Creative care for mental health patients

This post is the fourth in a series of posts reporting on the World Psychiatric Association (WPA) International Congress 2016, which I attended in Cape Town in November.

When Promise co-founder Dr Manaan Kar Ray was punched in the face in 2006 by a patient with whom he believed he had a good rapport, he found himself ashamed, mentally exhausted, and anxious about doing his job.

A second incident, in which a patient smashed a glass ashtray against a wall and chased him down the corridor, exacerbated his stress.

Today, years later, he has acknowledged the assault and the subsequent reflection provided him with a different frame of reference as to how mentally ill patients viewed the use of restraints in their treatment and whether, in their eyes, this constituted unprovoked violence.

Dr Kar Ray spoke at the WPA Congress. Together with Expert by Experience Sarah Rae, he created Promise, a proactive care initiative aimed at seeking out and embracing new ideas and, in the interests of patient-centred care, working to develop compassionate and creative alternatives for the care of patients with mental illness.

This was inspired by 2013 research that found huge variation in the use of restraint across England, with one centre reporting 38 incidents and another more than 3,000. There were also concerns about the face-down, or “prone” restraint method, plus related injuries, which numbered more than 1,000 in a single year.

Kar Ray, also a consultant psychiatrist at Fulbourn Hospital in Cambridge in the UK, pointed out that the use of mechanical constraints was commonplace in Europe and the developing world, and that he was sure “we can do better than this”.

“Our vision for Promise is to promote dignity by eliminating coercion in mental health. We need to have the courage to challenge the status quo, and not accept that because things have been this way for a long time, we should carry on this way,” he told delegates attending the congress.

Promise started with five founding members, are now thirty strong, and are constantly attracting more people keen on sharing and celebrating good practice. For caregivers, Kar Ray stressed that Promise’s message was clear: “We must contain the situation to keep patients and caregivers safe. But every time we lay hands on a patient is an opportunity for us to think whether there was something better we could have done upstream, ahead of the situation developing. If we can enhance the patient experience, maybe those situations don’t necessarily have to happen in the first place,” he said.

The Cape Town Promise Charter was signed following the session, and Kar Ray said this would help raise questions here, too, about whether restraint was indeed a necessity in the care of people who are mentally ill.

“Perhaps it’s not a necessary evil. Perhaps we are just stuck in the limitations of the past. And perhaps we need to shift out of that mindset, into a future full of possibilities,” he said.

The previous post in this series covered how psychiatrists can help break down the walls of racism and discrimination. My other reports from the WPA include an exposition of psychiatrists’ implicit contract with society, as well as African Union Commission Chair Nkosazana Dlamini-Zuma’s address at the opening ceremony of the WPA Congress, in which she called for international organisations to place more emphasis on mental health funding and activism.


Psychiatrists can help break walls of racism and discrimination

This guest post written by journalist Munyaradzi Makoni is the third in a series of posts reporting on the World Psychiatric Association (WPA) International Congress 2016, which I attended in Cape Town in November.

As racism and discrimination grow, global society is “a few words before a world war,” but psychiatrists can help fight the problem, an expert said at the World Psychiatric Association Congress.

“Racism and discrimination cause poor mental health,” Professor Levent Küey, Associate Professor of Psychiatry at Bilgi University in Istanbul, Turkey told the congress. In theory, the practice highlights the obstruction of people’s capacity to perform, it speaks to power control, denial of educational opportunities, the limitation of socioeconomic opportunities, and condemns people to poverty he said.

Küey, the author of The Book of Peace 2015, says border walls perpetuate discrimination and racism across the world. “What really has changed after the Berlin Wall came down?” he questioned. Küey noted that research had revealed that by 1989, 16 countries had border walls and by 2015 the figure had risen to 67. “A third of countries are building walls on their borders,” he said, adding that walls encourage fear or feed hate.

According to Küey, the “wall disease” was growing, entrenching discrimination as walls simultaneously banished people outside and imprisoned those inside them. “In the coming years, I’m afraid there will be more suffering as a result of these walls,” he said. Newly-elected U.S. President Donald Trump has been emphatic about his plans to build a wall between Mexico and the USA.

Küey said that in the 19th century racism was “authenticated” through scientific studies as “evidence” was produced to show that one race was better than another. Those attitudes persist. In 2014, for example, Nicholas Wade wrote a book which said some racial groups had genes that made them incapable of grasping certain mental skills.

