South Africa Can't Keep Up: Why We Need More Counsellors

Think of four people you know who are struggling with their mental health. When South Africa last measured this across the country, three of them would have received no treatment at all. The South African Stress and Health study found that only about one in four people with a mental health condition got any treatment in a year (Seedat et al., 2008). That survey was done in 2002–04, and more recent estimates are no more encouraging. For people without medical aid, a 2019 national study found that closer to nine in ten go without the care they need (South African Health Review, 2024).

This is not because South Africa's psychologists, psychiatrists, nurses and counsellors aren't trying. They work under enormous pressure. The problem is size. The need is huge, the resources are limited, and the gap between the two is where people get lost.

The size of the need

In the national survey done in 2002–04, nearly one in three South African adults had had a common mental health condition, such as depression, anxiety or a problem with alcohol or drugs, at some point in their lives (SA Medical Journal, 2009). Yet only about 15.5% of people have medical aid (Stats SA, 2025), so most depend on public clinics and hospitals, which are already stretched. Mental health gets about 5% of the public health budget, and 86% of that goes to caring for patients in hospital. That leaves very little for support in local communities, which is where most people first need it. In rural public clinics, there's less than half a clinical psychologist for every 100,000 people (South African Health Review, 2024).

Training more specialists is part of the answer, but it's slow. Becoming a clinical psychologist takes at least seven years of study, a supervised internship and community service. Because every trainee needs close supervision, there are few training places. Those standards exist for good reason: they protect the public. But even if training places doubled tomorrow, the extra psychologists would still take years to qualify. The people struggling now can't wait that long.

More hands, held to clear standards

The most realistic way to close the gap is to widen the circle of people who can offer support, working alongside specialists rather than replacing them. That circle includes Registered Counsellors (HPCSA-registered professionals trained for short-term counselling), social workers, nurses, community counsellors at clinics and NGOs, and well-trained counsellors who belong to a professional body. Their role isn't to diagnose or treat mental illness. It's to listen early, help people learn ways of coping before problems grow, notice warning signs, and refer people to specialist care when they need it.

There is strong evidence that this works. In Zimbabwe's Friendship Bench programme, trained and supervised community members offered up to six structured support sessions on wooden benches outside local clinics. Six months later, only 14% of the people they supported still had significant symptoms of depression, compared with 50% in the comparison group, who received enhanced usual care (JAMA, 2016). And it isn't a one-off: a 2021 review of studies on lay counsellors (community members trained to give support) backs this approach (Connolly et al., 2021). The bench itself wasn't the secret; the training, supervision and clear routes for referral behind it were. More counsellors without standards would simply create a different kind of gap.

The risk in the gap

South African law protects psychology closely. Only people registered with the Health Professions Council of South Africa (HPCSA), the official body that registers health professionals, may call themselves psychologists or Registered Counsellors. The law also keeps psychotherapy, hypnotherapy and psychological testing, among other work, for registered psychology professionals only (Government regulations, 2008). Counselling outside psychology is different. Words like "counsellor", "therapist" and "life coach" are open titles that anyone may use, with no required qualification, supervision or code of conduct.

That means someone with only a short online course can present themselves as a therapist. Calling yourself a psychologist without HPCSA registration is a crime. Calling yourself a therapist isn't, and that's exactly the problem. The people most at risk are those with the fewest options: someone in distress, without medical aid, who has no way of telling a trained counsellor from an untrained one.

This is the gap HICS was set up to help close. We're a voluntary, independent professional body, not a regulator set up by law, and HICS membership isn't HPCSA registration. We set clear standards that counsellors must meet before they're admitted, help members understand which titles they may use and which work belongs to psychology, hold members to a code of conduct, with a public complaints process to come, and will list them, with their consent, in a public directory. Counselling associations in the United Kingdom (BACP) and Australia (ACA) already work this way. We can't police everyone who calls themselves a counsellor. We will be able to give the public a reliable way to find those who have met a standard.

Before you book

If you're looking for support for yourself or someone close to you, a few simple questions go a long way. Start by asking their title. A psychologist or Registered Counsellor should appear on the HPCSA's free online register, the iRegister, where you can search their name. A counsellor should be able to tell you which professional body they belong to, so you can check its directory. Ask where they trained and who supervises their work, and ask what they would do if you needed more help than they can give. A good counsellor knows where their help ends and will be ready to tell you who they would refer you to. If you're looking for help for a child or teenager, also ask how they work with young people and how they'll involve you as a parent.

Some help can only come from a registered professional. If you need psychotherapy, hypnotherapy or a diagnosis, it's important, and important to us, that the person helping you is registered with the HPCSA. Registration means they have the qualifications the law requires, they answer to the HPCSA for how they work, and they must follow its ethical rules. That's why the law keeps this work for registered professionals, and why you can always check their name on the iRegister.

If something doesn't feel right, you're free to stop. Once HICS opens its route for concerns, you will be able to raise a concern about a HICS member, and you can report a registered practitioner to the HPCSA. And if you're not sure where to start, your GP, your local clinic or SADAG can point you in the right direction, including towards free support.

South Africa will need more counsellors for many years to come. The question is whether they'll be trained, supervised and accountable. That's the standard we hold our members to, and the one every person looking for help deserves.