Psychology’s health and future in South Africa

Registration categories

While the country has made significant progress in the development of professional psychology programmes and the establishment of five registerable ‘psychologist’ career options (i.e., clinical, counselling, educational, industrial/organisational, and research) as well as a ‘Psychometrist’ and ‘Registered Counsellor’ registration categories, one has to question the discipline’s movement from that position. The past 30 years or so has seen little advancement and initiative to take the profession and discipline further. The Registered Counsellor category emerged during this period but, while it constituted a necessary mid-level psychology professional, it failed to realise all of the expected gains considering the ethos and idea within which it was conceived. Psychology created the professional but failed to develop and encourage the appropriate job market and employment opportunities. The ideal would have been a plethora of positions created around the country within the Department of Health to enable the provision of basic mental health services for the multitudes of indigent communities reliant of government health services. Considering the prevalence of mental health problems (Stein et al., 2008), such an initiative would have had immense benefits for health and social upliftment in general. This is a missed opportunity, but it must be pursued, considering the dual benefits: such positions will enable increased mental health service provision, especially to underserved communities, while the increased uptake of registered counsellors will encourage universities to continue or resuscitate their training of this category of professionals. Many universities abandoned this training for, among other reasons, the lack of employment opportunities for their graduates.

The additional registration categories of ‘forensic’ and ‘neuropsychology’ are important developments and will fulfil a significant need nationally. However, the question still abounds as to whether these two occupational groups should have been considered as specialist-level psychologists. Considering that formalised professional psychology training in South Africa is in existence for around 40 years, there is a need to develop specialist and sub-specialist level training and registration categories. Without progressive thinking and innovation, the profession risks retaining a relatively flat structure, notwithstanding the psychometrist and registered counsellor categories. Perhaps a lesson from the structuring of the medical profession and its development of specialty and sub-specialty areas of registration is relevant. Considering developments in the science, there needs to be ongoing attention given to the various sub-fields in psychology and the extent to which these need to be advanced and incorporated into specialist-level training and practice.

A further issue involving the registration categories is the debate around the scope of practice as it relates to some of the categories. There are currently conflictual views around some of the categories (e.g., educational and counselling psychology) with concerns expressed by these professionals about their scope of practice as it is delineated in the legislation (Department of Health, 2011) and the reading of the legislation by various stakeholder groups including medical aid (insurance) corporations. This has implications for the remuneration of psychologists registered in some of the categories especially when attempting to claim for services rendered. The issue is seriously debated around the country and is believed to be the basis of a legal case to be brought to a South African court by at least one of the affected groups. The scope of practice matter is one that poses a threat to the profession, and it is in the interest of the discipline to resolve the matter since it has the potential to be a divisive force.

Social responsiveness

Barring a few voices, mainstream and organised psychology was largely unresponsive to critical social and human rights issues during the apartheid period. Considering that racist policy was primarily engineered by a psychologist, in the form of Hendrik Verwoerd, organised psychology was ideally placed to respond and denounce it. Being in the hands of White psychologists, the psychological association at the time chose not to consider the human rights transgressions and refused to speak out against the government of the day.

However, since 1994 psychology’s response to government policies has changed substantially. This was spearheaded by the Psychological Society of South Africa (PsySSA) which was born a few months before the country’s democracy. Since then psychology has been vocal on rights-based issues affecting society, the profession, and consumers of psychological services. These have included communications to the State President regarding the levels of violence in the country, as well as position statements on other human rights issues. PsySSA will have an amicus curiae role in a hate speech matter relating to sexual diversity soon to be heard in the Constitutional Court. A comprehensive position statement on sexual and gender diversity was issued by PsySSA in 2013, which is in stark contrast to the non-responsiveness of organised psychology during apartheid when, for example, aversion therapy methods including electroshock were used without informed consent in the military in attempts to ‘cure’ sexual and gender diversity within a rather homophobic environment (Psychological Society of South Africa, 2013; Van Zyl, De Gruchy, Lapinsky, Lewin, & Reid, 1999). South African Psychology has evolved significantly in its views and attention to ethics and human rights. This was evident in PsySSA’s response to the American Psychological Association’s involvement in the torture of detainees held on suspicion of terrorism at Guantanamo Bay (Hoffman et al., 2015).

