Читать книгу Apartheid and the Making of a Black Psychologist - N. Chabani Manganyi - Страница 11

2Baragwanath Hospital and Beyond

The completion of my master’s degree at Unisa in 1968 coincided with important and unexpected changes in my life. However, on its own, the receipt of the degree could not have resulted in the changes that took place from 1969 onwards. What mattered most was that I had recently changed jobs following an offer I had received from the Ellerine brothers, Eric and Sidney. They owned a chain of furniture stores, appropriately given their family name, which targeted the urban African market in Johannesburg and adjacent areas.

I accepted a position as employee relations officer at the head office in Germiston. In retrospect, it now appears as though the brothers Ellerine had prepared an acid test for me. Soon after my arrival I was given the task of investigating what the brothers considered to be a high turnover of black supervisory staff. I accepted the task with an open mind. It was not unreasonable to assume, as I did, that what my employers required from my inquiry was a finding which would help them resolve the problem.

Through my inquiry I established that the primary reason African supervisors were leaving the company was racist attitudes and practices on the part of white store managers in the group. I reported back accordingly and it was a rude shock to discover that my feedback failed to generate the serious examination of workplace practices that I had anticipated. To my surprise, I was shown the nearest door and told to resign or face summary dismissal. It became clear that employers such as the Ellerine brothers had no room for independent-minded black people like me. It was time to take my jacket and leave.

Knowing that the work I had carried out at the Ellerines’ request could not be faulted on the grounds of unbridled political zeal on my part saved me from undue anger and humiliation. Fortunately, I have never had reason to look back with any sense of regret, particularly since there is no way of knowing what the rest of my life would have become had I been allowed to keep my position.

I acted quickly and decisively by playing what is commonly described as a wild card. Soon after the Ellerines debacle, I approached Professor Lewis Hurst, then head of psychiatry at the University of the Witwatersrand Medical School. My request was simple. I had decided to abandon the practice of psychology in commerce and industry and to pursue a career in clinical psychology. It was a cry for help which Professor Hurst must have found difficult to ignore. The minimum admission requirement for internship training was a master’s degree, which I had. However, the most difficult hurdle, and one that could not be easily overcome, was the colour of my skin. Professor Hurst and I were faced with apartheid laws, which sanctioned complete racial segregation between blacks and whites in all significant spheres of life in South Africa. I could not be admitted at Johannesburg’s Tara Hospital, an established psychiatric training hospital, since in the 1960s all health facilities were segregated on the basis of race.

Professor Hurst approached Professor Robert Lipschitz, the head of neurosurgery at Baragwanath Hospital in Soweto, and in January 1969 I was admitted there as a clinical psychology intern in the Department of Neurosurgery and Neurology. This was an extraordinary decision – as far as I know it was the first time anyone had been placed in a neurosurgery department to serve an internship in clinical psychology, and nothing had prepared me for my role.

To satisfy the standard certification requirements of the Medical and Dental Council I had to work under appropriate supervision at the hospital for one full year. Uncertain as I was about the move, I was heartened by my reception by the professional staff of the department, including the black ward sister and her nursing staff. Professor Lipschitz carried his large frame and professional authority as head of neurosurgery with self-assured dignity. Interestingly, he managed to be both charismatic and reserved. A tall, heavily built man, he appeared worthy of his huge Rolls-Royce, in which he almost always travelled alone.

Gathered around him during the morning ward rounds was a team of outstanding professional men and women made up of speech therapists, occupational therapists, neurosurgeons, neurologists and registrars training to become neurosurgeons. Among them were senior specialists such as Dr Colin Froman, a lively and talented neurosurgeon who was one of the shining lights in those days. Looking back now, I remember how odd it was to be the only black person among the non-nursing professional staff of Ward 7.

Upon arrival at Baragwanath I did not know what to expect. My situation was aggravated by the fact that there was no psychologist in the team to oversee my induction and allocation of responsibilities. In practice this meant that for the first few months I had to take every day as it came. What eased the unfamiliarity of the situation was the fact that from the outset I was offered a room in which to live, in the black section of the doctors’ quarters on the hospital campus. Accommodation there made my life much easier since I did not have to travel from Atteridgeville to Soweto every working day. Nor did I have to undertake the thankless task of trying to find living accommodation in Soweto for the duration of my internship.

