Abstract
This study employed an intersectional framework to examine how Registered Counsellors (RCs) in South Africa’s public primary health care sector perceive their professional identities and practices. Guided by a constructivist paradigm, and features of a collective autoethnographic approach, the study adopted a reflexive thematic analysis approach to examine the written narratives of three RCs. Two Clinical Psychologists initially analysed the data, deriving themes; thereafter, the RC participant-authors reviewed the identified themes to assess resonance and credibility. The analysis explored how intersecting domains of identity shaped RCs’ experiences within the communities they served. Four themes were identified: (1) Negotiating Authority and Otherness in Public Mental Health, (2) RC Participants Engaging with Cultural Variability, (3) RC Participants Carrying the Weight of Mental Health in South Africa and (4) RC Participants Learning to Manage the Emotional Weight of their Role. The findings demonstrate how overlapping identities such as race, gender and culture influence RCs’ perceptions of professional practice, client relationships and approaches to cultural competence. Structural and social inequities further shape how RCs manage emotional and relational labour in under-resourced contexts. RCs negotiate tensions between similarity and difference, balancing cultural awareness with professional responsibility while bearing the emotional weight of community trauma and inequality. Reflexivity emerges as a socially and politically charged process embedded within unequal systems. Intersectional reflexivity enables RCs to challenge hierarchies and provide culturally responsive care. By foregrounding RCs’ relational experiences, this article highlights the transformative potential of identity-conscious mental health care practice in post-apartheid South Africa.
Keywords
Mental health (MH) disorders account for a substantial portion of South Africa’s disease burden (Herman et al., 2009; Kessler et al., 2007), with over a quarter of the population experiencing moderate to severe depression (Craig et al., 2022). This is driven by intersecting factors, including violence, trauma, poverty, unemployment, HIV/AIDS and the enduring effects of inequality and South Africa’s sociopolitical history (De Kock & Pillay, 2016; Nguse & Wassenaar, 2021). Most individuals with MH conditions do not receive treatment and fewer than one in ten access necessary care (Docrat et al., 2019; Sorsdahl et al., 2021).
South Africa’s history, from colonial rule through apartheid to the present-day ‘rainbow nation’, continues to shape the country’s social fabric (Mokoena, 2019). Racialised governance, gendered social roles and class distinctions have profoundly influenced the development of MH services and the field of psychology (Bantjes et al., 2017; Letsoalo et al., 2024).
The National Mental Health Policy Framework and Strategic Plan 2023–2030 acknowledge this historical context and call for sustained investment in education, training and institutional reform to strengthen the MH system (Department of Health, South Africa, 2023; Harriman et al., 2022). Despite these efforts, South Africa’s health care system remains deeply unequal, with over 80% of the population reliant on under-resourced public services, mostly accessed through Primary Health Care (PHC) services (Sorsdahl et al., 2021; Statistics South Africa, 2022). Effective integration of MH services into PHC is therefore crucial, though underfunding continues to limit trained personnel and resources (Patel et al., 2013).
To address the shortage of specialist MH providers and promote MH integration into PHC spaces, a task-shifting approach was adopted to transfer selected responsibilities from specialists to non-specialist health workers (Nyatsanza et al., 2016). The Health Professions Council of South Africa (HPCSA) established the RC category to form part of this initiative, creating a mid-level MH workforce to deliver preventive and community-based psychological services (HPCSA, 2022).
Although the RC category was introduced nearly 25 years ago, empirical research on their function remains limited. Most RCs work in private practice due to scarce public sector opportunities that are exacerbated by austerity measures and hiring moratoria (Fisher, 2017; Senkubuge et al., 2025). Pillay (2016) regards this as a missed opportunity, given RCs’ potential to strengthen the national MH system. The lack of empirical evidence on the long-term outcomes of RC interventions further hampers advocacy for their integration into public health structures and budgets (Joubert & Hay, 2020), while many RCs report feeling undervalued and unacknowledged as MH professionals in private practice (Salt et al., 2024).
Despite this context, no studies have explicitly applied an intersectional lens to examine how RCs’ multiple identities and professional roles interact with structural and historical factors within South Africa’s public PHC settings. Some research implicitly addresses intersectional dynamics by exploring how race, class, gender, geography and professional identity influence RCs’ experiences in PHC contexts. For instance, Salt et al. (2024) discuss the challenges faced by RCs in private practice, highlighting issues related to recognition and professional identity, which intersect with broader social determinants.
