Abstract
In recent decades, there has been a proliferation of neuropsychology training programmes globally, including in South Africa and other low- and middle-income countries (LMICs). Almost invariably, programmes in those countries privilege colonial origins of knowledge while excluding local epistemologies. Our objective in this conceptual article is to describe how a decolonial approach can be applied to the transformation of South African neuropsychology training programmes. Osmer’s practical theology guides our proposal. Osmer’s four tasks – descriptive-empirical, interpretive, normative and pragmatic – can help identify, analyse and challenge colonial legacies within academia and assist in developing justice-oriented scholarship. In the current article, Task 1 describes the landscape of South African neuropsychology and the characteristics of existing training programmes. Task 2 interrogates why those characteristics exist as they do. Task 3 proposes ways in which programmes ought to be transformed. Task 4 details how stakeholders can contribute to this transformation. We thus propose that neuropsychology training programmes in South Africa use this framework to develop relevant, equitable and inclusive teaching, research and clinical approaches.
Contribution: South African neuropsychology training programmes operate within Western, individualistic and androcentric ontologies, thereby marginalising indigenous epistemologies and discouraging inclusive participation. Although there is broad agreement on the need to adapt local practices, no previous work advocating for transformation of neuropsychology training programmes has used a strong theoretical framework or described precise change methodologies. We advocate a decolonial approach, allied to a convivial attitude and task-related practices a la Osmer, to ensure that South African neuropsychology is inclusive and contextually relevant.
Keywords: cross-cultural; decolonial; neuropsychology; Osmer’s practical theology; psychology; training; transformation.
Introduction
The Charter for Humanities and Social Sciences (Department of Higher Education and Training 2011) describes an aspirational direction for scholars working within and across the diverse array of disciplines typically found within faculties of humanities at South African universities. The Charter emphasises the central role of the humanities in creating a citizenry that is socially aware, responsible and ethical, and in defining a post-apartheid scholarship that is sensitive to, and relevant for, both the immediate and long-term developmental needs of South Africa, specifically, and the global South, more broadly.
Psychology is, almost invariably, a centrepiece of humanities faculties at South African universities. It attracts large numbers of undergraduate and postgraduate students, offering a broad range of training opportunities in research methods (including ethics), quantitative and qualitative data analysis, clinical work, and community initiatives. Of particular importance for this article is that psychologists have been at the forefront of scholarly initiatives aimed at decolonising and transforming African higher education spaces and at ensuring that university coursework is locally relevant and addresses the needs of the communities to which staff and students will deliver services (Kessi et al. 2020; Painter et al. 2013; Ratele 2017).
The subdiscipline of neuropsychology, which focuses on brain-behaviour relations and the effects of organic insults (e.g. stroke, viral infections) and environmental challenges (e.g. food insecurity, low socio-economic status) on cognitive performance, is a fast-growing branch of psychology that incorporates both experimental research and clinical practice. This growth encompasses not only the depth of thought within the subdiscipline, but also the emergence of training programmes globally, including in South Africa and other low- and middle-income countries (LMICs). The growth on those fronts does not, however, extend to the development of a local identity for neuropsychological research, clinical practice and (crucially for this article) training. This lack of transformation may be attributed to various interrelated causes. These include the relative youth of the subdiscipline (the Health Professions Council of South Africa [HPCSA] only recognised neuropsychology as a specialist registration category within the past 5 years; even the United States, where most neuropsychologists are trained, only developed formal guidelines for training relatively recently, in the 1970s); the fact that the small number of fully trained and qualified neuropsychologists who guide neuropsychological education in South Africa were, for the most part, all trained in strongly Euro-American principles; and the subject matter of the subdiscipline, which encourages a narrow focus on the brain as the source of all behaviour and places less emphasis on interpersonal and social aspects of psychology. Hence, we offer neuropsychology as a case study for how transformation can proceed in areas of the academy where the humanities meet the health sciences, where training programmes are relatively immature but discipline-specific knowledge is exploding, and where clinical service delivery elements are essential.
