‘Private practice was my second option’: exploring barriers and facilitators to the delivery of mental health care by registered counsellors in South Africa

Abstract

The category of registered counsellor was created to service the mental health care needs of the South African population at primary health care level. However, a lack of employment opportunities for registered counsellors within primary health care settings resulted in many opting to work within private practice. In this study, we explored barriers and facilitators to the delivery of mental health care by registered counsellors. We employed purposive and snowball sampling to recruit 15 participants, who were registered counsellors in private practice throughout South Africa, and registered with the Health Professions Council of South Africa. Semi-structured interviews were conducted online via Skype. The interviews were audio-recorded, transcribed, and analysed using thematic analysis. We used the Capability, Opportunity, Motivation model of behaviour and the Theoretical Domains Framework as conceptual frameworks in the study. We identified facilitators and barriers that registered counsellors experienced in their attempts to provide mental health care at a primary care level. We identified three themes and named them as follows: (1) registered counsellors feeling competent, capable, and motivated to engage in community work, (2) the registered counsellor as an unacknowledged mental health professional, and (3) limited alternatives to private practice. We regarded the first theme as a facilitator, and the other two as barriers to the provision of mental health care by registered counsellors in private practice. These findings suggest that registered counsellors felt motivated and capable of providing mental health care, but that structural barriers prevent them from doing so.

Introduction

The global burden of mental illness is responsible for 32% of years lived with disability, and 13% of disability-adjusted life years (Vigo et al., 2016). In low- and middle-income countries (LMICs), 76% to 85% of people who suffer from mental illness do not receive treatment for their condition (Dos Santos et al., 2016; World Health Organization [WHO], 2017). In South Africa, the burden of mental illness is compounded by serious socioeconomic factors such as poverty and unemployment (De Kock & Pillay, 2016) and by chronic communicable diseases such as HIV/AIDS and non-communicable diseases such as diabetes, all of which may contribute to the increasing burden of mental illness in the country (Myers et al., 2019). In addition, mental and substance use disorders have become the primary cause of years lost due to disability in South Africa (Docrat, Lund, & Chisholm, 2019).

The integration of mental health care (MHC) into primary health care (PHC) has been promoted as a means to reduce the treatment gap between those who are in need of MHC and the limited resources, including human resources, to provide this care (Patel et al., 2013; Petersen et al., 2017; WHO, 2013). Considerable effort is being made to scale up MHC in LMICs (Faregh et al., 2019).

One approach used in several interventions is the promotion of task-shifting, which aims to redistribute some tasks from health care specialists to non-specialised health workers (NSHWs) who have less training and fewer qualifications (Dos Santos et al., 2016; Nyatsanza et al., 2016). Task-shifting aids the integration of MHC into PHC. Staff such as nurses or community members are trained to provide basic counselling and referral within PHC. However, research has found several barriers to the implementation of task-shifting for MHC in PHC. For example, Petersen et al. (2019) found that some NSHWs avoided patients seeking MHC as these NSHWs did not want to be associated with them because of stigma and discrimination, whereas others did not want to engage in task-shifting as it added to their workload, and others were concerned with the lack of specialist supervision.

In South Africa, the registered counsellor (RC) category was conceptualised as a mid-level MHC worker who would increase human resource capacity for the mental health (MH) needs of communities (Health Professions Council of South Africa [HPCSA], 2022). RCs were intended to provide primary MHC in diverse communities to improve the well-being of those communities. These psychological services, rendered at PHC level, included basic counselling services, the prevention of mental illness, and the promotion of psycho-social health in communities (HPCSA, 2022).

However, a study found that most RCs were working in urban areas, particularly in Gauteng (33.3%) and in the Western Cape (28.4%; Fisher, 2017), indicating that RCs were not providing primary mental health care (PMHC) to rural communities, where 40% of the South African (SA) population reside (De Kock & Pillay, 2016), and who are most in need of their services. With the majority of RCs based in urban environments, they gravitated towards private practice and, according to Fisher (2017), spent almost 90% of the work week providing individual counselling. A. L. Pillay (2016) described the category as a missed opportunity and recognised that there was a failure in creating employment categories for RCs. Moreover, he stated that the category may still be rescued and that RCs can play an important role in MHC in underserved communities (A. L. Pillay, 2016).