This study bridges the gap by connecting the identified need for empirical insight into RC professional experiences with an explicit intersectional framework. By examining how overlapping identities and structural factors intersect in shaping practice, the study links theory, historical context and the RCs’ lived experiences. Such research can inform policy development, training and the integration of RCs into public health frameworks.
Intersectionality and MH practice in South Africa
Intersectionality examines how socially constructed domains of identity, such as race, gender, class, ethnicity, sexual orientation, language and socio-economic status, interact to shape experiences of privilege and oppression within systems of power (Crenshaw, 1989). These domains function as intersecting ‘axes’ along which social inequalities are structured, producing distinct configurations of advantage and/or disadvantage. Bhana (2014) critically notes that examining these domains in isolation oversimplifies the complexity of lived experiences. While constructs such as race, gender and class are socially produced, their effects are materially real, influencing access to resources, exposure to discrimination and everyday life conditions (Brewer et al., 2002).
Building on this conceptual foundation, an intersectional lens is particularly valuable for research in South Africa, as it helps illuminate how structural and historical forces sustain contemporary inequities. Studies by De Jong et al. (2021) and Isaacs (2024) show that overlapping identities – such as race, class, gender and structural inequalities – shape access to mental health services. Burgess et al. (2025) emphasise that intersectional discrimination and exclusion within sociopolitical and institutional contexts affect service access, further underscoring the importance of examining these dynamics in MH care. Informed by these insights, this article explicitly applies an intersectional framework alongside a constructivist approach to analyse the lived experiences of three RCs in low-income South African PHC settings, demonstrating how their professional identities and social positions intersect with systemic factors to shape practice.
Method
Participants
This article examines the written reflections of three RCs employed full-time by the Western Cape Department of Health and Wellness (WCDoHW) as part of an initiative to improve mental health services in under-resourced community clinics that primarily serve Black and Coloured communities. All RCs employed by the WCDoHW were invited to participate; however, only a few responded and three submitted written narratives. Those who opted to participate were given minimal prompting other than to consider their positionality from an intersectional standpoint when writing their reflection (Table 1).
Demographic of the RC-Authors (N = 3) and Psychologist-Authors (N = 2).
Procedure and instruments
An intersectional theoretical frame underpinned the examination of the RC-Authors’ written anecdotes to gain insight into the complex and intersecting social dynamics involved in counselling in South Africa (Crenshaw, 1989). The study employed core elements of a collective autoethnographic approach to explore the way that subjectivity is shaped through relationships and social contexts (Karalis Noel et al., 2023; Visse & Niemeijer, 2016). Situated within a constructivist epistemology and grounded in broader autoethnographic traditions (Klevan et al., 2021), the study emphasised that knowledge is co-constructed (Moalusi, 2020). Primarily, the analysis was conducted by the Psychologist-Authors; however, there was constant engagement with the RC-authors during this process to promote reflexivity. Guided by systematic textual analysis methods (Braun & Clarke, 2023; Kuckartz, 2019) and considering the significance of reflexivity that is characteristic of this type of research (Braun & Clarke, 2019), the hybrid methodology employed in this study effectively linked personal experiences to broader relational and socio-cultural contexts.
Reflexive thematic analysis (Braun & Clarke, 2019, 2023) was used by Psychologist-Authors 1 and 2 to identify themes; thereafter, the Psychologist-Authors engaged with the RC-Authors to evaluate the appropriateness of the themes. This participatory approach fostered authentic representation of the participants’ experiences, and minimised misinterpretation (Greenhalgh et al., 2016; Lappeman et al., 2021). The process of reflexive thematic analysis relied on reciprocal dialogue to support a truly collaborative, reflexive inquiry.
Consideration of positionality naturally extended to the Psychologist-Authors. As female Clinical Psychologists working within South Africa’s public health context, the Psychologist-Authors’ professional experiences and training shaped their engagement with and interpretation of the data. Reflexivity was maintained throughout the analysis by means of regularly engaging with the RC-Authors and writing personal journal reflections to remain mindful of the way that positionality intersects with the research process, and to recognise the findings as co-created through reciprocal interaction with the data. The RC-Authors’ written narratives were reviewed multiple times, and regular discussions were had to review coding decisions, reflect on interpretations and identify potential biases (Braun & Clarke, 2023). Both Psychologist-Authors observed that their own experiences mirrored the emotional and practical challenges faced by MH practitioners working in similar community settings.
