Professional boundaries and the identity of counselling psychology in South Africa

The discipline of counselling psychology in South Africa has recently been perturbed by debates over professional boundaries and the identity of counselling psychologists following the newly promulgated and much contested scope of practice for psychologists (Government Gazette, 2011). These debates, articulated elsewhere (Bantjes, Kagee, & Young, in press; Young, 2013), provide an opportunity for a re-consideration of the potential role of counselling psychologists in South Africa. We begin this editorial by drawing attention to domains that have traditionally been the focus of counselling psychology. We suggest ways in which counselling psychology in South Africa might reaffirm its identity as a socially relevant and important sub-discipline which is distinct from but nonetheless overlaps significantly with other areas of professional psychology. We conclude by considering some of the factors that impede the development of the discipline.

Delineating the domains and focus of counselling psychology

A large body of international literature describes three overlapping domains of practice that have historically defined counselling psychology: (1) enhancing human development and potential, including career development, empowerment, and assisting those who are negotiating major life transitions; (2) intervening to prevent psychological problems, reduce the negative impact of these problems, and/or promote health and well-being (Romano & Hage, 2000); and (3) alleviating emotional distress and symptoms of psychopathology, especially those that affect the large majority of people who exist on the mild-to-moderate part of the spectrum of psychopathology and who do not require inpatient psychiatric care. Such a tripartite delineation of the discipline of counselling psychology is not new; counselling psychology has been defined in this way for nearly 50 years (Jordan, Myers, Layton, & Morgan, 1968).

Traditionally counselling psychology has centred itself on humanistic values and focused on interventions which promote development, enhance psychological well-being, and prevent psychopathology. A philosophical orientation towards person-centred approaches that focus on health, development, and empowerment has informed the practice of counselling psychology in a wide and varied range of clinical and non-clinical settings. This orientation has resulted in approaches that acknowledge the therapeutic potency of relationships, emphasise people's strengths and well-being, and acknowledge the importance of socio-cultural, political, and developmental contexts. Consistent with this orientation is counselling psychology's tradition of valuing diversity, embracing multiculturalism, promoting social justice, and attending to the impact of socio-political and economic factors on the lives of individuals (Packard, 2009; Young, 2013). The sub-discipline of counselling psychology has much in common with other branches of psychology, most notably developmental, social, critical, community, clinical, and health psychology.

The skills and knowledge acquired by counselling psychologists through their training positions them well to offer individual and group psychotherapy in a range of settings in order to help people negotiate problems of living, alleviate symptoms of psychological distress, and restore psychological health. Evidence of such activities is found in the large number of counselling psychologists working in private practice and university counselling centres in South Africa offering psychotherapy to individuals exhibiting symptoms of psychopathology (Goodyear et al., in press). Beyond the focus on alleviating symptoms, counselling psychology's emphasis on humanistic values, development, prevention, and remediation positions the profession well, although not exclusively so, to make important contributions to the psychosocial needs of individuals and communities, particularly in the areas of social justice work, health psychology, and community-based public health interventions.

Social justice

Through most of its history, counselling psychology internationally has had a social justice agenda and has worked towards creating a just society by challenging injustice, discrimination, and inequality. This agenda is an inevitable extension of the discipline's humanistic orientation and its explicit acknowledgment of the importance of socio-cultural and political context in promoting well-being (Vera & Speight, 2003). However, the potential for counselling psychology to adopt an overt social justice agenda in South Africa remains largely unrealised (Leach, Akhurst, & Basson, 2003). This criticism echoes calls in the United States from critical, community, and liberation psychologists for counselling psychologists to reclaim a social advocacy agenda and to make social justice work integral to their practice (Ivey & Collins, 2003).

Perhaps the surest way for counselling psychology to give impetus to the social justice agenda in South Africa would be to orientate research, advocacy, and therapeutic efforts towards the issues and challenges of disempowered groups and those who have hitherto largely been neglected by applied psychology. These groups include individuals who are socially and economically marginalised, those who have been oppressed and disadvantaged by colonialism and apartheid, and those who are not adequately catered for by the overburdened and under-resourced national health system. Assuming such a role would force counselling psychologists to turn their attention to issues such as institutionalised racism, sexism, homophobia, transphobia, and disablism, which account for much of the inequitable experiences of black, female, gay, gender queer, and disabled people in South Africa. Immigrants and refugees are obvious further examples of people who fall into this category of neglect and who could benefit from the attention of counselling psychologists (Bantjes et al., in press).