In this article, we engaged RCs in private practice in South Africa. The purpose of the RC category was, however, not private practice, but rather to develop MHC practitioners who would be employed by the Department of Health (DOH) to provide PMHC services in under-resourced communities, who relied on government health services. These positions for RCs in the DOH did not realise, and almost half of RCs were funnelled into private practice to earn a living, most of them unwillingly (Fisher, 2017; Rouillard, Wilson, & Weideman, 2016). To date, there is no specific study that investigated whether RCs in private practice felt they were able to provide MHC in under-resourced communities, or explored what the barriers and facilitators are that RCs in private practice experience in relation to this task. We explored current practices of RCs in private practice and their perceptions of their own barriers and facilitators to provide MHC to diverse and under-resourced communities.

Method

Participants

A qualitative study was conducted among RCs in full-time or part-time private practice, living and working in South Africa. Qualitative research is used to understand perspectives and experiences of participants, and the meaning they allude to these experiences (Hammarberg et al., 2016) and was appropriate as this study was exploratory. To participate in the study, RCs had to be registered with the HPCSA as RCs, and have at least 1 year’s experience in private practice. We used purposive and snowball sampling to recruit participants. Purposive sampling, often used in qualitative research, facilitated the engagement of a well-defined sample of participants who were familiar with and had experience of the particular phenomenon being studied (Etikan et al., 2016). We recruited participants through local professional bodies by posting an electronic invitation flyer on several social media platforms. Participants contacted the researchers via their email addresses to indicate their willingness to participate.

The pool of participants consisted of 15 RCs between 25 and 67 years (average age = 41 years). Ten participants were female, and five were male. Twelve participants indicated that there were married, one was divorced, and two were single. Most of the participants (n = 11) were in full-time private practice. One participant had a doctoral degree, four participants had master’s degrees, and four participants were enrolled for master’s degrees. The participants had been registered with the HPCSA for 2 to 13 years, with a mean of 7.6 years.

Instruments

Semi-structured interview schedule. We developed a semi-structured interview schedule to explore barriers and facilitators to providing MHC to under-resourced communities. Participants were asked a number of demographic questions about their age, relationship status, qualifications, and years registered with the HPCSA. Participants were also asked to reflect on whether their training and subsequent skills prepared them for the delivery of MHC, what the environmental factors were that facilitated or impinged on their delivery of services, what motivated or demotivated them in their endeavours, and what their beliefs were about the value and importance of the work they did.

Procedure

We conducted individual, semi-structured interviews via Skype, in a safe and confidential space. Most of the interviews were conducted in English (n = 13), and were 45 to 60 min in duration. Participants were interviewed until saturation was reached after 15 interviews. Participants did not receive any remuneration. The interviews were all audio-recorded and transcribed.

Ethical considerations

Ethical clearance for this study was granted by the Research Ethics Committee at Stellenbosch University (N16/04/055). Potential participants were informed that they could withdraw from the study at any time, and were free to answer only the questions they felt comfortable with. Participants were provided with the contact details of a free counselling service in the event that they needed psychological assistance. Written consent was provided by the participants before the commencement of the interviews. Pseudonyms were used throughout the study to protect the identity of the participants.

