A year or so ago, a young woman arrived at the St Anne's Homes Women's Shelter in Woodstock, Cape Town, so traumatised after a brutal sexual assault that she wept, alone, in her room for a week.
"We have a counsellor at the shelter, but this woman was not able to open up about what had happened to her. She needed expert help," says Oslynn Macounie, the manager at St Anne's.
Macounie is showing Spotlight around the facility as she recalls some of the cases. St Anne's Homes is located in an old house on Balfour Street in Woodstock. The shelter, founded by the Anglican Church in 1904, is preparing for its 120th anniversary next year.
Its history is a long and proud one of providing a safe haven for society's most vulnerable.
Macounie says another woman who arrived at St Anne's after being physically abused by her partner, confided she'd been raped by her father from an early age. Another mother arrived at the shelter with her four-year-old daughter, who had been raped. The mother needed to protect the child in a safe space.
Psychological counselling was badly needed in both cases.
"We get calls every day, sometimes in the early hours of the morning, from people needing help and shelter for women and children who are suffering the aftermath of rape and GBV," says Macounie.
Not equipped to deal with mental health needs
"All these women need help with their mental health - but the gap between what they need and what they can access is enormous. There are so many cases where women need help with mental health issues - sometimes it can be when they have an outburst or an episode of sorts. The staff at the shelter are not trained to deal with mental health issues," says Macounie.
"For instance, we recently took in a woman who had previously been in Valkenberg Hospital. She had serious mental health issues. She had been abused by relatives who could not cope with her illness. When she arrived, her medication was finished, and we realised she needed urgent help. However, her hospital date was only a month from when she entered the shelter. There was nothing we could do about this."
Macounie says some of the women at the shelter were raped at a very young age. "And the trauma only comes forth in their adult years, when a different traumatic experience takes them back. Our counselling staff are not qualified to help - and we have to refer them to the necessary institutions for appropriate services."
However, Macounie says that the waiting list for these services in the public sector is long and private sector services are costly and thus unaffordable for many. Another problem is St Anne's is not able to do direct referrals to a mental health institution - it has to be done through a hospital or qualified psychologist.
The Department of Health fails women survivors of GBV over and over again - and we've raised this many times with them. - Bernadine Bachar, Saartjie Baartman Centre
No fighting chance
Elsewhere in Athlone, at the Saartjie Baartman Centre for Women and Children, the director Bernadine Bachar is also deeply concerned about the unmet mental health needs of rape and GBV survivors. Saartjie Baartman is a one-stop centre for women and children survivors of abuse.
"The Department of Health fails women survivors of GBV over and over again - and we've raised this many times with them," says Bachar. "We have a good relationship with our local community hospital and at times they come over here for sexual health assessments, pap smears, or vaccinations but when it comes to mental health support, there's a huge gap."
We have been saying for a long time now that the gap between what is needed in terms of mental health support, and what is offered, is one of the largest gaps for GBV survivors. - Bachar
She says that the centre often has to deal with women who are suicidal, but it is almost impossible to get them into a hospital for the 72-hour observation period. The staff and "house mothers" are trained in basic trauma and caring and so are not equipped to deal with "someone who is actively psychotic, has suicidal ideation, or is attempting suicide".
"Imagine what it is like in a place with 120 women and children, particularly in the evenings and [on] weekends and you are trying to support someone through any of those things. The stress it places on staff members as well is extraordinary," she says. "We have been saying for a long time now that the gap between what is needed in terms of mental health support, and what is offered, is one of the largest gaps for GBV survivors."
The repercussion of this, says Bachar, is that the GBV victim is never fully empowered to break away from the GBV or the sexual assault.
"We never give her a fighting chance to say, 'OK, these are the challenges you're experiencing now, this is the impact of GBV on you, now let's work with you and get you through these assessments, get you the medication you need, get you the therapy you need... and let's empower you to go back into society'. We don't give her that opportunity, so we're damning the next generation to the same situation," she says.
