Experiences and views of clinical psychologists working in non-urban areas of KwaZulu-Natal,South Africa

Abstract

The process of integrating mental health care into primary health care remains slow in many non-urban areas of low to middle-income countries. The present study explored clinical psychologists’ experiences of working in non-urban areas of KwaZulu-Natal to assess the progress of integrating mental health into primary health care. Twenty-nine clinical psychologists participated in this study and provided input on the following areas: clinical psychologists’ preparedness, through training, to work in resource-constrained non-urban areas; availability of mental health resources; and understanding of the clinical psychologists’ role in their work context. Over half (51.7%) of the participants reported that their training did not prepare them to work in resource-constrained non-urban areas and more than two-thirds (72.4%) reported a lack of basic resources needed for optimal mental health care in non-urban areas of KwaZulu-Natal. The findings reflect the need for comprehensive training of clinical psychologists to enhance their competency and confidence to work in resource-constrained settings. Furthermore, investment in the promotion of clinical psychology services and more conducive mental health service environments is necessary.

Keywords

Clinical psychology clinical psychology training competency non-urban areas resource constraints

According to the World Health Organization (WHO; 2011), mental health is a neglected priority, and the disparity of health resources between low- and high-income countries remains a global concern (Caldwell et al., 2018; Vergunst, 2018). Morales et al. (2020) emphasize that service disparities carry the risk of poor mental health outcomes in non-urban communities, which compromises efforts towards optimal mental health coverage (WHO, 2013). Furthermore, the scarcity of community-based mental health services, particularly in non-urban areas, is not limited to low- and middle-income countries but is observed worldwide (SASOP, 2017). A similar trend is prevalent in South Africa, particularly in KwaZulu-Natal (KZN). The state of mental health in KZN non-urban areas is described as both dreadful and degrading due to resource constraints (De Kock & Pillay, 2017; Morgan, 2015). Although researchers state that the prevalence of mental disorders in non-urban areas is not different from that of urban areas (Riding-Malon & Werth, 2014; Sutherland & Chur-Hansen, 2014; Vergunst, 2018), access to the few existing mental health resources and their utilization remains a persistent concern that weighs on families and communities (Burns, 2010; De Kock & Pillay, 2017; Morgan, 2015; Vergunst, 2018). Therefore, attention to the dynamics of non-urban communities, mental health service users’ needs, training and clinical competencies of mental health service providers in these settings is essential.

Psychology services in non-urban areas

For many years, mental health and psychology services operated at the tertiary level of health care; for mental health to fit in all the levels of care, it has to adapt to various contextual dynamics. In non-urban settings, mental health care has to fit in the established and multifaceted system of health care; some of these dynamics are discussed below. Vergunst (2018) states that South African non-urban communities are complex. Some of the factors that contribute to the complexity of these communities include significant barriers to accessing health care, for example, high transport costs due to travelling long distances to health care facilities, multi-layered pathways to mental health care, and lack of community-based psychosocial rehabilitation platforms (Vergunst, 2018). While there are no readily available data on the percentage of clinical psychologists who go into private practice, the clinical psychologists/population ratio in state health facilities indicates that clinical psychology and mental health services in KZN remain skewed and a scarce skill (De Kock & Pillay, 2017; Siyothula, 2019).

The scarcity of mental health services in non-urban areas predisposes these communities to alternative health care options. For example, Patel (2011) highlighted the significant role of traditional healers, particularly in the African context. He also alluded to the complementary nature of Western and traditional health helping systems even in well-resourced countries. In the (South) African context, traditional healers also play an important supportive role, are accessible, and share a similar community understanding of the conceptualization of illness (Mkhize & Kometsi, 2008), leaving less room for Western mental health care services as the primary point of contact. Shai and Sodi (2015) found that traditional healers are most likely to be consulted first or together with Western medicines for health concerns; this finding supports the assertion by Patel (2011) on the value of both health systems.