Data analysis

Transcriptions were uploaded to Atlas.ti Version 8 (2016) to manage the data. We employed the six phases of thematic analysis outlined by Braun and Clarke (2006) to analyse the data and identify relevant themes. This included familiarising ourselves with the data by conducting the interviews and listening to each audio-recorded interview, reading the transcriptions multiple times, creating initial codes, developing code groups, and identifying and refining themes and sub-themes. We engaged two theoretical frameworks, the Capability, Opportunity, Motivation model of behaviour (COM-B model; Michie et al., 2011) and the Theoretical Domains Framework (TDF; Smith et al., 2019), to loosely guide our search for themes. The COM-B model has three components, namely, capability, opportunity, and motivation. These components interact and determine behaviour, which, in turn, influences the components (Michie et al., 2011). The model suggests that for a particular behaviour, also known as the target behaviour, to be demonstrated, the individual must have the capability, the opportunity, and the motivation to perform the behaviour (Van Leeuwen et al., 2018). We employed the COM-B model as it provided a thorough analysis of behaviour and took into account the intra-psychic conditions of the participants and the social and environmental conditions (context) that needed to be present for their target behaviour to occur (Michie et al., 2011). The 14 domains of the TDF also focus on the context, capability, and motivation of the individual (Atkins et al., 2017), and provide a more detailed and granular understanding of behaviour. We employed the TDF in conjunction with the COM-B model as it facilitated the identification of barriers and facilitators to the achievement of a target behaviour (Atkins et al., 2017). The themes reflected the barriers and facilitators that RCs in private practice encountered when they provided MHC in under-resourced communities, or attempted to do so. To ensure trustworthiness of the study, the researchers consistently and thoroughly engaged and reviewed the analysis process.

Results

We identified three themes and named them as follows: (1) RCs feeling competent, capable, and motivated to engage in community work, (2) the RC as an unacknowledged MH professional, and (3) limited alternatives to private practice. We regarded the first theme as a facilitator, and the other two as barriers to the provision of MHC by RCs in private practice.

Feeling competent, capable, and motivated to engage in community work

Participants reported that they felt competent to provide MHC because they had the appropriate knowledge and skills to do so. Although some participants stated that their academic training was too theoretical, others regarded their academic training as a valuable and relevant resource, a facilitator for the delivery of MHC. Many participants reported acquiring the practical skills to provide MHC during their internships, especially those located in under-resourced settings. The skills acquired during internships included supportive counselling skills, career counselling, anger management and resilience counselling, screening, and language and cultural awareness. These skills may be considered pertinent to the delivery of MHC and can be regarded as facilitators of this endeavour. In the following statement, Mbulelo, a 27-year-old RC in part-time private practice, reflects on his training.

Yes, I think I’d say that I do have the knowledge and the skills to provide those services . . . I think for me uh the university that I went to uh they did uh I can say they did a very good job in training us to do community work – because they just threw us into community work when we wanted to sort of like run away from it . . . So I think for me personally . . . I am well-equipped in providing those um uh primary um services at a community level.

Participants reported that they continued to increase their capability to provide MHC with ongoing informal training, which was another facilitator of their task. This included continuous professional development (CPD) courses, study groups, supervision, workshops, individual research, and networking with colleagues.

In addition to feeling capable of providing MHC, participants stated that they were motivated to provide this service. They stated that they believed in the value of their role as MHC professionals, and that they were aware of the critical need for MHC in urban and rural under-serviced communities. Several participants stated that the placement of RCs in clinics or community health centres could facilitate accessibility to MHC and reduce stigma. Ilse, a 32-year-old RC in private practice for 7 years, reiterated this.

But there are community centres all over, and if there was access . . . if every rec centre had a mental health room, with a RC at least, it would make mental health less stigmatized or also more accessible.

Some participants reported that even though they were in private practice, they provided some MHC to people in underserved communities by offering their services pro bono, reducing their fees, or by engaging in voluntary work at community-based organisations. These participants added that they could only provide MHC in these ways if they had alternative incomes from part-time employment and, as was the case with one participant, a monthly pension. Lesley, a RC who was keen to provide MHC, reported that she could only do so if she supplemented her income from her private practice.

So the only way for my practice to survive now is through the alternative income. It seems like a lot of RCs are doing additional um work in other fields to try and just make ends meet. And not really practising what we’ve really . . . what we are supposed to be doing.

