Registered Containment Officers; A Grassroots-Level Mental Health Framework for South Africa

Dylan Grant Anthony Benyon*

Founder, Cognition & Co, South Africa

*Corresponding Author:Dylan Grant Anthony Benyon, Founder, Cognition & Co, South Africa.

Received: January 19, 2021; Published: April 30, 2021;

Introduction

  In January 2020, I had travelled to Hong Kong with the aim of finding employment in higher education. Unfortunately, my trip was cut short due to the spread of the COVID-19 virus. Shortly after Chinese New Year, I had no option but to return to South Africa in an attempt to distance myself from what would become a global pandemic.

  At this time, Hong Kong had stringent rules in place regarding personal protective equipment, and when I left the country I was given a number of face masks to wear during my travels. When I landed in South Africa, I decided that I would keep wearing a mask until I was back in my own home where I could begin the self-quarantining process. Upon boarding a flight from Johannesburg to Port Elizabeth, I was met with skeptical glances of concern and fear. As I found my seat, the gentleman I was to sit next to appeared extremely uncomfortable and did his best to look for another seat.

  By the middle of March 2020, South Africa had braced itself for the expanding pandemic and instituted a national lockdown. As the restrictions began to slowly lift, the use of personal protective equipment became commonplace and members of the public were not allowed out of their homes without a mask on. If at this point I had boarded a plane with a mask on, I no longer would have drawn feared expressions and worried glances.

  Why? This is because the entire population was forced to understand the severity and impact the invisible COVID-19 virus could have on their health and well-being. This being said, there is another invisible illness that plagues South Africa with compounding effects on individuals health and well-being; mental illness. If South Africans can take COVID-19 seriously, it shows that they have the capability to address mental illnesses in the same manner. This paper discusses the current state of mental healthcare in South Africa as well as provides a long-term preventative framework that will both destigmatize mental illness and create job opportunities for those educated in psychology and mental health.

  COVID-19 has forced South Africans to protect themselves by wearing masks; we can tackle mental health in the same way by removing our blinkers.

Literature Review

Global mental health

  As the relevance and impact of mental health disorders continue to grow around the world, calls to address the increasing burden on mental healthcare have been made apparent in research and literature [1]. Significant international developments have attracted growing interest from various countries to include mental healthcare as an essential component of universal healthcare coverage [1,2]. In 2015, mental health was included in the Sustainable Development Goals in order to secure global commitment to prioritize and address the unmet needs of the 450 million people in the world struggling with mental illness [3,4].

  Evidence based research at an international level has determined a number of cost-effective strategies designed to prevent mental illness and improve the overall mental health of populations around the world. Docrat.,et al. provides a brief overview of the strategies as follows; the explicit recognition and inclusion of mental health in the Universal Health Coverage agenda; intensified investments in mental health systems; reducing inefficiencies in the use of resources through the redistribution of budgets from hospi-centric care to the community; task shifting mental healthcare to non-specialist providers who receive ongoing specialist supervision; amplified training for all cadres of mental health professionals and specialists; the initiation of early interventions that are accessible to at-risk populations; integration of mental health in broader primary healthcare, and; the active engagement of those living with and effected by mental disorders in the reform process [1,4-6].

  These strategies detail a multifaceted blueprint towards dealing with universal mental health; however this paper will focus specifically on task shifting mental healthcare to non-specialist providers, amplified training for these and other mental health professionals, and the integration of mental health into school systems as an early intervention strategy.

Mental health in South Africa

  Over the past two decades, South Africa has taken a number of critical steps towards strengthening the country’s mental health system. The reformation of the Mental Health Care Act 17 of 2002 recognized that health is a state of mental, physical and social well-being, while addressing issues such as the provision of mental health services and discrimination against those with mental health illnesses [7]. The development of the South African National Mental Health Policy Framework and Strategic Plan 2013-2020 addressed the need to create an evidence based mental health policy that could provide a comprehensive scope in which to guide South Africa forward in terms of mental health promotion, prevention of mental illness, treatment and rehabilitation [8].

