A 2022 study by the Wits/Medical Research Council Developmental Pathways for Health Research Unit showed that a staggering 25.7% of South Africans are probably depressed, with only a quarter of those receiving treatment. A comparative study in Germany recorded 5.6% of the population suffering similar symptoms.
Mental health frequently receives less attention than its physical counterpart, but the consequences can be just as deadly. There are an average of 23 suicides in South Africa daily.
Given the mental health crisis, one might assume that the public healthcare system is well-equipped with mental health professionals, just as it is to deal with the HIV epidemic.
While there certainly are countries with worse statistics, South Africa’s 2.5 psychologists per 100 000 population is well below the global average. The US has a 33.3 per 100 000 ratio.
The shortage of qualified mental health professionals, combined with the extraordinary levels of depression and anxiety, has presented a business opportunity for charlatans — and something needs to be done.
The field of “wellness” is growing exponentially in South Africa, driven, in part, by the Association for Supportive Counsellors and Holistic Practitioners (ASCHP).
There is nothing inherently wrong with the wellness business, or indeed the ASCHP, so long as the practitioners “know the scope of their practice … the boundaries within which the counsellor operates without referral as defined by own work context” (ASCHP website).
Typically, this involves guidance with personal and professional development, dealing with the stress of day-to-day life, learning to find “inner peace” through mindfulness and techniques for improving productivity at work, among others. Practitioners are ethically bound to refer to a professional whenever mental health issues are suspected.
ASCHP counsellors are in no way qualified to diagnose or treat mental health issues such as depression and anxiety disorders. And yet, according to psychologytoday.com — a directory of counsellors and psychologists — this is precisely what some of those registered with the ASCHP specialise in.
One notes their specialisation as “trauma, PTSD [post-traumatic stress disorder], depression and anxiety”.
To become a registered psychologist or registered counsellor in independent practice, one requires a three-year degree in psychology, a one-year honours degree in psychology, and a two-to-four year master’s degree in clinical psychology or equivalent. Then professional registration with the Health Professions Council of South Africa (HPCSA) — this involves extensive training to follow strict professional and ethical guidelines, and board exams. Anyone who has tried to complete this mammoth task will tell you how incredibly competitive it is — there are limited slots available.
An HPCSA-registered counsellor requires a three-year degree, one-year honours degree, and practicals; or a four-year BPsych degree which includes practical training. The competitiveness and quality of the education results in well-trained professionals.
Even with this extensive training, registered counsellors are not trained to diagnose and treat mental disorders. They are trained to identify cases requiring referral to an appropriate registered psychologist.
While the ASCHP has SAQA (South African Qualifications Authority) as its official statutory body, a look through the profiles of those registered with ASCHP reveals that many of them have few relevant qualifications. Many have degrees in unrelated fields, or no degree at all. Some have perhaps done some short courses, the duration of which they measure in hours, not years.
Perhaps ASCHP justifies this through RPL (recognition of prior learning), but it’s hard to tell. A cynic might suggest that the two acronyms, ASCHP and HPCSA, are intentionally similar.
The ASCHP counsellors can, and often do, charge big money for their services, often north of R500 per hour. Their skill sets, on the other hand, are not at all similar.
Registered counsellors are the first line of community-based psychological support, work in health promotion, and are involved in screening assessments. They are trained in psychology, able to provide basic assessment and psychological interventions, and are strictly regulated.
They can be reported for malpractice and have their licences revoked.
While “registered counsellor” and “registered psychologist” are protected terms — you can’t (legally) just call yourself one — you can legally just call yourself a “general counsellor” or a “wellness counsellor” and charge the same fee.
Part of the issue is that thousands of psychology students graduate each year and find themselves at a loose end when their masters applications are turned down — as the vast majority are. They want a route into their chosen profession, and the ASCHP seems to provide just that. Only, it doesn’t. The scope of a wellness coach should not encroach on diagnosis and treatment.
I am not accusing all registered ASCHP counsellors of wrongdoing. The majority might well provide a valuable service, and there are too few registered counsellors and registered psychologists in South Africa to deal with everyone’s problems.
Being upset when something bad happens is normal, and help can be good. Life is tough for many in South Africa, and intervention from a competent wellness coach could well improve one’s attitude, one’s general wellbeing, and perhaps even help prevent future mental disorders.
But it is not just disingenuous for these wellness coaches to provide mental healthcare, it’s downright dangerous. For an ASCHP counsellor to treat mental disorders is like someone who’s completed a first aid course scheduling you for surgery.
So, what should be done?
First, it is a criminal offence to practice medicine without a licence — mental health is regulated the same as physical health. Any ASCHP practitioner claiming to offer treatment for mental disorders should be threatened with legal action if they don’t desist.
Second, websites like psychologytoday.com should be more responsible and refuse to advertise treatment for mental disorders from anyone not registered with the HPCSA.
Third, I would ban anyone not registered with the HPCSA from calling themselves a counsellor of any kind. It’s misleading, intentionally or otherwise. Poor treatment from untrained wellness coaches affects the reputation of trained professionals.
Finally, South Africans need to be better informed about who is qualified to deal with mental disorders, and who isn’t, who has received what kind of training, and who are they regulated by, if anyone at all.
Registered counsellors and registered psychologists do not get the credit they deserve.
Thanks to the ambiguities (potentially intentionally) introduced by some of those involved in wellness coaching, they are too regularly conflated with the charlatans.
Prof Benjamin Smart is a director at the Centre for Philosophy of Epidemiology, Medicine and Public Health at the University of Johannesburg.