is no requirement in the Bill 

for transparency in the appointment process or 

the functions of the Board. However, the Chief 

Executive Officer is directly accountable to 

the Board (Section 22(1)(a)) and carries out 

responsibilities which are subject to the direction 

of the Board (Section22(2)), and the Board 

determines its procedures in consultation with 

the Minister (Section 19). 

The Board is expected to govern the Fund 

in accordance with the provisions of the 

Public Finance Management Act. However, its 

functions include governance of the Fund, its 

operational and administrative functions, its 

policies, practices and decisions, the employee 

organisational structure, and determination 

of which health benefits are procured. These 

functions appear to stretch beyond financial 

management per se and will have a direct 

bearing on the health system. Nevertheless, only 

“appropriate expertise”, which is a subjective 

quality, is required for appointment as a Board 

member. 

True external accountability is needed. The 

Board is governing a Fund that will provide 

health services for the entire nation, at the 

nation’s expense. It must be accountable to the 

public directly, not only via Parliament. Therefore, 

the following must be specified in the NHI Act: 

1. Oversight by an external juristic body 

with no political connections in the 

appointment process of Board members. 

2. Transparency with open publication 

regarding all nominations, the qualifications 

of those nominated, the interview processes, 

appointments, and functions of the Board. 

3. Public access to information regarding 

the remuneration of the Board as well as 

the governance of the Fund, including all 

expenditure and organisational structure. 

• Provincial Departments of Health 

Provincial Departments of Health are included 

via a representative in the Benefits Advisory 

Committee and as providers of health services 

in co-ordination with the NDOH. There is no 

evidence of provincial involvement in drafting 

health policy or national plans other than 

through the National Health Council, which may 

reach a quorum even if no provincial heads of 

department are present. The implication is that 

national health policies and strategic plans may 

be developed without adequate input from 


SASOP 


PSYCHIATRISTS 

provinces, and thus may not be implementable 

at provincial level. 

While there have been multiple reports of 

provinces failing to implement national 

policy, including media reports by the South 

African Society of Psychiatrists, it must be 

acknowledged that the NDOH has not drafted 

a programme guideline for the implementation 

of the National Mental Health Policy Framework 

and Strategic Plan 2013-2020. Additionally, 

no funding has been allocated at national 

level for its implementation, or even for the 

implementation of the MHCA. With the present 

NDOH Annual Performance Plan, provinces are 

to establish District Specialist Mental Health 

Teams, however there is no funding allocated 

to these teams in the national medium-term 

expenditure framework. Questions have also 

been raised by the South African Federation of 

Mental Health and the NMHAP regarding the 

practicality of the recently gazetted NDOH Policy 

Guidelines for the licensing of residential and/or 

day care facilities for persons with mental illness 

and/or severe or profound intellectual disability. 

Hence, while there is a need for improved coordination 

of service delivery with provinces, 

there appears also to be a need for the NDOH 

to develop realistic and implementable policy 

and guidelines. 

The NHI Act should make provision for: 

1. Full provincial involvement in the development 

of national health policy and plans. 

2. Such policy and plans must be 

ratified by provinces as being relevant 

and implementable by provinces 

before being gazetted by the NDOH. 

3. Feedback mechanisms for rapid adjustments 

to be made when necessary, i.e. when 

problems in implementation represent a 

risk to users which cannot await standard 

quality assurance mechanisms of change. 

• Health Care Providers 

The Bill sets out obligations of the Fund in terms 

of payment and accreditation of health care 

providers, and duties of health care providers 

with respect to the rights of users. The Fund 

has a duty to “determine prices annually 

after consultation with health care providers, 

health establishments and suppliers in the 

prescribed manner and in accordance with 

the provisions of this Act” (Section 5(1)(f)). 

However, there is no provision for direct health 

care provider representation on any of the 

committees. The heads of medical schools 

and other members of the Benefits Advisory 

Committee, and the statutory councils, tertiary 

education institution and other members of the 

Stakeholder Advisory Committee do not have 

any scope in determining working conditions or 

reimbursement needs of practicing health care 

providers. This leaves only indirect representation 

on the Health Benefits Pricing Committee and 

one labour representative on the Stakeholder 

Advisory Committee through which the 

Fund may consult with health care providers 

regarding the cost of services provided. It is 

not possible to provide quality health care 

without addressing the needs of health care 

providers. The provisions of the Bill run the risk of 

dissatisfied and frustrated health care providers, 

with consequences of increased emigration or 

strong unionisation. Neither of these situations 

bode well for South Africa. 

The NHI Act should: 

1. Provide for health care provider 

consultation and negotiation in a properly 

structured and representative forum. 

2. Specify health care provider representation 

on the Health Benefits Pricing Committee 

and the Stakeholder Advisory Committee. 

CONCLUSION 

We thank the Minister of Health and the NDOH for the 

opportunity to comment on the NHI Bill. Overall, we 

welcome the intentions of the Bill to strengthen and 

reorganise the South African health system but have 

serious concerns about the Bill’s ability to do that. 

Our comments are in the interests of an improved 

system which will serve the population of South 

Africa, improving the health and mental health of all. 

We look forward to a health care system which does 

not discriminate between users, regardless of race, 

socio-economic status, or type of illness, impairment 

or disability 


10 

“How beautifully 

leaves grow old. 

How full of light 

and colour are 

their last days.”

SASOP 


PRESS RELEASE 

1 IN 6 TEENAGERS 

WHO USE CANNABIS 

WILL BECOME ADDICTED 

Research has shown that 9 % of individuals 

who experiment with cannabis will become 

addicted to it. This number increases to 1 in 6 

when use starts during adolescence. 

In response to the recent legalisation of cannabis 

for personal use, the South African Society of 

Psychiatrists (SASOP) notes with concern a growing 

public perception of cannabis as a ‘harmless’ plant, 

and that few measures have been instituted to 

address this. 

According to Dr Abdul Kader Domingo, member 

of the SASOP Special Group on Addictions, it is 

estimated that 1 in 6 teenagers using cannabis will 

become addicted to it. 

“HUMAN BRAIN DEVELOPMENT 

AND MATURATION IS A PROCESS 

THAT IS GUIDED BY THE BODY’S 

ENDOGENOUS CANNABINOID SYSTEM 

AND OCCURS UNTIL THE EARLY 20s. 

EXPOSURE TO PHYTO-CANNABINOIDS 

(CANNABINOIDS OBTAINED FROM 

THE CANNABIS PLANT) DURING THIS 

VULNERABLE PERIOD MAY DISRUPT 

THE PROCESS OF BRAIN MATURATION 

AND AFFECT ASPECTS OF MEMORY, 

ATTENTION, PROCESSING SPEED AND 

OVERALL INTELLIGENCE. CANNABIS USE 

DURING THE ADOLESCENT PERIOD MAY 

CAUSE LASTING COGNITIVE DEFICITS, 

EVEN AFTER SUSTAINED ABSTINENCE.” 

He points out that the Global Burden of Diseases 

Study of 2010 estimates that 2 million years lived 

with disability were attributed to cannabis. The 

South African Community Epidemiology Network 

on Drug Use (SACENDU) reports that, during the 

2nd half of 2016, cannabis was the most common 

primary substance of abuse for persons younger 

than 20 years presenting to treatment facilities in all 

areas across South Africa, except for the Free State, 

Northern Cape and North West. 

A REVIEW ARTICLE BY THE WORLD 

HEALTH ORGANIZATION IN 2016 

CONCLUDED THAT CURRENT EVIDENCE 

POINTS TO A MODEST CONTRIBUTORY 

CAUSAL ROLE FOR CANNABIS 

IN SCHIZOPHRENIA AND THAT A 

CONSISTENT DOSE-RESPONSE 

RELATIONSHIP EXISTS BETWEEN 

CANNABIS USE IN ADOLESCENCE AND 

THE RISK OF DEVELOPING PSYCHOTIC 

SYMPTOMS OR SCHIZOPHRENIA. 

Dr Domingo says that any change to the legislation 

regulating cannabis use should have been 


SASOP 


PSYCHIATRISTS 

undertaken in consultation with all the relevant 

stakeholders, be based on good quality scientific 

evidence and take into consideration the availability 

and accessibility of current drug addiction, 

prevention and treatment resources in South Africa. 

“SASOP concurs with the Executive Committee of 

the Central Drug Authority (CDA) of South Africa 

that the approaches to combat the use and abuse 

of psychoactive substances should include harm 

reduction (interventions aimed at reducing the 

harmful consequences associated with substance 

use), supply reduction and demand reduction/ 

preventative strategies.” 

“WE AGREE WITH THE EXECUTIVE 

COMMITTEE OF THE CDA THAT 

THERE IS CURRENTLY INSUFFICIENT 

EVIDENCE TO PREDICT THE LONG- 

TERM CONSEQUENCES OF THE 

LEGALIZATION OF CANNABIS.” 

“The ease of accessing an intoxicating substance 

may have an underestimated impact on the 

initiation, frequency and amount of use, and the 

subsequent risk of developing a substance use 

disorder. Legalization should therefore not have 

been considered at this point.” 

“The decriminalisation of cannabis removes the 

criminal penalty related to the use of cannabis; it 

allows for a distinction between a drug dealer and 

an individual experimenting with or addicted to a 

drug. While SASOP supports the human rights of all 

individuals, we argue that a decision to protect those 

addicted to substances should not be viewed as a 

simple binary decision based on criminal penalties.” 