  Despite the abovementioned acts and policies, research indicates that there are still considerable gaps and significant challenges faced by the South African mental healthcare system. Lund.,et al. identified a number of ongoing challenges such as: limited intersectoral policy integration, stigmatization of individuals with mental health illnesses, inadequate integration of mental with primary healthcare (particularly in rural areas), and lack of sufficient community-based mental health services to support the process of deinstitutionalization [6].

  In a recent study, Docrat.,et al. found that South Africa’s mental health expenditure was estimated to make up 5.0% of the total public health budget in the financial year of 2016/2017 [1]. At a provincial level, six of the nine provinces were spending less than 5.0% of their health budgets on mental healthcare for the same financial year as mentioned previously [1]. Chisholm.,et al. determined that in order to provide comprehensive mental healthcare to the country, South Africa would need to allocate up to 10%, but no less than 5.0% of the total health care budget to mental health [9]. While these financial concerns may not be the root cause of many of the issues plaguing South Africa’s mental healthcare system, they may further exacerbate the problems in other areas. For example, Burns identified that there are extensive shortages of mental health professionals in the various provinces, regardless of allocated budgets and resources [10].

  Throughout much of the South African specific literature cited above, as well as in the South African National Mental Health Policy Framework and Strategic Plan 2013-2020, there is a common theme of ‘scaling up’ the efforts to address mental healthcare in terms of efficiency and consistency to meet Global standards [1,2,8,10,11]. Despite the progressive legislature and empirical research on the topic, there are still a number of factors constraining the realization of South Africa’s mental health policies.

  If one was to visualize South Africa’s position on a continuum - where one end represents a preventative course of action and the other end represents a curative course of action - analysis of the literature would suggest that South Africa falls more towards the preventative end. Contrary to this perceived perspective, this paper is based on the underlying theory that in reality, available resources and funding are being directed towards the curative end, creating further disparity [12].

South Africa and Co-morbidity

  Despite the challenges listed above, South Africa is also afflicted by a number of compounding factors that further burden the state of mental health in the country. As a low- and middle-income country, South Africa struggles with a high unemployment rate of 29.1% with almost half (49.2%) of the adult population living below the upper-bound poverty line [13,14]. The association between poverty and mental health has also been well documented by a number of authors [6,15]. Research in developing countries has indicated that mental illness can be caused by poverty through extrinsic factors such as the stress caused by unemployment, violent crimes, and simply living in poverty [6]. Subsequently, mental health issues play a role in further increasing poverty due to the way and means in which these individuals do not actively engage in community life or seek employment [6].

  Another confounding factor that plays a dual role in inhibiting the development of mental health is its perceived low priority in comparison to physical health issues such as HIV/AIDS. According to Statistics South Africa approximately 13.1% of the general population is HIV positive [15]. As the HIV/AIDS pandemic is rife in South Africa, funding and resources are often in competition with other areas of healthcare [6,17]. Understanding and creating awareness regarding the link between mental health illness and HIV/AIDS may assist in holistically addressing a number of healthcare problems altogether [10,17,18].

Mental health in South African children

  The mental health of children and adolescents is a widely researched topic that leaves little doubt regarding its importance. Studies have shown that most mental disorders have their onset before the age of 18 years; some of which have age-specific indicators such as Conduct Disorder preceding Antisocial Personality Disorder [1,19]. With roughly 34% of the South African population falling under the age of 18 years, mental health service availability for the children and adolescents is extremely limited [1,11,20,21].

  A study by Docrat.,et al. showed that a mere 6.8% of mental health inpatient admissions and 5.8% of mental health outpatient visits in South Africa were for patients under the age of 18 years [1]. Adelman and Taylor state that children and adolescent mental health is a ‘major public health concern,’ and up to 22% of children under age 18 are in need of services for mental, emotional, or behavioral issues [22]. According to the World Health Organisation (WHO), up to 20% of adolescent mental health conditions are underdiagnosed and undertreated [20,23]. The ramifications of the mental health issues at a younger age can have far reaching consequences for the developing individual; research has shown that the mental health of adolescents can profoundly influence future health, mental health, social and economic circumstances of the affected adult [23]. Furthermore, the added pressure of the South African economic climate in terms of poverty and high unemployment can further worsen situations for emerging adults [20,24].

