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Mental Illness, Psychiatry, and the South African State, 1800s to 2018

Summary and Keywords

Definitions of and explanations for mental illness differ between societies and have changed over time. Current use of the term arises from secular and materialist epistemologies of the body and mind, influential from the 18th century, which rejected the spiritual or supernatural as causes of illness. Since the 19th century, a specialist body of study, of law, practices, professionals, and institutions developed to investigate, define, diagnose, and treat disorders and illnesses of the mind. This was the emergence of psychiatry and of a professional psychiatric sector. With origins in the West, at a time of capitalism and imperialism, psychiatry was brought to South Africa through colonialism, and its development has been strongly influenced by the country’s economic, political, ideological, and medico-scientific histories. There have been significant continuities: the sector has always been small, underfunded, and prioritized white men. Black patients were largely neglected. Discrimination and segregation were constant features, but it is helpful to identify three broad phases of the history of the psychiatric sector in South Africa. First, its most formative period was during colonial rule, notably from the mid-1800s to c. 1918, with an institutional base in asylums. The second broad phase lasted from the 1920s to the 1990s. A national network of mental hospitals was created and changes in the ways in which mental illnesses were classified occurred at the beginning of this period. Some new treatments were introduced in the 1930s and 1950s. Law and the profession’s theoretical orientations also changed somewhat in the 1940s, 1960s, and 1970s. Institutional practice remained largely unchanged, however. A third phase began in the 1980s when there were gradual shifts toward democratic governance and the progressive Mental Health Act of 2002, yet continued human rights violations in the case of the state duty of care toward the mentally ill and vulnerable.

Keywords: psychiatry, mental health, mental illness, madness, lunacy, asylums, human rights, community psychiatry, colonialism, apartheid, race

Control and Restraint in Early Institutions of Insanity

Myriad treatments and responses to mental illnesses have existed since the earliest human occupations of southern Africa. Across all communities, treatment was—and still is—sought from indigenous healers through local medicines, religious or spiritual guides, rituals, and practices. The formal, sustained, and dedicated provision for the control and care of persons identified as being mentally ill dates only from the 1800s, however.

After the introduction of carceral laws in the 17th century, jails were the only option for restraint of the dangerous or the abandoned mentally ill. This early period has been described as being characterized by “expediency and restraint.”1 The Dutch East India Company’s first Fort had a primitive structure for the accommodation of sailors and employees who were deranged, some because of excesses of alcohol consumption or illness. It was extended in 1674. Those detained were usually not treated differently from criminals. Some were later accommodated in hospital wards or annexes. For instance, a limited amount of space for “lunatics,” “madmen” (and women), or the “insane” was set aside at a hospital near the Company Gardens in 1772. Overcrowding was a constant condition of these facilities, and some patients were moved to the Slave Lodge.

Little changed following the British occupation from the early 19th century, although at the Somerset Hospital in Cape Town in 1818, some “beds were set aside for ‘lunatics’ who were cared for among the physically ill.”2 There was no other provision of this kind in the colony and these facilities were also woefully inadequate. In 1846, around fifty mental patients were moved to Robben Island. Conditions there were frequently described as dire, with frequent recourse to “mechanical restraints,” and there is evidence of abuse of patients. “Mental patients” were detained there to 1921. After 1891, however, whites had a segregated modern mental hospital at Valkenberg Hospital, just outside of Cape Town.3 Black lunatics were accommodated in separate buildings on the same estate after 1916.

In keeping with reform sentiments and, by instruction across British colonies, there was some improvement after the mid-1860s, including for a time at Robben Island. A new generation of “asylum doctors,” termed “alienists,” favored a treatment regime of “moral therapy,” which emphasized calm, order, pleasant surroundings, and socially appropriate gender-specific recreations, such as gardening and needlework. Not until well into the 20th century, however, were there medical treatments other than hypnotics, bromides, and calomel, all of which had serious side effects. Records also show the administration to patients of alcohol, chloral hydrate, laudanum, tincture of opium, cannabis indica, and “hemlock juice.”4

Mental illness and debility became a visible public issue during times of famine, warfare, economic hardship, and land dispossession. In South Africa, it has largely concern for and about whites, which drove state attention to the need to provide for the ill and vulnerable. On occasion, immigrants, especially from Britain, arrived at the Cape in a mentally distressed state, which had sometimes manifested only during the long sea passage.5 In the Colony of Natal, after the 1860s, this was also the case for indentured workers from India.6 For the latter, however, both prior to departure from the subcontinent and on arrival, they were subjected to medical assessment and, if found to be unwell or unstable, repatriated. The colonial state did not accept full responsibility for their medical “upkeep” at government hospitals or asylums and charged expenses to their employers in most cases.

As with Robben Island, other early structures for the accommodation of the insane were those that had been abandoned by the colonial military. In the Cape, these included Fort England Hospital in Grahamstown (from 1876), Fort Beaufort in the Eastern Cape (in 1897), and Kowie Hospital in Port Alfred (1889).7 These soon became racially segregated. Some black patients were admitted to the Grahamstown Lunatic Asylum until 1908. Superintendent Dr Thomas D. Greenlees held pseudo-Darwinist views that Africans were physiologically and mentally inferior to whites, with distinct differences in brain development.8 Separate facilities for black and white patients were “justified” in terms of alleged differences in brains, bodies, and behaviors. Not all colonial era psychiatrists subscribed fully to these views of human anatomical differences and, rather than exerting much influence, psychiatrists and asylum practice responded to and reflected “the consolidation of racist social practices outside the asylum.”9

In Natal, there were temporary lunatic asylums attached to the jails in Pietermaritzburg and in Durban. Records show that “lunatics, epileptics and idiotics” were also restrained at hospitals. In 1868, there were twenty-four inmates at the temporary asylum at the Pietermaritzburg jail, the cost of maintenance being met by the colonial government. In the early 1870s, a property of several acres with a building was purchased to serve as an asylum. It remained more prison than place of care, overseen by the “Keeper of Lunatics,” a former military officer, and guarded at night to prevent escape. Iron handcuffs were used. Black and white inmates were accommodated at this “miserable place,” and were kept in separate rooms or cells, stipulated to be no less than 510 cubic feet per person.10 These conditions were similar to those at other asylums in the region. Whites received better, more plentiful, and varied food and accommodation, a pattern common to South African mental care.

The Asylum Era: Diagnoses, Race, Gender, and Therapy

Colonial administrations accepted legal responsibility for the mentally ill (including persons with epilepsy and dementia) but many white inhabitants of the increasingly racially segregated towns resisted having asylums within the city limits. The objections were a fusion of fear and shame and, more creditably, the conviction held by “medical men” that fresh air, open views, and appealing landscapes were in themselves health-giving. In South Africa, racial prejudice and zoning played an important role in the siting of state asylums. Accordingly, once dedicated asylums began to be constructed, they were usually situated on the outskirts of towns.

Construction began on the Natal Government Lunatic Asylum (NGA, later named the Pietermaritzburg Mental Hospital, and more recently, Townhill) in 1880. It was sited on what was a barren hill then five miles outside the city. The first wards were opened in 1882. This was South Africa’s first purpose-built facility for the mentally ill. The Boer republic of the Orange Free State established the Oranje Hospital in 1883, also outside Bloemfontein, the capital city, toward Fauresmith.