IN 2001 PORTUGAL AUGMENTED 

THE DECRIMINALIZATION OF ILLICIT 

SUBSTANCES WITH DRUG DISSUASION 

COMMISSIONS, INCREASED THE 

NUMBER OF FACILITIES OFFERING 

DETOXIFICATION AND THERAPEUTIC 

ADMISSIONS, INCREASED THE NUMBER 

OF DRUG EDUCATION CAMPAIGNS AND 

REFOCUSED POLICING EFFORTS ON 

LARGE SCALE TRAFFICKING OPERATIONS. 

“The decriminalization of cannabis must be 

preceded by and augmented with similar socially 

responsible strategies for it to be successful in South 

Africa.” 

DR DOMINGO SAYS AVAILABLE 

EVIDENCE DOES NOT SUPPORT THE 

STRONG POSITIVE PUBLIC OPINION 

AND ANECDOTAL REPORTS FAVOURING 

MEDICINAL CANNABIS. 

“The exceptions are the moderate quality evidence 

of medicinal cannabis for treating chronic pain, 

spasticity due to Multiple Sclerosis and weight loss 

associated with HIV. This evidence includes trials 

investigating pharmaceutical medications based 

on phyto-cannibinoids. Good quality evidence does 

however exist regarding the frequently occurring 

side effects of cannabis such as confusion, dizziness, 

diarrhea, euphoria, fatigue and hallucinations.” 

“Any potential benefit obtained from cannabis must 

therefore be weighed against its risk of causing 

addiction, psychosis, cognitive impairments and 

a 2.6 times greater likelihood of motor vehicle 

accidents. SASOP further notes with concern the 

growing evidence linking cannabis use with an 

increased risk of an acute myocardial infarction as 

well as an ischaemic stroke.” 

HE CONCLUDES TO SAY THAT “SASOP 

COMMENDS THE MEDICAL CONTROL 

COUNCIL’S DECISION TO LIMIT THE 

USE OF CANNABIS FOR MEDICINAL 

PURPOSES TO REGISTERED PRESCRIBERS 

AND FOR INDIVIDUALS IN WHICH 

AN ACCEPTABLE JUSTIFICATION IS 

PROVIDED. 

“We support ongoing research on the use of 

cannabis for medicinal purposes to ensure that its 

purported and potential benefits can be scientifically 

measured against medical and societal risks.” 

REFERENCE 

Research on 1 in 6 teenagers can be found here: 

https://www.ncbi.nlm.nih.gov/pmc/articles/ 

PMC4827335/#!po=0.724638 


HCL

SASOP 


MEDIA STATEMENT 

“MY NAME MAY BE TOWER HOSPITAL, BUT 

MY SURNAME AND MY ‘ISIDUKO’ IS THE 

EASTERN CAPE HEALTH DEPARTMENT” 

By sub-texting his report on allegations of 

patient mismanagement and patient rights 

violations at the Tower Psychiatric Hospital 

and Psychosocial Rehabilitation Centre in 

this way, referring to an “isiduko”, the Health Ombud, 

Professor Malegapuru Makgoba seems to imply 

that although much has been said and reported 

on the whistle-blowing clinician, who at first glance 

appears to be the main focus of his report, that a 

more important responsibility for the bigger context 

of problems reported on at the hospital, still rests with 

the Eastern Cape Department of Health (ECDoH). 

This seems to be evident in his recommendation 

about the ECDoH, as a department with a track 

record of “successful failures”, while listing 14 aspects 

in which such failure has been demonstrated. 

The Ombud advises that whistle blowing about 

problems experienced at Tower Hospital was “just 

the needed lightening rod and representative of 

a broader systemic and prolonged poor-quality 

service delivery for mental health care users in the 

Eastern Cape”. 

IT ALSO RE-EMPHASISED, ACCORDING 

TO HIM, THE URGENT NEED TO REVIEW 

LEGISLATION, MOVING DECISION- 

MAKING POWERS IN THE PROVINCES 

BACK TO THE NATIONAL MINISTRY. 

He recommends that the National Minister appoints 

an Administrator with respect to the mental health 

services in the province, while he further notes that 

the management of the Tower Hospital Complex 

was so dysfunctional and “riddled with dead-end 

power struggles, (that) it must be overhauled with 

‘new blood’.” 

HE POINTED OUT THAT CODES OF 

CONDUCT WERE ALSO VIOLATED BY 

OTHER TOWER HOSPITAL STAFF MEMBERS, 

INCLUDING A SOCIAL WORKER 

INVOLVED WITH USERS’ MONEY, THE 

CLINICAL MANAGER, AS WELL AS THE 

NURSING SERVICES MANAGER AND THE 

CEO OF THE HOSPITAL. 

The hospital’s management team is reported to 

have experienced difficulties with role clarification 

due to a lack of understanding, while decentralizing 

power rendered hospital management 

ineffective in discharging their responsibilities. 

The Ombud’s summary statement that 

“institutionalised, systematic” violations of human 

rights of patients may not have occurred at Tower 

Hospital, therefore does not rule it out that specific 

violations of certain individuals’ human rights have 


SASOP 


PSYCHIATRISTS 

occurred. In several respects, the health ombud’s 

report actually seems to concur with the South 

African Society of Psychiatrists’ (SASOPs) report on 

the concerns raised at the time, which was released 

to the Eastern Cape MEC for Health and the Head 

of Department of the ECDoH on the 19th March 

2018. In general the SASOP mentioned in this report 

that “although hospital personnel of all categories, 

including senior management, largely seems to have 

had good will towards patients and patient-care”, 

there seems to have been a limited understanding, 

especially at senior management level, of how longstanding 

systemic failures and inadequacy of actions 

taken to address these failures, have exacerbated 

the situation and affected patient rights. 

SPECIFICALLY, THE OMBUD’S REPORT 

CONCURS WITH THE SASOP REPORT 

REGARDING PROBLEMS OCCURRING IN 

SPECIFIC AREAS SUCH AS POOR DEATH 

RECORDS AND RECORD KEEPING, THE 

DANGEROUS SECLUSION ROOMS AND 

MAINTAINING PATIENTS’ PHYSICAL HEALTH. 

With regard to whistle blowing, while the SASOP 

fully agrees that accurate information should be 

used and appropriate channels must be followed, 

the Society, however, wants to caution that Dr 

Sukeri’s whistle blowing actions about conditions at 

Tower Hospital must be considered in terms of the 

Protected Disclosures Act No 26 of 2000, as amended 

in 2017, No 5 of 2017. In addition, the SASOP as a 

professional specialist medical association and 

its adopted program of having a social contract 

with society, also has a responsibility to engage in 

communication with the general public, who are 

one of the stakeholders in the discussion about 

the professionalism that is expected from society 

members. 

SASOP’S “RAISON D’ETRE” IS TO 

PROMOTE, MAINTAIN AND PROTECT THE 

HONOUR AND INTERESTS OF MEMBERS, 

THE DISCIPLINE OF PSYCHIATRY AS A 

MEDICAL SPECIALITY AND TO SERVE THE 

COMMUNITY. 

Concordantly, the SASOP’s company rules include 

objectives such as to monitor, evaluate and advise 

on policies related to the delivery of clinical services 

and the protection of patients’ rights, to maintain 

standards in psychiatry by peer review, to promote 

and uphold the principles of human rights, dignity 

and ethics in the practice of psychiatry, to oppose 

unfair discrimination in the field of psychiatry, to 

promote the de-stigmatization of psychiatry and 

increase the awareness of mental illness and to act as 

a lobby group to further the interest of the discipline 

of psychiatry in both the public and private sector. 

The SASOP therefore wants to reiterate its earlier 

statement this month that medical professionals 

are at front lines of health care delivery and witness 

daily the direct impact of irregularities on the lives 

of patients. Clinicians should use the mandate 

according to available legislation to speak out when 

patients’ human rights are violated and should 

report incidents of malpractice, fraud, corruption, 

misadministration and management of facilities 

as well as lack of patient care and or neglect. 

Reporting on such wrong-doing promotes individual 

responsibility and organizational accountability 

however if left silent, the clinician enables and 

contributes to a culture of impropriety 

SASOP Board 

Johannesburg, 27 August 2018 

Office of the Health Ombud. Report on an investigation 

into allegations of patient mismanagement and 

patient rights violations at the Tower Psychiatric 

Hospital and Psychosocial Rehabilitation Centre. 23 

August 2018. 

(Available from: http://ohsc.org.za/publications/; 

retrieved 23 August 2018.) 

Xhosa clan names (isiduko (sing.), iziduko (pl.) 

in Xhosa) are family names that are considered 

more important than surnames among Xhosa 

people. Much like the clan system of Scotland, each 

Xhosa person can trace their family history back to 

a specific male ancestor or stock. 

(Available from: https://en.wikipedia.org/wiki/ 

Xhosa_clan_names;retrieved 24 August 2018) 

SASOP. Report on the Investigation of the Concerns 

about Institutional and Patient Rights Violations at 

Tower Hospital as Submitted by Dr Kiran Sukeri. 19 

March 2018 

SASOP. It’s time for medical professionals to be 

advocates. 2 August 2018. 