  Improving the mental health of children and adolescents in South Africa is another curative theme displayed throughout the literature on the topic. However, by not only improving but also preparing and educating children on the topic, we can mitigate the public health concerns through preventative measures. As the future of South Africa, it is of the utmost importance that children of South Africa are educated on the topics of mental health and psychology.

  The WHO has outlined a number of adolescent focused strategies aimed at protecting and promoting mental health such as early detection and early treatment [23]. While these strategies are extremely needed, especially in South Africa, they are curative measures that are difficult to implement in an already overwhelmed mental health system [6]. Instead, focus should be drawn to the preventative measures that would promote future generations of individuals with the ability to advocate for mental well-being and inherently extinguish the stigma associated with mental health.

  Literature on South African mental health promotion and prevention campaigns is underwhelming. The importance of these campaigns has been well researched and determined that mental health awareness campaigns are critical for adolescents in order to give them the social understanding and resilience to cope with the difficulties of life and how to identify and avoid riskier coping mechanisms [1]. The need to address adolescent mental health has been echoed through research over the past decade with little success [25]. Docrat et al summarizes by stating the following: “There is a critical need for accelerated action for improved access to treatment and targeted mental health prevention and promotion for adolescents” [1]. The aim of this paper is to address that very need.

Mental health in schools

  The teaching of mental health and psychological theories in schooling systems is not a new concept. Researchers such as Atkins.,et al. and Reinke.,et al. have been publishing on the topic for the better part of two decades [26,27]. A recent South African study by Mfidi studied the experiences of a sample of Eastern Cape teachers and school health nurses in dealing with the mental health issues seen in adolescents at their respective schools [28]. This research acknowledges that more needs to be done in order to address the mental health issues seen in the sample of South African schools and calls on the Departments of Health and Education to act together in an intersectoral collaboration to adequately address the issues [28].

  This being said, the South African education system is not completely void of mental health awareness topics. There is currently an established subject that contains mental health and psychological content (albeit extremely limited); Life Orientation. Life Orientation is a compulsory learning area (i.e. school subject) designed to guide and prepare students for life, its responsibilities and also its possibilities [29]. Further exploration into the Life Orientation syllabus shows that there is indeed an interdisciplinary focus on topics such as Sociology, Psychology and Political Science, however there are a number of factors that undermine the potential strengths of this subject in schools around South Africa.

  Firstly, many South Africa universities exclude Life Orientation results when calculating a student’s Admissions Points Score [30,31]. Therefore, the lack of necessity in achieving a good result in this subject may lead students to believing the subject, and unfortunately its contents, are not worth learning or putting effort into. Secondly, as some of the topics are psychologically heavy, many teachers feel inadequately prepared to discuss these topics [27,28]. Reinke.,et al. expanded on this concept stating that teachers reported an overall lack of experience and training in terms of dealing with student’s mental health in the classroom [27]. Many teachers believe that mental health is a concept that should be primarily dealt with by the school Psychologist or social worker [27,32].

  A lack of mental health professionals in South Africa has been cited in a number of articles and websites over the past decade [1,6,10,28,33]. A study by Muribwathoho found that this lack of mental health professionals undoubtedly extends into the South African schooling system and although a number of policies aimed at reform have been outlined, they are not appropriately addressing the issues [32]. The integration of mental health into education requires further reform and development in South Africa. This paper acknowledges both the research done within the South African context and at an international level, as well as providing a blueprint for an intersectoral intervention to address mental health reform from a grassroots level.

