A margin is that part of an area that is adjacent to the edge. To marginalize someone is to move them ‘to the margin of a sphere of activity, make economically marginal, impoverish’ (Shorter Oxford English Dictionary 2002). Margins are often understood as problem areas. For occupational therapists, they represent places for exploration and opportunities for contributing to social change through occupation-centred practice. Sometimes, occupational therapists work towards creating a new centre, through belonging and bringing people together. At other times, occupational therapy is about bringing people into a centre from the margins. And often it is about both. Sometimes, it is about appreciating that what is perceived to be marginal is not marginal at all. In short, occupational therapy on the margins is about being responsive to the social determinants of mental health and human wellbeing.

This chapter commences with a brief overview of global mental health challenges and the implications of these for occupational therapy on the margins in developed and developing countries. Sociology is suggested as a foundation for considering various dimensions of social oppression and the implications these have for humans as occupational beings. The story of Dorcas is used to illustrate social exclusion and inclusion as features of life on the margins. The chapter concludes by describing how occupational therapists working on the margins might orientate themselves, using a number of direction pointers. Pertinent references for additional reading to substantiate the points being made are provided throughout the chapter.

WHY MARGINS MATTER: CHALLENGES IN GLOBAL MENTAL HEALTH

In many countries, the practice of occupational therapy takes place mainly within health services. This has led to the development of mainstream occupational therapy theory, models and methods that focus almost exclusively on individual therapy, with secondary attention given to the socioeconomic, political and historical circumstances that impact on people’s health and occupational status. However, there has been a subtle but important shift in professional perspective; one that looks beyond a diagnostic, medical view of individual mental health to the social groups and communities within which people live, become unwell and are expected to recover. A methodological middle way is unfolding, in which occupational therapists recognize and address the interplay between personal troubles (individual biographies) and public issues (history and structure of the society within which the individual is located). The central commitment of this perspective is to build socially inclusive, egalitarian communities through recognizing the power of occupation for individual and collective human development and wellbeing (Kronenberg et al. 2011; Whiteford and Hocking 2012).

Different Worlds

This chapter was written by two occupational therapists: one based in an industrialized and developed country and the other in a developing African nation. Reflecting on the similarities and differences of mental health occupational therapy in the UK and South Africa, we were reminded of the roles that history, economics and politics play in shaping what the profession is able to offer in a particular society. The personalized mental healthcare packages promoted in developed countries are based on the availability of operational and resourced service infrastructures and regulated profession-specific functions, outputs and outcomes (Trentham et al. 2007; Slade and Davidson 2011). Occupational therapists employed by statutory mental health services in these contexts are structurally supported as they work in partnership with individuals and other stakeholders in the delivery of person-centred recovery programmes.

A different service trajectory is likely to exist for occupational therapy in low- and middle-income countries (LAMIC), due to under-developed mental healthcare systems and resource constraints associated with poverty and social inequality (Patel 2003; Lund et al. 2007). In these countries, mental health services, if available, are usually merged within primary healthcare and delivered through grassroots community structures to populations rather than individuals (Petersen et al. 2010). The emphasis of primary healthcare is on preventing disease and disorders, eradicating malnutrition, providing adequate shelter, opening access to basic education and creating jobs, as fundamental human rights and as social precursors for health and wellbeing (Farmer 2008).

Local Circumstances

Writing about mental health services in low- and middle-income countries (LAMIC), Murthy (2011, p. 333) stated that:

development of mental health services all over the world, countries rich and poor alike, have been the product of larger social situations, specifically the importance society gives to the rights of disadvantaged/marginalised groups. Economically rich countries have addressed the movement from institutionalised care to community care, building on the strengths of their social institutions. LAMIC have begun this process in a different way and have made significant progress. There is a need to continue the process by widening the scope of the mental health interventions, increasing the involvement of all available community resources, and rooting the interventions in the historical, social and cultural roots of countries. (Italics added)

Murthy (2011) argues for a broader scope of action that is both socially inclusive and contextually relevant. To achieve this requires identification of priorities for research and intervention, and contextually responsive mechanisms for implementation put in place, with consideration given to local circumstances. One example is the Grand Challenges in Global Mental Health initiative, which identified 25 top global challenges and six priority goals for research and intervention that will make an impact on the lives of people living with, or at risk for, mental, neurological and substance-use disorders (Collins et al. 2011).

Of particular interest to occupational therapists are the priority goals, which are briefly discussed in the next section.

