Abstract
In this article, perspectives of South African clinical psychologists (based in KwaZulu-Natal) regarding multicultural issues in clinical practice and training are presented. The discussion focuses on emergent themes from 13 qualitative semi-structured interviews. Themes from interviews were analysed using thematic analysis and techniques from a grounded theory approach. While the study focused on a number of contextual multicultural issues both in service delivery and in training, this article documents the experiences of clinical psychologists regarding multicultural challenges and concerns, as well as approaches and capacities used to improve service delivery in this area. These perspectives are important in the multicultural and multilingual South African context, where there is limited literature in this area as well as related aspects such as cultural competency. There are many different belief systems as well as historical and sociopolitical factors that may influence how clinicians and individuals presenting for treatment may understand their experience and symptoms. This article seeks to document some of the challenges this may present in terms of service delivery in this context. Understandings of the term cultural competence as well as suggestions (primarily as noted by participants) to address the gap between training, competencies, and the realities of service delivery are also presented. Questions and considerations for future research are also raised.
The relationship between mental health and social context has been highlighted in the literature (Constantine et al., 2007). In a seminal article, Sue et al. (1982) challenged prevailing misunderstandings regarding the development of appropriate counselling and therapy for different cultures, and specific cross-cultural competencies were recommended. These competencies were subsequently revised and defined as multicultural counselling competencies (emphasising attitudes, beliefs, knowledge, and skills) (Arredondo et al., 1996; Sue et al., 1992, 1998) and formed the basis of the American Psychological Association’s (APA, 2017) guidelines on multicultural education, training, research, practice, and organisational change (Drinane et al., 2016; Munley et al., 2004).
Cultural competency has also been viewed as the degree of compatibility between four factors, namely, community context, cultural characteristics of local populations, organisational infrastructure, as well as direct service support, and the way in which local mental health settings make services accessible, available, and usable (Hernandez et al., 2006, 2009). In this view, previous definitions of cultural competence are located within the broader context of the organisation in which they exist (Hernandez et al., 2009). The Multicultural Counselling Competency model has also been expanded to the Multicultural and Social Justice Counselling Competencies (MSJCC) paradigm (Ratts et al., 2015, 2016). Developed in the counselling field, it seeks to understand the complexities and diversity in multiculturalism, the influence of oppression and social context on mental health, and the need for social advocacy (Ratts et al., 2015). These broader contextual perspectives have relevance for the South African context, where historical sociopolitical factors have significantly impacted institutions, service delivery, and training, highlighted in the subsequent section.
Multiculturalism within the South African context
South Africa has an estimated multicultural, multilingual population of about 58,78 million people (Statistics South Africa, 2019). An apartheid legacy of discrimination and oppression has deeply impacted mental health services as well as training of clinical psychologists (see Pillay et al., 2009, 2013). Since the 1980s, there has been extensive debate regarding the relevance of psychology and its accessibility in meeting most South Africans’ needs (Long, 2013; Sher & Long, 2012). This has extended to understandings and use of the terms ‘culture’ and ‘race’ in clinical and research contexts (see Eagle, 2005; Hendricks et al., 2019).
The term multiculturalism has been used with a binary understanding, in which culture has been seen as an attribute of ‘Black lives’. This has permeated conceptualisations of community work and has been criticised for rendering normative the dominance of White culture within psychology and South African society.
In this context, however, clinicians may assess and treat South Africans in their rich diversity of race, culture, language, and other variables as well as people from foreign national backgrounds. Limited literature was noted at the time of the study as to how South African psychologists engage cultural issues in clinical settings. Research has looked at the use and development of culturally appropriate psychological assessment measures (e.g., Foxcroft, 2004; Shuttleworth-Edwards, 2012; Shuttleworth-Edwards et al., 2004), the development of multicultural competencies (Ngcobo & Edwards, 2008), the use and critique of different therapeutic approaches in the South African sociocultural context (Berg, 2009; Dugmore, 2012; Eagle, 1998; Smith et al., 2013; S. Swartz, 1999; L. Swartz et al., 2002), counter-transferential feelings in multicultural clinical contexts (Kometsi, 1999, 2001), cross-cultural power relations in the clinical dyad (see Eagle, 2005), as well as psychology and indigenous healing (Edwards, 2011). The need for research focusing on socio-economic issues and inequities has also been highlighted (Macleod & Howell, 2013) with a call to an Africa(n)-centred psychology which recognises all people, but particularly those that have been silenced (Ratele et al., 2018). Given that much of the work in this context focuses on a binary (as noted) cross-cultural or cross-race perspective, there is a need to continue to document a diverse range of viewpoints, from practicing clinical psychologists working in various circumstances. This study aimed to investigate how clinicians from different contexts in KwaZulu-Natal make sense of multicultural issues in their everyday clinical practice.