In this article, we use an overarching framework of decolonial theory and a specific framing perspective of Osmer’s (2008) practical theology questions to develop a foundation that can guide transformation of neuropsychology training programmes in South African universities. Ultimately, we encourage a transformational process that will seek to ensure that those training programmes, and the research and clinical approaches emanating from them, are relevant, equitable and inclusive.
Overarching framework: Decolonial theory
With numerous interpretations and definitions, decolonial theory remains difficult to implement; many academics are unsure how to grapple with it (Jansen 2023). Here, we define a decolonial approach to higher education as an ongoing process of developing a consciousness of the intrinsically colonial academy. Inherent in this definition is a recognition of: (1) the colonial origins of knowledge and their normalisation in African universities, (2) the fact that such knowledge excludes African participation in dominant discourse, and hence (3) the positioning of Western epistemic accumulations as superior, universal and contextually detached, while simultaneously devaluing African and other epistemologies (Chimakonam 2019). In this context of epistemic injustice, the African academy continues to operate from a colonial perspective and thereby maintains the continent’s unequal relationship with the world.
The specific processes and actions required by a decolonial approach to higher education are important to describe. The approach requires active questioning of unequal power relations in academic institutions, critique of dominant ideologies and examination of who might benefit from marginalising practices. It considers which sources or kinds of knowledge are promoted and which are disregarded, and advocates for the inclusion of multiple ways of knowing. Decolonial approaches make calls for engagement with blackness and related subjectivities (Kessi 2017). Essential within these processes and actions is the notion of conviviality, a behavioural orientation that emphasises collaboration and joint knowledge production in an attempt to disrupt the colonially derived, capitalist and hierarchical structure typical of academic institutions (Nyamnjoh 2017).
The outcome of this sort of decolonial approach is, broadly speaking, social change. It is designed to resist ongoing colonial harm – that is to say, to disrupt the unequal power relations that continue to shape economic, cultural and academic spaces (Matasci 2022). It invites the Eurocentric institution to embody anti-racism, feminism and anti-capitalism, to engage in a discourse of relevance in the academy and beyond, and, ultimately, to ensure knowledge production that is appropriate for the local context and that is mindful of social, cultural, linguistic, economic and political considerations.
With specific reference to the field of psychology, an African-centred approach to the discipline aims to humanise and give voice to previously marginalised groups (Ratele et al. 2018). However, South African institutions of higher learning face numerous challenges in adopting this approach. This is particularly true for subdisciplines of psychology, such as neuropsychology, that are geared towards professional training in clinical services. Resource constraints (e.g. small numbers of fully qualified staff members and clinical supervisors) mean that few institutions offer training in the subdiscipline. This situation increases the risk of training approaches being dominated by colonial perspectives, particularly in a relatively young subdiscipline without a strong history of staff sensitised to African sources of knowledge and ways of practice. For instance, changing the curriculum to be more context-specific may be particularly difficult when institutional policies are governed by hegemonic entities who are unlikely to approve ideas they perceive to be excessively radical (Jansen & Walters 2022).
However, this is not to say there has been no progress towards achieving an African-centred and decolonial approach towards psychology training at South African tertiary institutions (see, e.g. Macleod et al. 2024; Phiri, Sajid & Delanerolle 2023). Because decolonial theories have equipped academics with the language (and, sometimes, the tools) to engage in discourse around praxis, there is increased consciousness among both staff and students of the structural problems impeding systemic change. To add to this ongoing discourse, and to apply it specifically to the decolonial goal of transforming neuropsychology training in South Africa, we suggest using Osmer’s practical theology.
Specific framing perspective: Osmer’s practical theology
This model is, by its design, practical in nature (Osmer, 2008). We argue that this practicality lays out a clear roadmap for how to achieve the social justice we seek in the domain to which it is applied (in this case, neuropsychology training programmes in South African universities).