Similarly, non-urban residents have a known culture of strong networks that provide an immediate support base and possible distrust of external help, including clinical psychologists who may be viewed as outsiders with limited to non-existent local cultural, political, and economic understanding (Chipp et al., 2011). According to Hastings and Cohn (2013), ‘it is hard for rural psychologists to be accepted . . . suspicion of outsiders is not uncommonly recounted as facets of rural social life’ (p. 2). The distrust may subject psychologists to scrutiny with increased expectations to prove themselves to gain the trust of non-urban residents (Schank & Skovholt, 2006). Furthermore, Zingela et al. (2019) ascribe the distrust between Western and traditional parallel health systems to the minimal comprehension of the effectiveness of intervention strategies that each system uses in managing health concerns.

Considering that mutual trust is necessary for effective psychotherapy (Allen, 2021), psychologists working in non-urban communities should be aware of the dynamics that are beyond the clinical contexts (Zingela et al., 2019). These are important intricacies of non-urban contexts that may impact service access and delivery (Sutherland & Chur-Hansen, 2014).

On the one hand, the strongly interconnected networks, deep socio-historical and political roots, strong family ties, enduring attitudes towards life, and high reliance on religious activities are among the defining qualities of non-urban communities (Riding-Malon & Werth, 2014), which can safeguard against psychological distress. On the other hand, this reliance on families and communities usually means that they are the first resources of help and support to their mentally ill members. However, the same act of caring carries the risk of predisposing families of the mentally ill to psychological distress (Iseselo et al., 2016). Iseselo et al. (2016) also highlight that the families’ belief system may contradict that of mental health specialists and deter them from seeking help, thus depriving them of support and timely intervention from the health care system. Therefore, psychologists working in non-urban contexts should be familiar with these non-urban dynamics and help-seeking trajectories to be aware of the possibility of delayed presentation for mental health care and the prospects of intense and costly mental health interventions. Non-urban mental health service providers should also consider establishing collaboration with both formal and informal health resources to enhance access to help (Idriss et al., 2020). This collaboration could be attained by creating psycho-educational spaces in the formal health systems and showing an interest to learn from informal health resources.

Training issues and challenges for psychologists in non-urban areas

Globally, psychology scholars have raised concerns about urban-based and exclusive clinical training that mainly caters to urban communities and call for training that equips psychologists with relevant, inclusive, flexible, and context-sensitive clinical competencies (Pillay et al., 2013; Riding-Malon & Werth, 2014; Sutherland & Chur-Hansen, 2014). Also, Werth et al. (2010) found that most non-urban psychologists deal with specific ethical dilemmas not commonly found in urban areas; this suggests that current clinical psychology training may not be sensitive to all clinical contexts. To meet the unique health needs of non-urban communities, Sutherland and Chur-Hansen (2014) emphasize the need for training to incorporate clearly defined competencies for mental health care service providers. Therefore, training models that emphasize brief, evidence-based, community-oriented, and culturally sensitive mental health interventions are necessary for effectiveness in resource-constrained settings (Kohrt et al., 2018). For a diverse and resource-constrained country like South Africa, Mkhize and Kometsi (2008) advocate a collaborative approach and warn that ‘the training of mental health professionals is incomplete if it does not include exposure to, and collaboration between, the Western and traditional health care systems that continue to exist side-by-side in South Africa’ (Mkhize and Kometsi, 2008, p. 110). Hence, competencies that pay attention to the dynamics of non-urban communities and relevant context-specific issues such as higher levels of unemployment, poverty, financial stressors, and challenges in accessing services (Vergust, 2018) are long overdue. Similarly, Petersen et al. (2012) and Vergunst (2018) advocate utilizing readily accessible informal community interventions, adequate training, supervision, support, and interest in community-sensitive interventions that could enhance mutual benefits for non-urban service providers and service users.

A shift from traditional mental health care training approaches is necessary for psychology to remain abreast of the globally changing social and economic landscape that is particularly prevalent in non-urban areas. Ahmed and Pillay (2004) emphasized that the training of clinical psychologists in South Africa should be mindful of the country’s context and equip them to address the diverse needs of the majority of the population dependent on state facilities. Therefore, clinical psychologists’ training requires an approach that invests in this essential aspect of the behavioural health workforce (Domino et al., 2019; Jameson & Blanck, 2007). Domino et al. (2019) further encourage the training of clinical psychologists that incorporates recruitment, retention, and an increase in the supply of clinical psychologists equipped to practise in non-urban contexts. Such a training strategy should prioritize the mental health needs of the population it serves and impart relevant skills, attitudes, and expertise (Sutherland & Chur-Hansen, 2014). According to Urbanoski et al. (2012), sensitivity to the service users’ context improves therapeutic alliance, which is fundamental in the quality of the relationship between the service provider and the service user dyad and predicts treatment outcomes.