(Available at: https://www.sasop.co.za/Statements/ 

Prof_Responsibility; retrieved 23 Augusts 2018) 


in Mental Health

POLICY GUIDELINE 

THE SOUTH AFRICAN NATIONAL MENTAL HEALTH ALLIANCE PARTNERS’ RESPONSE TO THE: 

POLICY GUIDELINES FOR THE 

LICENSING OF RESIDENTIAL AND/ 

OR DAY CARE FACILITIES FOR 

PERSONS WITH MENTAL 

ILLNESS AND/OR SEVERE OR 

PROFOUND INTELLECTUAL 

DISABILITY 

Submitted for publication by Dr Lesley Robertson, drafted on behalf of SASOP and the 

Mental Health Alliance 

As South African citizens and organisations 

who are concerned that people living with 

mental illness (PLWMI) and/or intellectual 

disability (ID) are treated with dignity and 

respect in our society, we welcome the initiative 

by the National Department of Health (NDOH) to 

establish a regulatory process of non-governmental 

residential and/or day care facilities (NGOs) for this 

vulnerable and marginalised population group. 

WE ARE CONCERNED, HOWEVER, THAT 

THE GUIDELINES, BEING PUBLISHED IN THE 

WAKE OF THE LIFE ESIDIMENI DISASTER, 

INAPPROPRIATELY CONFLATE DIFFERENT 

TYPES OF SERVICES AND FACILITIES AND 

SEEK TO ENSURE THAT NGOS ARE ABLE 

TO PROVIDE THE SAME LEVEL OF CARE 

AS A CHRONIC CARE FACILITY LIKE LIFE 

ESIDIMENI. 

This can never be the case and we maintain that a 

facility like Life Esidimeni will always be required for 

some mental health care users. Some users, however, 

can appropriately use community based services 

and it is the licensing of these services and this level 

of care that the Guidelines should seek to regulate. 

In conflating the levels of care, we find the guidelines 

to be self-contradictory, not completely relevant to 

the role of NGOs, and not implementable. Thus, we 

support the press statement made by the South 

African Federation of Mental Health on 29 March 

and believe that stakeholder consultation was 

inadequate. 

APPLICATION OF THE GUIDELINES 

The Policy Guidelines specify their application is to 

facilities which are “not a designated psychiatric 

hospital or care and rehabilitation centre” (4.1). 

The “group homes, half-way houses, supported 

independent living facilities” … and “day care 

facilities, include home-based care, protected 

workshops and support groups” to which they refer 

(4.2) are defined by the guidelines in the context of 

a social role in the societal inclusion of PLWMI and/ 

or ID. Thus, they do not appear to offer a ‘health’, 

‘medical’ or ‘psychiatric’ role. In addition, the IUSS 

norms and standards for mental health (2.4) states 

that these facilities should be ‘homely’ and make no 

infrastructure requirements for hospital type care. 

Nevertheless, the guidelines seem to subsume all 

support services for PLWMI under a healthcare 

framework, reflecting an inappropriately medicalised 

understanding of mental health and disability and 

ignoring the intersectoral nature of communitybased 

support. This is at odds with the recovery 

model and principles of inclusion which underpin the 

Mental Health Strategic Framework, the Framework 

and Strategy on Disability and Rehabilitation, and 

not least, the United Nations Convention on the 

Rights of Persons with Disabilities, which South Africa 

has ratified. 



Furthermore, Section 72(6) of the MHCA allows for 

national or provincial departments of health (DOH) 

to “enter into agreement with any non-governmental 

organisation …to exercise powers and perform 

functions and duties under this Act”. 

THIS IMPLIES THAT DESIGNATION OF NGOS 

TO PROVIDE PSYCHIATRIC OR MEDICAL 

CARE SHOULD BE DONE IN AGREEMENT 

WITH THE NGO. ADDITIONALLY, SECTION 

45(2) OF THE NATIONAL HEALTH ACT 

NO.61 OF 2003 (NHA) ALLOWS THE DOH 

AND MUNICIPALITIES TO ENTER INTO AN 

AGREEMENT WITH NGOS TO ACHIEVE 

THE OBJECTIVES OF THE NHA. 

However, the Minister has not yet classified NGOadministered 

facilities into health establishment 

categories, as provided for in Section 35(a)(vi) of 

the NHA, and such a process would surely involve 

stakeholder agreement with the NGOs. 

AGAINST THIS BACKGROUND, WE 

HAVE THE FOLLOWING CONCERNS: 

1. Neither mental illness nor severe to profound 

intellectual disability are included in the 

definitions, and other conditions and user 

groups which may require similar levels or types 

of care are not specified. 

2. The definition of ‘‘manager” refers only to “heads 

of health establishments”, which may not be 

relevant to the socially supportive NGOs with 

which this document is concerned. Most of the 

said NGO-administered facility managers are 

lay people, and not qualified to provide health 

services. 

3. Related to this is the confusing application of 

the guidelines to day-care facilities, defined to 

include home-based care, protected workshop 

and support groups and means a facility that 

offers services, day time activities and social 

contact for an individual mental health care 

user and groups of mental health care users 

for treatment, rehabilitation, prevention and 

promotion activities. On this definition, day 

care centres would fall within the definition of 

a care and rehabilitation centre. But, care and 

rehabilitation centres are not within the purview 

of these guidelines. 

Protected workshops and support groups 

only function with the voluntary attendance 

of PLWMI and/or ID. Neither are intended, by 

their very nature, to provide health services. 

The assumption seems to be that all service 

users included under the guidelines are in 

constant need of medical care, which in itself 

is problematic. While ‘home-based care’ may 

constitute health care, it cannot be regarded as 

a ‘facility’. The Guidelines fail to account for the 

range of different services and activities needed 

by different individuals, in different contexts and 

at different stages of the life course. They also 

fail to address the area of overlap between daycare 

centres (as described above) and Early 

Child Development (ECD) centres. In most rural 

and peri-urban communities, community-based 

ECD centres offer the only possibility of day-care 

for children and youth with disabilities, including 

those with severe and profound intellectual 

disabilities. Enforcement of the guidelines would 

render this impossible, driving either the reinstitutionalisation 

of rural children and adults 

with disabilities, or the overburdening and 

collapse of fragile family and social networks. 

Further, South African educational policy 

and international best practice promote the 

inclusion of children and youth with disabilities 

in mainstream educational institutions wherever 

possible. The requirements imposed by these 

guidelines would increase barriers to inclusion 

and powerfully discourage organisations and 

services from accepting PLWMI, including 

children and youth. A similar effect is likely to 

occur with homeless and ‘abused person’ 

shelters, which frequently provide housing and 

support for PLWMI. 

4. The requirement of a Service Level Agreement 

(SLA) with the District Health Services in 8.2 is 

circular – districts are unlikely to enter into an SLA 

with an unlicensed NGO, and yet the SLA is a 

pre-requisite for licensing of the NGO. 

5. Under 12.2, the guidelines do not specify who 

is responsible for the transfer of users out of a 

non-compliant NGO, and where they should 

be placed. We note there is no plan in place for 

government run supported housing of PLWMI 

and/or ID. Our observation is that there is a 

high demand for NGOs, with a mushrooming 

of illegal facilities and no alternative social care 

setting. We anticipate that adherence to these 

guidelines will result in the mass transfer of users 

to government hospitals as well as an increase 

in the high numbers of incarcerated or homeless 

PLWSMI and/or ID already experienced in South 

Africa. 

6. In clauses 15, 17, and 18, and in Annexure B, the 

Policy Guidelines expect: 

a. PLWMI and/or ID to be admitted to residential 

and/or day care facilities under the MHCA 

(15.4, 17.2(e), Annexure B page 15 and 20). 

The MHCA admission and appeal processes 

for assisted and involuntary users are 

designed to protect the PLWMI and/or 

ID from unjustified restrictive hospital or 

institutional care, as under the colonial 

era mental health system in South Africa. 

As the guidelines refer to communitybased 

NGOs which take in PLWMI and/or 

ID after discharge from a hospital or care 

and rehabilitation centre, and which do 

not themselves provide restrictive, hospital- 



or institution-based mental health care, 

admission under the MHCA surely does not 

apply. Rather, if a person suffers a relapse of 

their mental illness, the proprietor/ manager 

would apply to a hospital for an assisted or 

involuntary admission if the person lacks the 

capacity to consent and their relatives are 

not available. 

b. the proprietor/ manager to take responsibility 

for access to and provision of mental health 

care appropriate to the level of severity of 

the illness (15.6, 15.7, 17.7, 17.8, 17.9, 18.1, 

18.2). 

Access to general and mental health care 

of PLWMI and/or ID appropriate to the 

level of severity of the illness, in equity with 

the provision of general health care, is the 

responsibility of the Department of Health. 

The NGO proprietor/ manager’s responsibility 

is to ensure that the NGO residents utilise 

the accessible mental health care services 

provided by the DOH. 

c. facilities to have a medical procedure room 

(16.7), sluice rooms (Annexure B, page 9) 

and registers for restraints and medicine 

dispensing (Annexure B page 20). 

The NGOs to which the guidelines are 

applicable serve a predominantly social 

role. Therefore, while they require a ‘first-aid’ 

room and an area to administer injections, 

they do not dispense medication, perform 

medical procedures, or use restraints. 

