Us, and them: time for a paradigm shift in African mental health policy

Posted on 10/11/2020
By Susan Fock-Tave

My name is Susan Fock Tave and I am from the Seychelles. Though a surgeon by trade, I had to give up clinical practice in 2014 on medical grounds, soon adopting the post of Principal Medical Officer in the Seychelles Hospital, the only referral hospital in the country. I was still finding my feet in this new position when I was asked to act as the Chairperson of the newly established National Mental Health Advisory Committee at a time when the national approach to mental health would be utterly transformed.

The Republic of Seychelles consists of 115 islands in the Western Indian Ocean with a population of just under 100,000. The right of every citizen to the enjoyment of the highest attainable standard of physical and mental health is proudly enshrined in Article 29 of our Constitution.

Seychelles, as is the case in many other countries, has its fair share of mental illness and mental ill-health. Discrimination and stigmatisation of people suffering from mental illness, though not rampant or institutionalised, is still a cause for concern. Until recently, persons with mental disabilities did not benefit from the social and financial protections reserved for those suffering physical disabilities. In 2006, the Mental Health Act marked a significant improvement on the Mental Treatment Act of 1906: disparaging language such as ‘Commissioner of Lunacy’ were ditched, and more decision-making powers were reserved for mental health professionals. But the 2006 Act still served to ‘protect’ society from mentally ill patients, and so did little to preserve their basic rights to dignity, privacy and autonomy. These contradictions meant that the act could never be fully implemented, which ultimately derailed progress.

‘disparaging language such as “Commissioner of Lunacy” were ditched, and more decision-making powers were reserved for mental health professionals’

A proposal to include Seychelles in a Pan-African project to review mental health legislation was welcomed with open arms. The project, led by the Commonwealth Nurses and Midwives Federation and funded by the Commonwealth Foundation, employed a multi-stakeholder approach–which meant that everyone who needed to play a part was included from the outset. The first step of the process was to establish a national advocacy group to pool experience and resources and agree on a piece of legislation, and so the National Mental Health Advisory Committee was born. Membership comprised mental health professionals, policymakers, a user of mental health services and a caregiver. This local working group was given technical support from Dr Soumitra Pathare, the Director of Centre for Mental Health Law and Policy at the India Law Society, and Ms Jill Iliffe from the Commonwealth Nurses and Midwives Federation.

Step two consisted of an assessment, not only of the 2006 Act but also of the legislative environment. This meant reviewing relevant legislation, policy documents and international conventions to which Seychelles is party. Most importantly, the 2006 Act was assessed for compliance with the Convention of the Rights of Persons with Disabilities, widely considered the gold standard for mental health legislation. The assessment was not favourable. In a presentation of review findings in October 2015, Dr Pathare summarised: ‘If you are a person with mental illness, you really don’t have a choice but to consent.’

‘No amount of tweaking could shift this paradigm. The recommendation, therefore, was to repeal and replace.’

Indeed, the 2006 Act appeared to be premised on the assumption that persons with mental disabilities have no capacity. Even when a person was determined to have capacity; their consent could be overridden by relatives or health professionals. And the consequences could be harshly punitive: unlimited ‘detention’ in a mental hospital–without the recourse of appeal. The only escape? Discharge at the discretion of a psychiatrist for ‘good behaviour’. Furthermore, the Act did not make provision for participation of persons with mental disabilities or their representative organisations in any of the regulatory bodies created under the Act. Ultimately, the Committee concluded that amendments to the 2006 Legislation could not change the fundamental spirit of the Act, which was designed to protect ‘us’ from ‘them’. No amount of tweaking could shift this paradigm. The recommendation, therefore, was to repeal and replace.

The result is the Mental Health Care Act of 2020, recently approved by the Seychelles National Assembly. It’s an exemplary piece of legislation that meets the high standards laid out in the Convention on the Rights of Persons with Disabilities, and in the words of that convention ‘it takes to a new height the movement from viewing persons with disabilities as “objects” of charity, medical treatment and social protection towards viewing [them] as “subjects” with rights, who are capable of claiming those rights and making decisions for their lives based on their free and informed consent’. I urge other African nations to build a collective will for change, draw on their own national mental health expertise, and enact reform. It’s my hope that the story of the Seychelles can inspire this cause.

Dr Susan Fock-Tave is Chief Medical Officer in the Seychelles Department of Health.


Reforming colonial-era mental health legislation

The prevalence of mental ill health is increasing worldwide. In many Commonwealth countries, colonial-era legislation needs to be updated and brought in line with the UN Convention on Rights of Persons with Disabilities.