Furthermore, non-urban interventions require integrating communal perspectives to effectively impact diverse settings (Sutherland & Chur-Hansen, 2014). Communal approaches prevalent in non-urban areas include the active involvement of non-specialists, family, and the community in the treatment of mental health care users, which could increase accessibility and acceptability of services, and help reduce discrimination and stigma of mental illness (Kohrt et al., 2018). The current training of clinical psychologists largely focuses on individualized interventions (Pillay et al., 2013) that are informed by a Western worldview.

Furthermore, in a culturally and linguistically diverse country like South Africa (Johnston, 2011), training should reflect the equitable representation of the country’s diversity. Pillay and Siyothula (2008) found that 14% of clinical psychologists in the Health Professionals Council of South Africa register were Black Africans and were trained post-1994. While this finding reflected growth from the pre-1994 training of Black clinical psychologists, the racial representation of clinical psychologists does not match the racial constituency of the South African population, where the ratio of Black Africans accounts for over three-quarters of the population (Statistics South Africa, 2021). Recently, Pillay and Nyandeni (2021) found that of the clinical psychologists trained between 2008 and 2020, only 14.8% were Black Africans. According to these authors, their findings reflect minimal growth in the training of clinical psychologists who speak indigenous languages of the majority of South Africans dependent on state health facilities. This slow progress maintains the pre-democratic inequalities in accessing basic health services by all South Africans (Pillay & Nyandeni, 2021). These statistics are even lower for clinical psychologists who work in the non-urban areas of KZN (Siyothula, 2019). Therefore, without training models that equip clinical psychologists with relevant competencies for all the contexts they practise in (Kohrt et al., 2018), the incompatibility between the expectations of service providers and service users is likely to ensue and compromise positive mental health treatment outcomes (Morales et al., 2020).

Background to the current study and KZN context

South African clinical psychology evolves from an exclusive past regarding access to training and psychology services (Manganyi, 2013). While the intentions and efforts of the profession to change the previous exclusions are commendable, Pillay and Nyandeni (2021) found minimal growth from the previous study (Pillay & Siyothula, 2008). More than 80% of the population are African and are dependent on the public health system for their health needs (Ngobeni et al., 2020, Pillay & Siyothula, 2008), and a third of the South African population lives in non-urban settings (World Bank, 2012). Almost 75% of the population has no access to mental health services (Council for Medical Schemes, 2014). Most non-urban KZN health districts do not have specialists or functional multidisciplinary teams (De Kock & Pillay, 2017). The South African Air Mercy Services (AMS) in partnership with the Department of Health (DOH) provided ‘flying doctor’ services in KZN until August 2020. AMS either transported patients from outlying communities with inadequate or no specialized health care to tertiary institutions or transported health specialists from urban to non-urban health facilities (Caldwell et al., 2018). Clinical psychologists also joined the AMS to reach non-urban patients needing mental health care services closer to where they live (Pillay et al., 2009). Sadly, this valuable service was disrupted by the Covid-19 pandemic, leaving non-urban communities once again without basic mental health care. While the AMS and DOH partnership stopped a few years ago in other parts of the country, in KZN it continued on an annual contract basis until August 2020. Although poor investment in mental health could partly explain the cessation of this valuable partnership that benefited non-urban communities, other health specialists utilized the same mode of transport to reach remote areas and their services also ended in the same period.

This article aims to explore the experiences of clinical psychologists rendering services in non-urban areas of KZN on a full- or part-time basis to understand the receptiveness of the non-urban health environment to clinical psychology services and (indirectly) assess the progress of mental health integration into primary health care.

Method

A purposive, descriptive cross-sectional research design (Polinkas et al., 2015) was considered relevant for this study to document the expectations and experiences of clinical psychologists working in non-urban settings.

