South Africa has trained more than 2,500 registered counsellors to address the country’s mental health crisis, but most of them can’t find jobs in the public health sector, where the shortage of psychologists and psychiatrists is the most severe.

The Health Department created a job category for registered counsellors in 2003 to compensate for the lack of access to mental health specialists at government health facilities. Just 450 psychologists serve state patients in eight provinces in South Africa, data shared in Parliament in June shows (Gauteng was not included), and the country has only 217 public sector psychiatrists. 

The role of registered counsellors can be compared to that of a paramedic, just for mental health, explains Jaclyn Lotter, the academic dean at the South African College of Applied Psychology (Sacap). 

A registered counsellor screens people to find out whether they need to be referred to a registered psychologist (who can diagnose mental illnesses) or to a psychiatrist who can prescribe treatment such as antidepressants if necessary. 

About one in three people in South Africa will experience depression, anxiety or a substance use disorder such as alcoholism at some stage in their lives, according to the 2009 South African Stress and Health Survey. Yet three-quarters of those who experience such mental health conditions will never be treated, a 2009 South African Medical Journal study found.   

Registered counsellors can provide short-term talk therapy to help people cope with stress or they can offer grief and trauma counselling. They’re different from volunteer or lay counsellors, though, since they need at least an honours or equivalent degree in psychology, as well as six months of practical experience before they qualify. 

The government’s plan was for registered counsellors to provide affordable psychological services in schools, prisons and public health facilities in underserved communities. Provincial health departments are, however, not compelled to hire them, which has resulted in the failure of the project for the most part. Researchers say provinces haven’t done enough to include these workers into their budgets. 

Help for half the price

An hour-long session with a private sector-registered counsellor costs R560. That’s about half the average price of a session with a psychologist, but it’s still too expensive for most people in South Africa. June data from Statistics South Africa reveal a third of the nation is unemployed.

Besides, the private sector is not where registered counsellors are needed the most.

Nearly 30% of posts for state psychologists are vacant, according to 2022 data shared by Health Minister Joe Phaahla in Parliament. This leaves millions of South Africans who need help to deal with common mental health conditions such as anxiety with nowhere to turn. 

The dearth of mental health specialists is especially bad in rural provinces. 

The Eastern Cape, for example, has the fewest psychologists in the public sector. Just two serve the province’s more than six million inhabitants.

There are also only two public sector psychologists in the Northern Cape, and just one psychiatric treatment facility with 287 beds for the roughly 1.3 million people in the province. 

When there’s so little expertise, generally only those who are the most ill are helped. Says Lotter: “[For] the majority of the population, the only time you get mental health intervention is when you’re really sick.”  

What could have been 

People – especially young folk – who get help to manage mental health conditions early fare better on treatment and lead better lives in the long term, research shows. For instance, an Australian government-funded programme providing mental health support to people aged between 12 and 25 reduced suicide ideation, self harm and days absent from class.

Catching mental health issues early also saves the health system money, because fewer people need to be booked into hospital for expensive treatment, often repeatedly. 

Research reveals South Africa indeed spends most (86%) of its mental health budget on patients who are admitted to hospital, according to a 2019 study in the journal Health Policy and Planning. The researchers found almost one-quarter of mental health inpatients are readmitted to hospital within three months of a previous discharge, costing the public health system an estimated R2-billion. 

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And Lotter says that’s the whole point of employing registered counsellors – to take pressure off public sector psychologists and psychiatrists and save the health system money.

Studies show it can work.  

In Cape Town, trained trauma counsellors had a huge impact on young people who were admitted to emergency departments at three hospitals, a 2015 study in the journal Substance Abuse Treatment, Prevention and Policy shows. 

These counsellors all had bachelor degrees, but they weren’t registered counsellors per se, although they played a similar role. They visited patients in the emergency room (as long as they weren’t too injured to speak) after they’d been triaged and while they were waiting for a doctor. 

Young people were screened to gauge how likely they were to develop a substance use disorder. Those who had a moderate to high risk of substance abuse, as measured by a test, qualified to participate in the study and were split into three groups. 

