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Systems of Governance

Out of sight and out of mind in High Care

Mike Abrahams recently spent seven weeks as an involuntary patient at Valkenberg Hospital, a state psychiatric facility in Cape Town. The following is his account of time under observation in a secure unit.

Sitting alone in the reception area of Valkenberg Hospital’s High Care Unit, I am trapped in silence. I am waiting, I don’t know for what or whom. In a small glass cubicle, a young woman sits paging through a magazine. She is completely oblivious of my presence – me and my bags: a back pack and three paper bags overflowing with books, papers and more, awkwardly carried in when I arrived. The driver who dropped me handed a brown file to the woman in the cubicle and left without a word.

The sense of calm I felt on my way here is disappearing in the cold silence of the reception foyer. I look at the décor. It is mostly quilt-like embroidery framed in black and dark brown panels, hanging on sanitised walls. It has the feel of the work produced in prisons and rehab centres, institutions I know well. My eyes return to one untrained cursive stitching, which claims: “We Comfort, We Care, We Heal.” It reminds me of inscriptions at entrances of prisons that shout: “We Serve With Pride.”

A big guy with an indifferent look appears through a wooden door in the white wall. He must have been buzzed by the solitary woman in the cubicle. No introduction, no explanations of what’s to happen next or where I’m being taken too. I must simply follow him. In that brief moment when he comes through the door, the silence is broken by shouting and wailing noises. Hardly looking at me, he says, “Bring your bags,” absent-mindedly clicking a pen in his one hand. He does not help as I struggle to carry them.

I start to panic as I watch him punch a code into a small pad next to the door, which is in fact a thick metal door camouflaged with wood on the outside. As the door clicks shut close behind me, I realise there’s no easy way out of here.

I enter a relatively large open area with a cubicle where a group of nurses are standing chatting. They show little interest in me, the new arrival. I am ushered into a small office with a small table and two chairs, not very different from the room where notorious Special Branch policeman, “Spyker” Van Wyk, so-called for having nailed a detainee’s foreskin onto a table-top during interrogation, interviewed me about 30 years ago.

Memories of that interview flood over me now. I was sitting with my back to the door, alone in a small interrogation room. Every now-and-then some security policeman would put his head through the door and say “We got the piece of shit,”or “You think you could run forever,” or “We been waiting for you, you little shit,” with an aggression in their eyes that sent shivers down my spine. While I was being interrogated by a Van Tonder and a Steenkamp, who smacked, threatened and shouted at me occasionally, I sensed someone entering the room and noticed a flicker in Van Tonder’s eyes. Then I felt a hand on my shoulder and looked up into the cruel eyes of Spyker. It was the second time I saw him up close that day. He was part of the group that arrested me at home earlier.

As they were waiting to take me away, I asked to go and wash my face, looking to escape through the window. Spyker followed me into the bathroom, closed the door behind us, took out his pistol, cocked it, placed it on the washing basket and whispered, “You go ahead, do it.”

As I looked up into Spyker’s eyes in the interrogation room, he squeezed my throat from behind, choking me until I almost lost consciousness. Earlier, when we’d arrived at the security branch building, he took me into the lift and said, “Don’t worry, you won’t fall down the stairs,” while he squeezed my testicles all the way to the top floor.

But such fears are not justified here. This is not a police building, it is a psychiatric hospital. I am here because my daughter wants me alive. After another attempt to take my life, she has admitted me to Valkenberg. She believes this is what I need and I hope she’s right.

My carer returns after a while: “Get onto the scale.” He registers my weight. “Stand against the wall,” he measures my height. Then I hear another burst of human noises: screams, cries and swearing interspersed by an authoritative voice shouting: “ONE LINE! ONE LINE! ONE LINE!” which is echoed by other voices.

“Name? Age? Address?” and other basic questions and my carer leaves me alone. I sit and listen to the noises beyond this small office, trying to imagine what kind of madness I’m about to join. I sit for what feels like hours, until a new face appears.

“Hi my name is…” he says. At this point, I’ve kicked into survival mode. Names don’t register, just where they’re located in the hierarchy of authority and what value they might be to me. I did hear this person’s name, but the moment he said he was an intern conducting a preliminary interview, his name slipped from my memory and disappeared through the open door to join the incomprehensible noises beyond the cubicle. The intern is too polite, almost apologetic, but he has no power and no value to me now. Only endless questions, some about my childhood, my past, my political involvement, what I do currently, how I ended up in hospital, why I try taking my life, how long have I been suicidal, perhaps I have an existential crisis – a diagnosis the head of the team will also reach days later – and so it goes.