6. There is a lack of clarity regarding financial, 

asset and human resource governance, apart 

from stating that the NGOs are funded by 

either or both Departments of Health or Social 

Development (2.3). In Annexure B pages 21 

and 22, the relationship be between the ‘service 

provider’, NGO manager, NGO Board, and the 

Departments of Health and Social Development 

is not clear. There is no clause requiring evidence 

of self-sustainability without a DOH subsidy as a 

requirement for licensing. 

7. The Policy Guidelines do not address the need 

for guardianship or custodial care of PLWMI 

and/or ID who do not have any relatives, or who 

are housed in NGOs at the request of social 

workers or the police because of abusive family 

homes or homelessness. 

8. There is no guidance regarding intersectoral 

responsibilities for the care, monitoring or 

adjudication of the facilities. 

OUR RECOMMENDATIONS ARE: 

1. Guidelines must distinguish between the 

different levels and types of care which NGOs 

may provide, acknowledging the wide range 

of individual need and the intersectoral nature 

of community-based services. They should 

be informed by the principles of the recovery 

model and inclusive development embodied 

in existing policy and legislation. Specific areas 

of overlap, for example with ECD centres and 

homeless shelters, should be addressed. 

The role of the NGO administered facilities to 

which these Guidelines are applied should not 

be conflated with that of designated health 

establishments: 

a. If there is a need for NGOs to provide certain 

health functions with the support of civil 

society, this must be delineated accordingly. 

Clear criteria for authorisation of individual 

NGOs to perform specified tasks is needed. 

b. Where the Department of Health needs 

an NGO to function fully as a health 

establishment, it should be designated and 

funded as such. 

2. There is a need for guardianship or custodial 

care arrangements in the case of homeless or 

previously abused PLWSMI and/or ID. Access to 

legal assistance and intersectoral arrangements 

between at least the Departments of Health, Social 

Development and Justice are required. These 

processes should be covered in the guidelines. 

3. Adequate financial support and sound 

governance are essential to the observance of 

basic human rights of NGO residents. 

a. Clearer guidelines on the financial 

management by the facility and its Board, and 

their relationship with the funder(s) is required. 

b. The amendment of Regulation 6, Government 

Gazette No. 38182 of 6 November 2014, 

added “Within available resources” to 

the State’s obligation to pay subsidies to 

appropriate non-profit organisations for 

the provision of community care, treatment 

and rehabilitation. Clarification as to the 

State and civil society’s respective financial 

obligations is essential. 

FINALLY, THERE IS NO ACKNOWLEDGEMENT 

BY THE NDOH OF THEIR INTER-DEPENDENCE 

WITH OTHER GOVERNMENT DEPARTMENTS, 

NGOS, CIVIL SOCIETY, USERS, AND THEIR 

FAMILIES, FOR THE CARE OF PLWSMI 

AND/OR ID. IF THE HUMAN RIGHTS OF 

SUCH VULNERABLE AND MARGINALISED 

PEOPLE ARE TO BE OBSERVED, IT IS VITAL 

THAT ALL ORGANISATIONS INVOLVED IN 

THEIR WELL-BEING WORK TOGETHER IN A 

COLLABORATIVE MANNER. 

We trust that the Policy Guidelines will be revised 

accordingly, and that the subsequent drafting of 

regulations will be accompanied by a thorough 

consultative process with all relevant stakeholders 


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SASOP HEADLINE 

NOVEMBER 2018 

EDITORIAL 

During my tenure as SASOP 

President from 2010 to 2012, 

I highlighted the need for 

us, as a society, to improve 

our communications, both 

“inbound” and “outbound”. 

I recognized, as have my 

successors, the vital role that 

effective communication 

plays in the function of a 

professional organization such 

as SASOP. Over the years, we 

have continued to improve our strategies both ways 

as the need to communicate with our members and 

the public has increased. As the SASOP newsletter, 

Headline has been instrumental in keeping our 

members abreast of what is happening within 

subgroups, at board level and has highlighted the 

achievements of individual psychiatrists. 

SEPTEMBER SAW THE CULMINATION 

OF THE TERM OF OFFICE OF PROF 

BERNARD JANSE VAN RENSBURG AND 

HIS TEAM AT THE 19 TH SASOP CONGRESS 

HELD IN PRETORIA. THE MEETING THAT 

WAS ORGANIZED BY THE FREE STATE 

SUBGROUP WAS SUCCESSFUL NOT 

ONLY IN TERMS OF THE ACADEMIC 

CONTENT AND ATTENDANCE, BUT ALSO 

AS AN OPPORTUNITY FOR NETWORKING 

AND MEETING OF SOUTH AFRICAN 

PSYCHIATRISTS ACROSS THE WHOLE 

SPECTRUM, FROM PUBLIC TO PRIVATE 

PRACTITIONERS. 

It was also an opportunity to recognise the 

achievements of our colleagues at the SASOP Dinner. 

I am delighted that Prof van Rensburg, who is now 

the immediate SASOP Past President, has agreed 

to take over the role as Headline Editor from me. 

We agreed that the SASOP Publications serve not 

only as a means to communicate, but also as a 

way of preserving history. As 2018 draws to a close, 

we can look back on another momentous year for 

South African psychiatry, and it surely needs to be 

documented. I trust that this issue of Headline will 

give you an opportunity not 

only reflect, but also to look 

forward to a dynamic 2019. 

Dr Ian Westmore (Outgoing 

Editor) 

October 2018 

A big word of thanks to Dr Ian 

Westmore for a great job done 

as Editor of the Headline years, 

during which he consistently 

ensured that pertinent 

information was captured in 

Prof Bernard Janse van 

Rensburg 

a format enabling effective communication with 

SASOP members. Also to Professor Christopher 

Szabo, editor of South African Psychiatry (SAP), 

with whom the SASOP has had an agreement 

for the past four years to publish Headline as a 

regular feature. During this time, the SAP has firmly 

established itself in terms of its aim to connect the 

discipline of Psychiatry nationally by providing a 

hub for exchanging news, views and reports and 

as such, has become the living account of life 

in and memory of the South African Psychiatry 

fraternity. 

Prof Bernard Janse van Rensburg (Incoming Editor) 

October 2018 



1. NEW SASOP PRESIDENT 

Prof Bonga Chiliza has taken over the reigns of 

SASOP as the new President at the conclusion of the 

SASOP AGM held on the 23 rd September 2018. Bonga 

is an associate professor/chief specialist and head 

of the Department of Psychiatry at the University of 

KwaZulu-Natal, and his many other involvements 

and achievements include being the Deputy Editor 

of the South African Journal of Psychiatry, being a 

member of the College of Psychiatrists’ Council and 

CMSA Senate, serving on a number of NGO Boards, 

including the SA YMCA and Life Choices, as well as 

being one of the Founding Directors of Harambee 

Medical Consulting and the African Global Mental 

Health Institute. 

IN HIS ADDRESS DURING THE SASOP 

2018 CONGRESS DINNER, BONGA 

IDENTIFIED THREE PRIORITIES FOR THE 

NEXT TERM OF OFFICE, INCLUDING: 

(1) STRENGTHENING OF A PUBLIC- 

PRIVATE PARTNERSHIP WITHIN SASOP; 

(2) EARLY CAREER PSYCHIATRY AND 

PRACTITIONERS; AND (3) CONTINUED 

LIAISON AND COOPERATION WITH 

SASOP’S SOCIAL CONTRACT ALLIANCE 

PARTNERS. 

Janse van Rensburg (Past-President), Dr A Lachman 

(Hon. Secretary), Dr I Chetty (Hon. Treasurer), Dr JP 

Roux (National Convener Private Sector Group) and 

Dr K Marooganye (National Convener Public Sector 

Group) - congratulations and best wishes! 

Incoming SASOP BOD - Absent: Drs S Seape, Dr JP Roux, Dr K Marooganye] 

You have the opportunity to read more about these 

priorities for the 2018-2020 term of office, in the 

President’s Letter section below. 

Outgoing SASOP BOD - Absent: Drs S Seape 

3. FROM THE PRESIDENT - SASOP 

PRESIDENT’S LETTER, NOVEMBER 

2018 

Dear SASOP members, 

The three priorities during my presidency will be to 

strengthen public sector psychiatry, build up public 

private partnerships, and focus on early career 

psychiatrists. 

Bernard and Bonga 

Bonga’s speech at Congress Diner 

2. NEW SASOP BOARD OF 

DIRECTORS 2018 TO 2020 

Similarly, the new SASOP Board for the next term of 

office has been introduced. They are: Prof B Chiliza 

(President), Dr S Seape (President-Elect), Prof ABR 

(1) Strengthening Public Sector Psychiatry. I think 

the time is right for SASOP to have a renewed 

and strengthened Public Sector Psychiatry 

Leadership. Recent events have called upon 

our leadership to rise and answer the call for 

advocating on behalf of our mental health 

care users (MHCU) and our profession. The 

Life Esidimeni Tragedy led to the death of 144 

MHCU following the Gauteng Marathon Project. 

The whistleblowing of alleged human rights 

abuses at Tower Hospital in the Eastern Cape 

led to an investigation by the Ombud’s office. 



The untimely death of Prof Bongani Mayosi, a 

giant in the medical fraternity and a mentor to 

many of us, following his battle with depression. 

These events have highlighted the neglect of 

mental health care in the country and the need 

for SASOP to take a leadership role in mental 

health care. 

