A community (dis)service: Reflections of a community service clinical psychologist

Economic activity of the client community

Given that the placement was situated in a semi-rural setting, in which the agricultural sector is the main contributor to employment, many of the patients seen were employed as farm labourers on a seasonal/temporary basis. Seasonal workers are paid less than permanent employees and do not receive any benefits such as housing or paid sick leave (Women on Farms Project & Centre for Rural Legal Studies, 2009). In addition, they are only remunerated for the hours worked and, as such, no work equals no pay.

Given these constraints, individuals employed on a seasonal basis frequently did not attend follow-up appointments as this came second to the priority of earning a daily wage. This meant that in these instances, therapeutic contact was terminated prematurely as a result of socio-economic challenges. This clearly illustrates that even though psychological services were accessible in that they were provided for in these communities, this particular patient population, who, by definition of their socio-economic profile, are intended to be the targeted beneficiaries of public health care facilities, were unable to access these services and as such were denied them.

It is, however, critical to pause here and to question whether the psychological service provision in the manner in which it was facilitated was responsive to the needs of this particular client community. Given the profile of the client community and taking into consideration the economic activities in which members of this community engage, should the mental health care provision not have been tailored to their specific needs so as to allow them to access the service in a manner that would be convenient to them and would not detract from their employment obligations? Here, the possibility of a mobile mental health care clinic could be explored, similar to the mobile clinics already operative within the ODM. This may ensure improved access for farm labourers, and particularly seasonal workers, to psychological services. Moreover, the tailoring of psychological services, and the provision thereof, with regard to enabling access, becomes even more fundamental within the ODM when one considers the paucity of public transport.

Public transport

The scarcity of transport also acted to prevent patients from accessing the psychological services provided. As per the socio-economic profile of the ODM (Provincial Government Western Cape, Provincial Treasury, 2007), 29% of the households surveyed indicated that transport was either not available or was located too far to be accessible. The lack of access to transport is further illustrated by less than 16% of all households surveyed having had access to public transport facilities within a 30-min walk. This means that approximately 84% of all households surveyed at that time did not have access to public transport services. As such, given the lack of transport and the socio- economic challenges confronted by the individuals within the ODM, many of them were unable to access the primary health care clinics within their communities as well as the services provided. Here, again, the point is emphasised that just because a service is provided and is available to a community, it does not automatically grant the community access to it, and if the service is not accessed by those for whom it has been intended, then it might as well be non-existent.

It becomes important for public health care providers to evaluate how responsive health care provision is to the needs of the client community. This may require the state to be quite innovative and to extend its practice beyond traditional parameters. Innovation will perhaps provide us with opportunities to ameliorate such barriers so as to ensure that the basic principle of access to health care provision is a given.

Referral process, intake, and case management

The appropriate access of the service was dependent upon whether the referring agent understood the scope of work of a clinical psychologist. Where the nursing personnel had been fortunate to undergo basic mental health care training, the referrals were often appropriate. There were instances in which the patients were not informed of referrals, nor had they given their consent in this regard. This is viewed with suspicion by the patient, which does not bode well for the formation of a therapeutic alliance, and in such instances, patients attended the initial session only.

The nursing personnel also held misconceptions of their own, particularly with regard to the number of patients that can be seen by a psychologist. As such, an additional component of the author’s work was to rectify these misconceptions and clarify the scope of practice of a clinical psychologist with the nursing personnel. It appears that this, too, has been the case for other community service clinical psychologists, who found that much ignorance still exists with regard to the role and function of psychology (Pillay & Harvey, 2006; Rohleder et al., 2006).

In the absence of psychiatrists and mental health nurses within the ODM, the author was tasked with having to see all patients who fall within the ambit of requiring mental health care services. In particular, the lack of these specialists appeared to raise anxieties in the nursing personnel. The nursing personnel frequently felt the pressure of having to contain and/or treat these patients in an already pressurised environment given the sheer volumes of patients who frequented the primary health care clinics on a daily basis. It is important to note here that this burdensome work environment has been found by Saraceno et al. (2007) to constitute a barrier to the integration of mental health services into primary health care systems, as nursing personnel, given their patient loads, do not possess the time to provide adequate care for patients who present with mental disorders (Grazin, 1999; Petersen et al., 2009).

This “pressure cooker-type” environment, in which the nursing personnel with limited knowledge with regard to mental health care found themselves, is likely to set off a panic reaction in any individual. In addition to this, as noted by Mkhize and Kometsi (2008), nurses within the primary health care system “did not feel empowered enough to deal with problems of a psychological nature” (p. 107), and one can understand why this anxiety resulted in the nursing personnel seeking containment for themselves via the referral of all patients presenting with what may appear like a mental health difficulty to the author. This emphasises how critical it is for generalised nurses located within a primary health care context to receive training in the identification of mental disorders and how to appropriately manage these, when, and if, required (Mkhize & Kometsi, 2008; WHO, 2001). After all, the development of a well-trained mental health care workforce will enhance the quality of mental health systems (Funk et al., 2009). This said, the author recognises that the nursing personnel may have, within their own practice, developed, tried, and tested coping mechanisms, aside from panicking, to manage such workplace stressors.