Mental health framework and COVID-19

  South Africa is currently in a precarious position in terms of the future of mental health. Having discussed the South African National Mental Health Policy Framework and Strategic Plan 2013-2020 above, it is important to note that this policy document has now entered its final year and mental health professionals around South Africa await the subsequent version and revision. In addition to this, South Africa has recently been devastated by the COVID-19 pandemic, forcing hundreds of thousands of citizens into lockdown, unemployment, and potential mental health turmoil [34,35]. Due to its current state and effect on South Africa, empirical research on the pandemic in relation to mental health is limited. It is difficult to determine the long-term effects the COVID-19 pandemic will have on the overall mental health of the various populations in South Africa, but many psychological experts believe that the outcomes will be dire [36]. It is imperative that South Africa uses these opportunities to redress the policies in place to create effective change within the Mental Health Policy Framework and Strategic Plan moving forward from the COVID-19 pandemic.

Mental health professionals in South Africa

  In South Africa, the primary Mental Health care-givers are Psychologists and Psychiatrists. Becoming a Psychiatrist involves completing a medical degree and further specializing in Psychiatry. These individuals work in similar settings to those of Clinical or Counselling Psychologists, however with the ability to prescribe medication to their patients [37]. Becoming a Psychologist in South Africa takes on a different route to that of Psychiatry whereby individuals must first complete an undergraduate degree, followed by an Honors degree, and finally a Masters degree in a specific category as described by the Health Professions Council of South Africa (HPCSA) [38]. The reason this is important in the context of this paper relates to how candidates are selected for these different programmes, and what job opportunities are available should graduates not be selected for Masters or a subspecialty.

  Students interested in pursuing a career in Psychiatry must first apply to study medicine and undergo rigorous scrutiny based on their written application and motivation, as well as their academic merit. Once a student has been accepted to study medicine they are tasked with completing 5 or 6 years (depending on the university) of medical training before beginning their internship and community service years [39]. If an individual would like to pursue a subspecialty in psychiatry, they will need to apply and be accepted before they can begin training.

  Along the route to becoming a Psychologist, thousands of students register for undergraduate degrees in psychology every year with the hope of one day becoming a Psychologist. After three years of studying Psychology at an undergraduate level, students will then apply for an Honours degree. Selection into one of these Honours programmes is based almost entirely on academic merit and again, thousands of students complete these degrees every year. Finally, having completed an Honours degree after 4 or 5 years of studying Psychology, students are then eligible to apply for a Masters degree and start along the final stretch towards becoming a Psychologist. However, in contrast to the previous application and selection processes these students have undertaken, the Masters selection process is a different impasse altogether.

  Spaces in coursework Masters programmes are severely limited and the selection process is highly competitive [40]. Only between 6 and 12 students are accepted into various Clinical and Counselling programmes at each of the accredited universities each year, totaling less than 100 students per category throughout South Africa [38]. In order for the universities to select their Masters degree students for the following year, students must pass through a rigorous selection process designed to show both the strengths and weaknesses in the applicant’s character.

  The reason this paper uses the comparison between Psychiatry and Psychology is that even if a Medical School Graduate is unable to continue studying and achieve a subspeciality in Psychiatry, these individuals are still recognized and registered as Medical Doctors and are legally and ethically allowed to practice as a General Practitioner (GP). In contrast, a Psychology Honours graduate, of which there are thousands produced by universities all over South Africa, is academically trained in Psychology but lacks the practical ability and training needed to work in any mental health fields or register with the HPCSA. This is extremely frustrating for the majority of Honours graduates as their way forward is often blocked by limited spaces available in Masters courses, and until they are eventually are selected, they are unable to find work in their studied field.

Poor use of psychology honours graduates

  As mentioned above, these Honours graduates are academically trained in Psychology and mental health, but lack the practical training to legally and ethically work in the field of Psychology. The training received by Psychology Honours graduates is insufficient when considering the multifaceted dimensions of dealing with another human-beings mental health. It is for this reason that there is no current HPCSA registration or category for these individuals in South Africa. While these individuals may not be practically trained in their recently graduated state, this does not mean that they are entirely useless in terms of mental health reform in the country. Some, if not many, of these graduates are well educated in the field of Psychology and have a great deal of volunteering and life experience.