Method
In-depth, semi-structured interviews explored, qualitatively, multicultural experiences of clinical psychologists from KwaZulu-Natal, and meanings attributed to these experiences. Themes from interviews were analysed using thematic analysis and techniques from a grounded theory approach (Charmaz, 1995; Glaser & Strauss, 1967/2006; Tweed & Charmaz, 2012). Qualitative methods were used as these enable rich description of complexity and facilitate the documentation of experience and interpretation of diverse and marginalised views (Sofaer, 1999).
Participants
A multistage sampling procedure was used to recruit participants. Context, districts, as well as race and gender were initially purposively selected to ensure ‘variation in experience’ (Field & Morse, 1996, p. 118), perspective, and diversity. Participants were selected from (1) urban (registered hospital–based clinical psychologists in the public health sector and psychologists in private practice in Durban and Pietermaritzburg) and (2) rural areas (registered hospital–based clinical psychologists in the public health sector, selected from three districts located diagonally across the province, in order to ensure geographical variability). The importance of including different contexts, given the historical development of services in the country, was also considered. Due to a paucity of rural participants (possibly impacted by an uneven distribution of services in these areas [Siyothula, 2019]), clinicians from an additional fourth district were conveniently sampled to allow for more participants.
In light of the phenomenon under study (multiculturalism) as well as the need for representivity and equity, random sampling was used to improve credibility (Patton, 2002), through increased racial and gender representivity. The underlying assumption was that given the multicultural nature of South African society, most clinicians would have had exposure to multicultural work and would be able to give perspective and comment regarding experiences related to this. An initial pool of potential participants for each area was screened to identify clinical psychologists with 3 or more years’ experience (recognised as a Health Professions Council of South Africa regulated indicator of experience within the profession). Once clinicians were identified, simple random sampling was conducted by hand to identify potential participants. Sampling continued until race and gender were sufficiently represented. This was undertaken to document a range of participants’ perspectives. Through this process, variation in terms of race 1 and gender was ensured. However, clinicians from particular racial backgrounds were not equally represented due to there being fewer participants identifying as Indian, Coloured, and male; only available participants could be included. Historically, the sociopolitical context of training and practice has been such that more White clinicians as well as females have been trained in the profession, possibly influencing this distribution (Pillay et al., 2013; Skinner & Louw, 2009). Thirteen transcripts were subsequently analysed: Black females (4), White females (4), Indian female (1), Black male (1), White male (1), Indian male (1), and Coloured male (1). Five interviews were conducted in both urban and rural hospitals (five each) as well as three interviews in private practice.
Instrument
An interview schedule was used to obtain the following information: understandings of the terms multiculturalism and cultural competency; multicultural challenges, concerns, approaches, and strengths; relationship of clinicians to community and impact on ethnic and cultural aspects of the work; community outreach; and multicultural resources, organisation recognition, support services, and professional programmes. The questions utilised were originally developed for cultural competence organisational self-assessment by Dwork (employee relations director, Beth Israel Deaconess HealthCare, Boston, MA, USA) (as cited by Andrulis et al., 2005). This schedule was used as it covers general areas of enquiry, with open-ended questions, which could be applicable in a number of contexts. It was considered useful particularly in the South African context, given the focus of questions on multi-ethnic and multicultural populations as well as service accessibility issues. Examples of questions included the following: Do you feel there are any challenging multicultural and/or ethnic aspects to your work? What resources do you utilise to provide the best care for multi-ethnic and cultural patient populations (e.g., use of specific services—interpreters, community liaisons)?