Lack of inpatient psychiatric facilities

In the absence of a dedicated psychiatric unit in the ODM, when patients were referred to the secondary hospital facility, they were admitted to the general ward and often discharged even if the author had recommended further psychiatric treatment. This renders much needed inpatient psychiatric care difficult and nearly impossible. In a situational analysis of the mental health services available within a South African rural district site, Petersen et al. (2009) also speak to the non-existence of a specialist unit for psychiatric patients and the fact that the management of these individuals within general wards proves inadequate.

While Pillay and Harvey (2006) are of the opinion that the placement of community service personnel in general hospitals “is a step in the right direction” (p. 269) as it offers such facilities the benefit of clinical psychology services, it is the author’s experience that, at a practical level, this complicated the case management of patients who required dedicated psychiatric care and the expertise of mental health specialists who are not readily available within general hospital facilities, particularly not within this placement site. Here, as argued by Jones (1998), what may be required, at an institutional level, is the development of the secondary hospital facility’s capacity to provide such inpatient care.

Given this context, the question remained as to how one would go about effectively case managing a particular patient when the care and support that they require are not available. For the author, it appeared that patients who were at their most vulnerable and who required support and treatment were, at times, left out in the cold (figuratively speaking) and effectively denied the treatment they required. This constitutes a human rights violation as the Bill of Rights speaks to the individual’s right to have access to health care services.

These limitations constitute a failure in the provision of a comprehensive public health care approach. In defining such an approach, Schaay and Sanders (2008), include as cornerstones, among others, “an integrated referral system, which facilitates the delivery of a continuum of care to clients, across different levels and places of care in the health care system without interruption; and the notion of multidisciplinary health teams” (p. 5). It is crucial, at this point, to reflect on the importance of multidisciplinary health teams, particularly given the fact that the author was placed in a district health system in which there were none. This meant that the care provided to patients was often not comprehensive and frequently did not fulfil all their needs, illustrating to the author that “[m]ultidisciplinary health teams are especially relevant in the management of mental disorders, owing to the complex needs of patients and their families at different points during the illness” (WHO, 2001, p. 56).

Here, the continuity of care for several patients was often interrupted and/or delayed due to resource constraints and/or a lack of specialist mental health services available within the ODM. Given these deficits in the provision of care, the author concurs with Saraceno et al. (2007) who, in reviewing barriers to the improvement of mental health services in low-income and middle-income countries, suggest that health care personnel located within the primary health care system should receive training in mental health and that this should be supported by the expansion of specialist mental health services at a community level.

Psychological care and therapeutic engagement

The quality of the psychological services provided was compromised by a number of operational limitations. The author was the sole provider of psychological services to 11 primary health care clinics, which diminished the quality of the therapeutic process in that follow-up sessions with patients could not occur as regularly and as consistently as required.

Essentially, with regard to the primary health care clinics located further away, follow-up patients could only be seen once every month, which is not sufficient for in-depth psychotherapeutic work. With regard to the primary health care clinics located closer to the administrative base, follow-up patients could, in theory, be seen every fortnight, which would provide some room for in-depth psychotherapeutic contact. However, in practice, this did not materialise, as due to the under-resourced context, there was often no space for follow-up patients as new patients had been booked by the nursing personnel 1–2 months in advance, in most instances. This meant that follow-up patients even at the primary health care clinics located closer to the administrative base could often only be seen once every 4–6 weeks.

Follow-up patients are considered to be those most in need of psychological care, particularly the continuity and regularity thereof. By failing to meet their psychological needs in terms of providing them with regular access to the service, they often attended the next session (4–6 weeks later) in crisis. As such, these patients were not provided with quality care as the service did not respond to their needs. In many instances, this delay in therapeutic contact increased the burden on other health care services in that hospitalisation was required and/or other health care personnel were called upon to assist with the crisis management of the patient. Here, when contrasted against the WHO’s (2003) definition of “quality,” it is clear that the practice within the ODM health system has fallen far short of this benchmark.

A focus on quality by the health system operative in the ODM would have, according to the WHO (2003), assisted in building trust in the effectiveness of the system by virtue of the fact that “[s]atisfactory quality builds societal credibility in mental health treatment [and] is the basis for demonstrating that the benefits of treatment for mental disorders outweigh the social costs of having such disorders” (p. 11).

It is disheartening for the author to have discovered that other community service clinical psychologists have also felt that the care they were able to offer their patients had been compromised by the very nature of their placement sites. Here, particular reference is made to Rohleder et al. (2006) who had completed their community service within the correctional services context and for whom the inability to appropriately assist patients “not only highlighted [their] isolation [from other mental health professionals] but increased [their] feelings of helplessness and futility” (p. 807).

