Closing South Africa's mental health gap: Why counsellors and clinicians need to work together

Jamie Bhana X Camryn Morris

If you've ever tried to find mental health support in South Africa, you may have run into a frustrating truth. Even though government policy increasingly pushes for care that's accessible and community-based, actually finding the right support can still be hard. There aren't enough professionals in the right places, services aren't always well coordinated, and it can be unclear who to turn to first.

Part of the solution isn't complicated. It's about different professionals working together, rather than being seen as separate or competing services. But collaboration only works when it is built around a clear understanding of scope, competence, ethics and referral responsibilities.

Different roles, working side by side.

Mental health and wellbeing support is provided by different professional categories, each with its own training, scope of practice and level of intervention. Although psychologists, HPCSA Registered Counsellors and ASCHP Specialist Wellness Counsellors may all use counselling skills, they do not provide the same type or level of care. Understanding this distinction helps ensure that clients receive support from the appropriate professional.

• Psychologists: psychological assessment and therapy

HPCSA-registered psychologists are trained to provide psychological services within the scope of their registration category, education, training and competence. Depending on their category and competence, this may include psychological assessment, formulation, diagnosis where applicable, and psychological interventions or psychotherapy.

Psychological therapy involves more than providing general emotional support. It may involve the assessment and treatment of psychological difficulties using structured psychological interventions appropriate to the person’s presentation. Psychologists may therefore work with more complex or persistent psychological difficulties and, where appropriate to their scope, provide treatment for diagnosed psychological disorders.

• HPCSA Registered Counsellors: primary-level psychological counselling

Registered Counsellors are also registered with the HPCSA as a category within the Professional Board for Psychology, but their scope is more limited than that of psychologists. Their role is primarily focused on primary-level psychological screening, assessment and interventions aimed at improving personal functioning.

Their counselling may assist people experiencing difficulties such as stress, adjustment, coping, relationships or other problems affecting everyday functioning, provided these fall within the practitioner’s scope and competence. Their role is not

equivalent to that of a psychologist and does not extend to the full range of psychological assessment and treatment provided by psychologists.

Where a person’s needs require more advanced psychological intervention, the Registered Counsellor should recognize this and refer appropriately.

• ASCHP Specialist Wellness Counsellors: wellness and primary-level counselling

ASCHP Specialist Wellness Counsellors belong to a separate professional pathway from HPCSA-registered psychologists and Registered Counsellors. Their work is centred on wellness, supportive counselling and personal development at primary-health-care level.

They may support clients with everyday challenges, coping, relationships, lifestyle, personal growth, wellbeing and other concerns that fall within their defined scope. The ASCHP describes the Specialist Wellness Counsellor as a higher-level wellness counselling designation, but this does not mean that the practitioner is a psychologist or psychotherapist. Importantly, the ASCHP scope specifically excludes psychotherapy. Wellness Counsellors are not qualified within this scope to diagnose pathology, use psychometric tests, or provide medical or psychological treatment protocols. Where a client presents with needs requiring psychological or medical intervention, referral is required.

Why does this matter right now?

South Africa's official mental health strategy calls for care that is more accessible and community-focused. Yet mental health resources remain unevenly distributed, with higher-level clinical services concentrated in particular settings and areas. This creates a practical problem: the person who needs support may encounter the system long before they ever reach a higher-level care.

What's needed isn't simply more practitioners. It's a properly connected system where people can access appropriate help early and where there is a clear, safe route to more higher-level care when their presentation, risk or lack of improvement indicates that it is needed.

This is where scope of practice becomes an ethical issue, not just a regulatory one. A counsellor who works beyond their training or competence can delay appropriate treatment, create confusion about a client's needs, or give a person a false sense that a more comprehensive assessment has already taken place. Equally, a system that sends every person experiencing ordinary life difficulties directly into higher-level clinical services can make already limited higher-level clinical capacity even harder to access.

The people falling through the cracks.

Without clear relationships between counsellors and clinicians, people can get stuck between levels of care. Someone might begin with supportive counselling and later show signs that require escalation- for example, significant suicide risk, psychosis, severe or complex trauma, substance-related difficulties, or symptoms that are persistent and worsening. The ethical responsibility is not to continue simply because counselling has already started. It is to recognise the change in need and act accordingly.

The opposite problem matters too. A person experiencing grief, adjustment difficulties, relationship strain, stress or another problem that falls within a counsellor's competence may not necessarily need higher-level clinical intervention as the first step. Appropriate early support can help people before difficulties become more severe.

The answer is a structured referral relationship rather than a hierarchy in which one profession is automatically considered more valuable than another. Referral should be based on the person's needs, the practitioner's scope and competence, clinical risk, and the level of assessment or intervention required.

Keeping it safe: Knowing where the lines are.

Working together does not mean blurring professional boundaries. In fact, effective collaboration depends on making those boundaries clearer.

For ASCHP counsellors, this means staying within wellness counselling and the specific competencies attached to their designation. Screening can help identify needs and guide referral, but screening is not the same thing as diagnosis. A counsellor may notice symptoms, document concerns, provide psychoeducation or supportive intervention within scope, and recommend further assessment. That does not turn a screening observation into a formal psychiatric or psychological diagnosis.

For HPCSA Registered Counsellors, the distinction is equally important. Their statutory scope permits psychological screening, primary mental-status screening, basic assessment and psychological interventions aimed at enhancing personal functioning, while excluding diagnostic tests. They are specifically expected to identify clients who require more advanced psychological assessment and to refer them to an appropriate professional.

For psychologists and other clinicians, ethical practice also means recognising the limits of one's own registration category, competence and experience. Registration does not make every practitioner competent to provide every form of assessment or intervention. The relevant question is not simply 'Am I a professional?' but 'Am I appropriately trained, competent and authorised to do this particular act with this particular person?'