  It is the opinion of the author of this paper that these individuals are not being used effectively to address the increasing burden of mental health issues in South Africa. These individuals are in fact an untapped resource in the fight for mental health reform and, with specific short-term practical training and a defined scope of practice, could address the mental health issues faced by one of South Africa’s key demographics; school children.

Grassroots level preventative intervention

  The goal behind this paper is to provide a framework and steps to be followed for a grassroots level intervention that aims to create mental health reform in South Africa. The framework takes on a proverbial “two birds with one stone” approach whereby the two identified areas of issue have the capacity to be mitigated by the other. The first area of concern that has been identified in this paper is that of mental health in South Africa. The literature above demonstrates the expansive research done on the topic, as well as the previous efforts by various government departments and regulating bodies to appropriately address the issues with limited success. As mentioned previously, the perspective of this paper determines that the majority of the funding and resources available to mental health in South Africa are predominately funneled towards curative measures rather than that of long-term preventative measures. Curative measures provide short-term relief through interventions such as; personal psychotherapy, and in- and out-patient treatment in mental health institutions, whereas preventative measures aim at securing long-term stability for an exponentially larger population demographic. The second area of concern is the poor use of Psychology Honours graduates in the field of mental health as well as their limited ability to find employment without an adequate registration and scope of practice. Divided, these areas are weaknesses in society; together, they can give South Africa strength.

Framework aims

  The first overarching aim is to introduce children in South Africa to mental health and psychological topics throughout their schooling career in order to psychoeducate the youth and destigmatize the field concurrently. By educating students on the benefits of mental health and well-being, they become better equipped to deal with the psychological stressors present in everyday life living in South Africa. In addition to implementing such widespread psychoeducation throughout schools across South Africa, the expansive reach will innately act as a tool in the destigmatization of mental illnesses. The long-term benefits of such an intervention are a generation of destigmatized young adults with a psychological understanding and awareness, and the capacity to inherently create future generations with similar characteristics.

  The second framework aim is to give Psychology Honours graduates a purpose in the landscape of mental health in South Africa. Currently, these individuals are an untapped resource of psychological knowledge and passion with the ability to create awareness and promote mental health on a large scale. While these individuals are not sufficiently trained with the therapeutic skillset required to effectively counsel patients with mental health issues, their academic understanding and passion for mental health can be utilized in psychoeducating students in a supervised and regulated manner. Appropriately educating the youth of South Africa on the importance of mental healthcare and psychological well-being is paramount in creating effective long-term change and the overall prevention of mental health stigma. Allowing for this to be done by passionate, educated graduates would essentially help close many of the gaps identified in the literature, as well as give those graduates a purpose and the ability to gain experience in a practical mental health setting.

  In order to create this mental health reform framework, it is clear that the aims outlined above have the capacity to address each other simultaneously. The framework is therefore dependent on the role and effectiveness of the Psychology Honours graduates, which will be discussed and explained in greater detail below.

  The implementation of such an intervention may also have a positive effect on other areas and members of the mental health field. Successful implementation could possibly relieve the pressure on Psychologists and Registered Counsellors working in schools and allow for streamlined focus cases specific to their scope of practice. Creating a designated registration also provides a framework in which to monitor and regulate the ethical conduct of these individuals.

Registered containment officers (RCO)

  As mentioned previously, Psychology Honours graduates are under qualified in order to effectively provide mental health counselling to others without further training. In addition to this, Psychology Honours graduates do not have a defined registration aligned to a professional body that regulates and monitors the quality of these individuals following their training. In order to address this, it is suggested that these Psychology Honours graduates undergo unique, interdisciplinary training that will allow individuals to register with the suggested title of Registered Containment Officer (RCO).