The repercussion of this is that the GBV victim is never fully empowered to break away from the GBV or the sexual assault. - Bachar
'System not geared to empower survivors'
Bachar relates one "very difficult" experience which took place at the centre a few years ago.
"A very young woman came in who had been sexually assaulted and needed to be in a safe haven. She had many mental health challenges and was actively suicidal. Trying to get her assessed was next to impossible, to the extent that she'd find a ruler, break it and try and slit her wrists with it. We had to literally watch her every minute, as anything was potentially a way to commit suicide. I can't tell you the stress that was engendered by that - trying to get her the proper care that she needed, to support her through it. She was terrified herself. We had staff members sleeping in the room with her to prevent her from harming herself in the night. I can't tell you how many times we tried to get assistance from the Department of Health, but it was impossible to get them, at any level, to take us seriously. One weekend, I had no option but to get into my car and go through with the client and a social worker and sit in that queue until I could get somebody to take it seriously. I was terrified she'd die at the centre."
Bachar tells Spotlight that she is aware of the challenges that the Department of Health faces and that they are "under-capacitated", which she describes as a systemic issue.
"The tragedy is that the system is just not geared to empower survivors - and that goes from law enforcement to the courts to our health services and at times the Department of Social Development too," she says.
She says GBV survivors have to deal with a wide range of consequences that impact their "entire being", including general health, mental health, ability to concentrate, and ability to parent effectively.
The tragedy is that the system is just not geared to empower survivors - and that goes from law enforcement to the courts to our health services and at times the Department of Social Development too.
Explaining the process, she says often women have four months at the centre. "Thereafter, we have second stage housing where women can stay for a further six months. If we're lucky, we have ten months with her, but that's a small percentage of all the women that come through here. If we need to get her back into the system for an assessment or to get her back on her prescribed medicine, we'd take her to the local community hospital, but it will take months to get her through the system for an initial consultation, [and] then to have an assessment.
"Often, by the time she gets that appointment, she's already left Saartjie... and all we can do is pray she keeps the appointment. We'll remind her of it often, but we don't know what challenges she will face once she's back in the community - like finding housing, getting her children back into schools, and finding a job, so it becomes a very tricky trying to give women the mental health support they need."
Lack of access to psychologists
According to Lisa Vetten, a research specialist on gender-based violence, this unmet need of GBV survivors, "is reflective of the broader neglect of mental health in SA of which Life Esidimeni was probably the ugliest example. "Mental health is not a priority in South Africa despite the great need. The domestic violence shelters really struggle. There are populations of women in shelters who have been through severe trauma and often had difficult childhoods, mixed with other compounding factors like becoming mothers at a young age.
... this unmet need of GBV survivors, is reflective of the broader neglect of mental health in SA of which Life Esidimeni was probably the ugliest example. - Lisa Vetten
"But shelters do not have access to private psychologists; they have to rely on the public system, and the waiting list is typically three to four months by which time the woman is out of the shelter. Or they will need to see a psychiatrist for a diagnosis, and to be prescribed medication... and by the time a space (at the psychiatrist) is open, the woman has left already. So that is of very little value," Vetten says.
"The issue of the availability of psychiatrists in rural areas is an even bigger issue than the under-supply in urban areas. Shelters do what they can but women often have quite serious difficulties that can range all the way from schizophrenia, to bipolar disorder, to very severe cases of depression and anxiety... so they need a diagnosis to be properly assisted. Then there are those who suffer from substance abuse. You can't get them into a facility."
Vetten also notes the "strange split" where a psychologist is defined as a health (not a social development) function, adds to the problem because the Department of Social Development does not provide funding for psychologists.
The revolving door
"Women staying in the shelters," Vetten says, "become part of this revolving door of the mental health system. There really is a category of women who are circulated between the institutions and hospital wards, then to their families, or outside until they are not doing well, and then back to an institution, which might have nowhere to release them so they are sent back to the shelter. It's just so unhelpful to the women."