This is consistent with the broader ethical principle that practitioners should work within their education, training, experience and competence. The safest system is therefore one in which professionals know both what they can do and when they need to stop, consult or refer.

What should referral look like?

A good referral system needs clarity on two fronts: what requires immediate escalation, and what requires a higher level of ongoing assessment or care.

• Immediate escalation: significant suicide or homicide risk, psychosis, acute behavioural disturbance, serious abuse or safeguarding concerns, severe intoxication or withdrawal, or another situation where the person's safety cannot be adequately managed within the counsellor's setting.

• Referral for advanced clinical assessment or ongoing care: symptoms that are persistent, worsening or not responding to appropriate support; significant functional impairment; suspected mental disorder requiring diagnostic clarification; complex trauma; significant substance-use concerns; or any presentation that exceeds the counsellor's training, competence or scope.

• Consultation and supervision: situations where the counsellor is uncertain about risk, scope, formulation or the appropriate next step. Ethical practice does not require a practitioner to work alone.

Referral should also be more than handing someone a telephone number and wishing them well. Where possible, the process should include an explanation to the client about why referral is recommended, informed consent for sharing relevant information, appropriate documentation, and communication with the receiving professional. Confidentiality remains central: information should be shared lawfully, ethically and only to the extent necessary, subject to applicable exceptions such as serious risk or other legal requirements.

What could this look like in practice?

Picture a simple, three-step system:

1. A counsellor provides appropriate early support — listening, psychoeducation, practical coping tools and wellness-focused intervention within their scope.

2. When the person's needs exceed that scope, the counsellor refers to the appropriate professional or service — which may include a psychologist, psychiatrist, medical practitioner, social worker, emergency service or another suitably qualified provider, depending on the need.

3. Once advanced clinical intervention has addressed the immediate or higher-level need, the person may, where appropriate and agreed by the relevant professionals, return to a counsellor for ongoing wellness and supportive care within scope.

This is particularly important in rural and under-resourced communities, where a community-based counsellor may be one of the first accessible points of contact. The solution is not to turn that first point of contact into a substitute for specialist care. It is to make that first point of contact safer, more connected and more capable of getting people to the right level of care.

Ethics should strengthen collaboration, not obstruct it.

Ethical practice is sometimes discussed as a list of restrictions — what a counsellor cannot diagnose, what a clinician cannot delegate, or when a referral is required. But the purpose of ethical standards is broader than restriction. They protect clients, clarify professional accountability and create the conditions for trust between practitioners.

For counsellors, this includes accurate representation of qualifications and professional status, working within scope and competence, maintaining appropriate records, protecting confidentiality, obtaining informed consent, using supervision appropriately, avoiding conflicts of interest and referring when a client's needs exceed one's competence or scope.

For clinicians, collaboration carries similar responsibilities. Referrals should not become a way of simply transferring responsibility. Where appropriate, clinicians should communicate relevant recommendations, respect the counsellor's defined role, and recognise that supportive and wellness-based care can remain valuable once acute risk or higher-level treatment needs have been addressed.

The goal is not for one profession to absorb the work of another. It is for professionals to understand where their responsibilities begin and end, and to make those boundaries work for the person receiving care.

Building it properly.

For this kind of collaboration to actually work, a few things need to be in place: clear maps of who is available and where; shared referral criteria; accessible supervision and professional consultation; consistent consent and documentation processes; clear expectations around information sharing; and mechanisms for reviewing whether referrals are reaching the right services and whether people are actually receiving care.

Training should also include practical knowledge of other professions' scopes. A counsellor needs to know what a psychologist, psychiatrist, doctor or social worker can offer. Clinicians need to understand what a counsellor can appropriately provide. Without this shared knowledge, referral pathways remain theoretical.

The bigger picture.

South Africa won't close its mental health gap by training more specialists alone. Nor will it do so by expanding lower-intensity services without clear safeguards. What's needed is a bigger, safer and better-connected system — one that values early support without confusing it with higher-level clinical care.

Counsellors and clinicians can each play an important part, but collaboration should be built on professional honesty: knowing what you are qualified to do, knowing what you are not qualified to do, recognising when a person's needs have changed, and making referral part of good care rather than a failure of care.

At the end of the day, it's not about who 'owns' mental health care. It's about making sure people get the right support, from the right person, at the right time — and that the system is safe enough to recognise when the right person needs to change.

References

Association for Supportive Counsellors and Holistic Practitioners. (n.d.). Designations and scope of practice.

Association for Supportive Counsellors and Holistic Practitioners. (2025). ASCHP Rules and Regulations.

Department of Health. (2023). National Mental Health Policy Framework and Strategic Plan 2023–2030. National Department of Health, Republic of South Africa.

Docrat, S., Besada, D., Cleary, S., Daviaud, E., & Lund, C. (2019). Mental health system costs, resources and constraints in South Africa: A national survey. Health Policy and Planning, 34(9), 706–719.

Health Professions Council of South Africa. (n.d.). Scope of professions and practices.

Health Professions Council of South Africa. (n.d.). Psychology: Guidelines and regulations, including the framework for Registered Counsellors.

Republic of South Africa. (2011). Health Professions Act 56 of 1974: Regulations defining the scope of the profession of psychology.

Jack, H., Wagner, R. G., Petersen, I., Thom, R., Newton, C. R., Stein, A., Kahn, K., Tollman, S., & Hofman, K. J. (2014). Closing the mental health treatment gap in South Africa: A review of costs and cost-effectiveness. Global Health Action, 7, 23431.

National Planning Commission. (2024). Mental Health Situational Analysis: South Africa.

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