Osmer (2006, 2011) proposes that one must engage in four discrete (and, oftentimes, sequential) tasks to generate transformational change. In this article, Task 1 (the descriptive-empirical task; or, orienting to what is happening) sets out to describe the context and characteristics (e.g. curricula, supervisor demographic profiles) of existing training programmes. Task 2 (the interpretive task) interrogates why that context, and those characteristics, exist as they do. These initial steps are crucial because, in the academic case we examine here, transformation means acknowledging who holds power in training programmes, changing power structures and challenging ideas about epistemology (e.g. which knowledge is valued, who decides which knowledge is taught).
Task 3 (the normative task; or, reflecting what should be happening) is perhaps the most substantial for our purposes. This task requires us to propose ways in which training programmes ought to be transformed so that those in contact with them can develop resistance to colonial harm and enhance context-specific and transdisciplinary ways of knowing so as to improve inclusivity (Kessi et al. 2020; Malherbe & Ratele 2022). Here, we will focus on areas in which transformation is imperative, ensuring that:
- curricula integrate culturally relevant content and foster critical thinking around the socio-cultural context of neuropsychological practice in South Africa
- a full slate of patient characteristics (e.g. culture, socio-economic status, trauma history, home language, quality of education) is considered in interpreting assessment results and in making diagnostic and treatment recommendations
- locally adapted and culturally fair assessment tools are used
- there is full appreciation of the impact of the language in which training and patient contact are conducted – although English is the default language, it is not the home language of many students or patients
- the neuropsychology workforce is diverse and able to provide services prioritising the local context.
Task 4 (the pragmatic task; or, what can we do) requires us to ascertain what practical and realistic steps can be taken in order to realise the desired transformation. In other words, it considers how resource constraints, socio-political, financial and environmental limitations, and access barriers might affect the work that Task 3 has imagined must be done. Hence, here we will detail ways in which academics, students and others can contribute to transformative processes.
The following sections of this article elaborate on each of those four tasks in turn, describing the context and characteristics of current training programmes, the reasons they exist as they do, ways in which they should be transformed, and how that transformation might proceed given the extant barriers and constraints.
Task 1: The descriptive-empirical task
Here, we describe the context and characteristics of neuropsychology training programmes at South African institutions of higher learning. Before delving into the details of those programmes, however, we give a brief account of the broader landscape of neuropsychology in this country.
Recent review articles describing the state of the subdiscipline in developing countries suggest that, in terms of research output, the extent of clinical service delivery, and the maturity of training programmes, South African neuropsychology represents an exceptionally positive case compared with other African countries (Hill-Jarrett, Ikanga & Stringer 2018; Kissani & Naji 2020; see also Ikanga & Mbakile-Mahlanza 2022). Moreover, the reviews refer explicitly to the fact that the roles South African neuropsychologists play in the country’s health system, and how they play those roles, are closely aligned with what might be expected of their professional counterparts in Western Europe and North America. Implicit in this statement may be a critique that African systems of knowledge and specific local concerns and challenges are not addressed adequately.
Three recent articles by South African neuropsychologists shed further light on the state of the field in the country (Ferreira-Correia 2016; Truter et al. 2017; Watts & Shuttleworth-Edwards 2016). Although published before the HPCSA’s formal recognition of neuropsychology as a professionally registrable practice category, these articles nonetheless provide useful information and context.
In their article reviewing the history and current status of neuropsychology in South Africa, Watts and Shuttleworth-Edwards (2016) concluded that, at the time of their writing, the availability of neuropsychology in South Africa was ad hoc and institution-dependent. This conclusion was supported by Truter et al. (2017), who reported that almost 20% of respondents to their survey (N = 95 individuals involved in South African neuropsychology, as either academics/researchers or clinicians, or both) indicated that their training included no formal clinical supervision. Ferreira-Correia (2016) notes that such supervision is a critical component of training for neuropsychologists, and that its absence in South African neuropsychological training is a gap long recognised as needing attention. The same author notes that while neuropsychological training and professional requirements ‘should somehow answer to an international standard’ (p. 67), local (and, by implication, cross-cultural) relevance should be prioritised.
Overall, a strong theme in reporting across these papers suggested that a lack of formal training programmes and opportunities was a strong barrier to the growth of the discipline. This is an ongoing concern. Currently, only one university offers formal training leading to qualification for a clinical internship and eventual HPCSA-sanctioned registration in the category of neuropsychology (Bush et al. 2023).
