Rural Realities: Resilience and Revelations From a Year in Psychiatry

fotoworld/Adobe Stock

As part of the mandatory community service year in South Africa (where newly qualified doctors are sent for a year to serve the community, often to rural settings), I found myself stationed in one of the country’s most rural regions, offering a unique and often challenging experience in psychiatry. For many, this year is a time of both personal and professional growth, and it was no different for me as I navigated the complexities of rural mental health care.

The Rural Setup: A Blessing and a Challenge

In the rural area where I served, access to specialized mental health care was limited. At my hospital, I was fortunate to have a visiting specialist forensic psychiatrist who would visit the facility around 6 times a month. Although she was always available for consultations over the phone, the isolation of being "left to my own devices" most of the time was daunting. The situation was even more challenging for others in similar positions who lacked the support of a specialist altogether. However, the unique nature of my position also meant I was managing forensic admissions and state patients, often working in a unit that felt more like an academic facility than the underresourced hospital that it was.

Cultural and Language Barriers

One of the most striking aspects of my experience was the significant cultural and language barriers. Most patients did not speak English, and I often had to rely on translators to communicate. On top of this, many patients came from communities where traditional beliefs in witchcraft, traditional healing, and prophecy played a significant role in their mental health perceptions. These cultural factors deeply influenced their delusions and posed a challenge in forming treatment plans that felt culturally sensitive while still adhering to medical guidelines.

The hospital itself had a 50-bed psychiatric ward which was often filled to over 120% capacity, thanks to the donated mattresses which allowed us to care for patients on the floor. This ward housed a diverse mix of patients, including adolescents, males, females, forensic patients, and state patients—all in the same ward. This setup, though efficient in one sense, made it harder to provide specialized care for such varied groups under 1 roof.

Some Unforgettable Cases

During the year, I encountered cases that not only tested my clinical knowledge but also my patience and ability to adapt. One of the most perplexing cases involved a boy, aged 15, who had stopped speaking at 13, despite normal development prior to that. All investigations were normal, and after weeks of patience and creative approaches—like playing Jenga with questions written on it, and chatting to him incessantly—he slowly began to answer in 1-word answers, eventually progressing to full sentences. Eventually, he revealed that he was hearing voices. Although he stabilized on olanzapine, we never reached a definitive diagnosis, which was a frustrating yet humbling reminder of the limitations of our understanding.

Another particularly challenging case involved a woman who was 32 weeks pregnant and admitted with extreme mania with psychotic features. With no access to electroconvulsive therapy (ECT) and after failing on atypical antipsychotics, she was started on lithium. However, her condition was complicated by the development of preeclampsia, and tragically, she experienced an intrauterine fetal death. Despite these challenges, she took another 3 to 4 months to stabilize and was eventually discharged and stable on a combination of lithium and olanzapine.

In a particularly jarring experience, I was physically assaulted by a patient who was frustrated by being kept in the hospital against his will. This was a stark reminder of the volatile nature of psychiatric care, particularly in settings where resources and security measures are limited.

Lessons Learned: Adaptability and Patience

During my year in rural South Africa, I learned some invaluable lessons. One of the most important was patience. Psychiatric management cannot be rushed, and the hope of quick fixes through excessive use of antipsychotics rarely leads to the desired outcome. It became clear that time was often the key factor in helping patients settle.

Working in a resource-limited setting also taught me how to make do with what is available. Our pharmacy stocked mainly risperidone, haloperidol, and clozapine, with occasional supplies of olanzapine and quetiapine. Managing medication stock-outs became an exercise in creativity, especially when switching patients between drugs based on availability. This situation also meant that I had to learn how to manage conditions like depression without access to a psychologist—cue my impromptu online crash course in cognitive behavioral therapy (CBT).

Perhaps one of the most surprising lessons was how important it is to respect patients' and families' wishes, even when they conflict with western medical practices. In some cases, patients improved significantly after seeking traditional healing, even if there was no biological basis. As a young doctor, this was something I initially struggled with, but eventually, I came to realize that respecting cultural beliefs and working in tandem with local healers often led to better patient outcomes.

Another key realization was that experience trumps textbook knowledge. Early in the year, I was reluctant to follow my consultant’s advice, as it often did not align with what I had learned in medical school. However, after 47 years of experience in rural psychiatry, her approach was grounded in practical wisdom. Almost always, her methods proved to be correct. This has taught me that sometimes a textbook diagnosis is less important than identifying and treating the symptoms. The reality of psychiatric care often does not align neatly with academic knowledge, proving that psychiatry is as much an art as it is a science.

Finally, I learned that flexibility is essential. Psychiatry, particularly in rural settings, is unpredictable and requires both medical knowledge and emotional intelligence. There is no one-size-fits-all approach, and flexibility in treatment is key to achieving the best outcomes.

Conclusion: A Journey of Growth

My year in rural psychiatry has undoubtedly been one of the most challenging yet rewarding experiences of my medical career. It has pushed me to grow not only as a doctor but as a person. Working in an underresourced environment with patients from diverse cultural backgrounds has highlighted the importance of adaptability, patience, and empathy. This experience has deepened my appreciation for the art of psychiatry and for the profound impact that cultural sensitivity, respect for patients, and personal experience can have on treatment outcomes.

As I reflect on this year of learning, I am incredibly grateful for the lessons it has taught me. Despite the many challenges, my passion for psychiatry has only strengthened. Many of my colleagues have grown despondent after this jarring year, some contemplating other career paths. For me, it has solidified my commitment to psychiatry and deepened my yearning to try to fill the immense need for mental health services in South Africa.

Dr Lehnerdt is a community service medical doctor working in Mpumalanga, South Africa.