Ethical considerations
This article contributes to a larger study on RC services in the Western Cape Metropole. Ethical clearance was granted by the University of Cape Town (REC-575/2023), the Western Cape Department of Health (WC_202211_034) and the participant-authors were purposively sampled via email. The RC participants were prompted to write a brief reflection of their experience as an RC working in public PHC, with particular focus on their positionality and the intersectional dimensions of their identity. All of the RCs in the metropole were invited to participate, with there being no negative consequence for declining participation. Given that the authors are colleagues, confidentiality, reflexivity and non-judgement were cornerstones of engagement during the data collection, analysis and revision processes. None of the authors held direct supervisory positions over one another during the development of this article; however, the authors were mindful of implicit professional hierarchies related to role designation and years of experience and observed how these dynamics may have shaped participation and interpretation.
Findings
The presented themes were developed using Braun and Clarke’s (2019, 2023) reflexive thematic analysis within a constructivist epistemology. They reflect patterns across the RC-authors’ unique experiences, rather than generalised claims about all RCs. The four analytic themes are: (1) Negotiating Authority and Otherness in Public Mental Health; (2) RC Participants Engaging with Cultural Variability; (3) RC Participants Carrying the Weight of Mental Health in South Africa; and (4) RC Participants Learning to Manage the Emotional Weight of Their Role.
Negotiating authority and otherness in public mental health
This theme captures how these RCs navigate professional authority and social identity in client interactions, reflecting the unique experiences of the participants. They described how race, gender and professional roles shaped client perceptions and engagement, revealing tensions between belonging, representation and otherness.
RC-Author 2 engages on stigma and representation:
My presence as an African Black male in this field has exposed me to crucial role of shifting a lot stigmatized topics amongst especially to men who think MH means one is weak. [And] has presented an opportunity for advocacy and leadership in diversifying the profession making MH relatable.
RC-Author 3 on understanding community needs:
[I] stand out as an isiXhosa male counsellor . . . it was also a way for [me] to understand the unique needs of people from [my] community.
RC-Author 1 on perceptions of race:
One patient even expressed relief upon discovering I was White, believing this would ensure a ‘better service’.
RC-Author 1 on otherness and gender:
I’ve been called many names by patients. ‘Snow White’. . .. and in predominantly Black communities, I’ve been called ‘nana’ or ‘Umlungu’. . .. Despite my modest work attire, I was met with catcalls. . . I quickly became aware of how other’ I was perceived–both as an outsider and, in some ways, as desirable.
Across these narratives, RCs actively negotiate the effects of their identities on professional relationships. Black male RCs leverage shared racial and cultural identity to build rapport and address stigma, while the White female RC reflects on how her race and gender intersect to confer both authority and otherness. These patterns highlight how social identity shapes professional practice within the historically racialised and gendered public mental health context.
RC participants engaging with cultural variability
This theme captures how RCs engage with cultural variability, balancing shared identity and perceived otherness to build trust and rapport. Participants described how race, language, tradition and religion shaped client interactions and therapeutic engagement.
RC-Author 2 on counselling shaped by cultural understanding:
[My] experiences have shaped [my] counselling approach, emphasizing the importance of cultural understanding in therapy. This focus enables [me] to connect deeply with individuals, building trust and rapport.
RC-Author 3 on how shared identity fosters rapport:
Black and Coloured communities feel more comfortable speaking to me as I am able to understand their cultural background.
RC-Author 1 on otherness:
Coloured and Black patients often assume that, because I’m White, I won’t understand certain cultural or religious concepts. This leads them to overexplain practices like ‘Ulwaluko’ . . . or ‘making Salah’ . . . prioritising my understanding over their own expression.
RC-Author 1 on rapport despite differences:
I have been surprised when patients choose to continue counselling in English with me, a White woman, who has less understanding of their culture and who cannot communicate in their mother tongue. . . Perhaps my ‘otherness’ is an asset in these cases?
Across these narratives, RCs demonstrate that engaging with cultural variability involves negotiating sameness and otherness, using knowledge of tradition, language and religion to engage clients effectively. The patterns illustrate how intersectional identities shape therapeutic relationships, highlighting the relational complexity of providing culturally responsive mental health care in South Africa.
RC participants carrying the weight of mental health in South Africa
This theme captures how RCs experience the multifaceted burden of mental health work in under-resourced communities, reflecting how social, historical and systemic factors intersect in South Africa. Participants described how clients’ hardships often extend beyond mental health, shaping therapeutic engagement and amplifying emotional strain.