Without this extra income, their delivery of MHC would be unsustainable. This is further evidence that RCs were motivated to work in under-resourced settings. We will now describe two barriers to the provision of MHC in resource-constrained settings by RCs.

The unacknowledged MH professional

Participants reported that, in their experience, RCs were not known to or recognised by other MH and health professionals, the government, and community-based stakeholders. Participants described this lack of recognition as a barrier to their delivery of MHC because it resulted in a lack of client referrals by MH and health professionals, and limited employment opportunities in government departments within community settings and PHC. In the following statement, Mbulelo, a RC who was particularly interested in providing MHC in needy and under-resourced communities, described his repeated frustrating experience of this lack of awareness of RCs.

I think other health professionals do not know about us, firstly. And I think um if you explain to some of the professionals, they still don’t understand. Some of them feel uncomfortable . . . even uncomfortable with referring clients um to you or recommending you because they actually do not understand what . . . who you are and what you actually do.

Some participants reported that they tried to provide MHC in schools as a RC, but the category was not recognised by the relevant departments, who seemed to prefer employing social workers and psychologists within the education system. Moreover, one participant, Paula, who had a part-time private practice and was employed part-time at a school, explained that the staff at the school did not understand the role and scope of practice of a RC, and confused RCs with social workers. Paula had been allotted social work tasks at the school, until she convinced the staff that this was not her field of expertise. Several other participants also reported this confusion of the RC with social workers, or psychologists, or lay counsellors. This meant that RCs often missed out on providing MHC, as was the case during the COVID-19 pandemic when only social workers were deployed by the government to assist with MHC of individuals and communities.

The lack of recognition by professional peers also acted as a barrier to referring clients. Some participants reported that MH professionals questioned them about their formal academic qualifications and knowledge of MH when they tried to refer clients. For example, Yibanathi, a 35-year-old RC in private practice, tried to refer clients to hospitals during emergencies but stated that hospitals did not accept her referrals. She resolved this recurring crisis by convincing clinical psychologists at hospitals to assist her with emergency admissions, but the experience left her feeling disappointed in the system. She describes this experience as disempowering.

For me at times, would be when you having emergencies, and you need to to refer immediately. Maybe to the nearest psychiatric hospital and that. And, like I said, at times being a RC is not recognized. So, it’s . . . you’re referring because it’s something urgent, but the person on the other side is . . . is saying: but who are you? How how is it that you want to refer this person to us?

Many participants reported that, in their experience, the perceptions of RCs by other MH practitioners contributed to their limited ability to provide MHC within communities. These perceptions included a fear that RCs would work outside their scope of practice, and it included the notion that RCs were inferior and irrelevant MH practitioners, and a belief that RCs were not legitimate MH professionals. The majority of participants reported negative feelings about the lack of acknowledgement and support from other MH professionals. They reported feeling demotivated at times and experienced feelings of inadequacy, inferiority, frustration, anger, disillusionment, and disempowerment. A number of participants reported that these barriers made them consider leaving the profession. Some participants stated that the oversight and marginalisation spurred them on to work harder and thoroughly, and to further their academic qualifications.

Limited alternatives to private practice

The majority of the participants reported that they had started a private practice as they could not find employment in the public sector. We identified this change in trajectory as a serious barrier to the delivery of PMHC by the community-trained and -oriented RC. Most of these participants reported engaging the profession because they believed in and responded to the government’s directive that the RC would scale up the deficient MH services and MH promotion in under-resourced communities. They reported feeling frustrated, betrayed, and disillusioned by the extensive lack of positions for RCs in government departments and institutions, and experienced this as a barrier to their target role. Matthew, a RC in private practice for 4 years, described his experience of this dilemma.

Yes. There’s a lot of frustration from that aspect because then what is the use for this category then. So there’s a lot of conflict from that point where people feel that – Ok. Why did we train? Why did we study so hard? And now we are not able to do what we are trained for? So there’s frustration from that end. And towards the HPCSA, the government and the various role players.

