As an overwrought Johannesburg continues to address rampant apartheid hang-ups, the responsibility of ensuring citizens’ equitable access to mental healthcare often falls on under-resourced, overburdened, yet empathetic providers struggling to meet demand.
If you’re looking for mental health support in Johannesburg, where exactly should you turn? Should you ask people you know for help – and would they judge if you did? Should you head to the nearest clinic, unsure if they’d assist with an invisible problem? What if you can’t afford help or medication? What if you’d rather look up alternative options online? How would you know the right service to select when seemingly infinite options appear in a Google search for “psychologist Johannesburg”? Although it’s been 30 years since the end of apartheid, South Africa’s young democracy is still trying to escape the shadows left by unjust and inhumane policies. These shadows not only obscure economic equality, but persist through generational trauma, haunting the collective psyche of South Africans to this day. To explore how Johannesburg, the country’s most-populated city, could set a national blueprint ensuring adequate mental healthcare access, we must first understand the people behind the service who navigate through troubled waters, trying to make a difference.
The promises of post-apartheid mental healthcare
For South Africa to overcome its traumatic past, it is essential for all citizens to have equitable access to mental healthcare. This principle was acknowledged by the country’s first democratically elected government and is clearly articulated in the policies it introduced.
On December 10 1996, then president Nelson Mandela signed the newly drafted South African Constitution, which became the “highest law of the land”, acting as the direct reference and regulator of all subsequent laws and policies. The Bill of Rights, contained in its second chapter, was drafted as a tool to define and monitor South African citizens’ human rights. Two enshrined rights that concern the state of mental healthcare are the right to “equality” and the right to “human dignity”. These are essential reference points, because they highlight the emphasis the government placed on ensuring that all citizens have equal access to adequate healthcare.
This broad emphasis on health was refined to address mental health concerns with the passing of the Mental Health Care Act in 2002. Among other stipulations, the Act promised to ensure that “various categories of mental health care users” were granted “[co-ordinated] access to mental health”. It also aimed to integrate mental healthcare “into the general health services environment”. For countless generations, previous governments blatantly mistreated the majority of South Africa’s citizens; in contrast, the introduction of these regulations acted as a sign of the new government’s solidarity with them.
However, despite these various renewed governmental policies, the tangible challenges that South Africans continue to face on a day-to-day basis, whether crime, economic pressures or systemic inequality, can muddy the public’s idea of mental healthcare. Because mental health is largely intangible, “fixing” a mental health issue feels more like a luxury than a necessity. This reticence to seek help means that 75% of South Africans actively struggling with mental illnesses do not receive the help they need. Meanwhile, the abundance of everyday stressors can be exacerbated by people’s mental health issues, trapping these seemingly dissimilar problems in an indefinite loop of re-aggravation.
In 2023 South Africa ranked third last of all measured countries by average mental health quotient, which is an online assessment tool used to “provide [a] comprehensive assessment of mental wellbeing”. The Mental State of the World report also found that South Africa had the second-highest proportion of respondents classified as “distressed or struggling”. These rankings are concerning, particularly considering the emphasis placed on improving the quality of, and access to, mental healthcare in the previous decades.
The incongruence between well-meaning government policies introduced in the hopeful past, and the current reality of overwhelming mental health issues that have not been addressed, is a theme that has persisted in Johannesburg and manifests in damaging ways.
Life Esidimeni: How to learn from the recent past
There is no mental-health policy failure in Johannesburg in the past 30 years that stands out as glaringly as the Life Esidimeni tragedy, when the most vulnerable people in society were neglected and left to rot as a consequence of government action.
In 2015, the Gauteng department of health cut ties with the Life Esidimeni hospital, which provided extended care and housing to thousands of psychiatric patients. The department of health aimed to relocate these patients to various nongovernmental organisations (NGOs) across the province. This decision followed the department of health’s recently introduced Mental Health Policy Framework, which, from 2013 until 2020, aimed to develop “community-based” mental health services like NGOs by deinstitutionalising mental healthcare services like Life Esidimeni hospital. However, this decision could also be explained more simply by the department’s need to “save costs”.