In terms of our own contribution to the empirical task, here we describe existing neuropsychology-related courses and curriculum offerings at South African higher education institutions. In the absence of direct input from relevant stakeholders at those institutions, we base our description on an informal review of publicly available information about neuropsychology-related offerings at 26 South African public universities (Businesstech 2015). We gathered this information (see Table 1) from official university websites and by consulting relevant literature on the history and current status of neuropsychology (and psychology more generally) in South Africa. We acknowledge that this is not an exhaustive or systematic review (e.g. we did not search for information from private colleges or other similar tertiary institutions, and our literature search, although comprehensive, did not use a formal set of eligibility criteria).
| TABLE 1: Results of Google Searches using each of the South African higher education institutions listed by Businesstech (2015) and ‘Neuropsychology’ as search terms. |
| TABLE 1 (Continues…): Results of Google Searches using each of the South African higher education institutions listed by Businesstech (2015) and ‘Neuropsychology’ as search terms. |
| TABLE 1 (Continues…): Results of Google Searches using each of the South African higher education institutions listed by Businesstech (2015) and ‘Neuropsychology’ as search terms. |
Regarding the web-based information we gathered for this article, our cursory search indicates that 20 of the 26 candidate institutions offered at least some neuropsychology coursework. Of the six that did not, five were universities of technology, and the other offered only courses in translational neuroscience and neurotherapeutics. Almost 70% of the institutions (n = 18) listed offerings at the postgraduate level; almost 40% (n = 10) clearly listed offerings at the undergraduate level; and almost one-quarter (n = 7) listed offerings at both undergraduate and postgraduate levels.
Overall, then, there appears to be an encouraging (although inconsistent and uneven) emergence of neuropsychology-related educational opportunities at South African universities. Offerings range from first-year courses in biological psychology through third-year courses focused on clinical neuropsychology to elective Honours modules taking a broad overview of the field. At the Master’s level, there are clear opportunities for neuropsychology research. However, across universities, these offerings are still limited in terms of accredited training leading to registration as a neuropsychologist.
Finally in this section, a key contextual concern is the demographic makeup of neuropsychologists in South African academic and clinical (i.e. private practice and hospital) settings. Unfortunately, there are no granular nationwide data regarding the demographics of neuropsychologists in academic settings (i.e. those employed as supervisors in training programmes). Regarding the overall population of neuropsychologists in the country (i.e. those who work in clinical practice and/or in academia), Truter et al. (2017) reported that: (1) fewer than one-third of the 95 participants who completed their online survey had more than a Master’s degree (n = 28); (2) the vast majority (n = 84) were female; (3) slightly more than half (n = 50) worked in private practice; and (4) fewer than 10% (n = 9) worked full-time at an institution of higher learning. The average age of this sample was approximately 47 years (range = 25–73 years).
A 2017 HPCSA survey (N = 2081) covering all psychology practitioner categories registered at that time described similar patterns of data. Most respondents to that survey were female (78.8%), white (73.8%), English-speaking (70.4%) and aged 31–50 years (32.7%). Of note is that fewer than 20% of respondents reported having a home language of one of the nine official African languages, and that black practitioners represented only about a quarter of the sample (24.7%), with most of those being in the Registered Counsellor category (which represented approximately 15% of the total sample).
The usefulness of the Truter et al. (2017) and HPCSA (2017) surveys is, for the current purposes, limited by their small sample sizes, their restrictions on access (participants needed stable internet connectivity to complete the survey), and the fact that they were conducted before the HPCSA established the neuropsychology registration category. However, their findings remain relevant for two reasons. Firstly, the vast majority of respondents to the Truter et al. survey will now be formally registered neuropsychologists practising in South Africa. Secondly, the demographic composition of the population of practising neuropsychologists is, given the similar admission criteria for MA-level qualifications, unlikely to differ substantially from that of other practitioner populations.