In the Cape Town suburb of Observatory, Valkenberg Hospital received white patients from 1891. The South African Republic’s government established the Krankzinnigengesticht (Lunatic Asylum) in Pretoria in 1892. Its initial regime of moral management was not sustained during the South African War. Under the British policy of reconstruction of the Transvaal Colony, it was completely rebuilt between 1904 and 1907 and was renamed Weskoppies Hospital. In the Cape, the post of an Inspector for Asylums was created in 1890 and occupied by Dr William J. Dodds up to 1914. This helped to establish a network of facilities in the Cape, which, by 1910, had five mental hospitals.

Patients were primarily allocated to these state hospitals according to their racial classification. Private, fee-paying patients were also accommodated. Most of these were classified “European.” Where there were family or social networks available to patients, visits, special foods, and other gifts could be received. Patients were also permitted to spend limited time outside the asylum with the understanding that they would return after this furlough leave. At Valkenberg in the late 19th to early 20th centuries, approximately one-third of patients were released as “relieved or recovered” after a relatively short period of time. At the NGA, the rate of discharge was somewhat higher, at around 40 percent.11

The material, architecture, and planning of colonial asylums reflected the ideology and structures of segregation. There were separate wards and wings for men and women, and the facilities for white patients included well-appointed dining rooms, verandas, games and ballrooms, gardens, and extensive grounds. Medically, there was only a basic classification of patients, largely on the basis of behaviors: manic and potentially dangerously violent or melancholic and withdrawn.

“Moral therapy” reflected class, gender, and race hierarchies, with black patients performing manual labor. While the use of mechanical restraints was to be phased out, straitjackets and seclusion continued to be used to pacify patients who were unruly or suicidal. At the NGA for a time, an early (mid-1880s) method of controlling disruptive African women patients was to drop them daily into a large pit specially dug for the purpose.12

From soon after opening, black male patients were in the majority in South African mental facilities. The larger presence of white men in the first decades of asylums is explained by the early orientation to settler needs. Within those societies, women were demographically under-represented. The most frequent “causes of insanity” among white men were alcoholism, epilepsy, mania, dementia praecox (later renamed schizophrenia), and “GPI” (general paralysis of the insane, the tertiary stage of syphilis). Women in general were regarded as congenitally mentally weaker and less adequate than men in this era of biological psychiatry. Proportionately, fewer black women were admitted as “mental patients,” and of those patients, an overwhelming majority had no recorded etiology (cause of illness) noted.13

Even so, it was also understood that social conditions, such as the stress of war, grief, or unhappiness, could cause mental imbalance. Industrialization, urbanization, agricultural impoverishment, human displacement, and upheavals (social, economic, political) all brought greater numbers of apparently mentally disturbed people to the attention of various authorities such as district magistrates, district surgeons, and police. They were then responsible for initiating the process of referral to mental hospitals. Especially in circumstances of violence and when there was little other choice, families and employers also continued to request that committal to a mental hospital be sanctioned. These facilities were usually overcrowded.

In South Africa, most whites, whether among the settler elite or not, shared the racist conviction that they were more intelligent and civilized than black people, yet, paradoxically, more vulnerable to mental breakdown and depression. For white patients, by the early 1900s, some destructive states of mind were being medicalized, understood as being caused by mental conditions or predispositions deserving of treatment: these included being suicidal, alcoholic, or addicted to drugs.

Little was known about the causes of mental illness among “coloured,” “Native” or “Asiatic” inmates and, in most cases, asylum staff rarely spoke African languages and made little effort to understand their charges. Diagnoses of black men’s illnesses included insangu (cannabis) smoking. In the increasingly detailed paperwork required before, on, and several months after admission to mental hospitals, “Unknown” was the most common term noted for the cause of mental illness for black patients, especially if they were women.

Non-medical staff were often from socially and economically disadvantaged communities, and working at an asylum was unpopular and poorly paid.14 Abuse of patients and patients’ abuse of staff were not uncommon. By comparison with Britain, South Africa was deeply under-resourced, and the numbers of persons in institutions for the mentally ill remained low. In 1910, of the just under two million black subjects in the Cape, the number of “registered insane” was a little above 1,000. In Natal, also recorded as “total insane” were 1,227 people, less than 1 percent of the population as a whole. Of these, the majority (931) were classified as “Native” or “Coloured.” Moreover, only approximately one-half of the total number of people officially recorded as being “insane” (611) persons were in an asylum or hospital or jail in that colony. The NGA had the second highest number of lunatics in the Union. Pretoria Asylum (Weskoppies) had more at around 1,000 patients.

Lunacy Legislation, 1868–1916

Cape Roman-Dutch law had no explicit provisions for the detention of the mentally ill. In 1866, the Cape Colonial Office issued instructions to resident magistrates regarding the procedures necessary for the detention of lunatic patients, with further legal requirements outlined in 1879. Resident magistrates, district surgeons, police, hospital authorities, employers, and family members could all play important roles in the process of bringing a mentally ill or deranged person to the point of committal. The Colony of Natal’s Custody of Lunatics Act (Number 1 of 1868) was the template for much of the mental health legislation enacted in the region at that time.15

This law was prompted by two factors: First, economic depression across much of southern Africa in the 1860s revealed the socially and mentally vulnerable who were without support. There was an obvious need for a public asylum. Second, it was promoted by Lieutenant Governor Robert W. Keate (1867–1872). Previously, he had been governor of Trinidad, where a major scandal in the early 1860s had revealed the abuse of inmates in the West Indies.16 This prompted the Colonial Office to audit relevant facilities across the empire. It also led to legislative reforms reflective of 19th century humanitarianism, universalism, and liberalism: that all men [sic] were equal before God and the law, and should be treated in humane ways. However, reality was very different.

The Natal Custody of Lunatics Act established a number of important principles. It provided for “the safe custody of, and the prevention of crimes being committed by, persons dangerously insane, and also for the care and maintenance of persons who are insane, but not dangerously so.” “Persons appearing mentally deranged or who attempted suicide” should be brought before a resident magistrate, who required that two medical practitioners swear an oath that the person was a “dangerous lunatic or dangerous idiot.” The magistrate could then certify detention “in strict custody” until discharge was authorized by the Supreme Court, or the lieutenant governor ordered transfer to a public lunatic asylum.

Relatives or guardians could also initiate certification of insanity or lunacy. Application could be made by other “responsible persons,” such as magistrates, police, or employers. In settler colonies with substantial populations of imported labor—such as Natal—this could be a useful clause.

The Act did not attempt to define lunacy or insanity. There was also no provision for treatment: instead, it emphasized the custodial nature of restraint. The principle of being held not guilty of a criminal offense by reason of insanity (established by the M’Naghten Rules of 1844) was entrenched.

The Cape Lunacy Act (No. 20) of 1879 was a very close copy of the 1868 Natal Custody of Lunatics Act. In 1891, the new Lunacy Act (35) was more directly derived from the English Lunacy Act of 1890. However, it acknowledged local realities of a small population spread over great distances and permitted examination and certification of supposed lunatics by a single medical practitioner. Following this, a Summary Reception Order legitimated detention for the maximum period of not more than one month. In 1897, an amendment made provision for voluntary patients. Legal scholar A. Kruger refers to this as “a milestone in the development from detention to treatment.”17

Orange Free State and the South African Republic (ZAR) lunacy legislation from the 1890s closely followed that of Natal and the Cape. In the ZAR, police could arrest and charge as lunatics those who, in the opinion of a constable, posed a threat to “public safety” or were “idle lunatic persons.” A 1902 Transvaal Proclamation (No. 36) provided for voluntary patients as well as for “urgency cases” to be detained, following application by the family as well as a medical certificate, for seven days. There were also restrictions on the use of “mechanical means of bodily restraint.” In 1893 and in 1906, the Orange Free State’s laws relating to lunatics were brought into line with Cape and Transvaal legislation.