In a vacuum, these promises of governmental support and collaboration with NGOs appear to be beneficial developments for impoverished communities struggling to provide adequate healthcare. However, in reality the NGOs these patients were relocated to were not properly screened, either being woefully under-equipped or “fraudulently approved” to house psychiatric patients. This ignored the department’s framework to ensure citizens with access to adequate mental health services through “[the establishment of] a monitoring and evaluation system”. This mass rehousing ultimately resulted in 144 psychiatric patients dying from neglect and improper care.
This lack of mental healthcare access and resources is particularly damning given that the Life Esidimeni tragedy occurred in Gauteng, South Africa’s wealthiest province, which houses 45% of all registered South African mental health professionals.
In the aftermath of the tragedy, the department of health’s revised Mental Health Framework, has sought to address the issues overlooked by the previous framework, now promising to ensure that “community mental health services will be scaled up to match recommended national norms”. Recently, Gauteng MEC for health and wellness, Nomantu Nkomo-Ralehoko, also committed almost half a billion rand to “improve mental-healthcare infrastructure and services across the province” this financial year.
A renewed focus on mental-health services appears to be a step in the right direction for Johannesburg. However, will this promise truly serve to assist those on the front lines of mental healthcare in the city, or will it simply prove empty once again?
Policy and regulations touting to improve mental healthcare access are an important first step, but they cannot stand on their own. The implementation of these ideas in real-world scenarios is the true test and, to understand the context in which they are applied, one must first understand the different types of mental healthcare in Johannesburg, as well as the various challenges the people running these facilities face.
The pathways to recovery
Unlike physical ailments, because mental illnesses are often ‘invisible’, it can be more difficult to grasp and confront them. The first step on the road to recovery is identifying the problem and realising the need to address it. The next step is often the most challenging: accepting that doing so requires external help. It can prove difficult to ask for help due to a variety of cultural and societal norms that create stigmas around mental healthcare.
Mental health stigma is rife throughout society: one place where they commonly persist and do much harm is within tertiary institutions. Universities are educational spaces, meant to inform and prepare students to tackle problems they face in the real world. However, according to the University of the Witwatersrand’s (Wits) Counselling and Careers Development Unit (CCDU), it is an ongoing process to deconstruct these stigmas during the time in people’s lives when they need the most mental-health attention. According to a study on adolescent mental health, it was found that 75% of people with mental illnesses develop their disorder before turning 24.
The CCDU is a free counselling service offered to Wits students, aimed at addressing mental-health concerns, as well as providing academic assistance and preparing students for life outside campus.
“People think that when you are seen coming to CCDU… you have problems,” says Lynette Sikhakhane, a CCDU psychologist. Sikhakhane says what stops many students from seeking out the CCDU is that “culturally… there’s a belief that you man up” instead of admitting to needing help. Highlighting a major misconception about therapy, Sikhakhane states that many students expect therapy to instantly “fix” their problems, when it is actually an incremental process of enabling self-understanding.
CCDU advocacy team leader, Vinoba Krishna says the unit aims “to incorporate the voices of students” into the mental-health assistance it provides. Part of this is dispelling misinformed expectations around counselling and therapy through effective communication and psychoeducation, as outlined in Higher Health’s mental health programme.
Krishna states that, despite the CCDU’s best intentions, “we aren’t able to do the work just by ourselves”, because of a lack of direct funding for mental health. He also emphasises the need to collaborate with “different stakeholders on and off campus” to ensure the best results for students.
The South African Depression and Anxiety Group (Sadag) has similar aspirations to help people in need and destigmatise mental health in South Africa in the face of limited resources. Sadag is a non-profit organisation that provides counselling via 24-hour toll-free emergency helplines and community-driven initiatives.