One group got just a flyer with information about mental health. The second group got a 20-minute consultation with a counsellor who spoke to them about how to address their consumption of alcohol or drugs. 

Group three got the 20-minute meeting and four hour-long sessions once a week, in which they worked with a counsellor to identify and address life problems that could lead to substance abuse. 

After three months, counsellors repeated the screening test and groups two and three showed a lower risk of developing substance use disorders than the patients who just got a flyer. Those in groups two and three also displayed fewer signs of depression.

But for most people who use South Africa’s government health facilities (Statistics South Africa says this is 71.5% of the population), there’s no hope of such benefits. In the small Northern Cape town of Kuruman, roughly a two-and-a-half hour drive from Kimberley, the situation is dire. 

Anneri van Zyl, a registered counsellor in the area, explains: “The only mental health professionals in Kuruman are [in the private sector]. Myself, and a clinical psychologist. At the state hospital, there is no access to any mental healthcare, there’s no one.”

Where are all South Africa’s registered counsellors?

There were 2,596 counsellors registered with the Health Professions Council of South Africa (HPCSA) in April 2021. 

The regulatory body couldn’t provide Bhekisisa with updated information about where all these health workers have ended up, but 2007 research in the South African Journal of Psychology found that only half of registered counsellors stay in the field, mostly because it’s so hard to find a job. 

Those who do find employment as a registered counsellor mostly work in the private sector, and generally in more urban provinces such as Gauteng and the Western Cape. 

This is the opposite of what this type of health worker was set up to achieve, the study authors argue. 

There’s a lot of work for us [in the public sector], but there aren’t any posts,” says Van Zyl.

By 2017, a quarter of 318 registered counsellors surveyed by the HPCSA said they worked in the private sector. Only 8% were employed in government schools and 7% were involved with other government education projects. 

Bhekisisa got in touch with the health departments in three provinces where the most people live to find out how many registered counsellors they employ. 

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In September, 33 registered counsellors were employed in Gauteng in clinics and community health centres, says the department’s spokesperson Vuyo Sabani. In the Western Cape, spokesperson Mark van den Heever says 18 such counsellors are employed in primary healthcare facilities. 

The health department in KwaZulu-Natal didn’t respond. 

Created and abandoned – why new health worker categories fail

Registered counsellors are written into South Africa’s action plan on mental health (which lapsed in 2020). They’re tasked with training community health workers to support people’s mental health when they do home visits in communities. 

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But that’s as far as the paper trail goes for registered counsellors. There’s no rule that forces provincial health departments to prioritise these health workers when recruiting mental health staff. A similar fate befell the country’s clinical associates (a type of health worker in between a nurse and a doctor, which was launched in 2008). 

Sanele Ngcobo, a clinical associate and family medicine researcher, says: “The Health Department creates these categories [which look good on paper] but there’s no clear direction on what to do with them, and how to use them in the health system.”  

About half of clinical associates worked in the public sector between 2010 and 2017, according to data provided to the South African Health Review.

A task team was set up to help integrate clinical associates into the health system in 2017, and they’re written into South Africa’s human resource planning until 2030, but Ngcobo says many of them are still leaving the state service for private practice because there are no posts for them. 

The Health Department didn’t respond to Bhekisisa’s queries about its plans to use registered counsellors more effectively. 

Meanwhile, South Africa’s mental health action plan does outline a move to get mental healthcare out of specialised hospitals and into clinics. However, it’s hard to assess to what extent this has been achieved, because the document doesn’t include any clear, measurable targets. 

Training institutions aren’t prioritising registered counsellors either. Lotter says some colleges and universities have stripped down their professional counselling programmes in favour of training and supervising master’s students, who go on to become psychologists. 

Only six of South Africa’s 23 accredited universities offer the psychology degree people need to become a registered counsellor. 

Those who do qualify face an uncertain future since health workers, managers and patients often don’t know the value that registered counsellors can bring.

Even registered counsellors themselves are sometimes unsure exactly what their job description entails. One such health worker told researchers: “The public doesn’t know what we do and I’m not sure how to explain it to them.” DM/MC

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.