New Age Gym: the yard session is an opportunity for patients to escape from "high care".  Photo by Rucera Seethal

New Age Gym: the yard session is an opportunity for patients to escape from “high care”.
Photo by Rucera Seethal

The intern and I exchange views about psychology and psychiatry. We have a conversation about euthanasia and agree to disagree. We speak at length about medication and chemical solutions to complex mental and emotional problems with social roots. He understands my resistance to taking medication, especially when I feel it alters who I am, or at least who I think I am. He insists on the necessity to take medication if I want to heal. I counter that I would if they provide me with the information of clinical tests and confirm that they were not tested on animals, “except elephants” – this comment is to confuse him and draw out the conversation because things have been very unpleasant beyond these interviews. And I am feeling combative, searching for weaknesses and fault-lines in the system. I test possibilities of discharging myself, searching for loopholes, there are none – I’m an involuntary admission, the property of the state, all powers have been surrendered. Any legal recourse would take too long.

After 40 minutes, he informs me that he cannot decide where I should be placed, but he will impress on the team not to place me in High Care. I will not see him again for the duration of my stay at Valkenberg.

The noise has receded, with occasional shouts of: “SECURITY!” “SECURE!” “TOILET PAPER!” “LIGHT!” Sometimes voices call: “NURSE! NURSE! NURSE!” or “When do I see my doctor?” or “When will I see the social worker?” Other times a torrid: “Nurse, jou ma se poes, as ek jou kry dan skop ek jou binne jou ma se poes.” “You don’t know me, you are lying to me.” “I’m not supposed to be here, the doctor said I must be discharged today!” “My family is waiting for me at reception.” “The doctor said the social worker will see me today.”

Then it goes quiet again. My carer returns and takes me to what looks like a recreational room. And leaves me alone with more child-like art on the wall: trees, sunflowers, hearts, and in desperate, unsteady hands, written loudly: love. A few nurses peep into the room and ask their colleagues in the cubicle: “Who’s this one?”

Thus far I have only been spoken to during interviews. Then I see the owners of the voices I have been hearing – patients in uniforms – approaching from two different directions and walking past the recreation room. Some approach me for a cigarette, but before I can reply, they are yanked away from the door by a nurse or security. They look like trapped animals. A security man shouts: “ONE LINE! ONE LINE! ONE LINE!” and the patients repeat the order to each other.

It is quiet again. A nurse appears and asks me to take off all my clothes. I ask why and in response she just hands me a tracksuit pants and a white sleeveless vest printed with the name of the hospital and the ward. The uniform the patients had on. I start walking toward the door and stop. By now I am terrified. The presence and power of the security personnel seem more dominant than that of the health workers here. I try asking a passing nurse a question and without stopping in her tracks or even looking at me she says: “Someone will attend to you.”

I strip, self-conscious and awkwardly in full view of the nurses in the cubicle while they look on indifferently. I decide not to turn away for some privacy, and perhaps dignity, as I undress, pretending to be as oblivious of them as they are of me. More patients noisily walk past the room I am in, some peeping curiously, others glaring at me like animals ready to pounce.

At this moment I wish I had read Sello Duiker’s The Quiet Violence of Dreams; it might have prepared me for some of this. I tried reading it many times but it was always too painful. I never got past the first 30 pages. I also remember how it took me years to read Bessie Head’s A Question of Power, and how it was only once it became prescribed reading that I actually managed to finish it. Reading Power was often accompanied by nightmares.

Bessie Head and Sello Duiker join me in the next interview, when my first carer returns with more questions. I’ve only been here for about two hours but it feels like an eternity, like my time in the hands of Spyker and his colleagues.

Without looking at me, he flips through a file, with a pen in one hand to record my answers: “Do you hear voices?” he shoots at me. I try a charming smile and reply, “No, but I believe there are many people out there who believe it is possible to hear voices and many others went to their graves believing that what these voices said is true.” I stop to study his reaction. I have decided to bullshit my way through this – maybe this is my impulsive response to authority.

He stops taking notes (or pretending to take notes) and looks at me. “What do you mean?” he asks. I keep to my line: “Well, there are people out there who believe a burning bush once declared: ‘I am the Lord your God.’” I say this in my softest, sincerest voice. He looks half-bewildered, half-irritated, searching my face. It seems as if he’s noticing me for the first time.

“Do you have special powers?” he says slowly, studying my face intently. I am starting to enjoy it: “Well, I don’t, but as I said before, many people believe some others have special powers. You know, like turning water into wine, opening a path in the sea, making the blind see, raising the dead and so on.” He writes a brief note while keeping his eyes on me and asks the next question. And so we go, testing each other’s resolve.