Procedure
The names and contact details of clinical psychologists were obtained from the Health Professions Council of South Africa (HPCSA) register (a publicly available document containing practitioners’ registration details) and the Department of Health. For private practitioners, this information was obtained through private practitioner forum databases and the following directories: Yellow Pages, Med Pages, and Net Pages.
Once site permission was obtained, semi-structured interviews (which lasted between 40 min and 1 hr) were conducted in each of the work contexts. All interviews were electronically recorded and transcribed verbatim by the researcher. One participant working in a rural context opted to be interviewed at the institution where the researcher was based due to a visit in the area. Several psychologists contacted were not available due to other commitments (White female [1], Black female [1], Indian females [2], and Coloured females [2]) and one psychologist expressed a reluctance to participate.
Ethical considerations
The study was approved by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (Ref no: BEO21/14). Prior to the interviews, written consent to participate in the study was obtained and prospective participants were informed about the research that participation was voluntary and that there were no consequences for them should they choose not to participate. Participants were also assured that personal information would be kept confidential and that no identifying information would be published or made known to any persons other than the researcher. These details would also be removed prior to data capturing. Permission to contact clinicians based at urban and rural public hospitals was obtained through the Department of Health. Individual institutions were also provided with an information letter outlining the purpose and procedure of the study.
Data analysis
Data were initially coded line-by-line to reduce the data and identify categories and descriptive patterns arising in the transcripts (Tweed & Charmaz, 2012). After focused coding, an independent rater was approached to examine the anonymised data and critically review the researcher’s conclusions. The rater had clinical and qualitative research experience, in similar health contexts. The researcher also had clinical psychology experience in each of the contexts identified, as well as training and research experience. This assisted with identifying relevant areas of focus and experiences in the study.
The first two interviews were analysed independently, after which the interpretations were compared. Any discrepancies were discussed to confirm and resolve emergent hypotheses and themes (Cook, 2012). Theory triangulation (constant comparison with literature) and triangulation of data sources (comparison of different perspectives of participants) were also used (Korstjens & Moser, 2018; Patton, 1999).
Results
Multicultural challenges and concerns as well as approaches used to address the realities of service delivery
Language
Language challenges, particularly in rural settings, were evident across all contexts. This was considered the main difficulty or concern and was associated, in one instance, with a sense of unease with regard to a lack of language proficiency or understanding, as well as some related feelings of guilt or inadequacy. The importance of language concordance in psychotherapy and its impact on access to services were also highlighted: Urban participant (1): Ja, I think there are quite, quite a number of significant um aspects um challenges in the sense that, that limits me in a way in terms of the services that I can offer as a psychologist and that would pertain um more language challenges.
Challenges related to translators also emerged. Participants expressed concerns regarding the selection of translators, lack of training, and possible abusive dynamics in situations requiring translators. Furthermore, concerns were raised regarding the lack of consistency of translators as well as the under-prioritisation of translation services and the perceived negative effects these had on psychotherapy. Language as a ‘gateway’ was a prominent theme, with home language or speaking the language of the culture being seen as the biggest tool or strength in their work, by some participants. Some approaches to address language discordance between the psychologist and patient were suggested by participants. These included referral (to a psychologist who speaks the same language as the service user), the use of translators, and learning a language spoken by patients. Although not elaborated on, addressing language obstacles at an organisational or institutional level as well as exploring mechanisms to improve practice and access to care were also recommended. Interpreters were considered a support and human resource, provided by some organisations. The terms interpreter and translator were used interchangeably, although these differ with regard to the spoken or written medium, respectively.
Broader socio-economic, political, and family context
Broader contextual issues within communities in KwaZulu-Natal and the impact of these were also raised. Numerous social problems with few practitioners were noted in an urban context. Concerns regarding the levels of violence or rape (as well as these being linked to patriarchy, sexism, objectification of women, and polygamy) were also raised in a rural context. Socio-political difficulties resulting in difficult emotional experiences for patients were also described: Rural participant (1): Many, many um socio-political difficulties and that I’m quite certain that that contributes to an undercurrent of desperation, of anger um of you know really you know you think of Maslow’s hierarchy of needs, your basic needs are not being met.