Occupational therapists can contribute to these and other Grand Challenge themes by adopting a critical stance towards the social contexts within which they work. A wider vision than the remediation of illness or disability is indicated, however important functional outcomes might be for individuals and their families. Townsend and colleagues (2007, p. 155) suggested that ‘outcomes of interest to occupational therapists in enabling social change may be to advance occupational rights’. Turner (2011, p. 320) wrote of a ‘hinterland of need’ in which increasing numbers of people in need of support and long-term help are likely to fall outside the remit of statutory care services. A critical stance is facilitated when occupational therapists become reflexively aware of the social dynamics associated with margins.

UNDERSTANDING THE MARGINS

In this section, a discussion of margins as a sociological concept is structured through a series of questions.

What are Margins?

Margins are conceptualized as fluid spaces or positions that social groups occupy on the basis of difference. A social group is a ‘collective of persons differentiated from at least one other group by cultural forms, practices or way of life’ (Young 2000, p. 37). A margin can be a physical place, a social space or a personal experience on the periphery of the social mainstream or dominant order. For every margin, there is a centre or core that represents some form or position of authority, power and privilege. Margins exist wherever humans congregate; they affect every form of social grouping, including families, communities, organizations and society, and are constantly changing in response to sociopolitical, economic, cultural and other forces that marginalize people on the basis of perceived difference.

Social Exclusion

Social exclusion is an alternative term used to refer to marginalization and has been defined as forms of disadvantage brought about by the cultural devaluation of groups or categories of people in society based on who they are perceived to be.

The concept of Social Exclusion captures the experience of certain groups who are ‘set apart’ or ‘locked out’ of participation in social life. Moreover, it brings attention to processes (italics added) of exclusion. This means understanding how disadvantage is produced through the active dynamics of social interaction, rather than through anonymous processes of impoverishment and marginalization.

(Kabeer 2000, p. 1)

Human Differences

There are many vectors and combinations of perceived and imposed difference involving complex constructs such as gender, race, class, ethnicity, ability, sexual identity and others. When differences become socially significant, they cause stratifications and divisions that elevate some people above others, giving them a disproportionate amount of resources, power and prestige. Social diversity and stratification are key organizing features of all societies. Certain categories, strata or groups of people are positioned on the continuum between centre and margin and are ranked in a hierarchy of social status which, from an occupational perspective, influences the forms and functions of occupation in society (Whiteford and Hocking 2012).

Assumptions

People everywhere, including occupational therapists, tend to think that their own positioning and way of life is how life is or should be for everyone else (Whalley Hammell 2011). This assumption can make them unaware, dismissive or critical of the lifestyles and social practices of those who are different from them, so that people participate in oppression either inadvertently or deliberately. Thus, social strata or divisions create margins which may lead to different forms of oppression (Young 2000).

Why do Margins Exist?

Margins exist because human difference is used as the basis for oppression (Macionis and Plummer 2008). Oppression refers to ‘the vast and deep injustices some groups suffer as a consequence of often unconscious assumptions of well meaning people in ordinary interactions, media and cultural stereotypes, structural features of bureaucratic hierarchies and mark mechanisms, in short the normal processes of everyday life’ (Young 2000, p. 36). The consequences of oppression for humans as occupational beings are important because oppressed people are prevented every day from developing and exercising their capacities and potential through what they do. Young (2000) differentiated five faces of oppression: exploitation, marginalization, powerlessness, cultural imperialism and violence.

Exploitation

Relations of power and inequality are enacted through the social process of exploitation, which occurs when the results of the labour of one social group are regularly transferred to benefit another. The powerful also get to make the social rules about what work is, who does what for whom and how work is compensated. For example, farm workers on some wine estates in South Africa owned by wealthy land barons used to be paid through the dop system, which entails wages in the form of wine rather than money. The health and social repercussions of the dop system are still evident in post-apartheid South Africa, where there is a high incidence of fetal alcohol syndrome and poor mental health among some farm workers (London 2003; McKinstry 2005; Cloete 2012).

Marginalization

Marginalization is the process by which ‘a whole category of people is expelled from useful participation in social life’ (Young 2000, p. 41). To be marginalized means to be different, excluded, unequal and potentially subjected to material deprivation or even extermination. As individuals, we all experience social marginality or exclusion from time to time but for some categories of people, such as immigrants, refugees, gays, lesbians and transgendered people, people with disabilities, the homeless and older people, being marginalized is part of daily life. Marginalization influences the type of occupations and range of opportunities for occupational engagement that are available to certain groups of people (Watson and Duncan 2010).