I mention the black doctors’ quarters because my experiences there played an important role in my induction into the social and intellectual culture of a racially segregated teaching hospital in the South Africa of the late 1960s and early 1970s. I lived in the company of a small number of black doctors training both as interns and registrars – that is, doctors who were there to complete their training and registration requirements or who planned to qualify as specialists.

We lived in a prefabricated building without aesthetic appeal on the far edge of the hospital grounds. A stone’s throw away from where we stayed lived our white counterparts, in relative comfort in a purpose-built doctors’ residence. I remember the complacency with which our white colleagues appeared to accept the naked racial discrimination that was rampant in those days at Baragwanath. However, we were reassured by the fact that our own living quarters provided us with ample opportunities – especially at mealtimes, when non-resident black professionals joined us – for lively discussions of professional questions, including issues of racial discrimination in the healthcare sector.

I remember some of my colleagues with a tinge of nostalgia today. Dr Joe Variava, a boisterous physician-in-training, was the political firebrand in our group. Another physician-in-training was Dr Dumisani Mzamane, a reserved, soft-spoken man who was a thorn in the flesh of the authorities, especially officials in the provincial Department of Hospital Services in Pretoria. He has since died. In the years after the completion of my internship it was the trio made up of Variava, Mzamane and I who campaigned actively against racial discrimination in salary scales, living conditions at the hospital and opportunities for professional advancement. It was in the doctors’ quarters that a significant part of my early socialisation as a health professional took place.

During my internship year I was not exposed on a regular basis to patients suffering from moderate to severe mental illness, the kind of patients that I would have encountered at a psychiatric teaching hospital. Nor was I under the daily supervision of a senior psychologist or psychiatrist. Such supervision would have been available to me had I been at a hospital catering for white psychiatric patients such as Tara Hospital in Johannesburg or Weskoppies Hospital outside Pretoria.

In the beginning, when the medical team was finding ways to accommodate my needs, I survived on the professional goodwill of medical staff who were in no hurry to make unreasonable demands on me. I kept my eyes and ears open, and it was not long before I learnt about what was described in medical terminology as a ‘bedside manner’ and ‘bedside teaching’. There was a dialect that everyone, including staff nurses and junior doctors, appeared to understand. Colleagues spoke of patients ‘presenting’ with this or that symptom, or with a ‘history’ of some condition or other.

In time I learnt that empathic listening and careful and systematic recording of the patient’s history (as told by the patient) are essential building blocks in the development of a treatment plan and relationship. In addition, Lipschitz and other senior specialists used their examination of patients as a method of teaching. It was during the ward rounds that one was likely to hear about the latest medical breakthroughs as the senior doctors referred to their and other people’s latest research published in journals such the British Medical Journal and several journals in the Americas. During each ward round doctors-in-training were given ample opportunity to present their patients and tell their colleagues what they had found during their examinations.

In the midst of all this order, especially during the first few months, I had to contend with the fact that there was no training plan laid out for me either by the Department of Psychiatry at the medical school or by the Department of Neurosurgery at Baragwanath. How was one expected to survive under such perverse uncertainty? The remarkable truth is that I did survive. As is often the case, there were many contributing factors. On close observation of the work in the ward, I was impressed by the confidence and professionalism of the clinical team in the course of their day-to-day activities. I sensed a common purpose among them and it was as if they all knew what that common purpose was. My curiosity was alerted and the desire to learn sharpened by the professionalism that prevailed.

One of the earliest lessons I learnt in the course of the ward rounds and the clinical conversations accompanying the examination of patients was the way the mental status of patients was assessed. In the work of neurologists and neurosurgeons, a patient’s mental status is one of the primary areas of concern. I noticed that three cardinal abilities were considered relevant: orientation to self, orientation to place and orientation to time. My awareness of the importance of indicators such as these led me to believe that I needed to master the basic tenets of the clinical conversation.

As was my habit throughout my career, I read myself into important but unfamiliar knowledge domains. I studied all the neurology and neuropsychology texts I could lay my hands on in order to develop a working knowledge of the brain and the clinical assessment of higher mental functions. Fortunately, such texts were not difficult to identify and to secure in the extraordinarily well-stocked academic bookshops of Johannesburg in those years.