Other contextual issues affecting families/communities included child or grandparent-headed families, neglect, insufficient protection, parentification, teenage pregnancies, and solicited sex which also become a cyclical pattern. Financial stressors as well as the affordability of therapy were noted as challenges in private contexts and were associated with culture, class, an apartheid legacy, current economic climate, lifestyles, financial management, and medical aid costs.
Culture
Culture was understood in terms of various dimensions, for example, economic (poor), racial (African or White) and ethnic (Zulu or Xhosa). More nuanced views of culture or lived experience were also cited, for example, ‘a culture with so much sadness’ and ‘a violent way of being’.
Challenges and concerns in this area included talking about culture, overcoming cultural obstacles or cross-cultural shock, errors or assumptions regarding culture, and difficulty defining culture. A need for awareness of culture when diagnosing was also noted. Challenges in understanding someone’s background or the subtleties and nuances of cultural experiences as well as differences in the perceptions of problems were also expressed: Urban participant (1): I think more from the client or patient’s perspective is that, they’re not going to get a, a decent service, number one or they not going to get, they gonna access the service but with a practitioner that doesn’t understand their background.
Participants also commented that there was a lack of assertiveness among their patients and that they experienced, in some instances, a lack of connection in the therapeutic relationship. The therapist was, however, also positioned as a ‘cultural broker’ and may assist with bridging a gap as noted in the excerpt below: Rural participant (4): When they see me they’re thinking because you Black you probably will understand this we, you know you as Africans we have this other part that spirituality is a huge part of our lives and traditional medicine so we know you going to understand this.
Learning about culture in relationship (e.g., growing up, interacting, or working with people from different walks of life) was also considered a strength.
Race and gender
Race and gender were highlighted as challenges within the private practice context. Participants also commented on how race and gender affect the type of service provided as well as the client’s experience of the service. Differences in therapeutic agency and perspective were also evident: Private practice participant (1): so I’m not getting a representative sample of Black men, but the people that seek help are usually one’s who want something from me very quickly and get very disappointed unless I write hundreds of letters and make it all go away whereas most of the Black women I see with very few exceptions are just enormously grateful for being listened to. Private practice participant (2): There are people who come to me specifically because they want help from, they are seeking help from a male African Zulu speaking psychologist and then that happens a lot, you know you, you get women who have medical problems you know who say no my husband will not see a female psychologist or my husband will not see an Indian psychologist so I came here because you are male African Zulu speaking.
Participants addressed racial as well as gender issues through explaining their role and boundaries.
Religion and spirituality
Religious and spiritual challenges were also raised by participants, with spiritual challenges being considered a core challenge in rural contexts (as noted, for example, in the previous excerpt by rural participant [4]). These included assessing whether behaviour was psychopathological or spiritual as well as where to most appropriately refer: Rural participant (5): then you have to consider that psychopathology and then you look at this in a spiritual form, where do you now refer?
Understanding roles or contexts
Understanding roles or contexts was also considered challenging, in terms of medical versus traditional interventions as well as understanding the role or experience of psychology. This was associated with challenges related to a lack of knowledge about psychology, the novelty of this approach, and service delivery expectations. Rural participants also expressed concern regarding mental health literacy: Urban participant (4): I think psychology being a very unusual profession for the majority of the population that never had access to services. You know I think for most people they are the first person in a family to see a psychologist.
How psychologists negotiate the therapeutic relationship in a multicultural context and whether they feel this negotiation is necessary were also noted: Rural participant (1): Sometimes patients will asking me directly what I feel about race or will say things like ‘well you’re just White, what do you know’. And I’m quite open to talking about that. I think it’s important to address that. And ja, find our similarities as well.
Types of health/ mental health issues
Unfamiliar conditions and complex multifactorial or continuous trauma were also evident: Rural participant (1): And certainly like when working with PTSD in this kind of rural context, it’s never a simple trauma. It is well okay there are a few you can’t really say never but it’s so often a multifactorial trauma or a more of a continuous or complex PTSD.