Participants

State-employed clinical psychologists with past and current experience of working in primary health clinics and district hospitals in Harry Gwala, UMzinyathi, and Umkhanyakude health districts in KZN were approached by the researcher for participation in this study. Thirty participants were targeted and 29 responded, constituting a 96.6% response rate.

Instrument

A brief self-administered semi-structured questionnaire was used to collect quantitative and qualitative data. The questions covered demographics, designation, and years of professional experience. The following questions were also asked: Do you feel that your training prepared you to work in non-urban settings? What has been your experience when you consult clients referred for psychological intervention? Do you feel that your clinical setting provides you with the resources to help you meet the mental health needs of the patients? The questionnaire was designed based on the literature in this area of research.

Procedure

Participants were given an information brochure describing the purpose of the study, conditions of participation, the consent form, and a self-administered questionnaire. The questionnaire took approximately 30 min to fill in. Participants were requested to omit identifying details to facilitate anonymity. The researcher collected and stored the questionnaires in a locked filing cabinet.

Ethical considerations

Ethical clearance for this study was obtained from the Biomedical Research Ethics Committee (BREC) of the University of KwaZulu Natal and the KZN DOH. The voluntary nature of participation was clarified, and a decision not to participate would have no adverse consequences for participants. Only participants who consented were included in the study.

Data analysis

SPSS version 25 was used to analyse quantitative data, while thematic data analysis was used for open-ended questions. Coding was performed by the researcher and verified by an independent non-participant who is familiar with qualitative research. Where participants’ verbatim responses are quoted, participants have been allocated numbers.

Results and discussion

The age range of participants was 24–60 years with a mean age of 38.93 years. The majority identified as female, 21 (72%); 7 (24%) were males; and 1 (3.4%) identified as other. Finding that the majority of participants were female is in keeping with the international gender distribution in professional psychology. Cynkar (2007) found a similar percentage (72%) of females enrolled in professional psychology programmes in the United States. Locally, a similar trend of gender imbalance in psychology is reported by the Health Professions Council of South Africa (HPCSA, 2017) and Skinner and Louw (2009), who describe it as the global feminization of psychology, influenced by more women than men entering and staying in the profession. Most participants, 24 (82%), were independent practicing clinical psychologists, and only 4 (13.8%) were doing their community service. The wide gap between independent and community service clinical psychologists could reflect the slow growth rate in the discipline of clinical psychology (Pillay & Nyandeni, 2021) and maintains the skewed population/clinical psychologists’ ratio in non-urban areas of KZN (De Kock & Pillay, 2017; Siyothula, 2019).

The psychologists’ experience in the profession ranged from 1 to 34 years. Just under half of the participants (44.8%) had between 1 and 5 years of experience and 31% had professional experience of 11 years and above. Finding that almost a third of interviewed participants worked in non-urban areas is encouraging as human resource constraints in non-urban areas remain prevalent (Sutherland & Chur-Hansen, 2014). Yet a significant shift is required to reverse an imbalance in the psychologist/population ratio that interferes with psychologists’ ability to meet the community needs in this context (De Kock & Pillay, 2017; Siyothula, 2019). Almost two-thirds, 62% (18), of the participants render services in non-urban areas on a full-time basis. However, this percentage is not reflective of the current provincial trend as most non-urban areas in KZN do not have clinical psychology services (Siyothula, 2019). Participants may have referred to their full-time employment status rather than the frequency of rendering services in non-urban areas as required by the question. Almost a third (31%) of the participants render services on a part-time basis by either flying in and out or driving in and out; this reflects the state of clinical psychology services in non-urban areas of KZN. A similar approach to the provision of clinical psychology services in non-urban areas of Australia has been reported (Sutherland et al., 2017).

Competency for non-urban context

Only 17% of the participants reported preparedness to work in a non-urban context from their theoretical training. Schweinsberg et al. (2021) support the integration of work readiness in the training of graduates. The low percentage of participants’ readiness indicates the need for the theoretical aspect of psychology training to invest in offering graduates essential competencies that enable them to cope with the demands of diverse contexts in which they practice. Over a quarter of participants (27.6%) referred to their internship as the component of training that prepared them for non-urban work as expressed by Participant 14:

As an intern, I was exposed to working in the community (+) with translators while getting intense supervision.

