Psychiatry at Valkenberg now –
In its present form, the psychiatric hospital in Cape people with mental health conditions and how they
Between the Liesbeek and Black rivers in Cape Town, Valkenberg Psychiatric Hospital’s original building, dating from around 1770, cuts an imposing silhouette. One of the area’s oldest surviving homesteads, it is three storeys high, light pink and has a steeply pitched roof and one tall turret flanked by dormers.
The shrubs around it are neatly trimmed, lilies bloom in winter-wet soil and guinea fowl chase each other around on the lawns.
Inside the historic building, now mostly used for administration, the head of the facility’s clinical unit, Dr Qhama Cossie, and deputy nursing manager Mapitsi Photo are seated at a small boardroom table. Photo checks the hospital’s records, confirming that there are 441 patients.
Available beds remain a challenge at the tertiary hospital, which is affiliated to the University of Cape Town (UCT). Admitting referrals only, the hospital consistently runs at full capacity, with long waiting lists. Its forensic waiting list at the moment is 14 to 30 days for minor offences and 14 months for serious offences. Hospital staff include 241 nurses, 11 psychiatrists, seven psychologists, 10 social workers and eight occupational therapists.
Earlier this year, the man accused of setting fire to the National Assembly and the Old Assembly in the parliamentary precinct, Zandile Mafe, was sent to Valkenberg for psychiatric evaluation. His initial mental health diagnosis was paranoid schizophrenia. He later applied to the Western Cape High Court to be sent for observation at a psychiatric hospital in the Eastern Cape.
Ins and outs of admission
Explaining the admission process for cases like Mafe’s and others, Cossie says Valkenberg has two options: clinical and forensic admissions.
“So patients enter through two different acts,” he says. “To be a forensic patient, you need to come through via the Criminal Procedure Act. So, if there’s a charge and there’s a question [about] mental illness, that person might be sent for observation.
“Let’s say there’s a crime but there might be mental illness involved. Then the courts rule that the accused has a 30-day observation period. Over 30 days, you are assessed by a psychiatrist.
“The decision they make can be that you’re fine, that you don’t have a mental illness, or that your mental illness did not influence your behaviour. Then you can go back to court and the court process can proceed.
“Or they might say that, actually, you’re not fine, you’re not well enough to appear in court. Or, at the time when you committed an offence, you were sick and influenced by the mental illness. So you go back to court, but the court process doesn’t proceed. You are then made a state patient.”
Then there are clinical admissions. “We have the general side, the acute side,” says Cossie, “where people come through under the Mental Health Care Act, under which you can either be a voluntary patient – where you have an illness and you want help, and you have the capacity to make this decision. Or you can be an assisted patient where you want help, but you lack capacity.
“And then there’s involuntary [admission], where
you
Above: Old equipment used for electroconvulsive therapy, one of the oldest and most controversial psychiatric treatments. lack capacity and you don’t want help, but you are deemed to need help.”
Managing risk
Cossie says mental healthcare 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 10% of mental health patients are referred to psychiatric hospitals like Valkenberg. “At the hospital, we manage risk. If the risk is low, then you can take treatment as an outpatient. But if the risk is high, that’s when you might need to stay at the hospital.
“The kind of risk varies. So there [are] people who are a risk to themselves; they might hurt themselves. There [are] people who are a risk to others, [and] there [are] people who are at risk from others, for example, someone who is vulnerable on the streets,” says Cossie.
The Mental Health Care Act was passed into law in 2004, a major juncture placing the focus on human rights and the humane treatment of patients. Cossie says the act has strict guidelines for aspects like mechanical restraint and seclusion.
“Back in the day, straitjackets and other restraining mechanisms were used. But nowadays we’ve got chemical restraints: medication. Someone who is very, very ill might need to be held down in order to give them medication, but even that is legislated.
“So if you do have to hold someone down, you have to report [it] to the mental health review board. And those forms go through to a high court judge.”
A glimpse inside
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.
In a more recent building, Photo guides us past a security guard into the clinical highcare unit, where male and female patients stay in separate wards.
The foyer is decorated with fabric applique art. It is quiet with empty grey laminated chairs – visiting hours are only later, from 2pm until 4pm. Rules for visitors posted against the wall dictate that no cellphones or cameras are to be used inside and no glass bottles or tins are allowed.
In the women’s high-care ward, 27 patients are presently being treated for various illnesses, including borderline personality disorder, schizophrenia and bipolar disorder. At the time of our visit, the patients are seated at tables having lunch. Many are wearing dressing gowns, handed to them because of the winter cold, a nurse explains.
The seclusion room, where patients might be kept while medication takes effect, has a mattress and a heated floor. Patients at high risk to themselves are not allowed to wear clothes inside the seclusion room, the nurse explains, as they might use the garments to hurt themselves.
‘Visitors should be careful not to make any promises to patients or to excite hopes that cannot be fulfilled,’ reads a rule
book from 1927
Past and present
In the administration building, Photo guides us past another security guard and along a corridor with wooden floors. Beyond an old marble fireplace and forensic observation consultation rooms is Valkenberg’s museum, where old equipment and surgical tools are on display, along with old staff photographs and framed extracts from a visitors’ rule book dated 1927.
“Visitors should be careful not to make any promises to patients or to excite hopes that cannot be fulfilled…” one reads.
Adjacent to the museum room is an old isolation room, its walls and door padded. A straitjacket with leather straps is draped over a chair next to a stretcher carved from