Therapeutic approaches, management, service, and resource needs
A lack or absence of services and service utilisation, high patient loads, as well a lack of follow-up or not knowing how patients have progressed were challenges noted in rural areas. A lack of access to service or no intervention (e.g., the provision of community service) was noted in urban hospital contexts, as well as patients defaulting follow-up sessions, the presence of waiting lists, and no collateral being obtained. Many social problems with few practitioners and time constraints were observed in both rural and urban contexts.
Concerns regarding the adequacy of care and difficulty releasing the expectation to provide specific cultural experience as well as practitioners’ perspectives of multicultural work as being too intensive or not lucrative enough were also expressed. Attempts to not reify cultural difference or promote specific cultural perspective were also noted in private contexts.
Official/available support services (as well as awareness or need for these) and resources to provide the best care for multi-ethnic and multicultural patient populations were conceptualised as absent, limited, inappropriate, or not available/needed.
A lack of official or formal professional programmes developing staff members in the cultural and/or ethnic aspects of their work was also raised. Some areas were noted by participants as not being recognised or marginalised by organisations. Concern was also raised, particularly in rural contexts, as to a lack of management and budget support for additional posts or resources. A lack of general resources/infrastructure (roads, housing, water, and jobs) was also noted. Reasons for limitations in resources and the impact of not having resources were also commented on.
Some resources were, however, identified, for example, appropriate referral sources. The type (e.g., a posture of understanding rather than judgement) and benefit of support (e.g., answering critical questions) were also commented on.
Cultural competency was conceptualised as engaging the process of approaching a different culture and how health concerns are talked about in clinical contexts. Knowledge as well as an emphasis on recognising the universality of emotions or humanity and aspects such as cultural sensitivity, understanding and/or awareness, empathy, and curiosity were also raised: Urban participant (4): So, so initially cultural competence would mean just becoming more and more familiar with how other cultures talk about uh their health concerns in, in clinical settings. Just understanding, just metaphors that are commonly used, ways of talking. Uh, those kinds of things. But, I prefer the term ‘cultural humility’ which I came across. Which you probably are also familiar with. So I much prefer that term which is suggestive more like open, curious attitude, ja, towards other cultures. Therapeutic posture included aspects such as being open, transparent and honest, being ‘as explicit as possible’ as a strategy, having an enquiring mind and adopting a ‘not knowing’ position.
Discussion
While participants raised a number of challenges and approaches to address these, some issues (described below) are particularly noteworthy.
Service delivery context
It is difficult to separate challenges of a multicultural nature from service and resource disparities as well as socio-economic, political, and family contextual difficulties. Historically, factors such as extreme violence, financial inequalities, disrupted family circumstances, and discriminatory practices have all impacted South African health services (Coovadia et al., 2009). Amenities in KwaZulu-Natal have also been historically disadvantaged in terms of infrastructure development, funding, and staffing (Burns, 2010). Disparities, particularly in relation to ethnicity, are not unique to this context (see Sashidharan & Gul, 2020); however, the South African scenario is impacted by distinctive elements such as the level of violence, for example, domestic violence, which may be mitigated or contingent upon broader processes in society (Waldman, 2006). Responses noted describe a context in which violence is endemic, deeply entrenched, widespread, and common (Vogelman & Eagle, 1991).
Other factors such as culture and gender have been addressed in the South African therapeutic literature, also noting the tensions that may evolve when feminist and multicultural values and principles are respected (Eagle & Long, 2011).
Language
The issue of language is particularly pertinent. Perspectives raised resonate with previous work done in this area (Drennan et al., 1991; Kilian et al., 2010) as well as more recent views (Elkington & Talbot, 2016), for example, the use of interpreters to assist with access to health and service quality.
Some approaches adopted are attempts to negotiate, as best as possible, the language barrier. Given training ratios, there is the likelihood that the majority of South Africans will not receive intervention in their home language, which has human rights implications (Ahmed & Pillay, 2004). The importance of being able to access therapy in one’s mother tongue and efforts to ensure this should be given priority, including enrolling more indigenous language speakers in training programmes.