The above participant’s response indicates that the internship equipped her with the skills for clinical practice. However, for effective mental health service delivery to be rendered during the internship, basic competency should be developed by the end of the theoretical training (Ahmed & Pillay, 2004). The internship should consolidate and enhance theoretical knowledge under clinical supervision and equip interns with skills that could not be obtained from the classroom environment (Stiles-Smith et al., 2019).

Although almost half (48.28%) of the participants reported that their training prepared them for working in non-urban settings, their explanations emphasized the practical training during internship, without specific reference to theoretical training:

More than half (51.72%) of the participants indicated that their training did not adequately prepare them for working in a non-urban context. For example, Participant 4 stated,

We were trained in assessment methods that were not often valid for the rural context. We did not receive training in short-term interventions.

In addition, Participant 16 stated,

We were not trained in working through interpreters, in particular, informal interpreters.

For these participants, their training was deficient and failed to equip them with relevant competencies for non-urban settings. Researchers also emphasize the value of clinical training that equips non-urban service providers with context-sensitive and discipline-specific competencies (Ahmed & Pillay, 2004; Schweinsberg et al., 2021; Sutherland & Chur-Hansen, 2014). Therefore, the finding that most participants expressed failure of their training to adequately equip them to work in the non-urban context where the majority of state-dependent South Africans reside (World Bank, 2012) is a major concern.

The lack of focus on the gap in preparing clinical psychologists to efficiently work in resource-constrained settings is captured in the statement by Participant 13: ‘Insufficient focus in my training (35 years ago!) on non-urban/ rural/ community psychology work’. This participant’s expectation of focused attention to all the areas of clinical practice from the theoretical aspect of the training is not unreasonable. There is growing research that highlights the need to support students with skills for the working environment as a vital function of tertiary institutions (Schweinsberg et al., 2021). Failure of training to equip psychologists with competencies for all aspects of clinical practice could hinder the expected efficient mental health service delivery at the beginning of the internship as indicated by Pillay and Kramers-Olen (2014).

Job satisfaction

Zopiatis et al. (2014) stated that workplace issues could influence employee attitudes. Therefore, it is important to understand the impact of job-related issues and develop strategies to improve both individual and organizational performance. The majority of participants, 24 (82%), expressed satisfaction with working in non-urban areas; for example, Participant 2 stated,

Non-urban community is deprived of psychological intervention; therefore, for me being the service provider is rewarding.

Only 5 participants (17.2%) expressed dissatisfaction.

Explanations from the satisfied participants included appreciation from service users and psychologists’ conviction that they provide the much-needed service. Furthermore, awareness that obstacles faced by service users referred to urban areas for mental health needs are not only limited to costly transport (Pillay et al., 2009; Vergunst, 2018) but also prolonged waiting periods convinced psychologists of the value of their services. Also, delays in timely interventions may result in complex mental health issues requiring specialized and costly treatments (Wang et al., 2007). Interestingly, none of the participants mentioned the financial incentive (rural allowance) paid to service providers to encourage them to continue working in non-urban areas in contrast to the Australian non-urban respondents who cited this benefit as one of the motivating factors to continue non-urban practice (Sutherland & Chur-Hansen, 2014). Only a few participants (13. 8%) expressed reluctance to continue working in non-urban contexts and cited personal professional development, lack of support, and experiencing non-urban work to be emotionally demanding. This finding reflects that non-urban work does not provide psychologists with access to peer support and supervision as in urban areas. Although the study was conducted prior to the Covid-19 pandemic, which opened opportunities for online resources, accessing them is not without its challenges. Zalat et al. (2021) report that unstable Internet connections interfere with uninterrupted online attendance of courses. Online support should not be a substitute for dependable face-to-face support, which is an option available to urban practicing colleagues.