RC-Author 1 on client hardships:
A recurring theme in sessions is that of ‘not having’ – not having money, not having support, not having safety, not having education, not having employment, not having hope . . . . I’ve learned that skills, techniques, and coping strategies that are effective in counselling where privilege is present, not poverty, are not always useful in the communities where I work.
RC-Author 2 on emotional burden of community context:
The focus in PHC is always on the patient, who are dealing and going through hardships and challenges of life, which at some point feels like there is no way out and feeling hopeless leading to emotional instability and wanting to give up. . .it has been a challenge in reaching or interacting with other communities due to gangsters, shootings and robberies, which makes it difficult to educate and equip them to help themselves for better good.
Across these narratives, RCs describe a heavy emotional burden shaped by the ways clients’ social realities intersect with systemic constraints. Crises such as poverty and violence shift counselling from therapy to coping, illustrating how these structural and social factors coalesce to amplify the demands of mental health work.
RC participants learning to manage the emotional weight of their role
This theme captures how RCs actively develop strategies to manage the emotional impact of their work in communities with high levels of need. Participants reflected on coping mechanisms, self-care and professional practices that help sustain their engagement.
RC-Author 1 on navigating privilege and client realities:
I realised that I had spent more on one meal than my patients receive in their SASSA Grant each month. It is hard to consolidate the two worlds . . . Listening to the six to eight traumatic stories in sessions with patients each day is a heavy weight that I don’t feel is thoroughly understood by people who are not in the profession.
RC-Author 2 on managing emotional strain:
This has been one of the more emotionally challenging aspects of my work. Learning how to manage the emotional weight of these situations, while still providing effective care . . . I have been involving myself in physical activities to manage the emotional toll.
Across these accounts, RCs develop personal and professional strategies to navigate the emotional demands of their role. The narratives highlight that emotional labour in mental health practice is inseparable from clients’ social realities, and resilience involves negotiating both personal identity and professional responsibility, as these experiences intersect to shape their professional practice.
Discussion
The article aimed to examine how intersecting identities shape RCs’ professional practice and experiences in PHC settings. Guided by an intersectional and constructivist framework, the discussion draws on the situated narratives of participating RC-authors, interpreting the findings through this lens to demonstrate how the interplay between history and identity—mediated by race, gender, language and culture—shapes professional identity and emotional labour in the communities they serve. This analysis provides valuable insight into RCs’ perspectives, how they navigate public mental health services in South Africa, and manage the emotional demands of their work. Of note, the themes identified reflect the unique experiences of these RC-authors and are not intended to be generalised to all RCs working in public health settings. The RC-authors’ narratives are presented not as separate descriptive accounts, but as the empirical foundation through which the complexity of professional practice in South Africa’s public mental health sector is understood. Overall, the study contributes important knowledge to the underexplored area of RCs’ experiences in the public sector.
The first theme, Negotiating Authority and Otherness in Public Mental Health, reflects how RC-authors experience and negotiate representation, authority and relational hierarchies in their professional practice. The two Black male RCs described a sense of shared identity and responsibility with clients, using their race, gender and culture to build rapport. RC-Author 2 noted that his presence as an African Black male may encourage other men to seek mental health support, reflecting how intersecting identities-race, gender and culture-operate relationally within historically gendered and racialised mental health systems to shape both client engagement and therapeutic dynamics (Masemola et al., 2022; Ratele, 2014).
These experiences align with existing research on Black male mental health practitioners in South Africa. For example, drama therapists trained through Wits University’s Drama for Life programme report that racial and gender representation enhances inclusivity and cultural relevance, helping clients feel understood, build rapport and express emotional vulnerability (Bome, 2022). Hammond and Mattis (2025) highlight how Black male therapists can challenge racial and gender norms, model vulnerability and leverage cultural competence to bridge understanding gaps. Integrating the RC-authors’ narratives with this literature underscores how intersecting identities are not just descriptive characteristics but actively shape relational dynamics, therapeutic processes and professional practice.
The second theme, RC Participants Engaging with Cultural Variability, reflects how RC-authors navigate differences in language, culture and social norms in their interactions with clients. A central aspect of RC-Author 1’s narrative is the experience of otherness, demonstrated by clients referring to her as ‘umlungu’ (‘white person’), a term in South Africa that carries historical connotations of authority and privilege (Fanon, 1952/1967; Hurst, 2023). Although the term may be used respectfully, it holds an ambivalent meaning–both acknowledging the practitioner and simultaneously reinforcing her otherness and underlying power imbalances. RC-Author 1’s experience highlights the convergence of her racial identity, professional role and positionality within South Africa’s colonial legacy, shaping how clients perceive and engage with her.