We will establish a robust Public Sector 

Executive Committee (PubSec Exco) that 

will be made up of senior psychiatrists in 

academia and government services across 

the country to guide SASOP on how to be a 

leading voice in responding to the needs of 

public sector psychiatry. 

MUCH OF MY TIME AND OUR IMMEDIATE 

PAST PRESIDENT, PROF BERNARD 

JANSE VAN RENSBURG, WILL BE SPENT 

ON SUPPORTING THIS EXECUTIVE 

COMMITTEE. SECONDLY, WE WILL RENEW 

OUR TRANSFORMATION EFFORTS OF THE 

LEADERSHIP OF SASOP AND PSYCHIATRY 

IN GENERAL. WE WILL ENSURE THAT THE 

LEADERSHIP OF SASOP CONTINUES TO 

TRANSFORM ITSELF UNTIL IS ALIGNED 

WITH THE DEMOGRAPHICS OF OUR 

COUNTRY AND IS ABLE TO FULLY ENGAGE 

WITH ISSUES THAT PLAGUE OUR COUNTRY 

SUCH AS RACISM, SEXISM AND OTHER 

FORMS OF DISCRIMINATION. WE WILL 

THUS EMBARK ON A STRATEGIC DRIVE 

TOWARDS SUCCESSION PLANNING FOR 

ALL KEY POSITIONS OF LEADERSHIP IN 

PSYCHIATRY. 

Thirdly, we will continue to take a leading role 

in the National Mental Health Alliance. The 

Alliance of NGOs in the Mental Health Care 

Sector is a wonderful vehicle with which to 

champion advocacy for our profession. We will 

continue to advocate for an equitable share of 

the health care budget in our discussions with 

the Minister of Health and other stakeholders. 

We will continue to respond to all policies that 

may affect mental health care in our country. 

We will live out our promise we made to our 

society when we engaged in a social contract 

with our community. 

(2) Strengthening Public Private Partnerships. 

SASOP is made up of psychiatrists that work 

in the public and private sectors, however we 

need to continuously remind ourselves that we 

are one group. We are a scarce resource. We 

need to work together. We have reorganised 

our structure such that the SASOP board 

will become an umbrella body with two 

strengthened vocational group boards, namely 

the Public Sector Executive Committee (PubSec 

Exco) and the Psychiatry Management Group 

(PsychMG) board. 

We will strive towards having shared processes 

between the vocational group boards in order 

to be more efficient. The communications 

functions of the boards have already proven 

to be a lot more efficient resulting in a visible 

media presence for the benefit of psychiatry 

and mental health care. We need to push 

ahead with some pilot work to prepare ourselves 

for the reorganisation of our health care system 

through the NHI. We are already piloting value 

based care models in the private sector. 

There is no reason why these pilots cannot be 

performed in both private and state sectors. 

(3) Early Career Psychiatry. The focus of my term 

as President of SASOP will also be to grow the 

organisation by focusing on young psychiatrists, 

registrars and medical officers. We need to push 

harder for psychiatry to be truly recognised as 

a major discipline in undergraduate medical 

education. All medical schools in our country 

allocate proportionate time to the teaching of 

psychiatry, however we are given very little time 

during medical internship. Yet, we are aware 

that medical doctors learn by apprenticeship, 

so if they do not get ample chance to work in 

our discipline as young doctors (interns and 

community medical officers) they will never 

fall in love with psychiatry. We need to also 

continuously look for ways to destigmatise a 

lifetime medical officer career in psychiatry. 

WE NEED TO INCREASE THE SUPPORT 

THAT IS OFFERED TO REGISTRARS 

ACROSS OUR COUNTRY. SASOP IS 

ALREADY ENGAGED IN REGISTRAR 

TRAINING THROUGH THE REGISTRAR 

FINISHING SCHOOL, HOWEVER THE CRY 

IS FOR US TO SUPPORT THEM EARLIER 

SUCH THAT WE CAN FACILITATE A 

MORE EQUITABLE TRAINING PLATFORM 

FOR ALL REGISTRARS REGARDLESS OF 

THE UNIVERSITY AT WHICH THEY ARE 

TRAINING. 

And lastly, as young psychiatrists start to 

practice, SASOP will support them through 

SASOP/PsychMG Roadshows that deal with 

practice issues such as billing. We will pilot well 

thought-out measureable mentorship programs 

that can be accessed by young psychiatrists 

in public or the private sectors. We shall invest 

in the training of our future academic leaders 



through initiatives like the African Global Mental 

Health Institute. And remember that your early 

years in the workforce are a great time to 

strengthen areas of weakness. So if any of us 

avoid doing the things we are not good at, we 

practically ensure that we will never improve. If 

leading a project scares you, volunteer to do it. 

Look for ways to stretch yourself, both big and 

small. 

Best regards 

Bonga 

Prof Bonga Chiliza, SASOP President (2018-2020) 

4.2 INVITED INTERNATIONAL FACULTY 

The invited international faculty included Profs 

Michael Berk (Australia), Damiaan Deneys 

(Netherlands), Frank Schneider (Germany), Stephen 

Stahl (US) and Drs Susan Young (UK) and Rebecca 

Sachs (US). Prof Schneider also presented a lecture 

on the 27 th September at the Johannesburg 

Holocaust and Genocide Centre, on “Psychiatry 

during National Socialism: Lessons on advocacy 

and reconciliation”. 

4. 19 TH SASOP NATIONAL CONGRESS, 

21-24 SEPTEMBER 2018, CSIR 

PRETORIA 

The highlight of the recent SASOP calendar was 

surely the national congress held in Pretoria this 

year, which was very competently organized by 

the spirited organizing committee of the Free State 

Subgroup. From SASOP membership, the SASOP 

board and myself again, thank you very much for 

your hard work and commitment, in particular to 

Dr Frans Brink who spent many hours away from his 

private practice and similarly to Dr Ian Westmore 

who selflessly devoted time equivalent to another 

“term of office” as coordinating mentor for the group. 

Prof Stephen Stahl, US 

4.1 OPENING SPEAKERS 

Two prominent opening speakers addressed the 

congress on Friday evening 21 st September 2018, 

Advocate Adila Hassim (SECTION27) and Dr Altha 

Stewart (current APA President). Advocate Hassim 

spoke on “Place of Dignity” or “esidimeni”, alluding 

to the experience of the human rights abuses 

during the Life Esidimeni tragedy and stake holders’ 

responses and responsibilities. Dr Stewart spoke 

on the priorities set for her term of office, including 

expanding APA’s global reach, its mentorship of 

young trainees and early career psychiatrists, and 

its involvement in contemporary social issues. 

Ian Westmore, Dr Altha Stewart, Adv Alida Hassim, Bernard Janse van Rensburg 

Prof Frank Schneider, Ms Kim Nates (JGHC), Bernard Janse van Rensburg 

4.3 SASOP AWARDS 2018 

Through the various SASOP awards, a number of 

people were acknowledge for their contribution to 

Psychiatry, the SASOP and the community. These 

included: 

1 SASOP President’s Award to Dr Mvuyiso Talatala 

(nominated by Prof B Janse van Rensburg) 

2 SASOP Honorary Membership to Dr Altha 

Stewart, APA President (nominated by the 

SASOP BOD) 

3 SASOP Excellence Awards to Prof Werdie van 

Staden (nominated by SASOP BOD), Dr Hoepie 

Howell (Nominated by FS Subgroup), Dr John 

Parker (nominated by Dr Qhama Cossie), Dr 

Lesley Robertson (nominated by SASOP BOD) 

and Dr Eugene Allers (nominated by Dr Thabo 

Rangaka) 

4 Community Awards to SECTION 27 (nominated 

by Prof B Janse van Rensburg) and GOLDILOCKS 

& THE BEAR FOUNDATION (nominated by Dr 

Gerhard Grobler) 



Dr John Parker, Bernard Janse van Rensburg 

Dr Mvuyiso Talatala, Bernard Janse van Rensburg 

Dr Altha Stewart Mvuyiso Talatala, Bernard Janse van Rensburg 

Bernard Janse van Rensburg, Dr Lesley Robertson 

Prof Werdie van Staden, Bernard Janse van Rensburg 

Dr Eugene Allers, Bernard Janse van Rensburg 

4.4 CONGRESS ORGANIZING COMMITTEE 

The Congress Organizing Committee and their 

portfolios included Dr Frans Brink (Convener 

and Invited speakers), Dr Michelle Nel-Botes 

(Treasurer), Ms Tertia de Bruin (Secretary), Drs 

Jeanette Pienaar and Ntswaki Setlaba (Social, Early 

Career Programme), Dr Francois Potgieter (Invited 

Speakers), Drs Andre du Toit and Jana Oosthuizen 

(Marketing), and Dr Ian Westmore (Early Career 

Programme). The scientific committee consisted of 

Profs Janus Pretorius and Richard Nichol and Drs Ian 

Dr Hoepie Howell, Bernard Janse van Rensburg 

Westmore and Francois Potgieter. 



Dr Ian Westmore 

5. MEDIA REPORTS AND STATEMENTS. 

SASOP and PsychMg recently commented on 

two issues in the media, namely depression in 

adolescents and the decriminalization of cannabis. 

Dr Sebo Seape, SASOP President-Elect and 

Chairperson of PsychMG was the spokesperson on 

watching out for teen suicide warning signs, while 

Dr Eugene Allers and Dr Liezl Weich were interviewed 

on the SASOPs position on the decriminalization of 

cannabis. [Dr Seape’s article and the press release 

on cannabis are included earlier in this issue]. 