Taken together, the results from our web and literature search suggest some growth in neuropsychology. This growth is, however, inconsistent and ad hoc. As neuropsychology emerges in South Africa, and against the backdrop of the description above, it is critical to determine how such growth proceeds and, crucially, who it includes and who it accommodates.
Task 2: The interpretive task
Here, we interrogate why (and, to some degree, how) the context and characteristics of training programmes, as described above, have come to exist as they do.
The historical epistemologies underpinning apartheid-era psychology in South Africa allowed discrimination and oppression to thrive through institutional and scientific racism (Louw 1997). During apartheid, race was not perceived as a socio-political construct, but was solidified into an ontological truth, deeply embedded in the epistemological fabric of the field of psychology and other social and natural sciences (Cooper & Nicholas 2012). Apartheid political frameworks were also heavily influenced by nativist views of intelligence, which had, as one of their cornerstones, the inherent intellectual inferiority of non-European racial groups (Herrnstein & Murray 1994). Such epistemology rationalised the subjugation of black South Africans by presenting their marginalisation as the inevitable and undeniable consequence of a natural and justified societal order founded on Christian nationalism, eugenics and social Darwinism (Nicholas & Cooper 1990).
Such perspectives, as well as direct government funding and related pressure to produce findings that would support racialised social oppression, permeated the scientific investigations of the day. These investigations, in psychology and other scientific domains, were often framed by governmental authorities as being politically neutral, but in reality sought to elevate race to a physical basis for discrimination and to hide the fact that it was a construct strategically deployed to sustain systems of oppression (Duncan et al. 2001). For instance, Fick’s (1929) study used racially biased intelligence tests to assert the intellectual superiority of white children over black children. Such studies (see also Jansen van Rensburg 1938; Junod 1920) reinforced racial hierarchies and hegemonic power relations, justifying inequities in access to education, resource distribution and employment opportunities. Black South Africans were portrayed as naturally suited for manual labour to rationalise the systemic oppression embedded in apartheid policies (e.g. the Bantu education system) and to allow industry to exploit their labour (Sehlapelo & Terre Blanche 1996; Soudien, Kallaway & Brier 1999). In summary, between the two World Wars, scientific research in South Africa was co-opted by the apartheid regime to legitimise discriminatory policies in political, educational, geographical and economic domains (Louw 2021).
These ideological and political agendas had profound implications for psychology research and practice in apartheid-era South Africa. Individual academics, tertiary institutions and statutory bodies took on these biases in an attempt to gain professional credibility, rather than contesting the prevailing system of institutional disenfranchisement and overt discrimination. As one illustration of this positioning, Van Ommen and Painter (2008) highlight the significant absence of black and female voices in academic psychology publications during apartheid.
This kind of systemic marginalisation was endemic in the South African academy, in its staffing complement and in the products of its professional endeavours. In a cruel irony, the discipline of psychology directly perpetuated entrenched racial inequities and socio-economic deprivation of black South Africans through the use of inherently biased Western-based psychometric testing, which invariably recommended a racially split dispensation of supervisory versus menial roles in the workplace (Cooper et al. 2014).
Further regarding the participation of black psychologists in teaching, research and clinical practice, apartheid policies (particularly with regard to educational inequities) restricted their opportunities. For instance, professional programmes used biased selection criteria to reserve the bulk of training opportunities for white candidates (Hayes 2000; Swartz, Gibson & Swartz 1990). Furthermore, although black individuals were permitted to be the subjects of psychological research studies, black communities were denied the agency to examine psychological phenomena from their own cultural and social perspectives (Van Ommen & Painter 2008).
With specific regard to clinical neuropsychological assessment, apartheid ideologies and policies shaped both theory and practice. Disproportionate resources were allocated to developing assessment tools that favoured the white minority. For instance, in 1953 a division of neuropsychology was formed within the Council for Scientific and Industrial Research (CSIR). The work of this division, which was primarily used to assist in the selection of workers in the military and mining sectors, was funded by the ruling National Party and hence aligned with their segregationist objectives (Foxcroft 2011). Such practices fuelled distrust in psychological assessments broadly, and in neuropsychological assessments particularly, because they tended to be used to perpetuate scientific racism in areas such as intelligence estimation and to overpathologise and misdiagnose black individuals (Laher 2024; Laher & Cockcroft 2017).