When he concludes the interview, I explain the assault on my senses, the indifference of staff since my arrival. I speak of not knowing what is happening or what is to happen next. I speak firmly but with respect and recognition of authority. He apologises for his behaviour and introduces himself for the first time as Nurse Thabo. He explains that this is standard procedure. But he does not tell me the process to follow. Instead he gets up, closes his thick brown file and tells me there’s some food in the dining room for me, sarcastically adding: “See, we do care.”

Institutional food always appears so unappetising. I have not eaten for the day but I stare at the pasta in the faded yellow plastic plate in front of me and finish the cold drink. I want to go out for a smoke. I ask two security guards who are reclining in their chairs with their legs stretched out where I should go. They are ‘busy’ watching the re-run of a soapie on TV. I stand next to them, pretending to look at the TV, but with occasional glances at them, trying not to show my impatience. One of them eventually gets up and unlocks the door of the TV room that leads to the exercise yard. I smoke two cigarettes in quick succession, in case I won’t get the opportunity again. The yard is full of dying, light-brown grass and Cape Town’s wind is flicking dust into my eyes.

I think of the security guards and wonder where they sit in the hierarchy of power. I notice how the patients/inmates defer to them instead of the nursing staff. Half way through my second cigarette I am called to register my possessions: books, a laptop, cellphone, some drawing materials, a penny-whistle, my cigarettes, a few coins and some documents. My papers show that I am a trade unionist and a nurse jokingly asks if they would be getting increases this year. I tell her yes, if they are prepared to strike for it. I can only keep my cigarettes. Books and everything else are against policy.

Back in the recreation room, I hear voices from where inmates disappeared earlier. Nurses huddle in the cubicle. The voices get louder. The TV-watching security guards unlock the door to the yard. I’m yanked by the shoulder as I stand by the door to see what’s happening and told to join the rest. One of the inmates, a grey-haired old man storms the nurses cubicle like someone possessed, banging on the glass door and windows, shouting and swearing: “Julle ma se poese, hoekom will julle nie hê ek moet die dokter sien nie. Ek moet nie hier wees nie, julle will nie my familie phone nie, julle gaan nou sien julle naaiers, vandag gaan iemand vrek!”

I would later learn his name is Simon and he has been in High Care for two months. Another younger inmate in his 20s, Joseph, with gangster tattoos on his arms and a Bible in his hand tries a different tack, appealing to the nurses in a nagging drawl: “Nurse, nurse, nurse, nurse,” he calls out, “the Social Worker said I’ll be moved to another ward today. When are they coming to fetch me?” He goes on and on and on, raising his voice. Finally he explodes, cursing, threatening them with punishment from the Almighty and accusing them of doing the work of the Devil. The nurses giggle nervously while the security guards take him out to the exercise yard.

A rough head count suggests we are about 30 in the yard. The perimeter is 76 steps if you take a brisk walk around the edge – I counted while watching others walk it. Some inmates, as soon as they step outside, immediately start walking. I try to find out from the security, the only staff among us: Can I see a nurse? (Later!); How do I get an interview? (Ask the nurses!); How do I find out where my ward is, where will I sleep tonight, how long will I be here? (No! No! No! One line!)

No easy way out: the entrance of Ward 2 at Valkenberg. Photo by Rucera Seethal

No easy way out: the entrance of Ward 2 at Valkenberg.  Photo by Rucera Seethal

I withdraw to look at my fellow inmates and on this first day it is a scary scene. They seem violent and deranged, like people that cannot be held responsible for their actions. One could dress them in animal suits and it would look like a zoo or a kiddies play, or place a sign that read “New Age Gym” and dress them in training outfits. But as long as it says “High Care” on the outside, we appear a group of crazy men.

Everybody smokes hand-rolled, heavy-smelling tobacco cigarettes. Andre is walking up and down singing “And wherever you are, I’m thinking of you;” Peter is staring straight into Andre’s eyes and screaming a different tune with the same message, “I’ll see you when I get there, if I ever get there;” Jefferson, also with a Bible under his arm, is impersonating John the Baptist on the banks of the Jordan; Ishmael, banging on the door, is asking nurses to free him; Sipho is rolling in the dust, jumping up only to pick up a stompie; Faried is trying to explain to the security that his sister is at reception waiting to take him home, but nurses won’t let him; Wellington’s walking in circles, interfering with those walking the perimetre and shouting “I miss my neighbour Salie,” over and over; Samuel has convinced a few that he won a trip to Mauritius and is inviting them to join him, in exchange for some tobacco; Moses keeps to himself, mumbling about his wife who is in the female section of High Care; John is throwing Johnson’s shoes over the 7-metre fence – I’d later learn that he does this everyday. Fikie, with a glass eye, talks to a group of youngsters about when he was a feared gangster on the Cape Flats, and they hang on to his every word while he smokes their tobacco. In another corner a young man, a boy really, is teaching a group how the number gangs work in prison. He claims he was born in prison.