Working with marginalised groups will inevitably prompt counselling psychology to confront diversity and multiculturalism. While the importance of culture and context is undeniable, discourses of multiculturalism need to be engaged with critically and with due regard for issues of intersectionality, universality, and globalisation.

Diversity, multiculturalism, and intersectionality

Critics have called attention to the ways in which counselling psychology has been strongly influenced by American ideology and has drawn primarily on theoretical models developed for wealthy White Western individuals (Painter & Terre Blanche, 2004). Counselling psychologists have consequently been prompted to engage actively with the indigenisation of counselling theory and practice in South Africa (Stead & Watson, 2006). These criticisms are not unique to South Africa, and similar arguments in other parts of the world have resulted in counselling psychology embracing multiculturalism as a ‘fourth force’ within psychological practice.

While we acknowledge the need for culturally salient psychological interventions, we refute the assumption that what has been referred to as an ‘African worldview’ is uniquely different from a non-African worldview. We caution against an essentialising view of culture that seeks to construct non-Western cultural practices as exotic and mysterious. Essentialising African culture discounts the fluidity and diversity of African beliefs, ways of being, and cultural practices, while simultaneously denying the ways in which African customs and ways of life might overlap with those of people in other parts of the world, including the post-industrial Western societies. Globalisation has seen to it that many countries in the Global South probably share more cultural currency with the Global North than is usually considered. It is within this complex hybrid cultural space, that straddles ‘western’ and ‘African’ cultures, that counselling psychologist in South Africa have to find a way to work.

Moving beyond multicultural discourses will allow counselling psychology to acknowledge intersectionality, that is, the interconnected nature of social categories and ways in which systems of oppression overlap and re-enforce one another. Intersectionality highlights the ways in which individual experiences are shaped by multiple intersecting identities and refutes the idea that social issues such as sexism and racism can be dealt with in isolation. The implicit challenge is for counselling psychologists to acknowledge the ways in which diverse human experiences are interrelated and inextricably connected by macro-level structures and forces that supersede cultural identities such as race, ethnicity, religion, gender, and sexual orientation. Furthermore, intersectionality prompts counselling psychologists to think critically about how any individual's experiences are shaped by their multiple identities and various social roles.

Health psychology

Counselling psychology, with its traditional emphasis on health promotion, is well positioned to make meaningful contributions at the interface between health, medicine, and psychology. The work of health psychology has particular salience in the context of the considerable burden of communicable and non-communicable diseases, as well as the disturbingly high incidence of interpersonal violence and injury related morbidity and mortality in South Africa. Claiming health psychology as an integral component of counselling psychology would open possibilities for the profession to work in medical settings and address important issues such as the relationship between lifestyle and illness, adherence to treatment, chronic pain, disability, and adjustment to chronic illness. An obvious extension of this would be for counselling psychologists in South Africa to expand their work in the field of sport and exercise psychology, especially as this relates to health promoting physical activity.

The work of health psychology has particular importance in low resource medical settings since it has been well established that attending to people's psychological needs improves their adherence to medical treatment and leads to improved health outcomes (Dalessandro et al., 2007; Nel & Kagee, 2013; Turner, Laine, Cosler, & Hauck, 2003). In spite of this, integrating psychosocial services into medical care in many countries in the global South has been slow and uneven (Freeman, Patel, Collins, & Bertolote, 2005).

Counselling psychologists have an important role to play in the health care system and a meaningful contribution to make in general medical settings in South Africa. This is a role that needs to be expanded and embraced, particularly in the absence of a clear tradition of health psychology in the country. The profession's scope of practice seems to place health psychology firmly within the domain of counselling psychology and opens the way for the profession to claim space in the health care system. Yet, paradoxically, no posts currently exist for counselling psychologists within the public health system, which is an issue requiring urgent attention.