Organised psychology has also shown its support to the #FeesMustFall protest campaign by university students and parents nationwide. While condemning the associated violence, PsySSA identified with the fee cause as a just one and supported the quest for more affordable higher education. Needless to say, organised psychology in the 1970s and 1980s distanced itself from the student protests of the time, largely due to its complicity with the apartheid government policies against which students were protesting.

It is vital that psychology continue to be socially responsive while also ensuring that it is responsible in determining what it responds to and what the response should be. Engagement in critical social issues is necessary, especially considering the vacuum created by organised psychology’s non-responsiveness during the apartheid era. This is going to be important over the coming years considering the number of sociopolitical issues that are surfacing nationally. Engaging in debates such as racism at national forums is crucial for national progress and unity as well as for the advancement of the discipline and its role in society.

International standing

With the country having had pariah status during the years of psychology’s growth, the discipline had a tarnished profile internationally, save for a few individuals. Notwithstanding the designing of one of the most racist and oppressive systems of the modern era by a South African psychologist, the country also produced and contributed eminent psychologists to the global arena including Arnold Lazarus, Stanley Rachman, Kurt Danziger, and others. Joseph Wolpe, who was a psychiatrist, also began his psychological research and theory development in South Africa following his medical training in Johannesburg.

Since 1994, there has been recognition from psychology associations around the world with numerous national bodies signing memoranda of understanding with PsySSA. The awarding of the International Congress of Psychology 2012 (ICP 2012) to South Africa and the successful hosting of the event bears testimony to the confidence shown in South African Psychology and the respect with which local psychologists are viewed internationally. The manner in which the world’s psychology flagship event was organised also confirms South Africa’s ability and competence in organising and presenting an international scholarly gathering that compares very favourably with those held in other countries. The country also occupies a position of prominence in the International Union of Psychological Science (IUPsyS) with the President (Saths Cooper) and Secretary-General (Ann Watts) being South African Psychologists.

Regionally, under the initiative of the ICP 2012 the Pan African Psychology Union (PAPU) was formed and South Africa is represented on the Presidency of this continental body representing psychologists. Furthermore, South African Psychology under the auspices of PsySSA will be hosting the inaugural PAPU Congress in 2017, again an honour and distinction of international proportion.

Included among the country’s psychology achievements and recognition is the large number of research and other academic contributions by South African psychologists published in leading international journals and books. Local psychology researchers have been contributing to the international body of literature for decades, with a considerably increased volume over the past 20 years. It has also been encouraging to note the extent of collaborations with internationally renowned figures in psychology and mental health, providing further evidence of the vigour of South African Psychology and the cutting-edge nature of the research being conducted.

With these and other notable achievements, the country is unquestionably well placed in the global psychology arena, and the respect it receives is well earned.

Teaching and professional training

While psychology as an academic discipline has been taught in South African universities since around the early 20th century, formal professional psychology training programmes began during the 1970s. Following legislation and approval, universities around the country were fairly quick off the mark to establish their professional training programmes, especially in clinical, counselling, educational, and industrial/organisational psychology. Formal research psychology programmes developed later. Currently, virtually all of the country’s universities offer professional psychology training. The programmes and curricula, which are accredited by the Health Professions Council of South Africa (HPCSA), compare very favourably to equivalent professional training programmes elsewhere in the world.

The extent to which South African trained psychologists are recruited by universities, health care services, and other organisations in high income countries, bears testimony to the level of respect accorded to the training programmes nationally. The country has seen its psychologists usurped by a number of high-income nations, especially the United Kingdom, Ireland, Australia, and New Zealand (Pillay & Kramers, 2003). While this is a troubling matter for poorer countries, it is a very healthy indication of the general appraisal of the quality of local training and perceptions abroad.