After Union in 1910, the four provinces retained their separate laws relating to “lunatics and lepers” until the Mental Disorders Act (38) of 1916.18 At the Select Committee on the Treatment of Lunatics in 1913, there were differences of opinion between long-serving physician or medical superintendents and the new generation of men who favored larger mental hospitals, a classification system influenced by Emile Kraepelin and Eugen Blueler, and a national network of mental hospitals between which patients could be moved according both to race and classes of disorder or mental capacity. The asylum at Bloemfontein, for example, was to be for “the criminal insane.”19 However, much duplication of facilities on the same site was required, as “the races” were not to mix.

The Mental Disorders Act (38) of 1916 showed that specialists in “mental science” and governments in the Union of South Africa were (as in many other countries) concerned with the eugenics-based supposed prevention of the mental and moral “degeneration” of whites. “Poor whites” were regarded as especially vulnerable to “racial mixing,” thereby allegedly “diluting” and “weakening” the race. These criteria were influenced by hereditarianism, a belief that mental defects and criminal tendencies were passed down through generations. In 1916, it named as “mentally disordered or defective persons” . . . “those who were incapable of managing himself [sic] or his affairs; those mentally infirm from age or decay of the faculties; idiots; imbeciles; feeble-minded persons; epileptics; and a socially defective person.”20

The administrative requirements for committal were standardized. Grounds for certification as “mentally disordered or defective” were the following: (a) that he is not under proper care, oversight, or control; (b) that he is cruelly treated or neglected; (c) that he has suicidal tendencies or is a danger to himself or others; (d) that he is an inebriate; (e) that the patient is in receipt of relief from public or charitable funds at the time of giving birth to an illegitimate child or during such pregnancy; or (f) the person having care or control of the patient consents. There were also stipulations regarding the observation of and expert testimony regarding persons who were mentally ill and who were suspected of having committed crimes as a result or during an episode of insanity. This law remained substantially intact until the early 1970s.

Administration was centered under the Department of the Interior. The first Commissioner for Mentally Disordered and Defective Persons (renamed Commissioner for Mental Hygiene after 1922), Dr John T. Dunston, planned a reorganization of state facilities. Under the new regime, less state attention went to financing asylums where the majority of inmates were black. They were, however, deliberately exploited as manual workers at the mental hospitals, as the asylums were now renamed. For whites, Dunston and the psychiatric sector aimed to reduce the stigma of having a mentally ill family member attend a mental hospital or clinic.

Professional Psychiatry and Mental Disorders from 1918 to the 1960s

After the First World War, psychiatric services and the profession itself became somewhat more respected, especially because of the prominence of shell shock among men and public recognition of trauma. Even so, its resources and influence remained limited. In the 1920s, psychiatry became an academic discipline at South African universities, albeit not well subscribed to or supported. National Commissioner of Mental Hygiene, Dr J. Dunston, was the first professor of psychiatry in South Africa at the University of the Witwatersrand.

Psychiatry therefore often reflected state ideological and economic priorities. Dunston was explicitly racist and a eugenicist, favoring sterilization as a response to “the problem of the feebleminded.”21 This was a matter of great concern during this time due to the “poor white problem.”22 There was ambivalence about implementation of eugenic measures, especially against whites. So, although deeply racially prejudiced and discriminatory, psychiatric thought and practice in South Africa did not bolster extreme measures in ways effected elsewhere, most notably Nazi Germany. Moreover, as before, “financial support of mental hospitals never became a main priority of the government” and the needs of white men continued to be given precedence.23

Dunston’s scheme for a national network of state services began to function, succeeding to a limited extent, as both patients and medical superintendents were moved around the country. In spite of repeated plans, few substantial upgrades were made to many of the older asylum buildings and inferior, often formerly military structures continued to be used to accommodate patients, the numbers of whom grew across the country. In the 1920s, Queenstown Mental Hospital was built in the eastern Cape and a former military hospital in Cape Town became the Alexandra Care and Rehabilitation Centre: it accommodated long-term white patients. Stikland was also opened in the city (Bellville) in the late 1930s.

In the Orange Free State, there was little change in institutional provision at this time. In Potchefstroom in the Transvaal province, another former military facility became the Witrand Institute in 1923. In Pietermaritzburg, dilapidated army barracks at Fort Napier were recommissioned as the province’s second mental hospital, with more than 300 black and white patients arriving from 1928. In Durban, the Napier Ward for the mentally ill was set aside at King George V Hospital.

A military convalescent hospital at Howick, close to Pietermaritzburg, was set aside for “the feebleminded” after the Second World War. It was named the Umgeni Waterfall Institute. Another such “institute” was at former Union Defence Force buildings at Alexandra in Cape Town, and at Westlake at Tokai Retreat. Collectively, Alexandra in Cape Town, Umgeni Waterfall in Howick, Witrand at Potchefstroom for whites, and Westlake in Retreat for “Coloureds,” accommodated a total of 3,138 whites and 815 “non-whites.”24

A new mental hospital at Sterkfontein in Krugersdorp opened in 1943. From 1946, Tara Hospital in Johannesburg became a converted military psychiatric hospital.25 First a branch of Johannesburg General Hospital, it became an independent psychiatric hospital run by the Department of Health and was dedicated to the care of white male patients, especially returning soldiers.

Psychiatric facilities at Lentageur Hospital in Mitchell’s Plain, Cape Town, date from 1974. Madadeni—a new hospital just outside Newcastle in northern Natal—had opened in the late 1960s.26 That facility catered to black patients, as did Bophelong in the so-called independent homeland of Bophututswana. The government also set up a state mental hospital at Umzimkulu in the Transkei.6 These hospitals were situated so as to map onto apartheid geographies and ideology. Even so, these national state and other provincial facilities were not adequate, and in the 1960s chronic long-term state patients were increasingly moved to commercially owned facilities.

Absolute numbers of patients accommodated do not accurately reflect the incidence of mental illness. Some groups were prioritized, notably white men, but the overall majority of psychiatric patients continued to be black men. Just after the Second World War, for 15,891 registered patients, there were only about 13,000 beds. This term was often a euphemism when describing the accommodation afforded black patients. In 1950, the figures were a total of 17,094 patients and 16,412 beds. These figures represented one bed for every 326 “Europeans,” and one in 1,204 for “non-Europeans.” As before, patients were segregated into separate wards or buildings.27 In 1960, there were 20,214 patients to 15,149 beds at thirteen hospitals.

In 1965, there were more than 22,000 registered patients, and approximately 17,500 beds at fifteen facilities. There were roughly equal numbers of beds for black and white patients, although by that date the number of black patients far exceeded that of Europeans. Slight decreases in the proportion of white patients reflected faster discharge rates due to some success in drug therapies as well as to the growing range of mental health services. In that year, there were a mere seventy psychiatrists registered with the South African Medical Council.