Professional misconceptions

Hughes et al. (2013) define professional misconceptions as discipline-inconsistent beliefs that originate from internal and external sources and reflect a genuine, replicable, and general phenomenon related to core beliefs about the discipline. Only 31% of the participants expressed that other health care professionals understand the role of clinical psychologists. This is a serious concern considering that community clinical psychology services are rendered within the district hospitals and primary health centres where these health professionals are the first contact for health care needs. If they do not understand the role of the clinical psychologists, there will be delays in appropriate and timely referrals (Wang et al., 2007). Almost two-thirds (62%) of the participants stated that other health care professionals who refer patients for psychological interventions do not understand the role or scope of practice of clinical psychologists. Participants based this assertion on the number of inappropriate referrals and unrealistic expectations from the referral sources which were often outside the scope of practice of clinical psychologists as reflected by the following responses. Participant 22 stated,

Frequent inappropriate referrals suggest that other professionals do not understand the role or scope of practice of clinical psychology.

Participant 26 stated,

They don’t entirely (understand) – you realize this in the referrals they send to you and how and when they expect your intervention.

Furthermore, 89% of the participants believed that service users misunderstood the role of clinical psychologists in this study. Participants mentioned being confused with other health professionals and cited requests by service users for medication (prescribed by medical doctors and psychiatrists) as the basis of their conclusion.

Resource constraints, challenges of working in non-urban areas and impact on service delivery

Resource constraints were reported by more than two-thirds (72.4%) of participants; lack of basic resources such as a conducive working environment, assessment tools, computer equipment, access to telephone, and Internet services were some of the reported deficits. Also, access to play therapy facilities, translators for non-IsiZulu-speaking psychologists and relief for vacation leave were reported as barriers to optimal service delivery as expressed by Participant 4:

‘No Assessment tools provided and ordered. Often the consulting rooms lacked privacy or were noisy and interruptions often occurred. Services of an interpreter were often difficult to secure’.

In addition, heavy workload, lack of support from management, time constraints for long-term therapy, missed follow-up sessions, many incidents of one-off sessions, professional isolation, and stunted professional growth were mentioned as prevalent challenges in non-urban contexts. For five participants (17.2%), these challenges contributed to their reluctance to continue working in non-urban areas. Also, staff shortages amplified by the ‘freezing’ of existing vacant posts caused by the moratorium in KZN and the lack of explicit strategies to retain resident clinical psychologists in state employment maintain the challenges expressed by participants. Despite recent new health posts to mitigate the effects of the Covid-19 pandemic, this initiative has not reversed the skewed psychologists/service users’ ratio in KZN non-urban areas.

Insights from clinical psychologists

Forty-eight percent (48%) of the participants shared additional perceptions of the state of mental health in non-urban areas and the understanding of clinical psychologists’ role. For example, participant 19 stated that

Non-urban areas are usually underserviced. People living in these areas are likely to have been previously disadvantaged. Continuing working in these areas can be viewed as a movement towards social justice.

Participant 21 stated that

Systemic problems are very frustrating- inadequate recognition of mental health needs by the Dept of Health therefore insufficient resources but huge pressure for services.

Furthermore, participants’ responses reveal frustration from the perceived lack of investment in mental health and the resultant compromise of mental health services. Other responses highlighted hopes and desire for a change in the current situation of mental health in non-urban areas as expressed by the response of Participant 26:

Being employed in non-urban areas is not that bad- provided there is sufficient support and provision of resources. Many people need our services though they don’t realize it. It would be easier if resources were available.

Despite most participants’ willingness to continue to work in non-urban areas, the current working conditions remain a challenge.

A limitation of this study is the small sample size, and therefore, the findings cannot be generalized. Another potential limitation is that some participants’ responses may have referred to their full-time employment status rather than the frequency of working in non-urban settings as intended by the researcher. A face-to-face interviewing approach may ameliorate this limitation.

Conclusion

Participants’ responses in this study indicate that the traditional training has not adequately prepared clinical psychologists to work in non-urban areas confidently. This finding amplifies the need for training models that equip aspirant clinical psychologists with the necessary competencies to practise in diverse and non-urban settings (Jameson & Blanck, 2007; Pillay et al., 2013; Sutherland et al., 2017). Similarly, most participants raised concerns about the resource constraints that persist in non-urban areas of KZN. While the value of integrating mental health into primary health care is well documented, the state of mental health in non-urban areas continues to reflect poor investment and neglect of mental health care. Therefore, moving forward, there is a need to focus on enhancing clinical psychology training to include non-urban work as well as addressing finance and other resource deficits in non-urban health care in South Africa.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Evy-Terressah Busisiwe Siyothula

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