Of relevance also, is the number of students enrolling at South African universities to pursue graduate studies in psychology after their initial and even graduate degrees in Europe and elsewhere. Evaluation and credentialing processes usually reveal interesting cross-national comparisons that show local psychology education in a very competitive light. However, it is also necessary for South African Psychology to stamp its mark on its teaching content. The need for locally relevant curricula has long been articulated, and concerted focus on the inclusion of theoretical models that incorporate African psychology perspectives is essential.

A long standing issue is that of equity and the need to train more psychologists of colour. As a function of apartheid, the training of Black psychologists was deliberately kept to a minimum. Nevertheless, since the advent of democracy, progress has been made in this respect but much more ground needs to be covered before the discipline can claim to be representative of the nation.

Currently undergraduate classes in psychology at all of the country’s universities are extremely large, demonstrating the popularity of the subject. However, the extremely small numbers selected into graduate professional training programmes means masses of psychology graduates are in search of employment each year. Much work is needed in helping graduates and the job market, take note of the value that psychology graduates can add, especially in corporate South Africa.

Recognition in the health care system

Psychology’s role as practitioners in the South African health care system is a relatively young one, with much of the development occurring in the last three or four decades. Previously, there were only isolated instances of psychologists involved as health care professionals since psychology graduates were more commonly employed in academic contexts. With the growth in the numbers of psychologists employed in state hospitals or consulting in private hospitals and practices came the challenges regarding their position and status within the hierarchy of the traditional medical model. Within the mental health care systems and facilities where psychologists began their early diagnostic and therapeutic roles, the teams have traditionally been headed by psychiatrists. Much has been written about multidisciplinary team (MDT) functioning, and the psychologists working in such teams do experience difficulties in some contexts, while others are able to negotiate these quite easily.

Psychologists in health care are recognised by the HPCSA as independent practitioners, meaning they are entitled to consult as such within the guidelines of professional practice. However, in some work contexts difficulties arise that appear to challenge the independence and autonomy of these practitioners. For example, some psychologists in state hospitals find their autonomy as mental health practitioners eroded through undue influences of the medical model resulting in irregular influences on referral pathways, reporting structures, employee performance appraisals, and status within the MDT. Being an independent practitioner, a psychologist should be able to receive referrals directly from external sources without such referrals having to be first vetted by another member of the MDT. In this context psychologists must guard against their roles being perceived as technicians rather than clinicians – they are trained to function as clinicians using all of the mental health diagnostic techniques and provide interventions of all types, excluding pharmacological treatments.

While this remains a challenge in some contexts around the country, the issue may relate to the abilities of psychologists to assert their positions within MDT environments and ensure that the autonomy of their profession and the breadth of their expertise are well understood. Psychologists need to also recognise that they have to initiate and claim the change they want to see in their professional status and autonomy – it will not be handed to them voluntarily.

Considering the soon to be established National Health Insurance (NHI) plan, it is important that psychology proactively contemplates its role in this structure, especially since the NHI is envisaged as a health care service aimed at providing quality health care for all. Given that mental health care is not currently viewed as a high priority relative to other health issues, despite its high ranking in terms of burden of disease, it is to the benefit of psychology and society to take the lead in putting mental health high on the NHI agenda as a way of transforming the country’s health priorities. In this context, psychology must also re-establish its illness prevention and health promotion expertise. The discipline has an established history of research and praxis in behaviour change models that support and enhance public health initiatives. To date psychology, especially in applied health care settings, is still overly focused on curative and treatment approaches at the expense of maximising its competencies in health and social change. Psychology is well equipped to drive interventions in key areas such as early childhood development, parenting, and family functioning in order to reduce the incidence of mental health and social problems while also promoting positive development.

Conclusion

Considering its troubled and divided past, psychology in South Africa has made notable strides and has received respect and praise from many quarters. In a number of ways, the discipline and some of its members have earned international acclaim, making substantive contributions to psychology globally. However, there are a few issues in South African Psychology that warrant serious attention and which if not addressed have the potential to disrupt its growth and development. Nevertheless, in the context of its difficult past and the challenges it has had to overcome, there is reason to believe that South African Psychology is healthy and has a promising future.