Closely associated with the difficulty of engaging in quality therapeutic contact with patients, and a contributory factor to this, is the under-resourced mental health context in which this placement was located. As such, in the absence of a psychiatrist and a mental health nurse, medication management was also a task with which the psychologist had to contend. Here, this often included education as to the possible side effects of the medication; monitoring such side effects if they were present; monitoring the usage of the medication and if this is done according to the prescription; and finally, monitoring whether the prescription had been filled for the following month. Here, this task of medication management acted to reinforce the misconceptions that patients may have had with regard to categorising psychology within the biomedical model, as often this was a process that had to be repeated with certain patients at every visit, and as such, the opportunity for in-depth psychotherapy was lost.

The provision of mental health care within the biomedical model

Within the client community, it appeared that the biomedical model continues to be the frame through which mental health care is viewed and understood. This is not dissimilar to other parts of South Africa or to other developing countries, where, according to Mkhize and Kometsi (2008), “the provision of mental health services has remained deeply ensconced within the biomedical model” (p. 107). This location of psychological services within the biomedical model coincidentally places the psychologist in a position of authority, and this potentially embellishes the relationship to, and with, the patient in a particular way by emphasising the concept of power. This renders formation of a therapeutic alliance, which is regarded as cooperative in nature, problematic in that it raises the expectation that a psychologist would (and should) go about his or her work in the same way as a doctor.

Petersen, Bhagwanjee, and Parekh (2000), in outlining a schema for the provision of mental health care at a district level, stipulate that the biomedical approach to patient care is incompatible with the provision of mental health care at a primary health care level. Here, the authors argue that the biomedical approach is “narrow” in its conception and understanding of mental illness and as such acts to potentially alienate the patient in the process. Instead, Petersen et al. (2000) advocate for a more comprehensive approach to mental health care, “which understands illness as emerging out of an interaction of biological, cultural, psychological and social imperatives” (p. 799).

The author, too, is of the opinion that a more comprehensive approach to mental health care provision would lead to psychological services being better received at the primary health care level. Many of the patients appeared to grapple with the collaborative approach inherent in psychotherapeutic work with the expectation that the psychologist should hold all the answers and should “fix” them. Here, patients found it difficult to engage with the concept of long-term therapy, and as such, many of the therapeutic interventions were expected to be brief, and patients would often prematurely terminate therapy.

It must be noted that the author is cognisant of the fact that this is not a dilemma solely confined to the ODM but that confusion as to the role of psychologists exists generally. The point, here, however, within this particular site of practice, is that these misconceptions act to compound existing barriers to access rendering psychological service provision within this client community even more problematic.

Supervision and management

For the community service placement, clinical guidance was lacking due to insufficient supervisory capacity given that the supervisor had a limited understanding of the clinical practice of psychology. Here, the following management approaches to psychological services provision proved problematic and compromised the quality of the service.

Management insisted that the statistics provided for individual therapy engagements were reflective of a private practice framework. Here, it must be stated that within the 12-month community service placement, the author saw 643 individual patients. On a monthly basis, dependent on the location, season, and time of the month, this translated to a minimum of 51 and a maximum of 79 individual patients. Management was of the opinion that a public health model of service would reach many more individuals and as such advised that the emphasis should be placed on group-based work as opposed to individual-based work. The author is cognisant that as psychologists, we have to render our services accessible to a wider segment of the population, particularly within rural and/or marginalised communities. Group-based work may potentially (when executed appropriately) provide this platform. The author is convinced that the approach, in the manner in which it was envisioned by management, was insensitive, and certainly not feasible, given the particular difficulties of practising psychology within a semi-rural setting where confidentiality is cardinal. Here, unlike their urban counterparts, individuals within rural and semi-rural areas often live in a closely woven micro-cosmos where “personal secrets” have no place to hide.

In addition, it appears that management did not understand (or appreciate) the socio-economic context within which the ODM is located, as it was assumed that group-based work would reach many more individuals without due consideration of the fact that similar constraints would exist for group-based work as for individual-based work with regard to people’s ability to access the service.

Resources and institutional support

In light of the associated difficulties in providing quality psychological services, the author is of the opinion that the NDH should perhaps in designating placements for community service follow a more responsive approach. The NDH has to ensure that emerging health care professionals allocated to placement sites have the necessary resources and support to deliver a quality service. Here, again, a focus on quality would serve the NDH well. The role of policymakers proves critical in facilitating such systematic improvement in that they have to design the national framework and associated institutional support that render adequate clinical care possible (WHO, 2003).

In improving the provision of mental health care in such a systematic manner, the NDH, in mandating appropriate institutional support, would then become more attractive to emerging health professionals, allowing for the public sector to be viewed as a viable employment avenue for them. Furthermore, as per the WHO (2001), human resource development, particularly that of mental health professionals, is critical for countries that lack an adequate number of such specialists. The WHO (2001) argues that “[o]nce trained, these professionals should be encouraged to remain in their country in positions that make the best use of their skills” (p. 111).