I like to tell my psychiatrist about my bad dreams. I lay out the details for her: corpses in bed next to me, gouts of blood pouring from my vagina, women hanging by their necks from the rafters. I tell her how I wake in the night, shaking and sweating, and often close my eyes only to sink right back into the dream. She listens, as she always does, with a look of gentle concern on her face. When I’m done, she typically does one of three things: increases my dose of vortioxetine, increases my dose of bupropion2, or increases my dose of esperide3.
She does not do this because of the content of my dreams. I know this. She manipulates the level of medications in my blood based on other, mundane things, such as how many times a week I shower or how long it takes me to get out of bed in the mornings. But I tell her about my dreams anyway because doing so makes me happy. It makes me feel like I am the latest in a long line of hysterics, stretching back all the way to Ida Bauer. It makes me feel, in other words, that my madness has a pedigree.
I am a medical student. Some time next year, I’ll be a doctor. In other words, my proximity to doctor-hood confers upon me a great deal of power. Here, where patient-centered care is taught but never practiced, the doctor is an authority. The doctor heals the sick — their word is their patient’s law. The medical student stumbles, puppy-like, towards the same role. The medical student is groomed, moulded, polished for authority.
I am a medical student. I am also mentally ill. I have been for a very long time, and probably will be for the rest of my life. After all, I know my prognosis.
These things are not meant to go together. The doctor — oath-swearer, pillar of the community — must be rational in the extreme. The doctor must think clearly and without bias. The doctor cannot dream of corpses in bed next to them. The doctor cannot fail to get out of bed because their legs feel like two heavy concrete pipes. The doctor cannot temporarily lose the ability to parse complex thoughts because their head feels full of a thick, dark liquid.
The doctor cannot subsist on yoghurt and crackers because they cannot go grocery shopping because they cannot leave their flat. The doctor cannot flinch as if they have been struck every time a stranger lays eyes on them.
The doctor cannot eat until their stomach hurts, then bend over the toilet and stick their finger down their throat.
I was working in the female high-care unit of Psychiatric Hospital X, and I was bored. This was a problem, because psychiatry was supposed to be My Thing, the thing I excelled at, the thing I would eventually specialize in and continue to do for the rest of my life. But just then, it seemed very dull. I flipped through folders and scribbled down notes and made phone calls, the endless tedium of healthcare. The patients did not rouse me from my boredom because they were all the same.
Well, not really. The women in the high-care unit had any number of pathologies between them. I saw women with schizophrenia, bipolar disorder, schizoaffective disorder, methamphetamine-induced psychosis, and so on. They presented in all sorts of ways. They told me a number of things.
“Yes, I was running down the street with a knife, to kill him. I wanted to kill him.”
“No, I don’t have any special powers. I don’t remember saying I had any special powers.
But maybe I was confused.”
“Yes, tik. When I can get it. But I can’t always get it.”
“The voices come from outside, through the windows. There are three voices. Sometimes they say mean things.”
“God chose me. He chose me as his prophet. I don’t want to talk to you any more because I know you don’t believe me.”
And so on and so forth. The common refrain though was always the same: can I go home now? The women wore their brown and pink uniforms, often too big for them. When can I go home? They were kept separated from the staff by plexiglass, dividing walls, locked metal gates. There’s nothing wrong with me, so can’t I go home?
They repeated it over and over, a Greek chorus of antipsychotic-slurred voices, and I was bored to death, and sick of the whole thing. As far as I could tell, just about every patient in the high-care unit was there against their will, committed involuntarily by concerned family and friends. They could only go where the nurses said they could. When they wandered too close to the exits the security guards would glance up from their cellphones and give them warning looks. We were keeping those women locked up against their will, but we were doing it for their own good. This was so obvious that nobody had to say it out loud.
Later, back at my flat, I’d lie in bed (I did very little besides lie in bed) and think about psych wards. My psychiatrist had suggested I institutionalize myself, back when things were bad, but I had weaseled out of it. The idea of being woken early in the morning so I could take my meds before attending group therapy sessions with a flock of other miserable women did not appeal to me. Anyway I couldn’t be in a psych ward — I was working in a psych ward. It was like two sides of a coin that I was flipping, over and over.