Bernard Janse van Rensburg, Ian Westmore, Dr Jeanette Pienaar, Dr Ntswaki 

Setlaba, Dr Michelle Nel-Botes, Dr Jana Oosthuizen, Dr Frans Brink, Dr Francois 

Potgieter, Prof Richard Nichol 

ADDENDA. 

1. SASOP AWARDS 2018 CITATIONS AND 

BIOS 

4.5 CONGRESS DINNER 

A 

COMMUNITY AWARDS 

The Congress dinner was held at the Rockwood 

theatre in Garsfontein, Pretoria and the guests were 

entertained by a musical tour through the past 

decades of popular songs which became “juke box 

hits” during the 1980s, 1990s and 2000s. 

1. GOLDILOCKS & THE BEAR FOUNDATION 

(Nominated by Dr Gerhard Grobler) 

To be received by Prof Renata Schoeman 

The Goldilocks and The Bear Foundation 

(www.gb4adhd.co.za) is a registered NGO and 

NPO which aims to remove mental health barriers 

to education. They visit underprivileged schools 

where they provide non-profit screening for ADHD, 

anxiety, depression, visual- and hearing problems, 

and developmental problems to the children. This 

ensures early referral, diagnosis and treatment, and 

improves the quality of life of these children. 

Dr Grobler’s nomination reads as follows: I am of the 

opinion that the Goldilocks and The Bear Foundation 

has fulfilled the following criteria: 

The Foundation worked in the field of psychiatry 

/ mental health for some time and has made 

significant impact in the community in the promotion 

of mental health and psychiatry, especially in the 



popular media as well as in the corporate world. 

I am of the opinion that Goldilocks and The Bear 

Foundation has acted in the interest of psychiatry 

and mental health in the community by improving 

the life of the chronically ill (with childhood ADHD). 

In my opinion the Foundation improved child 

psychiatry services. 

2. SECTION 27 

(Nominated by Prof B Janse van Rensburg) 

To be received by Ms Umunyana Rugege, the SECTION 

27 Deputy Director. 

SECTION27 is at the forefront of human rights 

activism in South Africa. It is a public interest law 

centre and seeks to use the law to protect, promote 

and advance human rights. The organisation’s 

activities include litigation, research and advocacy 

to advance and promote the rights to have access 

to health care services, basic education and food, 

as guaranteed by the South African Constitution. 

SASOP wishes to acknowledge the significant role 

that SECTION27 has played over time to advocate 

for mental health care users, psychiatrists and 

psychiatry in the country, as well as the sustained 

support of the advocacy and whistle blowing 

activity that SASOP and its members tried to sustain 

over the past two years. In particular the extensive 

work that was done by SECTION27 in relation to 

the Life Esidimeni tragedy, e.g. the legal support 

for the initial court actions brought against the 

Gauteng DOH in 2015/16 and during 2017, the 

subsequent Health Ombud’s report and eventually 

the Arbitration hearings. 

B 

EXCELLENCE AWARDS 

1. Dr John Parker (Nominated by Dr Qhama Cossie) 

I would like to nominate Dr John Parker for 

the Presidents award for outstanding service in his 

advocacy work. 

Over a number of years he has fought for the right 

of mental health patients to vote in South African 

elections. This right is now in the final stages of 

being realized. Dr Parker continues to teach and 

mentor junior doctors and psychiatrists at Lenteguer 

hospital in the area of Personal recovery and his 

work on the Lentegeur Spring Project has been 

recognized nationally. (https://www.westerncape. 

gov.za/your_gov/70/documents/public_info/ 

w/31274?toc_page=16). Dr Parker deserves to be 

celebrated by our society. 

Bio: Dr Parker is a psychiatrist at Lentegeur Hospital 

and a senior lecturer with UCT’s Dept of Psychiatry 

and Mental Health. He is the founder and Director of 

the Spring Foundation at Lentegeur Hospital which 

is a Registered NPO and PBO that is working to redesign 

what a psychiatric hospital looks like, feels 

like, is and does using ecological and Recovery 

principles. He works in the outpatients department 

and specializes in treating severe psychiatric 

disorders as well as complex trauma-related and 

personality disorders. His academic interests include 

social psychiatry and the environment, recovery in 

mental illness and Mindfulness Based Interventions. 

John is married and is the father of two daughters 

aged 13 and 14. He lives in Noordhoek in Cape 

Town and has a passion for yoga, surfing, mountain 

biking and camping in the wilderness. 

2. Prof Werdie van Staden (Nominated by SASOP 

BOD) 

Prof van Staden has been the editor of the SAJP for 

over 10 years, and is now overseeing the transition to 

the new publishing house, helping the journal into its 

new era and has worked to ensure that we have a 

reputable and respected forum for relevant content 

not only from South Africa but across the continent. 

Bio: As professor of philosophy and psychiatry, 

Werdie van Staden is Director of the Centre for Ethics 

and Philosophy of Health Sciences at the University 

of Pretoria, with an honorary clinical attachment 

at Weskoppies Hospital. He is chair of the World 

Psychiatric Association’s (WPA) Section for Philosophy 

and Humanities in Psychiatry, and honorary 

secretary for the WPA Section for Classification. He 

serves as editor for three international journals, and 

is chairperson of the Research Ethics Committee at 

the University of Pretoria. 

3. Dr Lesley Robertson (Nominated by SASOP 

BOD) 

Dr Robertson has been nominated for her advocacy 

role and work on national/provincial task teams and 

committees (Community outreach and advocacy). 

The SASOP BOD specifically wishes to acknowledge 

the hours of personal and professional sacrifice 

in ensuring our representation especially as state 

sector psychiatrists in the Life Esidimeni case. 

Bio: Dr Lesley Robertson is a Community Psychiatrist 

jointly appointed by the Sedibeng District Health 

Services in Gauteng and the University of the 

Witwatersrand. The promotion of access to quality 

mental health care and the related development of 

community psychiatric services in South Africa has 

become an overriding preoccupation. Her research 

interests include mental health services, rational 

medicine use and quality assurance in mental 

health care. In addition to being the SASOP National 

Convener of Public Sector Psychiatrists, she is a 



member of the Adult Hospital Level Expert Review 

Committee for the National Essential Medicines List, 

the Gauteng Provincial Pharmacy and Therapeutics 

Committee, and the newly formed Gauteng Mental 

Health Technical Advisory Team. 

4. Dr Hoepie Howell: (Nominated by Subgroup) 

Dr Howell was nominated by the FS Subgroup 

for her contributions to public sector and private 

psychiatry; her role in establishing the Registrar 

Finishing School; and her role in the continuing 

professional development of psychiatrists through 

the Lundbeck Institute. She has also served as a 

revered mentor to a few generations of psychiatrists 

locally and internationally. 

Bio: Dr. Hoepie Howell attained her medical degree 

and psychiatry specialisation in Bloemfontein, South 

Africa. She has worked as a psychiatrist in full time 

or part time private practice since November 1988. 

She was HoD and Chief Specialist in Psychiatry, at 

3 Military Hospital for 7 years and has worked as 

clinician in South Africa, New Zealand and Canada. 

In December 2009 she joined the Lundbeck Institute 

in Copenhagen, Denmark, where she developed 

and presented international, evidence-based 

education programmes for specialists in clinical 

neurosciences. In July 2013 she returned to South 

Africa, where she currently practices as psychiatrist in 

the private sector and continues as an independent 

consultant for CME for the Lundbeck Institute. 

5. Dr Eugene Allers (Nominated by Dr Thabo 

Rangaka) 

Dr Allers is a past president of SASOP and has pushed 

for the eradication of Stigmatization of Psychiatry and 

Mental Health. It was in his presidency that the idea 

of setting up a PsychMg was mooted. He remains a 

most energetic and committed Member of SASOP 

and activist in the Medico-Politico-Economic Arena 

of Healthcare in South Africa.SASOP and the South 

African Medical Fraternity is fortunate to have a 

person of his stature rooted in this country. 

Bio: Eugene Allers is currently working as a 

psychiatrist in private practice. He has been involved 

in the management of private practice since 1998 

and has served on several committees and boards. 

He is a past president of the South African Society 

of Psychiatrists and has chaired the private practice 

interest group within SASOP for several years. He has 

also, with the help of a team of psychiatrists, run a 

very successful anti-stigma campaign for SASOP. He 

was the chairperson of the Specialist Private Practice 

Committee of SAMA for 2 years. He is the editor of 

the Serenity Magazine and has been the editor of 

several publications. Currently Dr Allers serves as a 

consultant to the PsychMg board. 

C 

PRESIDENT”S AWARD 

• Dr Mvuyiso Talatala: (Nominated by Prof B 

Janse van Rensburg) 

Dr Talatala has been nominated by the SASOP 

President for this award following his work and role 

in SASOP’s opposition of the Life Esidimeni tragedy. 

Bio: Dr Mvuyiso Talatala served as the president of 

the South African Society of Psychiatrists (SASOP) 

from 2014 to 2016. He is an active member of 

SASOP having served in many other leadership 

roles in the society. He is a member of the Board 

of Directors of the Psychiatry Management Group 

(PsychMg) and has served as the chairperson of 

the Board of PsychMg from 2011 to 2015. He is in 

fulltime private practice at Dr SK Matseke Memorial 

Hospital in Soweto, Johannesburg. He is an honorary 

lecturer in the Department of Psychiatry, University of 

Witwatersrand, Johannesburg. 