Although attempting to follow new diagnostic and treatments being developed elsewhere, constraints on this system were significant. By 1950, there were only forty-nine certified psychiatrists, many in private practice. In 1965, there were eighty-six registered psychiatrists for a population of 20 million.28 Not until the 1970s were black psychiatrists in training at the country’s racially segregated medical schools. In 1977, there were 302 psychiatrists registered with the South African Medical Council.29

Programs for staff training were given at the mental hospitals themselves. Valkenberg, for instance, initiated these in 1922. Overall, the number of staff in the “mental service” was low, plummeting further during the world wars. These staff vacancies negatively affected the care of patients as well as the profile of psychiatry (including specialist nursing) as a profession. Iris Marwick, employed at Fort Napier Hospital before the Second World War and at Tara (Johannesburg) afterward, also active in national and international bodies, made several important contributions to improving this situation.30 Few qualified staff were able to communicate with black patients, however.

Nonetheless, sometimes patients and staff members collaborated to undermine the discipline of the institutions. In 1958, for example, one psychiatrist wrote up a case study of a man he judged a “psychopath.” He described how while at Sterkfontein the man had “run a dagga gang in the ward” by bribing “a Native Attendant” and had escaped from the hospital after getting a male nurse to leave a door open.31 A few years later, detained anti-apartheid activist Eleanor Kasrils managed to leave the Fort Napier Mental Hospital after being held there for assessment of alleged mental illness.32 Whether she had been referred from the Durban police cells rather than undergo further interrogation and then was helped to escape by a non-medical staff member is not certain, but possible. More usually, patients were recorded as breaking windows, smashing crockery, tearing and spoiling clothing and bed linen, and exhibiting physical and verbal harming.

Psychiatric Regimes and Treatments and Moves toward Community Mental Health Programs, 1930s–1960s

Causes (etiologies) of mental illnesses continued to be influenced by ideologies of race and gender, albeit in complex, shifting, and often directly contradictory ways. Some psychiatrists and specialists from disciplines such as anthropology and psychology emphasized “genetic heritage,” and “predisposition,” often associated with “races.” Others stressed social conditions, such as poverty, place, and upbringing. The legacy of 19th- (or earlier) century beliefs regarding intellectual abilities, attitudes, emotions, and psychological strengths remained influential. In this period, black patients most often received a diagnosis of schizophrenia and whites of depression or neurosis. Even when identified as suffering from the same syndrome, however, different allegedly racially specific causes and inclinations could still be ascribed.33

Africans were often described as being incapable of either guilt or depression and therefore seldom suicidal.34 Or, if suicide were attempted or completed, it was explained as the consequence of anger. White professionals wrote of urbanization as especially stressful for Africans, causing psychopathological states of mind. Such views undergirded segregationist and apartheid policies even where not necessarily directly cited by governments.

Continuing shortages of resources and staff meant limited possibilities for positive prognoses. As internationally, there was a mixture of treatment methods attempted. Many soon became controversial or were replaced by more effective treatments. From the 1930s, treatment regimens included convulsive therapies for manic depression and injections of camphor and cardiozol for schizophrenic patients; hyperthermia (produced by malarial parasites) for syphilitic patients; and electroconvulsive therapy (ECT), and insulin-induced comas.35 Some specialists performed leucotomies. One “program,” which was interrupted during the Second World War, involved 111 patients, of whom the majority were Europeans. All had been identified as being “irrecoverable.” In medical publications, the results were judged clinically and financially positive.36 Other commentators have subsequently noted that “some therapies . . . continued to be used without effect for several years.”37

More effective for some classifications of mental illness were, from the 1950s and 1960s, the new psychotropic drugs such as chlorpromazine, lithium, and imipramine.38 These could not necessarily cure patients, but dulled extreme symptoms and behaviors. More widely, sedatives and hypnotics—from barbiturates to minor tranquillizers such as meprobamate (sold as Miltown)—became widely prescribed by general practitioners. By the 1970s, warnings of prescription drug dependence appeared among white South Africans.

In 1944, the national administration of mental hospitals was transferred to the Department of Public Health. In 1946, an amendment to the Mental Disorders Act of 1916 reoriented psychiatric discourse away from disease and disorders toward the goals of treatment and recovery. Voluntary patients were encouraged and legal certification was no longer necessarily required. In other words, even preceding the new drug therapies, a shift was occurring away from mental illness and toward the ideal of regaining or achieving mental health. Even so, psychiatrists made distinctions between those who may be helpfully treated and those who could not. In the late 1950s, for example, it was argued that sociopaths were not appropriately accommodated at mental hospitals and that specialist units or hospitals should be set aside for this category.

There were efforts to deinstitutionalize patients. Mental health societies were established across the country to support local services such as specialist schools and rehabilitation or occupational centers for the “mentally handicapped,” for example. These organizations were duplicated by race as well as by psychosocial specialty. General hospitals also established inpatient treatment units for psychiatric patients and treatment for alcoholism. As Tiffany Jones notes, by and large, even these initiatives favored “those diagnosed with less serious afflictions and those deemed more necessary for maintaining apartheid strategies, that is, white men.”39 Even so, mental illness continued to be widely stigmatized.

The 1960s saw some movement toward a more progressive psychiatry. Examples of this were multidisciplinary approaches (e.g., inclusive of social workers, clinical psychologists, as well as psychiatrists), academic specialties, and the incorporation of psychiatry into general nurse training. Arguments highlighting the pressing need for black psychiatry professionals began to gain momentum, albeit, at first, for “Indians,” “Africans,” and “Coloured” practitioners to “serve their own communities.” Legal amendments gave further support to outpatient services. Clearly, those in better resourced communities fared better. The notion of separate communities was often mapped onto apartheid and separate development. Nonetheless, there was no commonly held view of what community psychiatry or community-oriented services should be within any community, or how they could be run in the best interests of those they were intended to assist.40

Protest, Politics, and South African Psychiatry, 1960s–2002

The assassination of Prime Minister H. F. Verwoerd in Parliament in 1966 by Dimitri Tsafendas shocked many South Africans. Tsafendas was found by psychiatrists to be mentally unstable and therefore was not sentenced to death. He was detained in prison for decades and was moved to Sterkfontein Hospital in 1994. The [Rumpff] Commission of Inquiry into the Responsibility of Mentally Deranged Persons and Related Matters of 1967 aired judicial, professional, and public doubts and debates about criminality and mental illness.

It was followed in 1972 by the [Van Wyk] Commission of Inquiry into the Mental Disorders Act, which surveyed mental health services, made recommendations about forensic psychiatry, and urged stricter measures of control of “the criminally insane.”41 The Mental Health Act of 1973 finally replaced the 1916 Act. Few if any improvements in material conditions—especially for black patients—were forthcoming, however, and accommodations deteriorated even further.

Endemic economic concerns prompted the Department of Health to subcontract accommodations for psychiatric patients to private enterprise, specifically, Smith Mitchell & Co. The state remained responsible for administrative admission, assessment, and treatment, but thousands of chronically ill patients—by far the greatest majority of whom were black South Africans—were transferred to old and wholly inadequate facilities formerly used for black tuberculosis patients.

By the mid-1970s, this arrangement had become fixed, albeit annually renewed, with more than 12,000 psychiatric beds at Smith Mitchell-managed institutions. One rationale was that this would facilitate better care and treatment for those with acute mental conditions. A commercial company, Smith Mitchell minimized expenditures and hired out patients’ labor to local businesses. The state also justified “racial differences” for its lower expenditure on drugs and anesthetics administered to black patients. As apartheid laws enforced segregated facilities and also forcibly deported thousands of people into “ethnic homelands” (Bantustans), most South African psychiatric patients were as deprived as they had ever been, and the chance of family contact was virtually eliminated.