Fatima Seedat, a Sadag development manager, says that for all South Africans to have equitable access to mental healthcare “a collective effort” is required from the government, civil society and NGOs. Seedat argues it is impossible to follow the “beautiful strategic framework” outlined by the government when “every year the healthcare budget decreases”.
The treasury cutting budgets across the board this past financial year also affected the department of social development, which cut even more funding from desperate mental-health NGOs.
The lack of funding available to Sadag and other mental-health providers highlights the inequality of access South Africans face. Naledi Nzimande, a Sadag volunteer councillor, says that “the most challenging calls” are when she wants to refer callers to professional help, but there aren’t any mental health resources nearby. Stephanie Gladwin, also a Sadag volunteer councillor, reiterates that the level of mental healthcare individuals receive is, in many ways, directly tied to levels of income. “If you’ve got money, it’s not a problem… South Africa has some fantastic mental-health professionals – it’s just reaching them that’s the only issue,” she says.
To combat this unequal access, Sadag has installed counselling containers in Diepsloot and Ivory Park, where they offer face-to-face counselling inside converted shipping containers. Seedat says this project aims “to fill the gap where it’s needed” in vulnerable spaces in Johannesburg.
When comparing mental-healthcare access in the public and private sectors, the disparity between funding and resources is stark. For example, about 80% of South African psychiatrists work in private practice. Although most South Africans access mental healthcare through the public sector, private mental-health services that offer specialised solutions to fill niche gaps in care are also important.
Private music therapist, Graeme Sacks, who operates in Parktown, believes his practice enables him to be sensitive to his client’s needs. “We’re all musical beings… [and music therapy] is a wonderful way to tap into people’s emotions,” he says.
As Sacks puts it, music therapy is an “evidence-based practice”, which uses “music towards clinical goals”, but in practice it’s less stringent. He says, as a music therapist, it’s about concerning yourself with “the situation that [clients have] grown up in” by “trying to find out about their culture, their musical taste”, without ever “imposing our stuff on them”.
This tailored approach to therapy offers clients individualised care and, if music therapy were available in the public sector, it would be a practical means to provide many South Africans with the specific help they require. Sacks says that “most medical aids don’t pay for arts therapies” and that, currently, “there are no arts therapists in public health”. This absence of access to arts therapy is a missed opportunity for the public healthcare system to provide equitable access to a niche form of specialised care.
Some specialised care in the public sector is available, at Johannesburg’s Tara Hospital, which is a publicly funded psychiatric hospital. It provides specialised care to referred patients who cannot be adequately treated at secondary and tertiary hospitals.
Senior occupational therapist and acting assistant director at Tara, Savannah Levi, believes that in Johannesburg, and South Africa at large, “What’s so hard about accessing mental healthcare, is that there are so many points, but none of those points correlate or integrate with each other.” Levi argues that the policies and ideas meant to integrate a variety of services are based on sound frameworks, but their lack of real-world implementation highlights the “disconnect” between theoretical and practical application.
Levi says Tara’s specialised service offers “a very protective environment for the patients”, meaning that sometimes they “don’t want to leave”. This highlights the benefit that specialised care affords people in need which, in theory, all citizens should have access to. However, Tara has only 140 beds and limited staff due to the high level of training requirements and capped job availability.
A new destination
Despite the government’s multiple continued failings in the broad mental-health landscape, hope still persists in those people willing to take up the struggle. Mental-healthcare providers aren’t required only to help people experiencing mental anguish, they’re expected to do so while juggling external economic and cultural challenges, on top of taking care of themselves. Although well-meaning mental health policies are important, what’s even more important is that they are actually implemented. In the best interests of the South African citizens, it is essential for all stakeholders to minimise confusion and collaborate towards a single goal, so that the people who need help the most are not forgotten.
FEATURED IMAGE: COLLAGE: Nelson Mandela Bridge heading into Johannesburg CBD, an image of a Recovery Unit sign inside Milpark Hospital, and a box or reference documents intended to help SADAG counsellers deal with depressed adolescent callers. Photo: Tristan Monzeglio
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