D 

HONORARY MEMBERSHIP 

• Current APA President: Dr Altha Stewart 

(Nominated by the SASOP BOD) 

Bio: https://www.psychiatry.org/newsroom/newsreleases/dr-altha-stewart-takes-office-as-apa-presidentthe-first-african-american-to-lead-the-organization 

Dr Altha Stewart, M.D., an Associate Professor of 

Psychiatry at the University of Tennessee, is the first 

African-American to lead the APA and the fourth 

consecutive woman chosen to lead the association. 

She is Associate Professor of Psychiatry and Director, 

Center for Health in Justice Involved Youth, at the 

University of Tennessee Health Science Center in 

Memphis. Her career has spanned three decades 

of public sector administration, including executive 

leadership positions in public behavioural health 

systems in Michigan, New York and Pennsylvania. 

Stewart has held numerous APA leadership positions 

including secretary of the Board of Trustees; president 

of the American Psychiatric Association Foundation; 

chair of the Conflict of Interest Committee and 

the Minority Fellowship Selection Committee; and 

member of the Joint Reference Committee and the 

Council on Advocacy and Government Relations. 

She also served as president of Association of 

Women Psychiatrists and president of the Black 

Psychiatrists of America. 

In her address at the APA Annual Meeting on May 

6, Stewart outlined three main areas of focus for her 

year as president: 

o 

Leadership opportunities for early career 

psychiatrists and residents and better 

reflecting their needs and their voices in 

APA strategies and actions 



o 

Global mental health where APA can and 

should lead the way for colleagues around 

the world in innovative treatment programs 

o Exploring social determinants of mental 

health, including racism, sexism, ageism and 

homophobia, that continue to affect the mental 

health and psychological well-being of many 

Americans, and how organized psychiatry can 

and should respond to these issues 

“I am looking forward to working with our internal 

and external stakeholders over the next 12 months 

to advance the goals of our organization and the 

profession of psychiatry around the globe,” Stewart 

said. “The APA will be active in speaking out about 

the challenges facing the nation and how they 

affect mental health. I want to thank my colleagues 

for putting their trust in me to lead this organization.” 

https://academic.uthsc.edu/faculty/facepage. 

php?netID=astewa59&personnel_id=339785 

ADDENDUM 2. WATCH OUT FOR WARNING 

SIGNS OF TEEN SUICIDE 

Statistics on teen suicide tell an alarming tale of lost 

potential among our country’s youth – a loss that in 

many cases is preventable if more parents, teachers, 

community leaders and mental health professionals 

are alert to the warning signals of mental distress. 

ALMOST ONE IN TEN TEENAGE DEATHS 

IN SOUTH AFRICA EVERY YEAR ARE THE 

RESULT OF SUICIDE, ACCORDING TO THE 

SA DEPRESSION AND ANXIETY GROUP 

(SADAG), AND UP TO 20 % OF HIGH 

SCHOOL LEARNERS HAVE TRIED TO TAKE 

THEIR OWN LIVES. 

The 2011 Youth Risk Behaviour Survey (YRBS) found 

that a quarter of grade 8-11 learners across all 

South Africa’s provinces had felt so sad or hopeless 

that they couldn’t engage in their usual daily 

activities for two weeks or more. More than one in 

six had either thought about suicide, made plans to 

commit suicide, or attempted it at least once in the 

past six months. 

The phenomenon is not unique to South Africa. The 

World Health Organisation (WHO) ranks depression 

as the third highest disease burden amongst 

adolescents globally, and suicide the second 

leading cause of death in 15- to 29-year-olds. 

THIS SUGGESTS A LARGE PROPORTION 

OF TEENAGERS ARE SUFFERING FROM 

UNDETECTED OR UNTREATED MENTAL 

AND EMOTIONAL HEALTH PROBLEMS 

WHICH CAN SERIOUSLY IMPACT ON THEIR 

FUTURE POTENTIAL. THE YOUTH ARE THE 

FUTURE OF OUR COUNTRY AND WE NEED 

TO ACT TO PREVENT THE DEVASTATING 

CONSEQUENCES OF THEM LOSING 

THEIR HOPE FOR THE FUTURE. 

Depression and other mental health disorders 

have a serious impact on the individual’s ability to 

function and perform their normal activities while 

the WHO notes growing evidence that promoting 

and protecting adolescent health brings long-term 

benefits to economies and society. Healthy young 

adults are able to make greater contributions to 

the workforce, their families and communities, and 

society as a whole. 

“Young people and mental health in a changing 

world” was the theme for World Mental Health Day 

on 10 October this year, acknowledging the impact 

on young people of multiple social and physical 

changes as they move through their teens towards 

adulthood, and the need to build mental resilience 

from an early age to ensure young people are 

equipped to cope with the challenges of today’s 

world. 

THE CAUSES OF DEPRESSION AND 

RELATED MENTAL ILLNESSES IN 

TEENAGERS AND YOUNG ADULTS ARE 

MULTI-FACETED. THERE IS THE STRESSFUL 

NATURE OF THE TEENAGE YEARS – 

FOR SOME TEENAGERS, THE NORMAL 

DEVELOPMENTAL CHANGES OF THESE 

YEARS, SUCH AS BODILY CHANGES, 

NEW PATTERNS OF THOUGHTS AND 

FEELINGS, CAN BE UNSETTLING AND 

OVERWHELMING. 

There are social changes too, like changing schools, 

the pressure of final exams, the prospect of leaving 

home to start tertiary studies or a job; as well as other 

stress factors such as family issues and changes in 

friendship networks, while the new world of alwayson 

technology and social media brings additional 

pressures. 

Problems appear too big, too difficult or embarrassing 

to overcome, and suicide may look like the only 

option. 

What then is to be done? 

Prevention of teen suicides starts with better 

understanding of the symptoms of depression. 

Suicides rarely happen without warning, and 



learning and recognising the warning signals is the 

most effective way to prevent suicide. 

MOST PEOPLE WITH DEPRESSION ARE 

NOT SUICIDAL, BUT MOST SUICIDAL 

PEOPLE ARE DEPRESSED. EXISTING 

MENTAL ILLNESS OR SUBSTANCE ABUSE, 

AND A FAMILY HISTORY OF MENTAL 

ILLNESS, SUICIDE, SUBSTANCE ABUSE 

OR VIOLENCE, HEIGHTENS THE RISK OF 

SUICIDE, AND A PREVIOUS ATTEMPT IS THE 

STRONGEST PREDICTOR OF ANOTHER 

SUICIDE ATTEMPT. 

Warning signs and symptoms 

• Changes in eating and sleeping habits, loss of 

interest in usual activities, neglect of personal 

appearance or hygiene, withdrawal from friends 

and family, or running away from home. 

• Alcohol and substance abuse, unnecessary 

risk-taking behaviour, obsession with death 

and dying, and numerous physical complaints 

linked to emotional distress. 

• Feelings of boredom, agitation, nervousness, 

sadness, loneliness or hopelessness. 

SOME TEENAGERS MAY ACTUALLY PASS 

VERBAL HINTS BY TALKING ABOUT DEATH 

AND DYING DIRECTLY OR INDIRECTLY, 

THEY MAY TALK ABOUT WANTING TO 

DIE AND BEGIN TO DISPOSE OF MUCH- 

LOVED POSSESSIONS, AND THEY MAY 

WRITE A SUICIDE NOTE. 

ALL THREATS OF SUICIDE MUST BE TAKEN 

SERIOUSLY. 

What to do 

Parents, teachers and friends concerned about a 

teenager at risk of suicide should be willing to listen 

without judgment, provide reassurance that they 

care, and to ask questions about suicidal thoughts. 

Don’t try to argue them out of suicide and avoid 

guilt-inducing statements like ‘suicide will hurt your 

family’. Rather let them know that you care and 

want to understand, that they are not alone, and 

that problems and suicidal feelings are temporary – 

that depression can be treated and problems can 

be solved. 

PEOPLE WANTING TO HELP A DEPRESSED 

TEENAGER COULD SUGGEST THAT THEY 

TALK TO AN EXTERNAL PARTY LIKE A 

TEACHER, DOCTOR OR COUNSELLOR, 

AND OFFER TO GO WITH THEM FOR 

SUPPORT. 

On any concerns of a suicide risk, the person should 

be taken immediately to a clinic or emergency room. 

Once the condition has been identified, continue 

to offer support and take an active role, for example 

by ensuring that they take prescribed medication or 

attend scheduled counselling sessions. Parents and 

educators have a great role in building children’s 

mental and emotional resilience – the ability to 

cope with everyday challenges and to overcome 

disappointments and failures as a normal part of 

life. 

THIS COULD INCLUDE INFORMAL LIFE 

LESSONS, TALKING ABOUT ISSUES AND 

PROBLEMS AND HOW TO DEAL WITH 

THEM, ROLE MODELLING HEALTHY 

EMOTIONAL BEHAVIOUR, AS WELL AS 

FORMAL LIFE SKILLS OR PSYCHOSOCIAL 

SUPPORT IF NEEDED 

Dr Sebolelo Seape, Chairperson of the Psychiatry 

Management Group (PsychMG) and psychiatrist. 