Evidence that a number of patients resisted discharge, arguing that their material conditions within the mental hospitals were not inferior to those where they would be obliged to return, makes for disturbing reading. These views reflect several things: that long-term patients became institutionalized; that relationships were formed between patients and sometimes between patients and staff; and that families and social networks outside at “home” and “on the street” often no longer existed and could be hostile, threatening, and precarious.

Criticism of human rights abuses and psychiatry in apartheid South Africa came from the local progressive press and organizations such as the United Nations Special Committee Against Apartheid, the World Health Organization, the International Red Cross, the Royal College of Psychiatrists, the Church of Scientology, the American Psychiatric Association (APA), and others. Although resisted by the Nationalist Party government (the 1976 Mental Health Amendment Act censored reporting, photographing, or even sketching mental patients or institutions, allegedly for reasons of privacy), some inspections were permitted, including by the APA in 1979.

Suspicions that the Nationalist government was detaining political activists in mental hospitals (as infamously happened in Soviet Russia) were not corroborated, though the great disparities in standards of care and facilities for black and white patients were documented. The APA’s report highlighted “unacceptable medical practices that resulted in needless deaths of black South Africans” and commented that “apartheid has a destructive impact on the families, social institutions, and the mental health of black South Africans. We believe that these findings substantiate allegations of social and political abuse of psychiatry in South Africa.”42 There were international boycotts against South African psychiatrists through the 1980s.

Within the country, the Society of Psychiatrists of South Africa (SPSA) had formed in 1952 with the mandate of advocating patients’ rights. Originally it was a subsection of the conservative Medical Association of SA (MASA). It did not represent all registered psychiatrists. Political differences meant that the profession was divided, and challenges to the state were not very effective. Some individuals intervened where they could to improve conditions and defended individuals, including political prisoners.

SPSA did submit a report to the Truth and Reconciliation Commission health sector hearings of 1996–1998 but no psychiatrist testified or in fact was a commissioner. The Commission’s summary of evidence on “the role of mental health professionals” and many other testimonies, however, contained evidence of neglect and abuse across various health sectors, professions, and institutions, including psychology, psychiatry, the police, and the military. They showed too that extreme mental strain and suffering was also the consequence of community conflicts and gender-based violence.43

Some psychiatrists were directly associated with the “version Project” of the SA Defence Force where ethical psychiatric practices were violated. Both male and female (white) conscripts underwent “sex-change” surgery, and/or shock therapy to “cure them of homosexuality.” These practices were most directly associated with psychiatrist and colonel Dr Aubrey Levin, dubbed “Dr. Shock” by the news media. Others who were drug-using conscripts did not receive treatment but rather, such harsh discipline that it amounted to torture.44

Democracy, Deinstitutionalization, and the State of Psychiatry from the 1980s to 2018

By the later 1980s, psychiatric services were devolved to provincial authorities. By 1994, institutional segregation and discrimination had technically been made illegal. The 2002 Mental Health Care Act was amended and became effective in 2004.45 Often acclaimed as one of the most progressive mental health laws in the world, this Act is firmly rooted in discourses of human rights and dignity, and the Constitution of South Africa. Its provisions, however, have often been ignored, unimplemented, avoided, violated, or have had unanticipated consequences.

In 2001, there were 14,000 “acute and long term patients” at 24 registered state psychiatric institutions.46 This decreased number of patients had not been the consequence of a lessening of mental health problems. Rather, it reflected further moves to deinstitutionalize patients. With the addition of five new provincial departments of health (Northern and Eastern Cape, Mpumalanga, Limpopo, and North West Province), theoretically hospitalized patients were geographically closer to their families and social networks of care, and each provincial administration had at least one mental health review board to safeguard patients’ rights.47 In the majority of provinces, these have failed to function.

Statistics from a 2001 report by Emsley highlighted the following important issues: First, there was approximately one registered professional to 100,000 people, a small number of psychiatrists relative to the population; of 429 registered psychiatrists, only about 170 were employed in state hospitals, the remainder being in private practice.

Second, a high concentration of personnel and facilities existed in urban areas, especially in the Johannesburg-Pretoria and Cape Town centers. There were no state psychiatrists whatsoever in North-West Province, and in Northern Cape and Mpumalanga, one each. Additionally, it noted a dire national scarcity of neurologists and of specialists in learning disabilities.

Third, most rural nonresidential mental health facilities recorded clients as seeking help for epilepsy (48%) and schizophrenia (22%). Fourth, cognitive-behavioral approaches to psychotherapy were dominant and treatment still focused on the treatment of the severely mentally ill pharmaceutically.48 Fifth, the number of black psychiatrists had remained low and, overall, the loss to South Africa of locally trained psychiatrists due to emigration had been significant.

Over the next decade, although there were some positive trends, new challenges had emerged, especially the notable deleterious impact of HIV/AIDS. In 2012, a National Mental Health Summit reported that “With the transition of HIV/AIDS to a chronic illness, common mental disorders in people living with HIV/AIDS are of particular concern . . . Depression and alcohol misuse [are] prevalent [in people living with HIV] and compromise adherence to antiretroviral therapy and virological suppression.”49

It further noted that “the burden of mental illness in South Africa is substantial, and is likely ‘to increase with the epidemiological transition to chronic and non-communicable diseases.’ Moreover, ‘mental disorders’ rank third in their contribution to the burden of disease in this country, and approximately 1 in 6 South Africans are likely to experience a common mental disorder (depression, anxiety or substance use disorder) during the current year . . . a staggering 75% of people who live with mental disorders in South Africa do not receive the care that they need.”50

In the absence of financially well-resourced institutions, adequate staff, integrated services, a failure to engage meaningfully with the widely consulted traditional medicines sector, and effective oversight structures, some recent reforms to legislation have in fact created new or have deepened older problems.51 For instance, direct admission to a psychiatric facility is no longer permitted, including by the South African Police Service (SAPS). Instead, there is a mandatory period of 72-hour observation at a district general hospital. While this is intended to allow time for non-acute or incorrectly assessed patients to recover or be referred to the appropriate therapeutic specialty, in practice it creates difficulties in general hospitals and, it is alleged, sometimes mentally ill people are picked up by the SAPS and dumped in other districts.52

Both structural and direct abuse of vulnerable patients has continued at some psychiatric facilities.53 The most well-known of these are exemplified in the inquiry into neglect and abuse of patients at Town Hill Hospital in 2005 and the so-called Life Esidimeni Scandal of 2016. In the latter, the hasty, unlawful, and callous removal of hundreds of patients in Gauteng from subcontracted psychiatric hospitals to numerous smaller, often unlicensed, and wholly unsuitable facilities led to the deaths of approximately 143 people in appalling circumstances. They were largely black South Africans with long-term mental conditions.

It has become a national scandal, investigated and reported on by the office of a newly established Health Ombud, which initiated an arbitration process with the victims’ families. The South African Society of Psychiatrists, civil society organizations such as Section 27, and many others have continued to emphasize that Constitutionally enshrined requirements exist that mental health users are due protection, care, and dignity.54 Historians also point out that it has been 150 years since the country’s first legislation to provide for the safe custody of the mentally ill, but South Africa’s most vulnerable citizens are still consistently abandoned by the state to which their care has been entrusted.