Disability theorists and activists argue that marginalization is a social issue rather than an individual problem experienced by disabled people. It is evident in the lack of access to public spaces, discrimination in the workplace and denial of the resources necessary for independent living and participation in society (Galvin 2003; Oliver and Barnes 2012). Occupational therapists believe that marginalization occurs when the ‘need for humans to exert micro, everyday choices about occupations’ is blocked by ‘normative standardization of expectations about how, when and where people “should” participate’ (Townsend and Wilcock 2004, p. 81). The impact of marginalization on occupation has been described as a form of occupational injustice (Townsend and Wilcock 2004; Wilcock 2006, pp. 221–243; Wright et al. 2006; World Federation of Occupational Therapists 2010).

Powerlessness

Powerlessness is a process by which people come to ‘lack authority, status, a sense of self’ (Young 1990, p. 57). Since politics is concerned with power and authority, it is the politics of a society that determines which groups of people become powerless and which groups are given access to power. Political power is dominance exerted by one group of people over another through authority or status; for example, the power of the medical profession to diagnose illness. People with power are distinguished from others in three ways:

■ They experience progress through the acquisition of specialized privileges, such as knowledge and resources

■ They are able to influence the course of events because of their status

■ They are treated with respect because they have some level of authority, expertise or position.

Poverty creates particular forms of powerlessness and ill-being. In a study of the experiences of poor people in 58 countries in the developing and transitional world, Narayan and colleagues (2000, p. 2) identified 10 interlocking dimensions of ill-being associated with poverty:

1. The body is hungry, exhausted, sick and poor in appearance

2. Capabilities are weak because of lack of information, education, skills and confidence

3. Security is lacking in both protection and peace of mind

4. Livelihoods and assets are precarious, seasonal and inadequate

5. Gender relations are troubled and unequal

6. Places of the poor are isolated, risky, un-serviced and stigmatized

7. Social relations are discriminating and isolating

8. Behaviours of the more powerful are marked by disregard and abuse

9. Institutions are disempowering and excluding

10. Organizations of the poor are weak and disconnected.

Occupational therapists work towards poverty alleviation by researching and addressing the social determinants of health and social inclusion (COTEC 2010; Smythe et al. 2011; van Bruggen 2011). However, occupational therapy has only recently begun to consider political practice as a basis for promoting social inclusion (Pollard et al. 2008).

Cultural Imperialism

Cultural imperialism occurs when the ‘dominant group in society imposes their own experiences, values, goals and achievements as the social norm’ (Young 2000, p. 43). When people deviate from this socially imposed norm, they are defined as inferior or their ways of doing and being are negated, marking them as the other. Being othered reinforces social difference and marginalization by imposing dominant discourses, lifestyles and worldviews.

Theorists of occupation have been challenged on the grounds of cultural imperialism and of short-sightedness for orienting their theories in terms of middle-class, white, able-bodied experiences (Whalley Hammell 2011). Occupational therapists have also been cautioned about uncritically assuming the validity of views, theories and practice models developed by dominant worldviews (Kondo 2004).

Violence

Violence is a social practice in which the social context makes it possible, and even acceptable, to act violently against certain categories of people. Members of certain groups live with the knowledge that they must fear random, unprovoked attacks on their persons or property, which have no other motive than to damage, humiliate or destroy, because of who they are or who they represent. Young (2000) argued that violence is directed at individuals simply because they are members of a group and that this deprives them of freedom and dignity. She suggested that violence directed at a particular group is also systemic because cultural imperialism affects how groups are viewed, leading to fear or hatred of the othered group, which is then embodied in harassment and irrational, violent acts.

Harassment is illustrated by the following example. A young man with learning difficulties used buses to travel around his local area. He would often try to strike up a conversation with people he did not know, which was well intentioned but not always socially appropriate. One group of youths taunted him for his naivety until he hit one of them, then they called the police. The youths thought that taunting a person with learning difficulties was harmless fun but the young man lacked the social skills to deal with his tormentors without resorting to physical violence.

Occupational therapists work towards understanding the impact of violence on occupation, researching effective interventions, creating collaborations and advocating for occupation-based public health and social services for youth and other groups at risk (Cage 2007; Goertz 2008).

How are Margins Experienced?

Margins are experienced subjectively in uniquely different ways. There is, for example, no single way of experiencing a psychotic episode, being a woman, being a person of colour or being poor. We should, therefore, avoid conflating people’s social positions, identities and values and refrain from essentializing their experiences of the margins.