Discriminatory behavior that has seen people split according to race, ethnicity, gender and religion has caused immense suffering to humanity. Worse, Küey maintained, it complicates emotional response. For instance, when self-discrimination is internalised, it is the hardest thing to overcome.

Mental health professionals have the expertise to deal with discrimination problems through anti-stigma studies and public awareness efforts, according to Küey. Education alone may have some effect, but it is limited. Using experience alone may have negative effects. Experience combined with supervision could have the best effect, he suggested.

“Psychiatrists must start challenging racist attitudes in their daily practice,” Küey said, adding that one way of doing that was to increase the competences of experts who understand cultural differences, class and gender.

The previous post in this series covered African Union Commission Chair Nkosazana Dlamini-Zuma’s address at the opening ceremony of the WPA Congress, in which she called for international organisations to place more emphasis on mental health funding and activism.

Call for mental health activism

This is the second in a series of posts reporting on the World Psychiatric Association (WPA) International Congress 2016, which I attended in Cape Town in November.

African Union Commission chair Nkosazana Dlamini-Zuma pulled no punches at the opening ceremony of the Congress, urging the World Health Organisation (WHO) to back them in a bid to see the World Bank switch from loans to grants to fund health projects globally.


“The World Bank shouldn’t give loans for health, they should give grants for health. And we hope the WHO shares that view,” Dlamini-Zuma told hundreds of delegates at the conference which was held at the CTICC in Cape Town in November 2016.

Her comments followed an address by Dr Shekhar Saxena, director of mental health and substance abuse at the WHO, who announced that the World Bank had committed, following a meeting with the WHO in April, to supporting mental health in a far bigger way.

The main message was that any country applying for World Bank loans for health projects would have to ensure a mental health component was included.

Continuing the call for activism for the mental health cause, Professor Dinesh Bhugra, president of the World Psychiatric Association, told the audience they had launched a Bill of Rights for those with mental illness in the House of Lords in London two weeks earlier.

A of total 61 organisations around the world had signed it, and the South African Society of Psychiatrists had indicated it too would sign the document.

“I need every bit of help from everyone here to change the way we treat our patients, who are the most vulnerable,” Bhugra said.

Earlier in his speech, Bhugra revealed the World Psychiatric Association had just completed a global survey of 193 countries, which threw up shocking results. These included that people with mental illness could vote in just 11 percent of the countries surveyed, that they enjoyed no employment rights in more than half the countries, and that 42 percent of the nations prevented those with mental illness from entering into any kind of contract, including signing a will or inheriting property.

“There are people from 92 countries here, more than half the number of countries that participated in the survey. I appeal to you all to use any power you have to change attitudes, to make sure those with mental illness are able to lead fully functional lives in communities without discrimination and stigma. Let the movement begin here,” the professor urged.

Saxena added, meanwhile, that the WHO had the necessary ammunition in the form of research and statistics, to back anyone fighting the battle for better mental health services and facilities.

They had proved, he told delegates, that any investment in mental health was just that – an investment, rather than a drain on resources.

“Every effort in mental health pays back much more than the investment. We have evidence of that and we will give you that ammunition you need,” he said.

Addressing the case for Africa specifically, Dlamini-Zuma pointed to WHO statistics which indicated that 40.5 percent of countries globally had no mental health policy, in spite of estimates that one in every four people would suffer a mental health condition.

While there were an average nine psychiatrists to every 100 000 people in the west, the comparative figure for the African region was just 0,05 per 100 000 people.

“We need a pan-African movement to ensure there is no discrimination against mental health patients, and we need to develop programmes and proper policies around mental health,” she warned.

As a continent, Africa needed to not only update existing mental health policies and community-based interventions, but to see these formalised at AU level.

With the enormous lack of human resources, Africa also had to find other ways of helping improve mental health, without relying exclusively on psychiatrists.

“In Africa we cannot rely on Western models where there are abundant resources. We need to look at creative ways of using what we have,” Dlamini-Zuma said.

But what should never be lost sight of was the importance of treating mental health patients with dignity, and working to break down the stigma hindering treatment across the globe.

“With health, the economy can’t grow … We can’t do anything without health,” she said.