Three other experiences opened the way for me in my search for more structured and meaningful ways of working with patients, especially within the general hospital setting. First, the University of the Witwatersrand ran one of the most advanced speech and hearing therapy departments in the country, under the able leadership of a no-nonsense elderly female professor, Myrtle Aaron. I had watched the speech therapists working in my ward and in other locations in the hospital, and I soon learnt that their specialty included the diagnosis and treatment of neurologically based speech and hearing disorders associated with brain dysfunction.

I had ample opportunity to observe them while they conducted intricate speech and hearing tests as well as neuropsychological tests to establish the form and seriousness of speech and hearing impairments following referrals by medical specialists. It was largely through my exposure to their clinical activities rather than those of the neurologists per se that I became familiar with the work of Alexander Luria, a man who studied psychology before he went on to study medicine. My attention was drawn to Luria’s world-renowned book Higher Cortical Functions in Man,¹⁰ which became the intellectual window through which complex knowledge of the human brain and its impact on behaviour in health and disease could be studied and understood by an outsider, which I was at the time. My familiarity with Russian and Anglo-American neuropsychology had its roots in Luria’s work, including his intellectual biography.¹¹

From my earliest introduction to Soviet and Anglo-American neuropsychology at Baragwanath, two areas attracted my interest. The first was what I describe as the neuropsychology of the body, the body image and its disturbances, closely associated with my doctoral research on paraplegia. About ten years later, interest in some themes of the clinical neuropsychology of disturbances of higher mental functions following head injuries took centre stage, a development which was intimately associated with my involvement in forensic and medico-legal work in my private practice and in the South African Supreme Court in the 1980s.

While at Baragwanath I undertook a close study of Luria’s book. In 1981, following my appointment at the University of the Witwatersrand, I was able to run a properly organised, part-time private practice with rooms in Commissioner Street in downtown Johannesburg. There my work included a significant number of medico-legal cases, often involving adults and children who had sustained head and other injuries during motor-vehicle accidents. It was during this period that, through study and practical application of techniques of neuropsychological examination, my knowledge of clinical neuropsychology expanded beyond Luria to include countless other practitioners, among others Australian neuropsychologist Kevin Walsh.¹²

In retrospect, what seems so remarkable are the detailed typed notes which followed my reading of the neuropsychology literature of the day, primarily as preparation for appearances in an inhospitable court environment in the 1980s and the beginning of the 1990s. Working in this manner provided me with wide-ranging knowledge of the field as well as sufficient preparation for the forensic assessment of clients and the professional exposition of evidence in court.

My reading on brain–behaviour interactions and my study of and research into body image was given impetus by well-known figures such as Paul Schilder and Macdonald Critchley, among many others.¹³ Consequently, I found myself increasingly at home in the course of the daily professional discussions and activities that took place during ward rounds and consultations in other parts of the hospital.

The second learning opportunity arose during encounters, first in Ward 7 and later in other wards in the hospital, with patients who failed to make ‘neurological sense’ to the doctors. Significant numbers of female patients from Soweto and adjacent areas were being admitted to our medical wards complaining of symptoms that resembled known neurological and other illnesses. The complaints included paralysis of limbs and fainting spells, the sudden onset of an inability to walk, urinary incontinence, epilepsy-like convulsions, blackouts, fainting spells and palpitations – conditions that could easily be mistaken for diseases of the central nervous system. It was common for one to learn from such patients that the illness had been of sudden onset. The burden of explanation soon fell on me as the only psychologist in the team and the hospital. The question I was increasingly being asked both in our unit and in the adult medical departments was, what do these pseudo-neurological symptoms mean? Hidden within such questions was often an unstated assumption that the patient might be malingering – that is, playing at being ill.