“The chemico-biologization of mental illness,” Mark Fisher wrote, “is of course strictly commensurate with its de-politicization . . . all mental illnesses are neurologically instantiated, but this says nothing about their causation.” After I read that in his book Capitalist Realism, I was so grateful that someone had put this into words for me that I googled Mark Fisher to learn more about him. I discovered that he’d killed himself back in 2017. That made sense to me.
Fisher was arguing for a political model of mental illness. He interpreted what he called “the pandemic of mental anguish” as a response to the global madness of late capitalism, whose exhaustive grip on modern human beings is both cruel and unnatural. Instead of thinking about mental illness — depression, for example — as having a biological cause — such as low levels of serotonin — we should consider the structural and social issues that induce those low serotonin levels in the first place.
This is not a particularly popular approach. In the latter half of the twentieth century, the era of Prozac and the DSM-III, psychiatrists turned away from the old embarrassing methods of Freud and Jung and reinvented themselves as scientist-clinicians who work with the brain and all its unfortunate fluids. That brain-focused model is popular among laypeople too. I have lost count of how many patients have explained to me, when asked how they interpret their illness, that they have “an imbalance of chemicals in the brain.” It is an easy explanation. By shifting the onus from the psyche to impersonal molecules misbehaving in the synapses, the individual — their personality, their strengths, their weaknesses — ceases to matter. This dissipates some of the self-stigma that many mentally ill people experience: the self-loathing, the “why can’t I just be strong enough to cope”, the memories of relatives wasting away in old asylums. It’s a good way for them to explain what’s going on without being looked at askance. My friend P. once tweeted a meme of Ina Garten, the Barefoot Contessa, cheerfully saying, “If you can’t make your own serotonin, store-bought is fine.”
But I sat in that ward at Psychiatric Hospital X and listened to the stories the patients told me. The girl my age who explained to me that her step-brother, who she’d tried to kill in a sudden fit of rage, had previously threatened to rape and murder her if she spoke to him rudely. The intellectually disabled woman whose boyfriend beat her and regularly allowed his friends to gang-rape her, but who continued to go back to him every time she was discharged from hospital because she was convinced he was her soul-mate. The woman who was convinced that her jealous neighbours were casting curses on her to make her skin darker, make her look less beautiful, less like the whites she had strived to emulate all her life. The unwanted pregnancies. The drugs they’d started using in primary school. The dead mothers and the lost jobs and the bare cupboards. The men, the men, the men, the men.
I wanted to take them by the shoulders and scream of course you are miserable. Of course you are paranoid. Of course you hear a voice telling you to kill yourself. Of course you want to die. The world has been so cruel to you that no-one could expect you to bear it. If you have gone mad YOU ARE RIGHT TO HAVE GONE MAD.
It’s not that simple of course. To be mentally ill is not a revolutionary act. At least, it’s not a useful one. An illness is something that causes pain and suffering; many illnesses lead to death. The motto of Psychiatric Hospital X is sometimes to cure, often to relieve, always to comfort. It is the duty of the doctor — of any health worker — to alleviate suffering where they see it.
It certainly doesn’t feel like you’re alleviating suffering when your patients beg you, over and over, to let them go home; when they tell you they hate this place, they hate the people here, the hospital is making them sicker. It feels like you’re a prison warden. I’m expected — I cannot believe that I am expected — to reconcile a person being held down and injected with antipsychotics against their will with comfort.
But I have to do it.
I can’t do it. I have to do it.
In medical school, you learn to be cruel. Well, rather, you forget how to be kind. Whatever gentleness you had is stripped away by years of all-nighters and grueling exams and endless calls, the stink of formalin and shit and placenta, the casual verbal abuse by superiors. You get tired and disillusioned; small talk and smiles and bedside manner become more and more of an effort. Little by little, you stop seeing people and start seeing patients, undisciplined and diseased bodies which must be dragged back to normalcy.