  The definition of containment in this paper may vary from what other authors have described in literature. The goal in this paper is not to further complicate the definition but to simplify it to its most basic and relevant form. In doing so, the author turns to the Oxford English Dictionary where it describes containment as ‘the act of keeping something under control so that it cannot spread in a harmful way’ [41]. While not specifically psychological, when observing the definition through a psychological lens, the term containment takes on an updated meaning with specific focus on the initial phases of psychotherapy.

  As part of an RCO’s scope of practice, they are to be trained to interact with a school-level client that is suffering from an emotional outburst. Their role in this relationship is to contain the situation by calming the student down and creating a safe environment in which to do so. In order to effectively contain the situation, the following protocol should be considered. This proposed RCO action plan protocol is an adaptation of the ALGEE model seen in Mental Health First Aid [42].

ALARMED system:

• Assess:Assess the situation for risk of harm or suicide.
• Liability: Explain the ethical considerations and liability the RCO has towards the client.
• Acceptance: Practice Unconditional Positive Regard and acceptance.
• Record: Create a record of the session to be given to a parent, or professional.
• Mental Health Professional:Refer the student to an appropriate mental health professional.
• Ethics: Discuss the ethical considerations with a supervisor.
• Debriefing: Discuss the situation and conduct of the interaction with a supervisor.

  In order to give perspective as to how the above protocol could be implemented, consider the following hypothetical example.

  During a school talk on mental health and suicide presented by the South African Depression and Anxiety Group (SADAG), a young girl towards the front of the classroom begins to get visibly upset and starts to cry. She is in grade 6 and has not encountered much information on mental health and well-being. As the presenter continues their talk, the young girl continues to get more distressed and eventually asks if she can be excused to go to the bathroom. It is at this point that the teacher alerts the RCO on campus that there is a student that may require containment.

  The RCO arrives at the classroom but waits for the student outside. As the student exits the classroom, the RCO approaches and asks the student if she is okay. She doesn’t respond but appears to be holding back heavier sobs. It’s clear that something that was said in the talk on mental health has resonated with the young girl and she is in distress. The RCO offers the young student the opportunity to go sit quietly in the RCO’s office, the young girl agrees. Upon reaching the office, the young girl remains quiet, holding back her tears the best she can. The RCO begins to build rapport by asking her name, how old she is, etc. They sit in silence together before the RCO begins to explain that they are there to talk and that when she is ready, the RCO is happy to listen. As the RCO continues to create an environment that allows the young girl to feel safe, she slowly begins to calm.

  The RCO explains that because of her age, there may be some details of what she says in this room that they will have to tell her parent or guardian. The young girl understands.

  The young girl begins to tell the RCO that about a week ago, she was travelling to school with a lift club and that the man that was driving the vehicle that day exposed himself to her. She did not know what to do or who to tell about the incident and she has been having nightmares about it. When the individual from SADAG was talking, it made her think of her nightmares and what had happened that day. They continue to talk about the situation and the RCO continues to reassure her that she has done nothing wrong and that they are there to help the student. Once the student is feeling less distressed, the RCO explains that he or she has to tell the young girls parents about the incident and that she might have to talk to someone else (a Registered Counsellor or Psychologist) about what happened.

  The RCO then makes notes regarding the situation and contacts their supervisor, Registered Counsellor or Psychologist to discuss the next steps that should be taken. This not only allows the RCO to get the appropriate referral, but also allows for the opportunity to discuss the ethical considerations and debrief if necessary.

  Each of the ALARMED steps have been outlined throughout this very simple example showcasing the effectiveness of a first responder that is trained in containment management. The RCO is not in a position to provide counselling for the distressed student, but help them contain their outbursts and protect them from further harm and the risk of suicide.

RCO training

  As the aim is to implement these RCO’s into schools around South Africa, training for RCO’s (in addition to having completed an Honours Degree in Psychology) will consist of two integral aspects; a Psychological element and an Educational element. The duration of training for RCO’s is one that is still to be defined depending on the outcome of this paper. However, over the course of their training, RCO students will complete both the theoretical training required, as well as a practicum consisting of roughly 360 supervised hours. Should this intervention be written into South African policies and legislature, the development of a curriculum will be required in order to gain approval from the South African Qualification Authority (SAQA). Details on the learning outcomes for each element are discussed below.