Participants attributed the lack of employment opportunities for RCs in the public sector to little or no understanding or recognition of the RC category by the government, the government’s preference for and funding of psychologists and social workers, and a lack of funds in the government to fund positions for RCs. Furthermore, participants, who were keen to work for the government in under-resourced communities, stated that securing positions in state schools, state hospitals, or clinics was difficult, often impossible. A participant, who managed to secure government contracts, had to do so via a registered service provider. This RC had a doctorate, however, and related that a RC with an Honours degree only had little chance of being employed by the government as government and community-based organisations preferred to employ or engage psychologists or social workers. Some participants stated that psychologists rather than RCs were employed as the RC was regarded as an inferior and insignificant MH professional. Despite these perceptions, many participants reported that they viewed RCs as important and essential MH professionals, especially as a first port of call for individuals and communities in need of MHC. Participants also related that they understood the difference between the scopes of practice of RCs and psychologists, and wanted to work with and alongside other MH and health professionals, and not be regarded as inconsequential or a threat. Funeka, a 25-year-old RC in private practice, stated:

Looking at employment, uh I think for me private practice wasn’t the way to go because I . . . I wanted to be working with the community being employed by government. But we are not recognized as RCs. They want psychologists. And for me, I thought we are employable as RCs because we can provide the type of intervention. And also looking in government hospitals, you find that there’s only one psychologist. And for them, it’s also pressure. So if they can use us RCs, MH can be a norm to people. People will know about it. Private practice was my second option.

As mentioned previously, participants reported that their experience was that they were overlooked in favour of social workers, despite the fact that both professions require a 4-year degree and were community oriented. Furthermore, participants reported that not only were social workers preferred to RCs, they also had more authority than RCs. Social workers, along with psychiatrists and psychologists, could admit a client to hospital for a psychiatric examination. RCs could only sign the form as an associate of a client (Republic of South Africa, 2002). Some participants stated that this was a frustrating and demotivating barrier to their delivery of MHC. Yasmin, an experienced RC, stated that, in her opinion, social workers were preferred and had more leverage than RCs because the academic training of the social worker included practical work from the beginning of the degree, which was not usually the case in the formal training of the RC, especially not at state universities.

So in terms of training I think the understanding is there’s too little training that a Registered Counsellor has as opposed to a social worker. The social worker gets more um . . . their course involves lots of uhm uh practical work – from the beginning – from the onset – whereas counsellors I don’t think that they receive so much practical experience in their degree, in their training.

For many, pursuing the category of RC is an alternative career, as students may choose to study psychology with the intended purpose of becoming a psychologist, but are not accepted into clinical and counselling training programmes.

The majority of participants reported that there were no or very few employment opportunities in the public sector. This meant that RCs had to consider private practice to make a living, and to justify the time and money spent on their training. Furthermore, participants reported that that most of them had to take on extra employment to supplement their insufficient private practice income. They regarded this as another barrier to their provision of MHC, as the extra employment was often not in the field of MH, and was energy- and time-consuming.

Overall, the limited alternatives for RCs to private practice elicited feelings of disappointment, abandonment, betrayal, conflict, uncertainty, irrelevance, and a sense of letting communities down.

I don’t know . . . it just feels like . . . I feel like RCs are are . . . You know, they sell us dreams, and then they dump it.

Discussion

Our aim was to explore the barriers and facilitators that RCs in private practice encountered in their provision of MHC to under-resourced communities in South Africa. We employed the COM-B model and the TDF to identify these barriers and facilitators. According to the COM-B model, intra-psychic (individual), social, and environmental conditions are required for a specific behaviour to occur (Michie et al., 2011). In this study, the capability and motivation of the participants to provide this kind of service were explored, and regarded as facilitators for the delivery of MHC services. Participants reported that they had the knowledge and the appropriate skills to deliver MHC to under-resourced communities, and that they honed these skills through CPD activities. Furthermore, participants noted that they believed in the value of their role as MHC professionals, and were keen and motivated to assist under-resourced communities as they were aware of the need for MHC in these communities.

