“It’s not like a broken leg that you can see and the world responds appropriately. A broken mind or soul is hard to identify” – Leigh-Anne Snyman, nurse specialising in patient support, Doctors Without Borders (MSF)
Since the onset of the COVID-19 pandemic, MSF mental health professionals across South Africa have had to rapidly adapt how they treat and serve patients. Technology has had to fill in several gaps where face-to-face contact is not possible in order to avoid disease transmission. Follow-up sessions with patients have been replaced with telephone calls, for example. The biggest shift, however, has been the increase in the number of people struggling with mental health issues since the start of the outbreak.
Adapting mental health services
“We have to be way more flexible and respond in areas and ways we would not have imagined,” says Cassandra Govender, a psychologist working as a mental health supervisor for MSF’s Tshwane Migrant Project. “Initially, people could not access our services as easily and continuity of care became difficult but we had to keep going. People need help processing the impact COVID-19 has had on their lives and the vast amount of information constantly being thrown at them,” Cassandra continues. “We are trying to support individuals and families by helping them understand mental healthcare responses and giving the extra support to those responses requiring intervention – counselling, admissions, medication, etc. We’ve also run a number of coping skills and substance support groups to help people manage the various difficulties they may be grappling with at this time.”
Yolanda Hanning a psychologist working as a mental health activity manager at MSF’s Sexual Violence Project in Rustenburg, says, “While the country had to adapt to the ‘new normal’ of lockdown: restricted movement, working from home, wearing masks et cetera, for victims of gender-based violence, it meant something else. As the world shut down to stay safe, staying inside for others meant being locked up with their abusers with scant opportunity to seek help or care.” During lockdown, the MSF team in Rustenburg observed a significant decrease in the number of victims of sexual and gender-based violence (SGBV) reporting for care at the Kgomotso Care Centres (dedicated SGBV clinics) in the Bojanala District. “The pandemic has placed great limitations on everyone’s freedom of movement and invariably increased the exposure of victims of gender-based violence to more danger. This could have increasingly severe impacts on the mental health as well as physical wellbeing and safety of victims and their families,” says Yolanda
While continuing to deliver integrated medical and psychosocial care to SGBV survivors, the project’s activities have shifted to include remote mental health and psychosocial interventions to support patients, health workers and key populations affected by the COVID-19 pandemic. Technology, where accessible, has been a useful tool. “People can be best supported through offering remote mental healthcare support or by attending online psychosocial interventions where it is possible,” Yolanda explains. In order to ensure continuity of care throughout the pandemic, patients who require ongoing mental health support have been receiving telephonic follow-up counseling sessions. Tele-counselling ensures that they still connect with patients and are able to offer mental health and psychosocial support services via telephone.
Reaching new patients
Sadly, not all people struggling with mental health issues seek or receive the support they need – something that is far too common among people who are homeless. One positive outcome of South Africa’s lockdown has been that the increase in shelter-based diagnosis of mental health illness, with increased counseling for people in need of mental healthcare. Psychologist Tasneem Bulbulia is one such MSF colleague who has been working in shelters in Johannesburg throughout the lockdown.
“We saw a patient who had been having auditory hallucinations for an extended period of time. Due to living on the streets and lack of access to required services he had never understood his illness or sought psychiatric attention. These auditory hallucinations were often very frightening and distressing. Once the patient had been referred and seen by a psychiatrist he improved dramatically,” Tasneem tells us. “Another example is a severely depressed patient who had been considering suicide for months. Lockdown and the feelings that accompanied it increased the severity of his depression. Having support, psycho-education and some basic coping mechanisms has improved his mood. We hope with ongoing support he will improve even further.”
Mental health support for healthcare workers
Of course, it’s not only patients who need psychosocial support at this time. Healthcare workers across the world are under enormous stress as they put their lives at risk to treat patients daily. A part of MSF’s team in Khayelitsha, Leigh-Anne Snyman is a nurse specialising in patient support. Working in Khayelitsha Department of Health and City of Cape Town health facilities, she found her role shifting when it became clear that staff needed mental health support. “I’m a registered nurse with a passion for training, so I took on the role of ensuring that all staff were trained on COVID-19 and received mental health support. As the disease came closer to home, the fear increased and our colleagues felt unsafe and distressed.
“Our project manager found an interesting article from a study that asked healthcare workers what they needed during COVID-19. Their answer was simple: to feel prepared, protected and supported, so we ensured that we followed a transparent process. My role was to ensure everything that related to staff safety, preparedness and support was displayed, forums to allow staff to voice their concerns were implemented and there was a psychologist that staff could call for confidential counselling and support, if needed. I made sure people knew about it. I checked in with people daily, just being a friendly presence reminding everyone that this will pass.”
Stigma about mental health persists
While the economic, social and psychological toll of the COVID-19 pandemic has amplified the need for mental health support in all communities, our mental healthcare workers are not convinced that psychological illness is really understood, or accepted yet.
“I am not sure if mental health needs will ever be fully understood or accepted. It’s not like a broken leg that you can see and the world responds appropriately. A broken mind or soul is hard to identify and the shame that accompanies it makes it hard to accept,” says Lee-Anne.
“The understanding and acceptance of mental illness continues to vary amongst different populations,” adds Tasneem. “Factors such as gender, culture, age and particularly general community acceptance, amongst other aspects, continue to affect the way people understand mental illness.”
Cassandra believes that there is still much work to be done. “In the migrant communities, I still believe there is lots of stigma regarding mental health. People only understand the term through the lens of illness… therefore people associate mental health with that extreme image. The stigma is spurred on by barriers to healthcare, which means people become revolving door patients and as a result relapse more often.”
Committed to making a difference
For our team of mental healthcare workers, COVID-19 might have affected the way they work but not the work itself. The pandemic has only reinforced their deep commitment to serve vulnerable individuals and communities. “The possibility that I may, in some way, make even one individual’s life seem easier or more bearable keeps me going,” says Tasneem. Cassandra echoes this, saying, “I think about all the people I have encountered in the world who are unable to access care, who have no one to fight for them and have no idea about how to get out of their circumstances. I show up every day for them.”
So what, if anything, has the crisis taught our colleagues?
“On difficult days, it is helpful to remind myself that it’s okay not to be okay,” says Yolanda. “Developing an acceptance of the uncertainty of life is crucial, and learning to live with this uncertainty is part of life.”
“I hope the world has learnt the importance of needing to work together to achieve wellbeing and safety in society and that without supporting and caring for our most vulnerable we cannot all truly be safe and well,” says Cassandra.
In South Africa MSF has been providing mental health support in the following projects:
- The Tshwane Migrant Project, which offers healthcare and mental health services to migrants and asylum seekers since 2019 in Gauteng
- The Sexual and Gender-based Violence Project in Rustenburg (established in 2016), which provides support for people who have been exposed to sexual and gender-based violence, in community health centres called Kgomotso Care Centres (KCCs) in the North West Province
- The HIV and TB project in Khayelitsha, where MSF has been providing community-based treatment for 20 years in the Western Cape.
- During the COVID-19 pandemic, health workers have provided care and support in various shelters for homeless people across Johannesburg and Tshwane.
- MSF also runs a long-standing HIV and TB project in Eshowe in KwaZulu-Natal Province