I was consulted so often about patients in this class that the first paper I had published in South Africa’s premier medical publication, the South African Medical Journal, was on cases of hysteria among African women. The article appeared in May 1970. I had given the paper the title ‘Neurotic Compromise Solutions and Symptom Sophistication in Cases of Hysteria in the African’, but, without the courtesy of a discussion with me, apartheid gatekeepers at the journal’s headquarters had replaced the word ‘African’ with the derogatory term ‘Bantu’. I experienced this as a hostile and offhand rejection of the word ‘African’. Nonetheless, inexperienced as I was, in writing the paper I had put my finger on an important health issue which was developing under our noses.¹⁴

The history of hysteria, including its celebrated female patients and colourful healers in centuries gone by, remains a subject of continuing interest today. In 2011 I revisited the field of women and hysteria, and to my surprise I found that, although the diagnostic terminology has received a notable facelift, Asti Hustvedt, in her excellent study entitled Medical Muses: Hysteria in Nineteenth-Century Paris, could still report that

while modern medicine no longer talks about hysteria, it nonetheless continues to perpetuate the idea that the female body is far more vulnerable than its male counterpart. Premenstrual syndrome, postpartum depression, and ‘raging hormones’ are amongst the most recent additions.¹⁵

She adds that hysteria has assumed many ‘new incarnations’ and new diagnostic categories, among them chronic fatigue syndrome. What she found most remarkable was the degree to which new terminology had replaced the antiquated diagnostic system of the past. Here, then, is the story of an illness with a long and fascinating history in the West, an illness that intrigued me enough to have inspired the subject matter of my first publication as a clinical psychologist-in-training.

A third learning opportunity occurred during consultations conducted by psychiatrists working on a sessional basis in the hospital. Within the general hospital context in which I worked, outpatient work by part-time psychiatrists appeared peripheral to the work of the hospital. Although my role was largely that of a participating observer, I learnt a great deal in those years about the practices of psychiatrists in general hospital settings. Their consultations often took the form of a question-and-answer session between psychiatrist and patient, with the African nurse as an interpreter. I remember a certain dry matter-of-factness during the exchanges between psychiatrists and their patients. The practice was that I was permitted to observe their work during consultations at weekly outpatient clinics. Some of the patients would have been referred by me for psychiatric consultation, while others came directly on the strength of requests from doctors in the medical wards.

My relationships with consulting psychiatrists both at Baragwanath and at other Johannesburg-based teaching hospitals were the weakest link in my training. The patient histories that most psychiatrists solicited through poorly trained African interpreters were often shoddy and truncated. I sat through most of their sessions with patients only to hear the psychiatrists mention their treatment of choice, a predictable recourse to Valium, Stelazine or Largactil depending on whether the patient was believed to be neurotic or psychotic. It was as though the psychiatrists believed that all that was necessary in the treatment of those patients was pill-popping. The treatment interventions of psychiatrists in Johannesburg’s outpatient clinics in those years appeared to me to be disturbingly perfunctory.

One of the most striking features of life in a hospital such as Baragwanath at that time was the fact that, in the main, and in spite of apartheid laws, health professionals worked first and foremost as professionals in the execution of their duties. That is not to say that race and racism were consciously set aside; apartheid laws ensured that segregation was enforced with regard to residences, eating facilities and, of course, toilets and ablution facilities.

Over and above the opportunities sketched above, I benefited immensely from the fact that all the black doctors who were interns or registrars were engaged in further training as doctors and as specialists. Without planning on anyone’s part, I had landed in a hospital in which university-type activities such as teaching, learning, conducting research, publishing and studying for higher qualifications were part of everyday life. This was an unexpected but welcome bonus, with unintended consequences – a supportive learning environment that would have been non-existent in an ordinary psychiatric hospital in those days.

In this regard I remember the late Dr Benson Nghona, a University of the Witwatersrand graduate and a registrar in medicine during my time at Baragwanath. He, Dr Henry Smail and I were full-time residents in the black doctors’ quarters. Nghona, who was a few years older than I was, became my closest friend at the hospital. He neither smoked nor used alcohol. He was easy-going and friendly, but could be described as a bookworm. Remarkably, he was the most apolitical man I knew in those days.

I will always remember Nghona as the man who took me along to the medical school library in Hillbrow in his Mini and familiarised me with the workings of Index Medicus, a reference text that contributed enormously towards my literature searches in the course of my doctoral studies between June 1969 and December 1970. I also remember that close to the medical school library was a specialised bookshop that sold a wide range of medical and related books. Dr Nghona’s exemplary dedication to his field of study and profession did not escape the notice of the ambitious young man that I was in those days. He was one of my earliest role models.