Although the research done about RCs in South Africa is limited, our findings are similar to those of other researchers, who found that participants reported that their academic training had provided them with the relevant knowledge in the field of MH (Abel & Louw, 2009; Elkonin & Sandison, 2006, 2010; Fisher, 2017). Furthermore, the academic training of RCs was generally well complemented by their obligatory internships where participants learned necessary and relevant skills to provide MHC (Elkonin & Sandison, 2010; Fisher, 2017; Kotze & Carolissen, 2005). These skills included trauma and grief counselling, understanding and managing HIV/AIDS, career and lifestyle decisions, study skills, group counselling with a focus on anxiety, depression, self-esteem, sexuality, anger management, referrals, and engaging multicultural and diverse settings (Abel & Louw, 2009; Elkonin & Sandison, 2010; Fisher, 2017). In this study, the majority of participants related that, after their academic training, they had acquired the necessary skills to provide MHC during their internships, especially if the internships were based on under-resourced settings in South Africa where there was a dire need for MHC.

Research has shown that RCs have not been successful in fulfilling their role as mid-level MH professionals trained to contribute to the reduction of the MH treatment gap in South Africa (Abel & Louw, 2009; Elkonin & Sandison, 2006, 2010; Fisher, 2017; Kotze & Carolissen, 2005; Rouillard et al., 2016). Rouillard et al. (2016) established that although participants in their study understood the value and importance of the role of the RC, and were more affordable and accessible than psychologists, they experienced many disconcerting challenges. These challenges included their own lack of clarity about their title, role, and scope of practice as RCs, as well as a lack of understanding and recognition of their MHC contribution by the public and other professionals. These uncertainties deterred many RCs from registering with the HPCSA, and had them move into alternative careers where they did not work as RCs although they were aware of the under-resourced communities in need, and keenly motivated to assist these with MH wellness and provide MHC (Abel & Louw, 2009; Rouillard et al., 2016).

In this study, the social and environmental opportunities for RCs to provide MHC were limited. Participants described their experience of a lack of recognition and acknowledgement by MH and health professionals, the government, and community-based stakeholders, as well as the lack of employment opportunities for them in the public sector. Participants regarded these as critical barriers to their delivery of MHC. Our findings in this regard are similar to previous research (Elkonin & Sandison, 2006; Fisher, 2017; Rouillard et al., 2016), which found that the vast majority of participants felt that there was insufficient recognition and respect for RCs in the profession of psychology and by the public. These participants reported that they felt inferior in the profession, they perceived psychologists as looking down on them, they were often confused with lay counsellors by the public, and their qualifications and ability to provide MHC were unknown to the profession and public alike. This perceived professional and public unawareness and disregard of RCs affected their sense of their role as MH professionals as they constantly had to describe their qualifications and justify their competency (Abel & Louw, 2009; Elkonin & Sandison, 2006, 2010; Fisher, 2017; Kotze & Carolissen, 2005; Rouillard et al., 2016).

Task-shifting has been proposed as a method of reducing the treatment gap at PMHC levels (Myers et al., 2019). However, research indicates that this model has marked limitations (Petersen et al., 2019; Thornicroft et al., 2016). Non-specialist health workers, such as community health workers and nurses, engaged in task-shifting were often deterred from engaging because of the stigma and discrimination attached to mental illness. Others regarded the task of MHC as an extra and overburdening addition to their work, and complained about the lack of specialist support and supervision (Petersen et al., 2019). Placing RCs, who are trained and willing to provide MHC in PMHC settings, in these positions is a viable solution, but needs the support of key stakeholders such as the DOH.