Essentializing

Essentializing is a form of cultural imperialism in which dominant constructions of the world and of particular groups of people come to be reiterated, solidified and accepted as reality. It involves generating ‘internal categories of personhood that are unchanging and timeless, that come to be inescapable, and that bear a determining influence of sorts on the person in question’ (Parker 2004, p. 140). Therapists may essentialize when they draw conclusions about people’s experiences of being marginalized, based on clinical expertise or having worked with particular groups of people. The ability to make informed clinical judgements about a person’s mental state or level of functioning should not be conflated with understanding their experience.

Intersectionality

Experiences on the margins, including those arising from occupational engagement, have direct implications for identity. Identities ‘exist at the level of representation, being expressed in images and symbols, texts and ideologies, including those to do with legislation’ (Yuval-Davis 2006, p. 198). People’s identities and subjective experiences are shaped by the intersection of different social divisions such as class, race, gender, ethnicity, sex, ability and age (McCall 2005). The term intersectionality was first introduced to women’s studies by Crenshaw (1989) as a theoretical paradigm grounded in identity categories. It is used to ‘describe the relationships among multiple dimensions and modalities of social relations, subject formations and categories of analysis’ (McCall 2005, p. 1777). Intersectionality is highly complex, creating a wide range of different experiences, identities and social locations that fail to fit into any single master category of social difference (McCall 2005) (see Ch. 13).

Oppression

While people’s experiences of being marginal or socially excluded will be uniquely their own, they may nevertheless be subject to the social dynamics of oppression. For example, they may experience:

■ Disabilism, which excludes and stereotypes people for their bodies, mental faculties or general health

■ Racism, which is a powerful type of prejudice that asserts that one race is innately superior or inferior to another

■ Prejudice, which is an inflexible and distorted generalization about a category of people.

In short, different social positions create hierarchies of access to economic, political, cultural and other resources for living, including opportunities for occupation. The perception of being positioned on the margins influences what people think and feel about themselves and the occupational choices they make (Galvaan 2012). The impact of these structural conditions on people’s occupations and occupational engagement is illustrated in a case study later in the chapter.

Why do Margins Persist, Change or Expand?

In the preceding section, intersectionality was discussed in terms of personal characteristics. In this section, intersectionality is considered from a structural perspective in which geographic, economic, political and cultural conditions intersect to create, maintain or shift margins within and across societies.

Volatile Systems

Not all governments wish to give all their citizens a say in how the country is run, or work towards equal opportunities for everyone. This means that democracy cannot be assumed as an overarching political dispensation supporting professional initiatives for social inclusion. Different forms of social inequality can occur in different regions of the same country, as well as across countries and continents. For example, in some countries, geographic and political-historical circumstances have resulted in long-running civil unrest and even wars, which carry major consequences for the health and wellbeing of citizens and for public services, including occupational therapy. Of relevance to mental health occupational therapy will be the increasingly significant and visible impact of global events on national governance and, ultimately, at local level on what the profession has to offer individuals and constituencies with mental health concerns.

Development Surge

In the 21st century, the world has experienced a surge in social development due to technological advances (see national and regional United Nations Human Development Reports 1990–2012). However, existing margins will not only persist but become exaggerated. For example, in the coming decades, the development surge will be evidenced by three major social changes (Morris 2010):

■ Large-scale urbanization, as people migrate in search of work or to seek relief from famine, disease and poverty

■ Increased energy use that will exacerbate current levels of climate change and environmental degradation

■ Advances in information technology that will speed up globalization and proliferation of war-making capacity.

Most of the world’s poorest people live in an ‘arc of instability’ (Morris 2010, p. 602), which is what the US National Intelligence Council calls the region stretching from central Africa in a rainbow-shaped arc across the Middle East to South-east Asia. Much of what happens environmentally, politically and socially in this region will reverberate across the world and influence how professions such as occupational therapy respond nationally and internationally to socioenvironmental imperatives.

Global Trends

Historians and sociologists suggest that the next 40 years will be the most important in global history, with top priorities being the avoidance of all-out nuclear war, slowing down global ecological deterioration and managing mass human mobility (Morris 2010). For example, the number of people facing food and water shortages is predicted to leap from 600 million to 1.4 billion, most of them living in and migrating from the arc (Morris 2010, p. 601). With declining harvests in the region, food shortages will create 200 million famine and climate migrants across the globe, five times larger than the world’s entire refugee population in 2008. In short, the scope of need created by marginalized populations will increase across the globe between 2008 and 2025.