I had started my internship at Baragwanath in the deep end of the pool at the beginning of January 1969. By 21 November there were definite signs that I was no longer out of my depth and was beginning to thrive – it was on that date that my paper on hysteria among African women was accepted for publication by the South African Medical Journal. Little did I know at the time that I would encounter a significant number of such patients within the teaching-hospital setting of the university as well as in the private practices of general practitioners in Soweto during the years that followed.

In the course of time, the prevalence of patients in our medical wards suffering from psychological rather than physical illnesses resulted in increased requests for my services outside the neurosurgery department. I inadvertently became the resident consulting psychologist for Baragwanath as a whole between 1970 and the first half of 1973.

During my three-and-a-half years at Baragwanath I was also drawn into the regular clinics conducted by a small group of highly dedicated female paediatric neurologists. Here I learnt a great deal about the neuropsychological illnesses of childhood, including childhood autism, a condition that was attracting a great deal of international attention at the time. I did not know then that years later this exposure to the work of paediatric neurologists would prove beneficial in my private practice and medico-legal work with children. In important respects, therefore, fate handed me a varied range of learning opportunities – more than I had bargained for, and most probably many more than I would have been exposed to in regular South African psychiatric hospitals in those days. However, I never had the privilege of learning what a typical clinical psychology internship in South Africa entailed. In my most generous moments I imagined that one would have learnt some of the basics of psychometric diagnostic testing as well as aspects of counselling and psychotherapy.

At Baragwanath my yearning for further study was difficult to ignore. Conditions were so auspicious that, in 1969, I was ready to register as a doctoral student under the supervision of Professor Roux. I did so with the full knowledge and active support of Professor Lipschitz and his senior colleagues. The theme of my doctoral research was body image in paraplegia.¹⁶ It was a daring move on my part to have decided on a research topic in a field that, in today’s terms, falls into the challenging and fascinating domain of neuropsychology. I am still heartened by the fact that no one expressed any uneasiness about the unusual research subject I had chosen. I can only assume that both Lipschitz and Roux believed that I could meet the challenge.

My research sample consisted of male paraplegics receiving treatment and rehabilitation in Ward 12, a unit under the direct supervision of Professor Lipschitz. Paraplegia, commonly the loss of regular use of the lower limbs, is a result of traumatic injury to the spine. In the course of individual development from childhood to adulthood, each of us develops a concept or image of his or her body. Such a body image is a psychological and mental representation of one’s identity as one experiences it in good health and in serious conditions such as paraplegia. The mental representation of one’s body may be distorted – that is, interfered with – by physical and psychological trauma such as the loss of the mobility of one’s legs following injuries to the spine.

My interest in disturbances of the body image was aroused by the noticeable attention such disturbances were receiving in the neuropsychological literature of the late 1960s and early 1970s. Fortunately, I encountered none of the difficulties I had experienced with my promoter in the course of my master’s research, and in November 1970 I was ready to submit my thesis for examination.

Although much has been said in recent times about racism in South African institutions such as the National Institute for Personnel Research (NIPR) and among the country’s leaders in the years of apartheid, I must admit that, as a young African psychologist who was working largely under conditions of professional isolation, I experienced the NIPR, with its substantial psychology and social science library and research atmosphere, as a welcome haven. My unrestricted access to the institute’s substantial book and journal collections, its reading areas and its earliest computer system contributed immeasurably to my doctoral research and development as a psychologist. I seized the opportunity to interact with and observe research psychologists at work outside a university and hospital setting.

Some of the researchers, such as Dr S Barran, who later left the country, offered me collegiality and friendship at a time when my professional identity was in its formative stages. During the closing stages of my doctoral studies my work was facilitated in no small measure by the installation of new computer facilities, which saved me from what would have turned out to be an unwelcome and time-consuming treatment of complex non-parametric statistical tests of significance during the analysis and discussion of my research results. In the winter of 1971 I was awarded the degree of DLitt et Phil at a graduation ceremony for black graduates of Unisa held in Ga-Rankuwa, an African residential area outside Pretoria.

By the time I began my first postdoctoral year at Baragwanath in 1971, I had started thinking and dreaming about academic work in a university as a prospective career. However, I soon found out that no black university was willing to employ me as a lecturer in psychology. I applied for a lectureship at my old university, but the fact that I was a former student who had completed his doctoral studies by the age of 30 failed even to secure a formal letter of rejection of my application.