References: 

1. World Health Organisation: http://www.who.int/ 

mental_health/world-mental-health-day/2018/ 

en/ 

2. South African Depression and Anxiety 

Group (SADAG) – resources and 

information on teen suicide: http://www. 

sadag.org/index.php?option=com_ 

content&view=article&id=1840&Itemid=153 

3. South Africa Youth Risk Behaviour Survey, 2011: 

http://www.hsrc.ac.za/en/research-data/ 

view/6874 


REPORT 

SASOP CONGRESS 

2018 EXHIBITOR STANDS 

Part of what makes the annual SASOP conference possible is the support it 

receives from industry leaders and pharmaceutical companies. The exhibition 

they put on is always impressive and a worthy showcase for their products. 

Donovan Cassiem, Annelize Marais, Lesetja Kgobe and Alicia Janse van 

Rensburg 

Minette Viljoen and Lorinda La Grange 

Nishani Sookdeo and Lydia van Tonder 

Elizabeth Otto, Cheryl Paul and Joan Rampall 

Linda Fortuin 

Shouqat Mugjenker, Lara Vinagre, Michelle Orrico and Jabulani 

Gololo 

Itumeleng Makhale, Tarryn Hayes-Hill, Nonhlanhla Senzani, Sune Venter, 

Marike Hollander and Siyanda Ngidi 

Mala Rampershad, Divan Mitchel 


REPORT 

Babre Trytsman, Katlego Masoko and Wanda 

Mileham 

Colleen Cherry 

Marinda Bosman and Lance Bloem 

Erica Palin, Julie Howarth, Charmaine Thomas, Itzelle Jonker, 

Chantall Hayes and Magda van der Merwe 

Zenobia van Wyk, Trevor Lukoto, Tetelo Mashigo and Samantha 

Loveday 

Hanri Wright, Leonie Viljoen and Portia 

Mmenu 

Marco Gonçalves, Victor Behrens, Wendy 

Oosthuizen, Sally-ann Kotzé 

Eugenie Wicksell, Estie Muller, Mando Nteo and Keeran Maharaj 

Dr WJ Sanders and Anneke Cilliers 

Sean Fisher, Lize Porter and Dina Avyidi 

Joey Hanekom 


INSTRUCTIONS TO AUTHORS 

South African Psychiatry publishes original contributions that relate to South African Psychiatry. The aim of the 

publication is to inform the discipline about the discipline and in so doing, connect and promote cohesion. 

The following types of content are published, noting that the list is not prescriptive or limited and potential 

contributors are welcome to submit content that they think might be relevant but does not broadly conform to 

the categories noted: 

LETTERS TO THE EDITOR 

* Novel experiences 

* Response to published content 

* Issues 

FEATURES 

* Related to a specific area of interest 

* Related to service development 

* Related to a specific project 

* A detailed opinion piece 

Feature articles will be sent for commentary to be published with the article. This will constitute a form of open 

peer review or there will be anonymous peer review. 

REPORTS 

* Related to events e.g. conferences, symposia, workshops 

PERSPECTIVES 

* Personal opinions written by non-medical contributors 

NEWS 

* Departments of Psychiatry e.g. graduations, promotions, appointments, 

events, publications 

ANNOUNCEMENTS 

* Congresses, symposia, workshops 

* Publications, especially books 

The format of the abovementioned contributions does not conform to typical scientific papers. Contributors 

are encouraged to write in a style that is best suited to the content. There is no required word count 

and authors are not restricted, but content will be subject to editing for publication. Referencing should 

conform to the Vancouver style i.e. superscript numeral in text (outside the full stop with the following 

illustration for the reference section: Other AN, Person CD. Title of article. Name of Journal, Year of publication; 

Volume (Issue): page number/s. doi number (if available). All content should be accompanied by a relevant photo 

(preferably high resolution – to ensure quality reproduction) of the author/authors as well as the event or with 

the necessary graphic content. A brief biography of the author/authors should accompany content, including 

discipline, current position, notable/relevant interests and an email address. Contributions are encouraged and 

welcome from the broader mental health professional community i.e. all related professionals, including industry. All 

submitted content will be subject to review by the editor-in-chief, and where necessary the advisory board. 

REVIEW / ORIGINAL ARTICLES 

Such content will specifically comprise the literature review or data of the final version of a research report 

towards the MMed - or equivalent degree - as a 5000 word article 

* A 300 word abstract that succinctly summarizes the content will be required. 

* Referencing should conform to the Vancouver style i.e. superscript numeral in text (outside the full stop with 

the following illustration for the reference section: Other AN, Person CD. Title of article. Name of Journal, Year of 

publication; Volume (Issue): page number/s. doi number (if available) 

* The submission should be accompanied by the University/Faculty letter noting successful completion of the 

research report. 

* This will constitute peer review given that the examination process involves 2 independent 

examiners, with any revisions generally having been undertaken to the satisfaction of both your 

supervisor and Head of Department. 

All submitted content will be subject to review by the editor-in-chief, and where necessary the advisory board. 

All content should be forwarded to the editor-in-chief, Christopher P. Szabo - Christopher.szabo@wits.ac.za

The fine art of mental health treatment 

S5 Adco-Talomil 20 mg. Each tablet contains citalopram hydrobromide 24,99 mg equivalent to citalopram 20 mg. Reg. No. 35/1.2/0272. S5 Adco-Paroxetine 20 mg. Each tablet contains paroxetine mesylate 

equivalent to 20 mg paroxetine. Reg. No. 36/1.2/0096. S5 Adco-Mirteron 15. Each film-coated tablet contains mirtazapine 15 mg. Reg. No. 39/1.2/0217. S5 Adco-Mirteron 30. Each film-coated tablet contains 

mirtazapine 30 mg. Reg. No. 39/1.2/0218. S5 Venlafaxine XR 37,5 Adco. Each extended release capsule contains venlafaxine HCl equivalent to venlafaxine 37,5 mg. Reg. No: 43/1.2/0577. S5 Venlafaxine XR 75 

Adco. Each extended release capsule contains venlafaxine HCl equivalent to venlafaxine 75 mg. Reg. No: 43/1.2/0578. S5 Venlafaxine XR 150 Adco. Each extended release capsule contains venlafaxine HCl 

equivalent to venlafaxine 150 mg. Reg. No: 43/1.2/0579. S5 Adco-Alzam 0,25 mg. Each tablet contains alprazolam 0,25 mg. Reg. No. 30/2.6/0212. S5 Adco-Alzam 0,5 mg. Each tablet contains alprazolam 

0,5 mg. Reg. No. 30/2.6/0211. S5 Adco-Alzam 1,0 mg. Each tablet contains alprazolam 1,0 mg. Reg. No. 30/2.6/0213. S5 Serez 25. Each film-coated tablet contains quetiapine fumarate, equivalent to quetiapine 

free base 25 mg. Reg. No. 43/2.6.5/0796. S5 Serez 100. Each film-coated tablet contains quetiapine fumarate, equivalent to quetiapine free base 100 mg. Reg. No. 43/2.6.5/0797. S5 Serez 200. Each film-coated 

tablet contains quetiapine fumarate, equivalent to quetiapine free base 200 mg. Reg. No. 43/2.6.5/0798. S5 Serez 300. Each film-coated tablet contains quetiapine fumarate, equivalent to quetiapine free base 

300 mg. Reg. No. 43/2.6.5/0799. S3 Valeptic CR 300. Each controlled release tablet contains sodium valproate 300 mg. Reg. No. 44/2.5/0067. S3 Valeptic CR 500. Each controlled release tablet contains 

sodium valproate 500 mg. Reg. No. 44/2.5/0068. S5 Adco-Zolpidem Hemitartrate 10 mg. Each tablet contains zolpidem hemitartrate 10 mg. Reg. No. 36/2.2/0132. S5 Adco-Zopimed. Each film-coated tablet 

contains 7,5 mg zopiclone. Reg. No. 33/2.2/0450. S4 Ebitine 10 mg. Each film-coated tablet contains memantine hydrochloride 10 mg. Reg. No. 45/32.16/0496. 

For full prescribing information, refer to the package insert approved by the medicines regulatory authority. 

2018092810100780 

Adcock Ingram Limited. Reg. No. 1949/034385/06. Private Bag X69, Bryanston, 2021. 

Tel. +27 11 635 0000 www.adcock.com

Restored Sleep 

The 

• An effective hypnotic 1 

• ‘Intermediate’ half-life (6 - 8 hours) 1,2 

• Unaltered REM sleep 1,3 

• Rapid sleep onset and maintenance of sleep 1,2 

• Refreshed morning awakening 1 

Definition: 

• Helps reduce anxiety symptoms associated 

with insomnia 1,4,5 

- Caution should be exercised in patients suffering from anxiety 

accompanied by an underlying depressive disorder 

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 ® 

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, 

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: 

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. 

For full prescribing information refer to the package insert approved by the medicines regulatory authority. 

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. 

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: 

sanofi-aventis south africa (pty) ltd., Reg. No. 1996/010381/07, 2 Bond Street, Midrand, 1685, South Africa. Tel + 27 (0)11 256 3700, Fax +27 (0)11 256 3707. www.sanofi-aventis.com SAZA.LOME.16.11.0952

South African Psychiatry - November 2018

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