Joseph the Bible-bashing “former” gangster approaches me and demands a cigarette, in his gangster manner. I tell him to fuck-off if he doesn’t know how to speak properly. He starts shouting loudly in my face about how he is a child of the Lord and how I’ve been sent by Satan to test his faith. He towers over me as he accuses all of us of being destined for hell, except for Jefferson who wanders around the yard preaching to anyone who will indulge him. Fearing a possible assault by Joseph, I burst out laughing like a mad man – I’m now one of them, I realise at that moment.

Then another voice shouts, “Joseph, you want to be moered again? Leave him alone, or do you want to cry again?” Enter Frank, more than six foot tall, one of those who walk in circles non-stop. Joseph rushes to the door in the TV room, “You always want to fight with me. Nurse! Nurse! Nurse! That big one is fighting with me,” he screams. He wants to go to the recreation room because everybody is testing his faith. Rafiek joins him in the screaming and after a while they’re both taken in. A few minutes later, they shout from the room to be brought back to the yard and so it goes until supper time.

I thank Frank and tell him I prefer to take care of myself. He rolls me a cigarette and starts walking in circles again. Out of nowhere, Johan sprints and stops right in front of me and starts shouting his full name. He would later tell everyone he is my son-in-law and cry for me at night when I’m taken to the seclusion cell. Frank intervenes again, pushing Johan away and threatening him with violence. Then a grey-haired man named Curtis starts selling ‘fish’, running up and down and jumping into the air. Jefferson tries to calm him down but only gets him more exited: “This is my schizophrenia and I will behave in the way my schizophrenia want me to behave,” he says. Curtis goes on selling snoek, calling names of people only he knows, swearing at others who owe him money for three hours.

It is unbearable. I want to press my hands against my ears, I want to join in the shouting, I want to walk in circles like a trapped animal, I want to laugh and cry at the same time. But I don’t. I want to stay in control. Albert is crying because he misses his neighbour; Joe joins in because he misses his wife; Rafiek and Ishmael start singing, the same song this time: “Wherever you are, I’m always with you.” I am tempted to join the singing and crying. I think of my kids, of the women who still live in my heart and who briefly allowed me to settle in theirs, I feel sad and feel the moistness of my eyes. I turn my back on my fellow inmates and look away, through the fence, and escape from High Care for a short while.

“One line! One line! One line!” The voices of the security guards, echoed by many of the inmates, bring me back to the enclosure. I see how my fellow inmates rush to form a queue outside the dining hall door. This is the language and behaviour of oppression, I will not submit to it. I’ll make enemies with the security but I will not be party to this. I get shoved and pulled into the line. After a few days, the guards will allow me to join the queue only once we start walking. The door to the yard gets locked, we are counted, then another door, to the dining hall, opens. I’ve already decided not to eat. The tables are set, plastic plates and cups, four people per table. I count us again, we are 36. Many thank God for the food, thank the staff for the care promised, ask for forgiveness for shouting and swearing at the staff, promise to do better tomorrow, ask God to help us to be better tomorrow and beg God to heal us and get us out of High Care.

Names are called, medications are dished out. Some want more than prescribed, others want something to help sleep, others argue that the dose is too much. Ruben pretends to be asleep when his name is called. He eventually spits the meds into the tea that he doesn’t drink, someone sees him and tells the nurses. “Open your mouth! Lift up your tongue!” A security guard grabs him into a choking grip from behind until his legs start giving way and drags him to a chair. I too refuse to open my mouth, get choked and escorted back to my chair. Violence and fear are hanging over the room. Joseph descends on my food when he realises I don’t intend eating it. A note is written by a nurse in a file. I suspect it is about me refusing to eat.

By the second day I will eat all three meals, just in case they see the need to add to my medication. Simon also refuses medication and he fights the security. The on-duty doctor is summoned and immediately injects Simon to drain the fight and anger out of him. The fire in Simon’s eyes is quickly replaced with a glazed look and he is taken into the seclusion cell. Calm returns. Someone prays. We are escorted back to the TV room but not allowed go to the yard. The medication kicks in and this is visible: some lie around on the floor, others get hyper, but the shouting and singing continue. Does this medicine cure? Or does it merely give the staff and security a peaceful shift?