Discussion of the Literature

South African historiography of mental illness and psychiatry faces similar challenges to those elsewhere: often limited evidence, the ethical use of sources, of theoretical interpretation, and the difficulties of “making sense of” grappling with “insanity” itself.55 These methodological and theoretical issues are amplified by the country’s many therapeutic paradigms and by the ways that colonialism, segregation, and apartheid determined the provision of psychiatric services by race.

Histories of the state and psychiatry are therefore necessarily framed in political contexts. South African exceptionalism (its comparatively large settler communities, wealth, and white-dominated strong state) has shaped its history in somewhat different ways from other African countries. Most notably, it was for whites that state psychiatric facilities were largely intended, yet it was a majority of black patients who were accommodated in them.

Broader issues of the colonial archive and knowledge production are often inseparable from studying the history of mental illness, psychiatry, and the state in South Africa. Sally Swartz’s body of work since the 1990s is especially important in analyzing how these have created particular kinds of documentary evidence, especially about black patients. These persons have been doubly discursively erased, as black and as mad. She highlights how little can be known about patients as individuals. Even where documentary records were kept—and these were prolifically generated by a “bureaucratic machinery” of colonial officialdom—recorded details were brief, sometimes not giving even the patient’s full name. In addition, many records have been deliberately destroyed, embargoed, banned, or censored. Others have been lost due to neglect or concerns for confidentiality. Into the 21st century, deep stigma continues to silence many who experience mental illness.

Medical professionals have written about South African psychiatry since the 1890s. Much of their work was published in medical journals. Contemporary writings of the time by people such as psychiatrists Thomas Greenlees, Dudley Kidd, and B. J. F. Laubscher, and their contributions to ethno-psychiatry, psychology, and scientific racism in South Africa are discussed by scholars such as Saul Dubow, Jock McCulloch, Shula Marks, Marc Epprecht, and Tiffany F Jones.56

More than a dozen articles authored by Dr. Max Minde between the 1950s and the 1970s and published in the South African Medical Journal are the best examples of the narrative genre. They remain helpful in terms of detail as he had access to some primary documents that are apparently no longer in existence. A more critical, historically informed, and progressive form of medical expert literature that has its roots in the anti-apartheid ethos also exists.57

Five institutions have received the most detailed attention, largely for reasons of source materials: Valkenberg (but note too, the asylum on Robben Island and other reflections on madness in the 19th century by Harriet Deacon); the Natal Government Asylum (later Town Hill in Pietermaritzburg); the Grahamstown Asylum; and Weskoppies. Contemporary accounts of the latter in the 1930s can be found in writings by psychoanalyst Wulf Sachs (author of Black Hamlet, 1937, also titled Black Anger) and African American activist Ralph Bunche.58 Xhosa prophet Nontetha Nkwenkwe was detained at both Fort Beaufort asylum and Weskoppies, as detailed in Edgar and Sapire’s African Apocalypse (2000).59

The preponderance of studies of asylums and 19th-century psychiatry is largely a consequence of the greater availability of sources. After 1916, records were collated under the Commissioner of Mental Disorders (later of Hygiene or Health). From the 1920s, many records were destroyed by legal instruction. Parle has argued that scholars, including those of archives, should interrogate the ethics of naming patients. Alternatively, anonymizing identities could underscore ongoing stigma.

Questions of madness as protest and resistance, the exercise of bio power, and the power of psychiatry and its institutions as instruments of social control have been—to a greater or lesser extent—key in South African historical literature. Sally Swartz’s analyses of asylum discourse and architecture, drawing on Foucault, are extremely skillful and insightful. It may be argued, however, that at a wider level the issue of social control is perhaps most useful in showing that it was toward white South Africans that the state’s attention was largely directed.

Indeed, in 1991, Megan Vaughan questioned the extent of usefulness of notions of “Othering” and of a “grand confinement” of the mad in Africa (as per Foucault and others). In short, South Africa had no need for the labeling of black people who were socially disruptive as insane, since there were many more brutal and punitive policies and practices put into practice by the colonial and apartheid states.

The corpus of work by Shula Marks has been foundational. Her attention to the “micro-physics” of power as analyzed through records of nursing staff in mental hospitals remains powerful. She has published several important articles on Valkenberg and on colonial psychiatry as well as a Foreword to African Apocalypse (2000). The book reflects many of the themes of academic and critical assessments of South African psychiatry that have appeared, beginning in the 1990s. These were often influenced by broader debates originating in the United States, France, and the United Kingdom and centered on “the asylum” and on the dramatic increase of mental patients and disorders in the 19th century. In turn, these arose from social and feminist histories and, by the 1960s, from the anti-psychiatry movement and Foucault (after translation into English). Scholars of empire and insanity and the imperial “civilizing mission” have also been increasingly referenced.60

Also influential, the Comaroffs’ essay “The Madman and the Migrant: Work and Labor in the Historical Consciousness of a South African People,” published in 1991, pointed to the possibilities of viewing madness as trenchant political critique. Exemplars of this line of analysis are the many debates about Dimitri Tsafendas, sanity, protest, and state deployment of psychiatry as label and punishment.61

Individually and collectively, three monographs provide comprehensive discussions of primary sources and theoretical debates about race, gender, insanity, and the state in South Africa from the 1800s to the late 1990s.62 They highlight how the absence of patient voices has shaped the ability to write these histories.

They also point to the limited reach of the psychiatric sector and have argued that the extant documentary sources should be read “against the grain” in an effort to access as far as possible the agency and subjectivity of family members as well as persons who are mentally ill (or identified as such). Tiffany Jones’ important book remains unparalleled in exploring the many contradictions of the apartheid era.63 She also shows that psychiatrists did not speak with one voice and that protests against state abuses and neglect often came from a variety of people and places.

Recently, Fanon’s diagnosis of colonialism as itself the cause of psychopathologies has often been cited and calls for decolonializing scholarship. The most frequently referenced are Fanon’s Black Skin, White Masks [1952] and The Wretched of the Earth [1961].64 The contradictions or complementary of archival-based histories with Fanon’s more schematic approach require consideration.

Some historians have sought to illuminate how family members—black and white—were often important actors in committal processes. However, there is far less documentary material to support this line of analysis in South Africa than there is for other settler colonies (see Catharine Coleborne for Australia and New Zealand). Tiffany Jones has conducted substantial oral interviews: a project that will hopefully be extended as there is wider acceptance of the necessity for critical histories of mental health.

Considerations of archival and academic ethics are considered by Parle and by Sally Swartz. Swartz discusses the dilemmas of using visual sources, especially photographs of patients. Even more recently, studies of Grahamstown Asylum by Rory du Plessis and Kylie van Zyl deliberate on these issues and open up new vistas in the historiography.65 There are reproductions of images of vulnerable psychiatric patients via digital media. Whether this reflects a wider acceptance of the mentally ill or contributes to their objectification needs further discussion.

Acknowledgments

With thanks to Alice Morrison for assistance.

Primary Sources

For the South African medical-psychiatric literature—often an important primary source—some professional journals are of special relevance, especially the South African Medical Journal which has a digital archive dating to the 19th century. Advertisements have not been included, however. The South African Journal of Psychiatry is an open source publication.