Bruce Levine argues that “becoming a psychologist or psychiatrist means jumping through many hoops, all of which require much behavioral and attentional compliance to authorities … the selection and socialization of mental health professionals tends to breed out many anti-authoritarians.” Once you’ve jumped through enough hoops, of course, you become the authority your patients should comply to; “resistance to … diagnosis and treatment create(s) enormous anxiety for authoritarian mental health professionals,” and these disobedient patients are damningly labelled as non-compliant, the term in their files warning other health workers of the patient’s rebellious tendencies. Nobody likes a patient who argues or disagrees or refuses treatment. Just let me do my job, you want to scream, sleep-deprived and hungry, just do your job and let me fix you like you’re supposed to be fixed. I know what’s good for you. I know better.
No one, of course, is as non compliant as the psychiatric patient being held against their will. Yes of course we lock them up, we say, if we let them go home they’re going to kill themselves. Yes of course we tie them down to the bed, if we don’t they’re going to hurt themselves. Yes of course we force them to take their medication, even if it makes them sick, makes their speech slur and their hands shake. If we don’t . . .
. . . if I don’t take my medication, my death drive kicks into gear. I start to fantasize about how it would feel to put a gun (I have never fired a gun) to my temple and blow my brains out, what a relief, the ultimate trepanation. I spend long hours in bed and in the shower, weeping, tearing at my own skin. Sometimes I can’t read or write, can’t string two words together, I’m weighed down by a sort of cosmic grief. Wouldn’t forcing me to take my medication, then, be a kindness? Wouldn’t taking away my autonomy, caring for me without my consent like I’m a badly-behaved child, be a kindness?
Aren’t we being kind?
We’re being kind, I think, writing a referral to a social worker so that my patient can get a child support grant, R420 a month, yes, that will certainly alleviate suffering.
We are the kindly ones.
Of course, it’s impossible to talk about psychiatry in South Africa without talking about Life Esidimeni. I’ll briefly summarise: the Gauteng department of health had a contract with Life Esidimeni, a group of privately run psychiatric facilities which housed close to two thousand mentally ill and intellectually disabled patients requiring chronic care. In late 2015 the department ended this contract in an effort to “deinstitutionalize patients” — a worthy goal, perhaps, even if the real reason was more likely to save money.
Either way, countless patients were rapidly transferred from Life Esidimeni: some were returned to their families, some were shifted to new hospitals, and approximately 1700 of them were moved — transported in trucks — to various care homes run by (unregulated and unprepared) NGOs, many of which were unlicensed. The results were swift and predictable. Family members who visited found their loved ones starving, dehydrated, neglected and abused, often in overcrowded, understaffed and unhygienic environments. By 2017, 144 of our country’s most vulnerable patients were dead. Causes of death ranged from pneumonia and uncontrolled seizures to hypothermia and dehydration to the almost comical “natural causes.”
When Freddie Collitz died at the Mosego Home in Krugersdorp he had a head wound, blisters on his ankles and a sore on his nose. Deborah Phehla, an intellectually disabled woman who died at Takalani in Soweto, was found on post-mortem to have hard plastic and brown paper in her stomach, which her mother believes she ate because she was not being fed.
The scale of the tragedy is overwhelming. As the death toll climbed, it became more and more obvious that the patients were considered dead long before they actually died. The lives of mentally ill and disabled South Africans are disposable, less valuable than those of animals or insects.
In 2018, while the scandal raged, I was in my fourth year of medical school. I remember rotating through the emergency unit at Hospital Y, swapping stories during my lunch break with a girl my age who’d tried to kill herself for the second time in three days. She was in the habit of cutting words onto her forearms with a razor; I explained that I’d been in the habit of cutting the underside of my feet instead, with a pair of scissors, and that if she didn’t want to talk to the emergency-room doctors she might as well talk to me. I was the doctor, or something like that; she was the reluctant patient. More importantly, we were both young women with broken brains, who could bond over the desire to shed our blood. Eventually she asked for my number, because she liked me and wanted to meet up for coffee under better circumstances, and I had to explain to her that this wasn’t allowed. In other words I closed the iron gate of professionalism in her face. I was the doctor, she was the patient. There were miles of blood-soaked distance between us. We could not simply be two people talking because just then, I was more of a person than her.
“Do you ever see things other people don’t see?”