As reported in several other studies, RCs did not only experience a lack of recognition as MH professionals, they also struggled to find employment, especially in the public health sector (Elkonin & Sandison, 2006; Fisher, 2017; Kotze & Carolissen, 2005; Rouillard et al., 2016). However, RCs were not the only MH professionals who encountered this challenge. South Africa’s government has taken steps to improve the MH system in the country. This endeavour included the development and adoption of several plans and policies such as the Mental Health Care Act (MHCA) of 2002, the South African Mental Health Policy Framework and Strategic Plan 2012–2020 (MHPF), and its 2023 update (DOH South Africa, 2013, 2023; Sorsdahl et al., 2023). To date, however, there are still serious obstacles to the implementation of the MHCA and the MHPF. These obstacles include a lack of adequate funding, poor co-operation and planning by government departments, mismanagement of the provision of MH services, and a dearth of MH human resources (Y. Pillay, 2019). Among others, the acute shortage of MHC human resources is reflected in the 0.97 psychologists, 0.31 psychiatrists, and the 1.83 social workers employed in the public sector per 100,000 uninsured citizenry. Although nurses are represented more positively at 80 per 100,000 uninsured citizenry, only a minimal number are trained specialist psychiatric nurses (Sorsdahl et al., 2023). This ratio is significantly inadequate in relation to MH services required to deal with the country’s MH burden and treatment gap (Sorsdahl et al., 2023). According to L. Pillay and Layer (2018), positions for psychiatrists and psychologists remain unfilled in the public health sector. This means that a limited number of professionals are required to provide MHC to more and more SAs who are not only in need of MHC, but who live in poverty with unemployment and violent crime on the increase.

According to Elkonin and Sandison (2006) and Fisher (2017), it was the public and professional ignorance of the competencies and role of RCs that led to their lack of employment opportunities. Fisher (2017) found that the limited employment opportunities for RCs was the result of a lack of marketing the category and little advertising of employment opportunities, especially by the government. When there were jobs for RCs, these came with low, unsustainable earning capacity and, according to Docrat et al. (2019), were found in only some provinces in the country, and not in others. Furthermore, the lack of employment funnelled many RCs into private practice (Abel & Louw, 2009; Fisher, 2017; Rouillard et al., 2016) where most of their focus was on individual counselling (Fisher, 2017). This is supported by research that found that more RCs were in private practice than employed in the public and private sectors (Abel & Louw, 2009; Fisher, 2017).

No previous research has been done on whether RCs in private practice could and did provide MHC to under-resourced communities in South Africa. This is an important question, given the original intention of the category to provide easy access to MHC in impoverished and under-resourced communities, rather than the engagement of private practice. In this study, the researchers found that the delivery of MHC to under-resourced communities by RCs in private practice was limited and unsustainable, but that it did occur. Those who provided MHC to underserved communities in need of MHC did so pro bono or at greatly reduced fees, or worked as volunteers. However, these participants had to have alternative employment to facilitate this pro bono and volunteer work.

This study engaged a small sample and convenience sampling that may not have fully represented the target population. The interviews, however, elicited in-depth and rich data, and were continued until saturation was achieved. Although the interviews were conducted in English and Afrikaans only, which excluded potential participants who were not proficient in these two languages, the participants were of diverse backgrounds. Finally, as most of the participants were working in urban settings, this skewed a more credible sample of the distribution of RCs throughout the country, and limits transferability of the study.

Recommendations

Earlier research has posited recommendations about the deployment of RCs in the country to reduce the treatment gap. This includes the deployment of RCs at the PHC clinics throughout the country to provide psychological services as this level, as well as supervise and train community MH workers in screening and referral (Petersen et al., 2009, 2011). This initiative would benefit the country in two ways, in that not only will MHC services be scaled up in needy communities, universities will be encouraged to reinstate their training programmes for this category as there would then be employment opportunities for their graduates (A. L. Pillay, 2016). Furthermore, RCs in the public sector should be appropriately remunerated, and provided with opportunities to progress in their career (Sorsdahl et al., 2023).

Conclusion

This study found that RCs in private practice stated that they had the skills and knowledge to provide MHC in diverse and under-resourced communities, and that they were motivated to do so. However, two critical barriers limited their rendering of this important service. One was the lack of acknowledgement and engagement by other MH and health professionals, the government, and the public, and the other was the limited employment opportunities in the public sector.