This mistrust persisted even after South African universities (ostensibly independently of National Party influence) began introducing postgraduate neuropsychology courses and curricula in the 1970s. These courses and curricula were often facilitated by academics defying international sanctions against apartheid South Africa and were almost invariably based on Western neuropsychological practice (Boyle et al. 2023). Hence, early research efforts emerging from those academic programmes prioritised the adaptation of Western-developed assessment instruments to local contexts, rather than creating culturally specific and locally appropriate tools. This prioritisation persisted in the immediate post-apartheid era, despite growing awareness of the limitations of applying tests designed for WEIRD (Western, Educated, Industrialised, Rich, and Developed) populations to samples drawn from more diverse cultural settings (Aghvinian et al., 2021; Cockcroft & Laher 2022).
In summary, marginalisation of black academics and the lack of diverse representation not only distorted the field of psychological research, but also perpetuated a one-dimensional view of human behaviour, propagated the dominance of Eurocentric narratives, disempowered diverse cultural subjectivities and oppressed the potential of the broader South African population (Dlamini, Tesfamichael & Mokhele 2021; Duncan et al. 2001). Even post-1994, the legacy of this institutional and scientific racism continues to shape the subdiscipline of neuropsychology, from student admissions and staffing through curricula, training and service delivery1 (Harriman et al. 2022; Joosub 2019; Sorsdahl et al. 2023; Truter et al. 2017).
Task 3: The normative task
Here, we propose ways in which training programmes ought to be transformed in order to be more inclusive and to respond appropriately to local context-specific needs. We focus on five areas in which transformation is particularly important:
- curriculum content
- considerations with regard to assessment interpretation as well as diagnostic and treatment recommendations
- choice of assessment tools
- considerations with regard to language in which student training and clinical service delivery are conducted
- workforce demographic composition and ability to deliver contextually sensitive and relevant services.
We are not implying that these are discrete or isolated issues; instead, we argue that they interact strongly with one another and with the overall project of decolonising South African neuropsychology training programmes.
Integrating culturally relevant content into training programme curricula
Ultimately, the curriculum of all South African neuropsychology training programmes must foster critical thinking around the economic, linguistic and socio-cultural context in which clinicians practise and patients live.
Broadly speaking, this means those curricula must incorporate perspectives and knowledge from the African continent and embrace them in the same way that Euro-American epistemologies are currently embraced (Baloyi 2021). This correction of imposed epistemic injustice does not mean that Euro-American theories and sources of knowledge must be discarded entirely; after all, South African training programmes must produce graduates who, for better or worse, can participate in the dominant discourse on the world stage. Rather, it means that neuropsychology curricula in this country must centre (South) African ways of teaching, learning, researching and practising (Heleta 2018; Ndlovu-Gatsheni 2020). For example, pedagogies must shift from being strictly lecture-based and hierarchical to incorporating dialogical and relational models of knowledge-sharing that value ubuntu and collective wisdom where storytelling, case-based communal reflection and language-specific contextual teaching play central roles (Le Grange 2016). Research methods must shift from strictly positivist approaches that prioritise standardisation and objectivity to incorporating participatory action research, narrative inquiry and ethnographic methods that emphasise community engagement, indigenous knowledge systems and contextual understanding of brain-based phenomena (Chilisa 2012). Student assessments must shift from strictly individualised, time-bound exams to incorporate reflective journals, community-based projects and oral presentations in multiple languages with tools that better support culturally grounded, locally meaningful expressions of knowledge and understanding (Ramoupi 2014).