“Do you ever hear things other people don’t hear?”
“I used to, like I told you. But no. Not anymore.”
“All right. Ma’am, do you ever get a strange feeling that other people can read your mind, or know what you’re thinking?”
“Or do you ever feel like you can read their minds, and know what they’re thinking?”
That woman smiled at me nervously. She was old enough to be my mother. She was sitting before me with the attitude of a schoolgirl, determined to answer correctly. I’d explained to her that I was just a student, and that I wasn’t the one who’d make the decision to let her go home or not, but I knew she thought making a good impression on me was crucial. Like, maybe if I liked her I’d put a good word in with the doctors, or something. From across the table she tried to read my notes upside-down.
“No, no. I’ve never had nothing like that.”
I had another dream. In this one, I reported to the general medicine ward at Hospital Y to begin my rotation there. Before I could see my first patient something in my spine cracked, snapping me forward onto all fours on the dingy linoleum. It was more comfortable than being upright. I could move faster and more fluidly like this than I did on two feet. I threw my head back and laughed. I crawled out into the corridor and the patients left their beds to follow me like I was the Pied Piper. I woke unnerved and angry with myself, with the banality of my own subconscious.
I did not tell my psychiatrist about this dream. It was probably a waste of time, all this dream stuff — I figured I should stop pretending to be Freud’s Wolf-Man and stick to the facts. Instead, I told her about how I was cooking for myself more often and binging and purging less. She told me I was doing better, and I was pathetically grateful. It was like having a parent without the attendant mess of daughterhood. (This, incidentally, is called transference, the redirection of emotions felt in early childhood onto the substitute figure of the therapist.) So as not to disappoint her I didn’t bring up the fact that I’d been taking more of my antipsychotic than I should — that fuzzy, empty-headed feeling it brings an excellent respite from my constant tearfulness — and sometimes drinking myself to sleep.
Instead I said awkwardly, “I suppose I’m having trouble thinking about my career. I’ve spent the last few years putting up with med school so that I can be a psychiatrist some day, so I can help other mentally ill people, but, well … I know my politics are pretty far left, and I don’t expect you to agree with me, but …” I danced around the issue a while longer, suddenly too embarrassed to say words like anti-authoritarian and anarchist, before laying it out: I don’t know if I can allow myself to be part of a system in which people are held against their will for the crime of being mentally ill. I don’t know if the good I can do in that system will ever come close to outweighing the harm I will cause.
My psychiatrist looked at me for a long moment. I realised, suddenly, that this probably came off as rude: I’d insulted her career, her life’s work. Then she said, “Look, you know psychiatry is about more than that, right? You’re a medical student; they love throwing you in the deep end. It’s not all as bad as the Hospital X high-care unit. A lot of your patients will come to you voluntarily.” She paused. Then she smiled. “Maybe,” she said, “instead of practicing you could go into mental health research, or policy development. You know, try to change things.”
On 15 September 2020, most of the way through writing this piece, I OD’d on my antipsychotics. Surprisingly, this was an accident. I’d been on edge all day, swallowing pills to ward off a panic attack and I lost track of how many I’d taken. In the evening, the muscles in my neck and right arm began to contract painfully, distorting my stance, making it impossible for me to stand still or lie down. This was cervical dystonia, also called spasmodic torticollis. Dystonia (dys, abnormal; tonia, muscle tone) is a relatively common adverse effect of antipsychotic medication: involuntary movements caused by dysfunction of the brain’s basal ganglia. I had observed it in patients many times before. I stood in front of my bathroom mirror and stared, fascinated, at my writhing body, until the pain became agonising. I took an Uber to Hospital Z, where I contorted in a narrow bed and clenched my teeth around screams while the doctor on call phoned the poisons helpline for advice.
“I wasn’t trying to kill myself,” I assured her, between spasms, “I really wasn’t trying to die!” It was important to me that she understood that even though I was someone who had to take multiple psychiatric drugs on a daily basis, I wasn’t a psych patient. I was really a normal person who could for the most part perform basic human activities, such as going to the bank or doing laundry, without having to fight the urge to stick my head in an oven or walk into the sea. In fact, I was a medical student, just like she had once been. I was practically an arbiter of rationality.