Psychological element

  As a prerequisite for RCO training, students must have already obtained an Honours Degree in Counselling Psychology from a South African university. This is to ensure that these students have a grounded theoretical understanding of Psychology before commencing training. The main psychological focus of RCO training is a Rogerian approach to rapport building and containment techniques. While the use of Person Centered Therapy would not fall under the RCO scope of practice, the ability to build rapport in a manner that shows unconditional positive regard is crucial in creating an environment to contain and regulate a student’s outburst.

Educational element

  The educational aspect of RCO training is crucial as RCO students will be required to teach Life Orientation within a school environment, as well as conduct workshops to help educate both students and teachers on mental health. The educational training will consist of both theoretical training as well as an in school practicum, similar to that done by Bachelor of Education or Postgraduate Certificate in Education students. Once again, the actual curriculum would need to be well defined in order to gain SAQA recognition and the practical element would require supervision in order to obtain the partial registration with the South African Council of Educators (SACE).

RCO registration

  As part of the interdisciplinary and intersectoral collaborative effort to create mental health reform in South Africa, cooperation between the different regulating bodies would be essential in order to achieve success implementing this initiative. We call upon the HPCSA to consider creating this new registration in order to standardize and regulate the efforts that are to be made by these RCO’s. Due to the educational role in which these RCO’s will be implemented it is also important that their registration is governed by an accredited educational board such the SACE. Having this dual registration will regulate the registration through a well-defined scope of practice for the Psychological element and an underlying educational code of conduct for the educational element.

RCO scope of practice and code of conduct

  Registered Containment Officers are psychological practitioners with the ability to perform basic psychological screening and create mental health awareness for individuals and groups. Their role in society is limited specifically to school environments and may not work in private practice with this registration. Their psychological duty to students in a schooling environment is a form of containment, limited to one containment session, before being referred to a Registered Counsellor or appropriate Psychologist. Their registration also includes educational duties whereby they are required to use their academic understanding and passion of psychology to psychoeducate through teaching Life Orientation.

  More specifically, the registered containment officer will:

1. Use the basic counselling skills obtained in training to provide emotional support towards a student in distress, with the aim of containing any outbursts until a Registered Counsellor or Psychologist can be contacted or referred to.
2. Create and implement presentations and workshops for both teachers and students with the aim of psychoeducating with preventative focus.
3. Promote mental health awareness through campaigns implemented on school campuses around South Africa.

  The following acts fall within the scope of practice of registered containment officers:

1. Being the first line of schooling based psychological support.
2. Providing containment counselling services within a school environment.
3. Performing basic psychological screening for the purpose of mental health as a preliminary screening tool in order to refer appropriately.
4. Provide only containment counselling in conjunction with interdisciplinary support teams.
5. Teaching of Life Orientation specifically within a school environment.
6. Abide by and follow the South African Council of Educators Code of Conduct as an educator towards learners, parents, colleagues, and the community.
7. Provide psychoeducation and mental health promotion.
8. Report writing and providing feedback to clients (if over 18 years) or parents on interventions.

Department of health and department of education

  In order to operationalize the framework as described above, creating a dual registration will not be the only intersectoral hurdle. Combining the efforts of both the Department of Health (DoH) and the Department of Education (DoE) is crucial in order to facilitate implementation and distribution. The DoE would need to be consulted in terms of introducing a revised version of the current Life Orientation curriculum that would have a stronger focus on mental health and psychology. If this was to be considered, then research would need to be conducted in order to create this new curriculum before the training of any RCO’s can begin as their training would include this curriculum.