Overall, the curricula should foster critical engagement with the ways in which colonial and Western epistemologies have shaped the field and should encourage students to consider how these frameworks can be adapted to better suit local contexts. More specifically, we suggest that modules on cross-cultural neuropsychology must be a core element of training programmes. These modules must not only address the fundamentals of culturally competent assessment (Brickman, Cabo & Manly 2006; Byrd et al. 2021; Rivera Mindt et al. 2010), but must also teach students ways in which to critically examine the intersections of (for instance) culture, socio-economic status, food security, healthcare access, and neuropsychological functioning (Dreyer et al. 2023, 2025; Majoka & Schimming 2021). Throughout the curriculum, course content must prioritise indigenous narratives, case studies, and scenarios that reflect the circumstances, concerns, and constraints of the diverse South African population. Such content supports the practical application of culturally informed pedagogical approaches, thereby ensuring training is relevant to the communities practitioners will serve (Joosub 2019).
Patient-centred assessment, diagnostic, and treatment approaches
A large body of literature confirms that performance on standardised neuropsychological tests (and hence, by inference, cognitive and behavioural functioning in real-world environments) is influenced by a broad range of non-organic variables: culture, socioeconomic status, level and quality of education, trauma history, and home language, among others (Ardila 2013; Reyes et al. 2024). Hence, training programmes must emphasise the importance of a full understanding of these patient characteristics when interpreting the results of clinical assessments.
Similarly, neurorehabilitation interventions, as well as diagnostic and treatment recommendations in the broadest sense, should be aligned with the patient’s cultural milieu to improve effectiveness (Ferreira-Correia, Barberis & Msimanga 2018; Joosub 2019; Pereira et al. 2017). An excellent example of such alignment is practised by some neuropsychologists working in New Zealand’s Māori communities: the incorporation of ecologically valid practices (primarily the inclusion of the patient’s family members as a central component in treatment approaches) allows for optimal rehabilitation after neurological injury (Dudley, Wilson & Barker-Collo 2014; Pitama et al. 2017).
In essence, trainees should be equipped to adapt their assessment, diagnostic and therapeutic approaches to individual and contextual differences. This adaptation will help ensure that, for instance, interventions and treatment recommendations are not only clinically sound, but also meaningful and actionable for patients from various backgrounds (Fernández & Evans 2022).
Adaptation of culturally fair and locally relevant assessment tools
Assessment of cognitive function lies at the heart of neuropsychology (Lezak et al. 2012; Sherman, Tan & Hrabok 2023). Hence, the tools supporting such assessment are critical instruments for all neuropsychologists. Because of a lack of locally adapted, culturally fair and linguistically suitable tools, South African neuropsychologists tend to rely on assessment instruments developed, standardised and normed in the global north (primarily the United States). The use of such instruments outside of their original context can lead to misleading (and potentially harmful) evaluations of cognitive abilities. This is particularly the case when tests are applied without carefully examining potential cultural biases, when their validity within the local cultural context has not been established, or when local normative data are either not available or not applied (Fernández & Evans 2022).
Pioneering work by Luria (1963, 1976) emphasised the importance of cultural flexibility and adaptability to socio-contextual nuances in neuropsychological assessment. Subsequent work in the same tradition has emphasised that cognitive constructs such as processing speed, which are strongly emphasised in the Euro-American assessment orthodoxy, may hold less value in cultures where accuracy and deliberation are prioritised (Ardila 2005; Pereira et al. 2017). For instance, Mulenga, Ahonen and Aro (2001) found that Zambian children, relative to normative data from similar-aged North American children, tended to perform significantly more slowly on tests assessing information processing speed, yet performed at least as well on non-timed tests assessing visuospatial abilities.
Training programmes should therefore prioritise, in their clinical practica, the use of assessment instruments that have been locally validated and normed, and that are sensitive to educational, linguistic, socio-economic and cultural diversity (see, e.g. Albertyn et al. 2022; Ferrett et al. 2014a; Ferrett et al. 2014b; Phillips et al. 2019; Van Wyhe et al., 2017). Similarly, training directors and research supervisors should encourage their students to become involved in large-scale collaborative efforts aimed at: (1) developing new instruments that tap into the lived experiences of local communities and/or (2) adapting existing instruments so that they are culturally and linguistically fair to local test-takers. Such efforts will contribute significantly to building a more contextually relevant assessment repertoire (Macleod et al. 2024).