Women staying in the shelters become part of this revolving door of the mental health system. - Vetten
Another issue, according to Vetten, is when women with mental health conditions like bipolar disorder run out of medications because of stock-outs at clinics and are referred to a hospital only to be told they've missed their appointment and go back to the shelter without the medication needed to manage their disorder.
"It's really not acceptable that women are put in a position where they run out of their medication. Shelters don't necessarily have the training or the support. If somebody's condition is well managed, then it is fine, but if it is not, that woman is treated like 'pass the parcel'. She's sent somewhere to see if they will take her, then sent somewhere else. She'll never get proper help."
Funding challenges
Sharon Kouta, the programme manager for the GBV programme at the organisation Networking HIV and AIDS Community of Southern Africa (NACOSA), tells Spotlight that as GBV incidence increases, the costs of mental healthcare become out of range for most NGOs.
"As part of our sexual violence programme, we provide for clients to access a psychologist. I recently got two quotations - one for R950 and another for R1 250 per session," she says. "If a woman needs to decide if she's going to pay her rent and buy food, or have a session with the psychologist, it's clear what her choice will be."
Kouta says it is also not only affordability that is a challenge but also the number of available specialists.
Both Vetten and Kouta say budget cuts and the relocation of donor funding to a focus on prevention have reduced the availability of services.
"There is also the unhelpful, unhealthy competition that's developed between some provincial social development offices and NGOs, where the state decides they want to take over services," says Vetten. "But the state doesn't have the same level of experience and are not psychologists. So if anything, over the last five years or so, the availability and the quality of mental health services for victims of GBV has declined and there's been a de-skilling in the sector."
If a woman needs to decide if she's going to pay her rent and buy food, or have a session with the psychologist, it's clear what her choice will be. - Sharon Kouta, Nacosa
Vetten, who has done extensive research for the National Shelter Movement of South Africa, including on mental health needs, says shelters across the country are trying hard to provide mental health assistance to those they serve, "but it's really difficult".
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"There are ways to solve this, but it needs different kinds of funding models and a greater willingness. One big problem is that the Department of Health has yet to recognise that gendered forms of violence are a health issue," she says.
What can be done?
When asked what she believes should be done for women with mental health needs, Bachar says the health department should be more accessible - "and as soon as possible because we have so little time to actually assist people".
"Priority should be given to them, particularly if they are actively psychotic or suicidal. They need help immediately, rather than being put in the general system where they might get an appointment in five or six months' time, during which they will just fall apart."
Bachar also stressed that health staff should be much better trained to deal sensitively with GBV survivors so as not to cause secondary traumatisation.
"What we are doing at Saartjie Baartman, but with which we are struggling to get the Department of Health on board [with], is what we call a GBV hub - where we pull all the roleplayers across all community-based organisations and government departments together to walk the woman through all the service providers to ensure she doesn't fall through the cracks. If we could get DoH on board, it would be great."
Departments respond
According to Esther Lewis, spokesperson for the Western Cape Department of Social Development, social workers employed and funded by the department are trained to provide psychosocial support - whether in shelters or at our local offices - and this includes counselling services. "Clients who need psychological and psychiatric services are referred accordingly."
Lewis concedes that substance use disorder is a contributing factor to GBV. "There are, however, DSD-funded in-patient and community-based services available.
The department also launched a treatment programme aimed specifically at women at the Kensington Treatment Centre." She also admits that funding remains a challenge in both the public and non-profit (NPO) sectors. "In the GBV space, DSD has changed the funding model to service providers that allow for more flexibility and is "working hard at establishing and maintaining relationships with other government departments, for example, health, police, justice, the NPO sector, and community structures".
According to Mark van der Heever, provincial health spokesperson, they are working closely with social development for case referrals. He says all residents are able to access mental health services at any of our facilities. Van der Heever says they also provide services through community health workers who, when they identify someone in need of mental health services, refer them to the appropriate primary health care facility for further assessment and care. He said the Thuthuzela Care Centres also provide one-stop-shop services in our healthcare facilities for GBV survivors.