The night shift nursing staff enter and start by counting us. Then they shake hands with everybody, asking how we are doing. I try telling them it’s my first day and I don’t know where I’m supposed to sleep, but get dismissed with: “We’ll attend to you later.” It never happens. We are 36 mental patients trapped in the small TV room. Some walk around up and down, I join them. Others watch TV, or just slump on the floor. The scene is similar to earlier in the yard, only slown down by the meds.

I’m worried about sleeping arrangements.

Three hours later: “One line! One line! One line!” I gather it’s time to go to the wards. I approach the staff again to query sleeping arrangements and am told just to find a vacant bed. At some point the line splits and I decide to go with the queue on the right, where most of the troublesome ones go, and away from Frank. I must assert myself to survive. It is prison bars being unlocked with some electronic pad; I look over my shoulder and see the same apply to those who turned left. Wow! This is real prison!

Behind bars, I walk up and down looking into each room. They all house four beds – a sponge on a cement platform, a bed-sheet and one threadbare blanket. I don’t ask who sleeps where; I don’t want to create the impression I want to sleep with some and not others. In the last room there’s an empty bed. Fred, Riedewaan and another inmate who’s name I never got, occupy the other three beds. With nothing to read, some cigarettes but no matches, I decide to try to sleep. Others still walk up and down shouting at the security for a light, trying to get the attention of night shift nurses to negotiate appointments with social workers or doctors the next day, all to no avail.

And without warning, the lights go out. Some of the inmates continue walking and singing while others go from bed to bed in search of tobacco. Fred softly calls someone named Farieda over and over and Selwyn’s crying. Themba can be heard praying louder and louder in the dark. Tshepiso and Sean are arguing about the sequence of events some days earlier when a group of young women walked past the exercise yard and gave them sweets; Sean still has the sweet wrappers as evidence for his version. A few days later, he would convince Tsehpiso that he was not even present at the scene and the whole thing threatens to spill over into a fight. In the middle of the night, some inmates are hovering over my bed, wanting to search me for cigarettes. I whisper in an icy voice that I will kill anyone who touches me, and I mean every word. My voice scares even me. I am not bothered after that. I sleep and dream of street kids.

Day Two and nobody appears violent anymore. I realise we are all just sick and all of us are trapped in a system that doesn’t understand us. So we visit the violence upon those weaker than us. The nurses are above the security guards, the security are above the patients and the stronger patients are above weaker ones. The social workers and doctors are almost never seen.

On Day Four I decide to go on a hunger strike. I will announce my strike on Day Six, during a visit from friends who can take the story to the media. I am moved to a better ward.

In the meantime, since Day Three, I’ve slept in the seclusion cell every night. I managed this by purposely breaking the rules and getting the predictable punishment. After Day Three, I just voluntary walk into the seclusion cell and I tell the night shift staff that the day shift staff placed me there. There is quietness and absolute darkness in the seclusion cell. I exercise every night until I am exhausted enough to get a peaceful sleep.

“One line!” – every morning that is the call. Then we strip naked and queue for a cold shower. Every third day, we get a change of clothes and bedding. We queue naked, old and young, in front of the nursing staff. I have decided not to cover myself. I wash and dress myself as if they are not there. Thing is, I am not there. Everyday I mind-travel to walks in Finland, to the Frida Kahlo museum in Mexico, to walks in Brazil, but mostly to Skeleton Gorge in Kirstenbosch, beyond the waterfall to the top of Table Mountain, where I can look over the Greater Cape and view the concentric circles of exclusion that make up the city.

I only escape from High Care during shower time. The rest of the time I refuse to think beyond the fence that keeps me in, I refuse to even know the time. I am an involuntary admission; I have no control over my life, over time, over anything. I belong to them and knowing time does not alter the meaningless routine: One line! Cold shower. One line! Breakfast. One line! Exercise. One line! Morning sleep. One line! Lunch. One line! Exercise! One line! Supper! One line! Medication. One line! Tobacco. One line! Medication. One line! Medication. One line! Medication…

And so from day to day, I pass down the line, from ward to ward, seven weeks in the institution until I can leave, uncured, but with relief.

And as we progress from ward to ward we become calmer and notice more things around us. Trees and birds and other things we couldn’t see in High Care. And when I eventually end up in the final ward before discharge, I understand High Care better. And the staff there – in the face of the painful illness and desperation among us – are also powerless. I understand that I will leave but they will stay.

I still wake up many mornings with a desire not to live.





Mike Abrahams is trade unionist and writer based in Johannesburg.

This account also features in the “How Body?” section of Chimurenga Vol. 16: The Chimurenga Chronic (available here).

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