Important South African government laws, commissions, and Hansard (before 1994) usually require library or archive hard copy searches. Recommended here are university library government publication repositories (under threat as collections have been “rationalized” at several universities) and legal deposit libraries, including in Cape Town, Pretoria, Bloemfontein, and Pietermaritzburg.66

Commissions of Inquiry (or Select Committees) and government department reports from the colonial era remain vitally important. Examples include the SC 14–1913 Report of the Select Committee on Treatment of Lunatics and the Reports of the Commissioner of Mentally Disordered and Defective Persons.67 Many of the latter have extensive and detailed statistical tables. Jones’ book covers the most important aspects of these statistics though there is scope for further analysis. This statistical model replaced the more individual reports of physician superintendents or asylum officials and there is little qualitative information conveyed in them.

Records relating to the asylums and mental hospitals themselves and their patients and staff are scattered across archives. A directive issued in 1927 that records be destroyed after seven years has ensured that they are limited. This edict was not uniformly observed, however. At the National Archives in Pretoria, researchers are hampered by the absence of useful finding aids beyond the NAAIRS online system, but some relevant records remain preserved in such collections as Governor General’s Records (GG), Prime Minister’s Office (PM), Department of Health (GES), Department of Treasury (TES) 732 F4/29, Executive Council (URU), Public Works Department (PWD), and Secretary of Native Affairs (NTS). This wide spread of collections is reflected at provincial levels, especially, again, of the four former provinces of the pre-1994 Republic of South Africa.

The bureaucratic machinery of committal as a mentally ill person was both a medical and a legal process, which by 1916 required a complicated and elaborate administrative network of officials (resident magistrates, district surgeons, asylum doctors, and judges) that, where preserved, documents the person’s path to and sometimes from the psychiatric sector. For the region of KwaZulu-Natal, for example, more than 15,000 folders of documentation relating to the admission and certification of persons under the Mental Disorders Act of 1916 to the late 1950s, are preserved in the Registrar of the Supreme Court (RSC) collection at the Pietermaritzburg Archives Repository.

The records of Town Hill and Fort Napier Hospitals to 1910 are, again, scattered across state administrations, but the more detailed internally kept records (including Patient Case Books to 1916, staff “punishment registers,” and the like) have been destroyed in recent decades or are to be found in private hands and, possibly, uncategorized in libraries. Other institutions have undergone the same fate: fortunately, a section of Valkenberg’s records is held by the University of Cape Town. Application must be made to consult them. Similarly, some records relating of the Fort England (Grahamstown) Asylum are now housed at the Cory Library.

For the apartheid era, the researcher is best referred to the varied collections and holdings referenced by Tiffany Jones, which include the archives of the Departments of Justice (DJA) and of Mental Health (DMHA) at the National Archives in Pretoria; the Gay and Lesbian Archive of South Africa, WITS University; the Citizens Commission on Human Rights Archives, Johannesburg; and the Truth and Reconciliation Commission Records. For recent investigations into the death of more than 140 patients in Gauteng, see the Office of the Health Ombud, cited in “Democracy, Deinstitutionalization, and the State of Psychiatry from the 1980s to 2018”.

Finally, civil society and the media—print and digital—have played an active role in reporting on mental health issues, scandals, and tragedies. Less analyzed are biographies, novels, memoirs, artwork, music, and other contexts in which mental illness has been expressed or represented.

Further Reading

Emsley, R. “Focus on Psychiatry in South Africa.” British Journal of Psychiatry 178, no. 4 (2001): 382–386.Find this resource:

    Jones, Tiffany F. Psychiatry, Mental Institutions and the Mad in Apartheid South Africa. New York: Routledge, 2014 [2012].Find this resource:

      Jones, Tiffany F. “Promoting Unequal Access in South Africa? Contemporary Assertions of Community-Based Mental Health Services and the Legacy of Community Psychiatry from the 1940s to the 1960s.” Kleio 38, no. 2 (2006).Find this resource:

        Jones, Tiffany F. “Contradictions and Constructions of Psychiatric Perceptions in Apartheid South Africa, 1948–1979.” Master’s thesis, Dalhousie University, 2000.Find this resource:

          Kaplan, Robert M. “The Aversion Project—Psychiatric Abuses in the South African Defence Force.” South African Medical Journal 91, no. 3 (2001).Find this resource:

            Marks, Shula. “The Microphysics of Power: Mental Nursing in South Africa in the First Half of the Twentieth Century.” In Psychiatry and Empire, edited by Sloan Mahone and Megan Vaughan. Houndmills, Basingstoke: Palgrave, 2007.Find this resource:

              Parle, Julie. States of Mind: Searching for Mental Health in Natal and Zululand, 1868–1918. Scottsville: UKZN Press, 2007.Find this resource:

                Parle, Julie. “The Voice of History? Patients, Privacy and Archival Research Ethics in Histories of Insanity.” Journal of Natal and Zulu History 24–25 (2006-20077): 164–187.Find this resource:

                  Parle, Julie. “Family Commitments, Economies of Emotions, and Negotiating Mental Illness in Late-Nineteenth to Mid-Twentieth Century Natal, South Africa.” South African Historical Journal 66, no. 1 (2014).Find this resource:

                    Swartz, Leslie. Culture and Mental Health: A Southern African View. Cape Town: Oxford University Press, 1998.Find this resource:

                      Swartz, Sally. Homeless Wanderers: Movement and Mental Illness in the Cape Colony in the Nineteenth Century. Cape Town: UCT Press, 2015.Find this resource:

                        Swartz, Sally. “Multiple Voices and Plausible Claims: Historiography and the Colonial Lunatic Asylum Archives.” In Medicine and Colonialism, edited by P. Bala. London: Pickering and Chatto, 2014.Find this resource:

                          Swartz, Sally. “The Black Insane in the Cape, 1891–1920.” Journal of Southern African Studies 21, no. 3 (1995).Find this resource:

                            Szabo, Christopher, and Sean Z. Kalinski. “Mental Health and the Law: A South African Perspective.” British Journal of Psychiatry International 14, no. 3 (2017).Find this resource:

                              Vaughan, Megan. Curing Their Ills: Colonial Power and African Illness. Stanford, CA: Stanford University Press, 1991.Find this resource:

                                Notes:

                                (1.) Lynn Gillis, “The Historical Development of Psychiatry in South Africa from 1652,” South African Journal of Psychiatry 18, no. 3 (2012): 78.

                                (2.) Gillis, “Historical Development of Psychiatry,” 78.

                                (3.) Harriet Deacon, “The Medical Institutions on Robben Island 1846–1931,” in The Island: A History of Robben Island, 1488–1990, ed. H. Deacon ( Cape Town and Johannesburg: Mayibuye Books and David Philip, 1996), 57–75; and Sally Swartz, “The Black Insane in the Cape, 1891–1920,” Journal of Southern African Studies 21, no. 3 (1995): 399–415.

                                (4.) Gillis, “Historical Development of Psychiatry,” 79; and Max Minde, “History of the Mental Health Services of South Africa: Part V—Natal,” South African Medical Journal (hereafter, SAMJ), 49 (1975): 324.

                                (7.) Gillis, “Historical Development of Psychiatry,” 79.

                                (8.) Thomas D. Greenlees, “Insanity among the Natives of South Africa,” Journal of Mental Science 41 (1895): 71–78.