How do People on the Margins Respond?

How people respond and what they are able to do depends on their circumstances, such as the amount of freedom they have to act to their advantage, their ability to transform resources into valuable activities, the distribution of opportunities within society and the balance of materialistic and non-materialistic factors affecting their welfare (Anand et al. 2005). For example, adequate food and shelter are prerequisites for bodily health; safety and security are necessary for bodily integrity; affiliations with other people depend on being respected and having some control over one’s environment requires access to personal, material and political resources (Nussbaum 2000). Individual and collective forms of agency, resilience and resistance characterize people’s responses to their various capabilities.

Agency

Agency is the ability to take action towards a desired end or to produce an effect (Shorter Oxford English Dictionary 2002). An agent is someone who acts and brings about change, whose achievements can be evaluated in terms of his or her own values and objectives (Sen 1999). Agency is therefore crucial to assessment of a person’s capabilities, allowing for an examination of whether or not economic, social and/or political barriers impede their ability to pursue the things they need and want to do that give expression to their being (Sen 1999).

Resilience

Resilience has three defining characteristics: the amount of change that a system (such as a person, household or community) can undergo and still retain some control over its function and structure; the degree to which the system is capable of self-organization, and the extent to which the system is able to learn and adapt (Berkes et al. 2003, p. 13). Emotional resilience is particularly important for mental health under the adverse personal and social circumstances associated with marginalization. It refers to the range of protective mechanisms and processes that enable people to withstand the potentially damaging effects of stress (Rutter 1987). A word of caution is indicated. Implicit in some discourses of agency and resilience is a tacit acceptance of the oppressive ways in which society functions (Duncan et al. 2011b, p. 68). Appreciating the resilience and agency of people on the margins should not divert attention away from resisting the social inequality to which oppressed groups are subject.

Resistance

To resist is to strive against, to withstand or to be in opposition to something. Resistance can take various forms: individual or collective, passive or active, violent or non-violent. People facing similar forms of oppression and social injustice may resist by mobilizing civic action for their rights through various forms of activism, including lobby groups, social movements, protest action and even riots (Deutsch 2006). A ground swell of resistance for social change can bring about substantive shifts in policy formulation, resource distribution and power alignment. See, for example, the impact of the Cuenca Declaration (People’s Health Movement 2005) in South Africa and other parts of the world and the Mental Health Resistance Network in the UK.

OCCUPATION ON THE MARGINS

Occupational therapy has long been concerned with using occupation to promote development as a life course process synonymous with the unfolding of human potential and bio-psychosocial maturation (Clark 1979). However, the profession is also concerned with using occupation as a means for community development in a socio-political process synonymous with democracy, pluralism, justice, equity and respect for a universal code of human rights (Galheigo 2011). Occupational therapy practice on the margins aims to address both individual and social forms of development (Kronenberg et al. 2011). This requires the occupational therapist to remain aware of the impact of biography (personal stories), history (a society’s story) and structure (prevailing governance systems and social environments) on people’s occupations. Four aspects of the numerous ways in which occupations can be affected by marginalization are discussed here.

Occupational Injustice

Prevailing sociopolitical influences determine the form and degree of occupational injustice that exists among different groups of marginalized people. Hence, occupational deprivation, alienation and imbalance, and other forms of occupational injustice, including occupational apartheid, manifest differently in different societies and contexts. These terms are defined in Chapter 3.

Intergenerational Transfer of Occupations

People develop shared identities and consciousness of their social category over generations because parents confer their social position and repertoire of occupations on their children (Young 2000). For example, the unfairness of an inferior education may be perpetuated across generations, with illiterate or semi-literate parents being ill-equipped to guide their children towards optimal performance when studying. Particular cultural knowledge, values and histories, therefore, advantage or disadvantage students from differently privileged backgrounds (Price 2011). Even the particular valorization of some ways of knowing over others (e.g. science and empiricism over religion and cultural mythology) and ways of acquiring knowledge (e.g. individual achievement and competitiveness over shared knowledge and collective achievement) may confer advantage or disadvantage in the education system.