What followed soon thereafter, however, was a windfall. I was invited to undertake an extensive coast-to-coast study tour of clinical psychology training centres at premier US universities. I term it a windfall for two reasons. One was that the invitation came as a surprise and at a time when I needed that kind of wide-ranging professional exposure. The second was that the trip included a visit that resulted in my subsequent return to Yale University as a postdoctoral fellow in July 1973.

I still remember how novel and memorable everything connected with the visit turned out to be. Hearing the song ‘Oh Happy Day’ on take-off and landing on the flight from Johannesburg to Paris was heart-warming and unforgettable. From Paris it was off to London. The US leg of the journey began with my arrival in Boston. During a visit to Harvard University I enjoyed an interesting hour or so in the company of the prominent psychiatrist Robert Coles. I left his office with copies of his well known series Children of Crisis. I travelled to Connecticut by train and arrived in the visibly affluent town of Westport, where I spent a number of days observing the daily work of an American private psychiatric hospital. It was there that I first observed group-therapy sessions as a treatment modality within a private hospital setting. During my stay in Westport I undertook a day’s visit to Yale University’s Department of Psychiatry, in the Connecticut Mental Health Center (CMHC) at 34 Park Street in New Haven, where a series of meetings had been arranged. My discussions with several senior staff members revealed that professional staff in the Department of Psychiatry included men and women from psychiatry, psychology, social work and nursing, each of whom participated to varying degrees in the treatment of patients and in teaching and supervising pre-doctoral students and postdoctoral fellows.

Although I visited Yale in the early stages of my study tour, I was so taken by what I learnt about its postdoctoral programme that I made up my mind then that I would like to return to New Haven as a postdoctoral fellow as soon as was practicably possible. I promptly discussed the matter with Dr Jesse Geller, the responsible academic at the time. The discussion was not in vain because I was able to learn, before my return to Westport that day, that my prospects for admission were good. At that time I was unaware of the part played by the state of Connecticut and Clifford Beers in the development of psychology in the US, including the establishment of the National Committee for Mental Hygiene (now known as the National Mental Health Association) in 1909.¹⁷

Following my visits to Harvard, Westport and Yale, there was much to experience and learn in New York City and the rest of the country. The experience I relished most in America’s world-renowned metropolis was my visit to the Harlem Counseling Center on 125th Street. It was a black-run facility that catered primarily for black and Hispanic residents of Harlem. During my visit I familiarised myself with an approach to mental health that was gaining ascendancy in the early 1970s – the practice of what was popularly known as community psychology, a tradition that had been introduced to me during my discussions at the CMHC. At the Harlem Counseling Center mental health professionals were developing community psychology treatment strategies that required professionals to work where people lived, in order to enable regular community members to act as agents for positive mental health change.

After my New York visit my itinerary included visits to psychology departments at Emory University, the Georgia Institute of Technology, and the smaller, predominantly black colleges in the southern city of Atlanta, Georgia, which are such a notable feature of the higher-education sector in that city. In California, upon arrival at Stanford University, my itinerary included a visit to the Center for Advanced Study in the Behavioral Studies, where I was pleased to meet Professor Monica Wilson of the University of Cape Town.

Although it was Christmas time, visits to the University of California in San Francisco and Los Angeles followed, as well as a day’s stay at the California Institute of Technology. It was that visit that resulted in a longish association between myself and Professor Ed Munger, who was instrumental in securing my participation in the regular meetings of the Pugwash Conferences on Science and World Affairs in the years following my visit.

A snapshot of such a wide-ranging visit leaves out many experiences and interesting individuals from whom I learnt a great deal. The tour exposed me to a world of applied psychology that was varied, purposefully structured and, in some instances, community based. It was a far cry from the minimalist hit-and-miss experience I had had to create for myself at Baragwanath. By the time I left J F Kennedy Airport on my way back to Johannesburg I was determined to return to the US, and specifically to Yale. I wanted to take advantage of the opportunity for advanced training that my hosts and I had discussed. As I understood the situation at the time, there could have been no better remedy for the deficiencies of my race-based training at home than a postdoctoral fellowship at Yale.