Community and public health interventions

Counselling psychology, with its emphasis on understanding people within their socio-political, economic, and developmental contexts, is well positioned to play a role in public health by planning, implementing, and evaluating programmes that seek to address psychosocial problems at a community level. South Africa's need for community and public health interventions informed by sound psychological theory and empirical evidence is obvious given the country's high rates of inter-personal and gender-based violence, childhood physical abuse, road traffic accidents, industrial accidents, burns (Edwards, 2005), psychological trauma (Williams et al., 2007), widespread substance abuse (Seedat et al., 2009), and high rates of suicide (Bantjes & Kagee, 2013). The unmitigated psychological trauma caused by these social problems does much to disrupt individuals' lives by disturbing inter-personal relationships, precipitating psychopathology, promoting substance abuse, and causing poor physical health. The implications for counselling psychologists are twofold: one is to produce research and influence policy that addresses endemic social problems, and the other is to undertake interventions that seek to address both the causes and consequences of these social problems.

Counselling psychologists have another important public health contribution to make by vociferously advocating to displace the primacy of biological models of psychopathology. Work is needed to highlight the limitations of traditional bio-medical models and how these understandings of psychopathology divert attention away from the impact of social conditions and the role of the state (Boyle, 2006). The challenge for counselling psychology is to develop psychological interventions and models of psychotherapy that better emphasise socio-political contexts.

Funding the work of counselling psychology

There is an inherent tension in what we have proposed about expanding the role of counselling psychology beyond the consulting room, as it raises questions about who should and will pay for counselling psychologists to do social justice and community-based public health work. To propose that counselling psychologists should provide services to the poorest and most marginalised members of society is to suggest that the profession should take on the state's work of economic redistribution (i.e., the transfer of resources in the form of psychological care from the haves to the have-nots). Furthermore, much of what we propose here to be the labour of counselling psychology (i.e., social justice work, health psychology, and community-based public health interventions) will produce a combination of merit and public goods that have widespread social benefits beyond their market value. Merit goods, first described by Musgrave (1957), are goods and services that have broad social benefits beyond the benefits that accrue to the individuals who directly consume them, for example, vaccines. Merit goods are judged to be beneficial to society at large, and it is thus argued that they should be provided by the state to individuals on the basis of need rather than on the basis of an individual's ability to pay for them. Public goods (also sometimes called collective goods) were first described by Samuelson (1954) as goods ‘which all enjoy in common in the sense that each individual's consumption of such a good leads to no subtractions from any other individual's consumption of that good’ (p. 387). The nature of public goods is such that they have no market value as once provided individuals cannot be prevented from consuming them. It falls to the state within a free market economy to provide public goods and subsidise merit goods, and to finance their provision through taxes.

What we have proposed for counselling psychology in South Africa can only happen on a grand scale in one of two ways. The first option is for the state to recognise how the labour of counselling psychologists may create public and merit goods that will need to be funded by creating posts for these professionals within the public sector. Alternatively, counselling psychology can only assume its full role in South Africa if the country shifts from a capitalist market orientated economy to one that is organised on socialist principles. The shifts that such an economic revolution would bring within the health care system and the accompanying changes it would precipitate in state spending on social services would inevitably open space in public service for counselling psychologists.

Conclusion

Counselling psychology in South Africa is well poised to make a meaningful contribution to the mental health care needs of the country. Its philosophical orientation and the traditional areas of focus within the discipline allow for its practitioners to extend their reach beyond the consulting room and adopt advocacy roles, engage in community interventions, become integrally involved in policy formation, and actively work to change oppressive socio-political and economic structures that have a negative impact on psychological well-being. Counselling psychology in South Africa will, however, only be able to grow fully into this role through the provision of public money for this work. In the absence of state-funded posts, most counselling psychologists will be confined to providing psychotherapy to that small group of individuals in South Africa who can afford private care. Such a situation will exacerbate petty squabbles about professional boundaries between sub- disciplines in psychology and aggravate turf wars between psychologists in private practice who contest each other's right to do psychotherapeutic work in order to protect their income in a small and saturated market.