Inequity of Opportunity to Access Preferred Occupations

For society to function well, it requires hundreds of different occupations, the performance of which becomes categorized according to social divisions such as class, gender and race. Hence, some sociologists argue that social stratification has beneficial consequences for the operation of a society (Macionis and Plummer 2008). Occupations hold positions of varying importance because they require different levels of knowledge and competence; for example, while removing garbage is considered to be an unskilled or semiskilled job, a long training is needed for acquiring the skills to design and build a bridge. Difficult and scarce talent requires extensive education so the more functionally significant a job is, the more society will reward the person who performs it with income, prestige and power. Social history and strata determine the range of opportunities for learning and developing through occupation available to certain categories of people; for example, youths in wealthy families are more likely than those born into poverty to achieve education and pursue their aspirations in terms of the types of occupations they are able to participate in. Personal and social histories combined with intersectionality have a profound impact on the occupational choices that are available to people (Galvaan 2012).

Inequity of Occupational Choice

People can be trapped on the margins where they are forced by circumstances beyond their control to make certain choices about what they do every day. Consider, for example, the people who live on the garbage dumps of large cities, the forced labour of child soldiers or people bound by caste or disability to perform occupations such as begging. Subject to complex social dynamics, some may resort to, find themselves forced to, or even choose to participate in antisocial occupations (Twinley and Addidle 2011) such as those associated with tagging, gangsterism and drug pedalling. Young (2000, p. 42) has also brought inequity of occupational choice into well-resourced spaces, stating that ‘even if marginals were provided a comfortable material life within institutions that respected their freedom and dignity, injustices of marginality would remain in the form of uselessness, boredom and lack of self-respect’.

The next section illustrates some of the ways in which biography, history and structure operate at an individual level and the strategies that a person might develop to overcome them.

Biography on the Margins (Case study 29-1)

Dorcas (Case study 29-1) was one of five people who participated in a study investigating the dynamics between chronic poverty, psychiatric disability and occupation in households living in peri-urban slums near Cape Town, South Africa (Duncan et al. 2011a, b).

CASE STUDY 29-1

Dorcas’ Story

Dorcas, aged 55, was born and raised near Mount Frere in the rural Eastern Cape, South Africa. As in so many other households at that time, her father worked on the mines in Johannesburg and sent remittances home whenever he could. Her mother contributed to the family income by selling indigenous medicinal plants foraged in the nearby mountains. The youngest of five children, Dorcas learned from an early age how to tend the soil, plant and harvest maize and vegetables, mind livestock, raise poultry, crochet scarves, knit jerseys and run a homestead. Living in a bartering economy, each family member was allotted chores and everyone contributed to the livelihood of the household, irrespective of age. Dorcas’ older brother, working at a dairy in Cape Town, sent home second-hand clothes for his sisters to sell. Dorcas learned how to trade clothes. After her father’s death, when Dorcas was 12 years old, the five siblings were distributed, by her mother, among the extended family because she could no longer support them. Dorcas lived with an aunt and completed Grade 7 at a Catholic school.

Dorcas married a shepherd with whom she had two children. She was expected to move to his clan location where she had to serve the older women, while continuing to secure an income by cultivating and selling vegetables and crocheted goods. Dorcas had her first psychotic episode when she was 28 years old. Hearing voices and believing she was bewitched, she set fire to two huts, causing her husband’s family significant loss of material assets. She was tied up and locked away for 2 days in a mud hut until her family sent an ambulance to take her to a psychiatric hospital, where she stayed for a period of time. The marriage ended in divorce and Dorcas moved from the rural village to the city with her two children in search of work. Both the children grew up and left home.

Dorcas lived in a two-roomed shanty dwelling made of corrugated iron and cardboard sheeting in Khayelitsha, Cape Town. Like many of her neighbours, she had no access to electricity, used wood or paraffin for fuel and had to share a communal tap and toilet with many other households. Most people in this community were unemployed, very poor and migrated between the city and their rural homes in search of work. Dorcas survived on a disability grant (approximately £100 per month). She had a number of admissions to hospital for psychotic behaviour, such as running around naked in public and becoming unruly and irrational. She received monthly antipsychotic medication, which causes extra-pyramidal symptoms such as hand tremors, a drooling mouth and fatigue. She found the side-effects of medication almost as debilitating as the mental disorder itself. Her older brother was willing to take responsibility for her when she was ill and she had one close friend, Modloko, who supported her in running a small informal business selling second-hand clothes. Dorcas reported stigma and social exclusion:

even when I go to the tap to get water the children make fun of me, calling me ‘rakie’ (mad person) … sometimes people take their waste shit and put their toilet in a plastic bag and put it by my front door.

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