  The second intersectoral discussion would require the DoH to implement legislative changes that would find it compulsory for South African schools to employ RCO’s to teach the new Life Orientation curriculum and work within their scope of practice in a school environment. This would have to be implemented in stages or limited to various provinces at first as training RCO’s would take at minimum 6 months, depending on the requirements to be set by the HPCSA and SACE.

  Considering the various intersectoral cooperation, it is vital that a multidisciplinary team be assembled to monitor progress and communicate with the various departments and statutory bodies. Listed below is a basic list of the various implementation stages:

• Stage 1: Acknowledgement of this paper by the HPCSA, SACE, DoE and DoH.
• Stage 2: Allocation of an overseeing research team.
• Stage 3: Discussion regarding implementation viability.
• Stage 4: Agreement of implementation from the HPCSA, SACE, DoE and DoH.
• Stage 5: Creation of new dual registration for RCO’s from HPCSA and SACE.
• Stage 6: Revision of Life Orientation curriculum from DoE.
• Stage 7: Legislative changes implementing RCO’s in schools (DoH).
• Stage 8: Development of RCO training in Higher Education (DoE).
• Stage 9: Training and supervision of RCO’s.
• Stage 10: RCO implementation in South African schools.

  Some of these stages could potentially occur concurrently with other stages; however it is the need for intersectoral cooperation and collaboration is paramount. There are potentially other hurdles that could cause issues at each stage, and if that is so, the author of this paper calls for further research into the various stages of implementation in order to foresee and address any problems.

Conclusion

  Over the past two decades, emphasis on mental health reform has received global acclaim. From mental health’s inclusion in the Sustainable Development Goals to the recognition and inclusion of mental health in the Universal Health Coverage agenda, it is clear that the world and its leaders are taking mental health seriously. In low- and middle-income countries such as South Africa, implementing mental health interventions with the ability to create widespread change and destigmatization has proven to be difficult undertaking. Literature on the subject shows a valiant effort made by the South African government over the years; however the research also presents a detailed catalogue of the governments’ inadequacies and shortfalls.

  Upon further inspection into the state of South African mental health and the attempts to align with global standards, research shows that resources and funding are often funneled towards curative interventions rather than preventative. While this often sees quick turnaround, the reach of such interventions is limited and short-lived. The preventative intervention outlined throughout this article is designed to use untapped resources to expand the reach of mental health professionals and create realistic change within all cultures and societies throughout South Africa.

  The untapped resource mentioned above is a population of eager, educated Psychology Honours graduates passionate about mental health and desperate to implement change where possible. Through intense interdisciplinary practical training, it is possible to give these individuals the tools needed to implement a grassroots level intervention in the schools around South Africa and begin creating generations of children and adults with a psychological understanding that promotes mental well-being.

  Creating the RCO dual registration will give Psychology Honours graduates a means in which to gain experience in the field of Psychology in an ethical manner. In recent times, many of these frustrated, desperate Honours graduates have opted to practice privately outside of the scope and guidelines outlined by the HPCSA. The potential harm caused by untrained Honours graduates may have a compounding effect on public mental health following COVID-19. There is currently no literature available on this situation where graduates are practicing without an HPCSA registration. A call for research within the South African context is crucial in order to further understand the implications and ethics of such a situation.

  While this framework is not without its imperfections, it is a critical first step in creating an intervention with a preventative focus and the potential to induce widespread, generational change in South African mental health. Research has addressed the fact that South Africa needs to implement such an intervention and ignoring this would only further add insult to injury. The creation of the RCO registration and progressive changes to schooling legislature on mental health could provide the mental health reform desperately needed in South Africa. Considering the effects of COVID-19 and the dramatic effect it has had on the South African economy, it is imperative that we use the available resources to create long term change. According to literature, South Africa has been trapped within a revolving door whereby resources are funneled towards short term curative options. Creating preventative change allows South Africans the ability to foster future generations of emotionally aware and psychological confident individuals that understand the benefit of mental and physical wellbeing.

Funding

  This manuscript was written independently and was not funded by any organisation or institution.

Conflict of Interest

  There are no conflict of interest concerns that the author is aware of.