Psychiatric Clinics Cape Town
Kym Wash
Cossie says mental health care has become decentralised, with most patients being treated by general practitioners at clinics or district hospitals nearest to where they live. A contributing factor to this is the availability of antipsychotic medication. He says only about ten percent of mental health patients are referred to psychiatric hospitals like Valkenberg.
Around the administration building, a few other historic buildings stand abandoned, waiting to be restored. Newer buildings and wards have been added, but Cossie says infrastructure remains a challenge.
NOTE: This article is the second in a Spotlight special series on the history and ongoing relevance of several old hospitals in South Africa. Not only do we find the stories of these places fascinating, we think they provide valuable cultural and historical context for healthcare services today. The first story in the series, about Brooklyn Chest Hospital, can be read here.
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The history of psychiatry in South Africa stretches back to the first settlement by Europeans in the Cape of Good Hope in 1652. Its development falls into 3 phases with some overlaps. The first was a period of expediency and restraint during the early stages of the occupation of the Cape by the Dutch East India Company; the second, which could be called the psychiatric hospital era, was under the control of the British from the earlier part of the 19th century towards the beginning of the 20th century; and the third, broadly speaking, is the modern period since then. This article traces major developments over these 5 centuries to the present time, when psychiatry has become a highly evolved modern medical discipline.
These institutions were governed by the so-called Lunacy Laws and specific regulations dealing with the mentally ill which varied in the Boer Republics; but, with Union in 1910, the responsibility for psychiatric hospitals was vested centrally in the state Department of Health which was also responsible for new legislation (the Mental Disorders Act of 1916).
Since the period covering the transition of the 19th into the 20th century, each new nosology has opened up enquiry and experimentation. The DSM and ICD have split the atom, so to speak, and we can now examine the minutiae of each diagnostic entity in terms of pathogenesis, course, outcome, and the therapeutic effects of a particular psychotropic drug or therapeutic agent.
There has been much change in the modern era, i.e. from about the mid-20th century. Although beset with the residual problem of large chronic populations, psychiatric hospitals offered the components of modern psychiatry including outpatient clinics, a therapeutic team approach, social and community services, occupational therapy, rehabilitation, etc. The transfer of responsibility for psychiatric services to provincial health authorities in 1987 gave a major impetus because of the emphasis on curative services and more diverse venues and forms of therapy. In the process, psychiatry came closer to general medicine and lost some of the stigma that had bedevilled it.
Under the apartheid regime, strict legislation concerning separate facilities and accommodation for black patients was enforced but, beginning in 1991, transformation and consolidation began in some hospitals and lead to the total abolishment of racial distinctions when a new government came to power in 1994.
The next phase was arguably the most significant in the long history of psychiatry: the development and use of effective psychotropic drugs, more particularly, for psychotic and depressive conditions. These arose out of a better understanding of biochemical and physiological processes in the brain and, as experiments multiplied and knowledge grew, many psychotropic medications were developed. Chlorpromazine was the first in 1955; this quieted patients so that violent and disruptive behaviour could be controlled, and made it possible for hospital stay to be reduced and patients to be treated in the community. Of the many other medications developed since, some were quite specific, some more efficient, and some more dangerous. Many have fallen by the wayside. Lithium was discovered in 1949 as an effective treatment for some forms of bipolar illness, and imipramine was introduced in 1958. They did not cure, but controlled or abated symptoms and in many cases violent behaviour; they made it possible to look beyond mere custodianship to active therapeutic measures, notably psychological treatments, group and outpatient therapy, therapeutic communities, etc.
It did not, however, prove possible to phase out psychiatric hospitals because of the special situation in South Africa with its large peri-urban and rural populations, poor transport, overcrowding in informal settlements, and poor community and social support services. But, as indicated, psychiatric hospitals have moved with the times: they began to offer a variety of purpose-orientated treatments and therapeutic facilities, e.g. a psychogeriatric unit at Stikland Hospital and a province-wide system of community care at Oranje Hospital in Bloemfontein. Outpatient clinics were established at most hospitals, and legislation in 1976 made provision for a community service in country areas associated with particular psychiatric hospitals. Peripheral outpatient clinics were established in many parts of the country which catered mostly for patients who had been discharged from hospital, but also for newly referred patients.
Tara also pioneered the training of specialist psychiatrists, ofwhom there was an acute shortage in South Africa. Apart from a few inprivate practice, most of whom had been trained overseas or practisedjointly as neurologists, and a few senior psychiatrists in mentalhospitals who registered when the specialist register of the SouthAfrican Medical Council was instituted, most psychiatric hospitals werestaffed by medical officers who gained their experience in the workingsituation.
The first South African academic training was initiated at theUniversity of the Witwatersrand in 1949, leading to the Diploma ofPsychological Medicine with specialist registration thereafter. Thiswas based on the equivalent British qualification and was associatedwith registration for the MMed degree. Seven candidates had graduatedin 1951, a second group in 1952, and similar training programmes weresubsequently established at all South African medical schools. About 20psychiatrists are now registered annually with the South AfricanMedical Council. It was soon realised that a diploma was notappropriate for this important medical discipline, and the Fellowshipof the Faculty of Psychiatry of the College of Medicine was created in1961.
The first full-time post of Professor of Psychiatry (Professor LHurst) in an academic department was created in 1954 in a jointappointment between the Transvaal Provincial Department of Health andthe University of the Witwatersrand. Academic departments and thefulltime appointment of professorial and other staff followed at allmedical schools.
A significant development was the action of the Department of Healthin 1974, beset with an overload of chronic patients and a shortage ofbeds in its psychiatric hospitals, to transfer large numbers of chronicpatients to a private health server known as the Smith MitchellOrganisation. Objections were raised in some quarters, as a largeproportion of the patients were black, but the Society of Psychiatristsand an investigative team from the American Psychiatric Association,were satisfied after full inspections that the facilities and serviceswere acceptable. This freed up many hospital beds, allowing psychiatrichospitals to concentrate more on acute illnesses and intensivetreatments. However, pressure on psychiatric hospitals soon built upagain.
The role of the Society of Psychiatrists in the story of psychiatry in South Africa is significant.7 Its origin had been first a combined group of psychiatrists,neurologists and neurosurgeons of the Medical Association of SouthAfrica, formed in Johannesburg in 1953, which soon thereafter splitinto separate specialities, each retaining its own identity. TheSociety of Psychiatrists was formed in South Africa in 1962. TheSociety has established branches in all provinces and has made animportant contribution to the needs of psychiatric patients and theprofession, acting as a pressure group for the mentally ill and holdingregular conferences and meetings on academic topics and importantissues of the day. Under its revised name, the South African Society ofPsychiatrists (SASOP), it now celebrates its 60th anniversary.
In common with other medical disciplines, psychiatry had to functionwithin the legislative framework of a oppressive apartheid regime thatenforced the segregation of black patients and subjected them toindignities and restraints. SASOP made many public representations togovernment and responsible controlling authorities regarding abhorrentpractices and legislation that affected the mental health of theirpatients, e.g. the care of political detainees, and the effects ofthese enforcements on the mental health of individuals affected by theinfamous Immorality Act, the Mixed Marriages Act etc.7 Numerous psychiatrists tried to mitigate some of these effects onindividual patients. The Society has maintained high ethical standardsand remains committed to the Declarations of Hawaii, Tokyo and Helsinki.
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