Cultural competence
The approaches used by psychologists resonate with the core aspects of cultural competence discussed in the literature, that is, awareness, knowledge, and skill. Indigenous knowledge was also used in contrast to other approaches (e.g., humanistic approaches) to transcend therapeutic challenges. This is important in terms of how clinicians may bring new knowledge or ways of being which may have been previously marginalised, for example, ‘African cultural values’ (Eagle & Long, 2011, p. 337).
Interpersonal stances which embody cultural humility need to be encouraged. These are respectful and not self-focused, but orientated to the other, valueing their cultural experience and background. (Hook et al., 2013). The approaches of cultural brokering and cultural matching also require more exploration in South African contexts (see Eagle, 2005; Ibaraki & Hall, 2014; Kirmayer & Jarvis, 2019).
Although not a specific focus of the study, the construct of race was referred to by some participants; however, associated challenges were less present. Within the South African context, while race is integral to identity, it remains a difficult aspect to speak about within the therapeutic arena (Esprey, 2017). As noted by Sue (2015), the need to talk about race is however crucial. Honest dialogue about race is a way of decreasing prejudice, healing ethnic and racial division, increasing literacy about race, as well as improving inter-group relations (Sue, 2013).
Continuous professional development, which enhances self-reflection and dialogue to assist in becoming more comfortable with one’s own and other cultures, is recommended. Safety and anti-racism training as well as accreditation and standards for training and practice may also have benefit in this context (Kirmayer & Jarvis, 2019). Building agency for psychologists (whether related to language, cultural issues, or infrastructure) is also pertinent.
A number of limitations were noted in the study. First, due to the availability of clinicians, theoretical sampling (gathering more data to refine categories [Charmaz, 2014]) was only conducted in the private context. Furthermore, sampling in other contexts would contribute to greater meaning saturation. The interviews were also conducted over an extended period (June 2016–February 2019). However, given the gradual development of services in this area, many of the core issues identified are unlikely to have changed significantly over this time.
The researcher’s and rater’s backgrounds (English, first-language speakers) may have influenced the conclusions reached, as they were not from the same background as all the participants. Another criticism of the write up of the study was the lack of disclosure of the race of participants, which would have added more nuanced understanding of perspectives. Given the small sample, this was opted for in the interests of confidentiality. Although still widely used and sometimes contentiously so, the use of racial categories is also problematic (Hendricks et al., 2019). There is a need to continue to develop our understanding and usage of these constructs, within research and clinical contexts, to reflect the complexities. Work done in other contexts in this area may also be helpful (e.g., related to the American Census; Mays et al., 2003).
Conclusion
This study was located in three different contexts (rural and urban public health as well as urban private practice) which were characterised by various multicultural challenges, including language, religious or spiritual factors, culture, race, gender, role, and clinical context. Different approaches to address these challenges were also suggested.
There is an urgent need to strengthen and develop accessible, equitable, and culturally appropriate community- and clinic-based services, as well as mental health promotion and prevention programmes, which are aligned with the realities of clinical contexts and focus on vulnerable groups (Maulik et al., 2020; Pillay et al., 2009). This is particularly urgent in light of the recent Covid-19 pandemic, flooding, and unrest in KwaZulu-Natal which are likely to have compounded difficulties significantly. Of particular emphasis is the need for training to build more contextually appropriate assessment and intervention, address the language challenges, as well as develop depth in cultural competence.
A multicultural vision ideally requires intercultural interaction and equitable participation by all cultural groups in society (Berry & Sam, 2014). In its strategic plan for 2019–2022, the Psychological Society of South Africa (PsySSA, 2020) expressed a commitment to psychological work that advances social justice and relevance, in service to the majority of South Africans. It is imperative that we continue to work to address the challenges, in the interests of the mental health and healing of those we seek to serve.
Footnotes
Acknowledgements
The author acknowledges the clinical psychologists who participated in the study and Dr. Anna Voce who assisted with the rating of interviews.
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.