“But if you’re a medical student,” the doctor said dryly, drawing something up in a syringe, “you should know not to mess around with drugs like this.”
“I’m just fucking stupid,” I muttered, then shrieked as my neck extended and dragged my back into an arch.
“Don’t be too hard on yourself,” she said, and gave me an injection of benztropine, a drug which forces the basal ganglia to behave themselves. This was followed up by intravenous midazolam, a fast-acting benzodiazepine beloved by hysterics everywhere. Afterwards, surrounded by beeping machines, I sank into dreamless sleep.
The next morning I was sent off to a certain Psychiatric Emergency Unit for an evaluation, because no matter how many times I explained that I’d overdosed by accident, nobody believed me. A history of depression, it seemed, could only lead to one possible outcome. I saw “acute dystonia, ?psychotic features, paranoia” on my referral letter and was incensed. I sat on a hard plastic chair as a bored medical officer asked me a handful of questions, scribbling down things on a form I couldn’t see. I would later find out that he’d involuntarily admitted me because he believed I was in danger of harming myself. This was frustrating. He hadn’t bothered to ask me whether or not I wanted to be admitted — he’d just assumed I’d refuse and so went straight over my head.
The worst part was that he was right. Of course I would have refused.
As a medical student, of course, I was treated better than most of the patients in the Psychiatric Emergency Unit. I was given a private room to make sure there was no chance of other students seeing me during their rotations. The nurses were cheerful and kind, even when they took away my phone and laptop and clothes. The psychiatrists joked around and reminisced about their time in medical school. “We’re worried about you,” they said. I was asked over and over if I’d intended to kill myself. Over and over, I said no. I slept fitfully. I ate bland food with a plastic spoon. I cried once, when nobody was around. I watched the other patients from a distance, guessing at diagnoses. I recognized the writhing movements of mild dystonia in some of them. Now, I thought glumly, I knew what that felt like.
By this point I really was paranoid. What if I forgot how to act like a normal person in front of the psychiatrists? Worse, what if I wasn’t a normal person and was just too obtuse to figure it out? I watched my every move and every word that came out of my mouth, which probably made me seem even more suspicious. What if I ended up on all fours, crawling? I replayed every conversation I had with the doctors in my head. Had I said anything that suggested I needed a long admission? What would my parents think?
I was jumping at shadows. I wanted so badly to get out. Nothing seemed worse to me than the possibility of staying there, in that yellow-walled yellow-floored room where we were all revolving clumsily around each other. On another day I might have strode into the Psychiatric Emergency Unit cheerfully, with my scrubs on and my stethoscope around my neck, but on that day I was wearing a thin blue gown long enough so that I kept almost tripping over, and I was cold and miserable and staring, longingly, through the window at the road that led down to my apartment.
I was well aware of the irony. It tasted awfully bitter.
When I finally talked my way out of the 72-hour psychiatric hold and into a discharge, I was so grateful I wanted to hug someone. Of course I didn’t, because hugging is unprofessional, and in the psych ward professionalism bulldozes all the delicate vulnerabilities of the human brain.
Psychiatry is like bandaging a bullet wound. Maybe it hides the worst of the damage, makes it look pretty, soaks up a bit of blood and distracts from the pain. But there’s still a bullet in there, and you’re not really going to be alright until the damn thing comes out. And the bullet is the 30 percent unemployment rate. The bullet is how one percent of South Africa’s population owns 67 percent of its wealth. The bullet is the three South African women (on average) who die every day at the hands of their intimate partners. Yes, the bullet is the 144 mentally ill and intellectually disabled people who died of neglect before anyone noticed that something was wrong. You know what I mean, don’t you?I say I need a psychiatrist, but what I mean is I need a revolution. That’s how it is.
Maya Surya Pillay was born in Durban, South Africa. She is currently a medical student at the University of Cape Town. Her writing has appeared in Ja. Magazine, Type/Cast, New Coin and the Johannesburg Review of Books, among other places. She can be found on Twitter as @canefires.
Feature image by Steve Johnson on Unsplash