RC-Author 1 also narrates her concern about not speaking an African language. Hagan et al. (2020) argue that language significantly affects MH care quality, emphasising the need for improved services in South Africa. Yet, RC-Author 1 notes that many mental health care users choose to continue counselling with her despite language barriers, underscoring the complexity of rapport-building beyond shared language and sameness. This suggests that cultural competence, reflexivity and relational attunement may mitigate linguistic difference. Intersectionally, language here interacts with race, power and professional identity rather than functioning as an isolated variable.
The third theme, RC Participants Carrying the Weight of Mental Health in South Africa, reflects how RCs experience systemic pressures, resource constraints and the social burden of working in under-resourced public mental health contexts. Research has shown that doctors and nurses experience significant strain and exhaustion due to limited resources, poverty and violence in primary MH settings (Purbrick et al., 2024; Tununu & Martin, 2020). Human et al. (2023) explained that overburdened health care environments and exposure to trauma exacerbate practitioners’ emotional strain. Viewed through an intersectional lens, these burdens are not solely individual but emerge at the intersection of structural constraints, social inequality and professional expectations, shaping both practitioners’ well-being and their clinical practice.
The fourth theme, RC Participants Learning to Manage the Emotional Weight of their Role, reflects how RCs develop strategies to cope with the psychological demands of their work. Salt et al. (2024) found that RCs operating in private practice often reported feeling unacknowledged as MH professionals. In contrast, the RCs in this study did not reflect the same sentiment. This distinction may reflect differences in structural and systemic conditions between the public and private sectors. For example, in public settings, RCs are more integrated into multidisciplinary teams; these contextual differences highlight how structural location intersects with professional identity to shape experiences of recognition and legitimacy, and how support systems within teams may facilitate emotional management.
The study’s findings highlight how RCs’ intersecting identities and the structural and social contexts in which they work are central to understanding their professional identity, practice and relational experiences of mental health care delivery. While these findings provide valuable insight into the experiences of the participating RC-authors, they are limited to this context and sample, and further work could examine how intersecting identities shape RC practice across other settings.
Conclusion, limitations and recommendations for future research
This study offers valuable insights into how intersecting identities-race, gender, language, culture and professional role-shape the experiences and practice of RCs in South Africa’s public PHC system. A key strength of the study is the inclusion of two Black male RCs, offering perspectives from an underrepresented demographic in the mental health space. Collaborative analysis by two mental health professionals, who are familiar with working in similarly under-resourced communities, ensured a nuanced and informed interpretation of the narratives.
Several limitations should be considered. First, the small purposive sample of three RCs limits generalisability across diverse provinces and health care contexts. Second, reliance on self-selected participants may have introduced bias, with more reflective or motivated individuals disproportionately represented. Third, the exclusive use of written narratives, coupled with participants’ selective narration, may impact the richness and authenticity of the data. In addition, the co-constructed nature of the analysis, shaped by the researchers’ positionality and theoretical lens and the focus on Western Cape clinics, may limit transferability to other regions and contexts. Finally, findings reflect a temporal snapshot in a rapidly evolving mental health policy landscape, which may affect relevance over time.
Recommendations for future research build directly on the findings. Larger, more diverse samples of RCs across multiple provinces, including urban and rural settings and the use of a variety of qualitative methods (e.g. interviews and focus groups) would produce richer, more contextually grounded data. Future studies could also explore how RCs’ intersecting identities influence client engagement and therapeutic dynamics across different public mental health settings, including further examination of the impact of Black male mental health practitioners in South Africa.
In conclusion, the findings highlight the importance of attending to intersecting identities and structural contexts in understanding RCs’ professional practice, relational dynamics and emotional labour. This underscores the value of intersectional analyses for informing future research, policy and context-sensitive interventions in South African mental health care, while remaining grounded in the lived experiences of RCs.
Footnotes
Ethical Considerations
This article contributes to a larger study on registered counselling services in the Cape Metropole. Ethical clearance was granted by the University of Cape Town (REC-575/2023) and the Western Cape Department of Health (WC_202211_034).
Consent to Participate
Verbal informed consent for participation in this study was obtained from all individuals involved. The participants were also co-authors of this article and were actively engaged throughout the research process.
Consent for Publication
Verbal informed consent for publication of this study was obtained from all participatnt-authors.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Data Availability Statement
Due to the personal and reflective nature of this autoethnographic research, no underlying data are publicly available. All relevant information is contained within the article.