                                (9.) Harriet Deacon, “Racial Categories and Psychiatry in Africa: The Asylum on Robben Island in the Nineteenth Century,” in Race, Science and Medicine, 1700–1960, ed. W. Ernst and B. Harris (London and New York: Routledge, 1999), 102.

                                (10.) Parle, States of Mind, 89–95.

                                (11.) Parle, States of Mind, 111–113.

                                (12.) Minde, “Natal,” SAMJ, 324.

                                (13.) For a discussion of colonial etiologies, see Parle, States of Mind, esp. 95–121.

                                (15.) Parle, States of Mind, esp. chap. 1.

                                (16.) See Sally Swartz, “The regulation of British colonial lunatic asylums and the origins of colonial psychiatry, 1860–1864,” History of Psychology, 13 (2010), 160–177.

                                (17.) A. Kruger, Mental Health Law in South Africa (Durban: Butterworth, 1980), 14–17.

                                (18.) The Lunacy and Leprosy Laws Amendment Act (No. 14) of 1914 facilitated the transfer of patients between provinces.

                                (19.) Parle, States of Mind, esp. chap. 6.

                                (20.) Kruger, Mental Health Law, 23

                                (21.) John T. Dunston, “Sterilization of the Unfit,” S AMJ 6, no. 4 (1932): 112–117.

                                (22.) Saul Dubow, Scientific Racism in Modern South Africa (Cambridge, UK: Cambridge University Press, 1995), esp. chaps. 5 and 6; and Susanne M. Klausen, “‘For the Sake of the Race’: Eugenic Discourses of Feeblemindedness and Motherhood in the South African Medical Record, 1903–1926,” Journal of Southern African Studies, 23, no. 1 (1997): 27–50, and important later publications.

                                (24.) Tim Hart and Dennis Neville, Department of Archaeology, University of Cape Town, “Phase 1 Cultural-Historical Assessment of the Proposed Westlake Development Area,” May 1998.

                                (25.) Jones, Psychiatry, esp. chap. 1.

                                (28.) Jones, “Contradictions and Constructions,” Table 1, 39.

                                (29.) Gillis, “Historical Development of Psychiatry,” 81.

                                (30.) Leana Uys and Lynn Middleton, eds., Mental Health Nursing: A South African Perspective, 5th ed. (Cape Town: Juta, 2010), 8–14.

                                (31.) M. Ginsburg, “The Psychopath and the Mental Hospital,” South African Medical Journal hereafter SAMJ 22 (1958): 318–321.

                                (32.) Jeanette Eleanor Kasrils; Ronnie Kasrils, The Unlikely Secret Agent (Johannesburg: Jacana, 2010).

                                (33.) Jones, “Contradictions and Constructions,” 73ff.

                                (34.) Parle, States of Mind, esp. chap. 5.

                                (35.) Gillis, “Historical Development of Psychiatry,” 79.

                                (36.) A. S. van Coller, “Prefrontal Leucotomy Studies,” SAMJ, 23, no. 15 (1949): 261–262.

                                (37.) Gillis, “Historical Development,” 79–80.

                                (38.) Editorial, “The Ataracic Drugs (Tranquilizers),” SAMJ, 31 (1957): 161–162

                                (40.) Jones, “Promoting Unequal Access,” 189–190.

                                (41.) R. P. 180/1972, Report of the Commission of Inquiry into the Mental Disorders Act of 1916 and Related Matters (Pretoria: Government Printer, 1972).

                                (42.) American Psychiatric Association (APA), “Report of the Committee to Visit South Africa,” American Journal of Psychiatry 136, no. 11 (1979): 1498–1499.

                                (43.) Truth and Reconciliation Commission of South Africa Report, 1998, vol. 4 and chap. 5, esp. 142; Bernard Janse van Rensburg, “Reconciliation and Psychiatry in South Africa,” British Journal of Psychiatry International 12, no. 3 (2015): 62–64.

                                (47.) Jonathan K. Burns, “Implementation of the Mental Health Care Act (2002) at District Hospitals in South Africa: Translating Principles into Practice,” SAMJ 91, no. 1 (2008): 46–49.

                                (48.) Emsley, “Focus on Psychiatry,” 382.

                                (49.) Crick Lund, Inge Petersen, Sharon Kleintjes, and Arvin Bhana, “Mental Health Services in South Africa: Taking Stock,” African Journal of Psychiatry 15 (2012): 402.

                                (50.) Lund et al., “Mental Health Services,” 402.

                                (51.) Lund et al., “Mental Health Services,” 402.

                                (52.) For example, “Welcome to ‘Mad Town,’” The Witness, August 25, 2009.

                                (53.) Dan Mkize, “Human Rights Abuses at a Psychiatric Hospital in KwaZulu-Natal,” South African Journal of Psychiatry 13, no. 4 (2007): 137–142.

                                (54.) Health Ombud Report, “No Guns: 94+ Silent Deaths and Still Counting,” May 2, 2017.

                                (55.) Julie Parle, “The Voice of History? Patients, Privacy and Archival Research Ethics in Histories of Insanity,” Journal of Natal and Zulu History 24–25 (2006–2007): 164–187; also, of many examples, see Sally Swartz, “Review Article: Colonial Lunatic Asylum Archives: Challenges to the Historiography,” Kronos 34, no. 1 (2008): 285–302.

                                (56.) Marc Epprecht, Heterosexual Africa? The History of an Idea from the Age of Exploration to the Age of AIDS (Athens, OH: Ohio University Press, 2008).

                                (57.) R. Emsley and K. Sukeri, “Lessons from the Past: Historical Perspectives of Mental Health in the Eastern Cape,” South African Journal of Psychiatry 20, no. 2 (2014): 34–39.

                                (58.) R. J. Bunche, An African American in South Africa: The Travel Notes of Ralph J. Bunche, 28 Sept. 1937–1 Jan. 1938, ed. R. Edgar (Athens, OH: Ohio University Press, 1992).

                                (59.) Robert Edgar and Hilary Sapire, African Apocalypse:The Story of Nontetha Nkwenkwe, a Twentieth-Century South African Prophet (Johannesburg: Witwatersrand University Press, 2000).

                                (60.) Jim Mills, Madness, Cannabis and Colonialism: The “Native-Only” Lunatic Asylums of British India, 1857–1900 (Houndmills, Basingstoke: Macmillan, 2000); and Waltraud Ernst, “The European Insane in British India, 1800–1858: A Case-Study in Psychiatry and Colonial Rule,” in Imperial Medicine and Indigenous Societies, ed. D. Arnold (Manchester: Manchester University Press, 1988), to name only two.

                                (61.) See most recent (October 2018) by Niren Tolsi, “Tsafendas: Setting the Record Straight” and “Tsafendas and the Tapeworm,” New Frame.

                                (62.) Parle, States of Mind; Jones, Psychiatry; and Swartz, Homeless Wanderers.

                                (64.) Frantz Fanon’s Black Skin, White Masks (London: Pluto, 1967 [1952]) and The Wretched of the Earth (Harmondsworth: Penguin, 1967 [1961]).

                                (65.) Rory du Plessis, “Photographs from the Grahamstown Lunatic Asylum,” Social Dynamics 40, no. 1 (2014): 12–41.

                                (67.) Report of the Select Committee on Treatment of Lunatics (Cape Town: Cape Times Limited, Government Printers, May 1913); Reports of the Commissioner of Mentally Disordered and Defective Persons (later of Hygiene or of Mental Health) for the Union of South Africa from 1918 to 1970.