Language considerations in training settings
South Africa’s linguistic diversity (12 official languages and a population featuring millions of multilingual individuals) poses significant challenges for neuropsychology training programmes (Watts & Shuttleworth-Edwards 2016). Although English is the default language of instruction and clinical documentation in the vast majority of training settings, it is not the home language of many students or patients (indeed, it is not the home language of almost 90% of people in this country; Statistics South Africa 2016).
In the sphere of assessment, for instance, as implied above, most standardised tests used by South African neuropsychologists (regardless of whether in training or in actual practice settings) are available only in English and/or have only normative data based on English-speaking standardisation samples (Truter et al. 2017). Consequently, there often exists a linguistic disparity between the tests being used and South African test-takers. These discrepancies can have significant negative consequences, including inaccurate performance evaluations or misdiagnoses (Sabanathan, Wills & Gladstone 2015). Thus, the linguistic biases inherent in widely adopted standardised neuropsychological assessment tools pose a significant barrier to accurate cognitive assessment for individuals with socio-demographic backgrounds different from those of Western European or North American standardisation samples (Fernández & Evans 2022).
Addressing this disconnect requires deliberate strategies within training programmes. Modules on effective cross-language communication and the use of interpreters should be integrated into curricula. Moreover, there is a pressing need to develop bilingual or multilingual resources to support both academic learning and clinical work. By actively recruiting multilingual students, programmes can help build a workforce better equipped to provide neuropsychological services in patients’ preferred languages, thereby enhancing the quality and accessibility of care (Baloyi 2021).
Diversity in the neuropsychology workforce
Creating a neuropsychology workforce that reflects the demographics of the South African population is critical for advancing equitable care. Training programmes must make strenuous efforts to attract students from under-represented groups (e.g. black women and individuals from rural or underserved communities). Recruitment strategies must be paired with tangible supports such as financial aid, mentorship opportunities and targeted outreach initiatives. Furthermore, training programmes should nurture leadership potential across a diverse range of students, ensuring all are empowered not only to succeed within the field, but also to shape its future direction in meaningful and inclusive ways (Govender & Naidoo 2023).
Outcome goals for transformed programmes
The proposed transformations aim to establish training programmes that equip graduates with the knowledge, cultural sensitivity and clinical skills necessary to work effectively in South Africa’s diverse linguistic, socio-economic and socio-cultural contexts. These reforms are designed to confront and challenge systemic inequities by fostering inclusivity (of marginalised and underrepresented groups, as well as diverse epistemologies) and embedding both cultural competence and epistemic fluency throughout the educational process. Ultimately, the goal is to develop a neuropsychology workforce that is deeply attuned to the needs of South African communities, particularly those that have historically been marginalised or underserved.
Task 4: The pragmatic task
Here, we attempt to ascertain which sorts of practical and realistic steps can be taken by staff, students and other stakeholders in order to realise the desired transformation. We consider how resource constraints, access barriers and other limiting factors (be they sociopolitical, financial or environmental) might affect the work that Task 3 has imagined must be done. Reflective strategic responsiveness and consequent transformative action may redress entrenched contextual challenges related to neuropsychological training. As a first step, then, all stakeholders must reflect on and critically engage with: (1) the current situation, (2) the desired direction for transformation and (3) the practical realities that impede change.
Regarding the current situation, as described above, the legacy of the apartheid regime’s systematically racist policies persists. Unequal access to and funding for specialised training programmes, such as those serving neuropsychological education, has resulted in a lack of diversity within both the academy and the professional ranks (Ikanga & Mbakile-Mahlanza 2022; Watts & Shuttleworth-Edwards 2016). Moreover, the envisaged growth in academic programmes following the promulgation of registration regulations by the HPCSA in 2019 has not materialised. The development of the discipline is further circumscribed by South Africa’s disparate healthcare model and the limited availability of neuropsychological services and training opportunities catering for the majority of the population.
Over and above these structural barriers is the fact that many, if not most, South African neuropsychologists are not well-prepared to manage the complexities of the cultural and linguistic diversity that characterises their patient populations. The slow progress towards category registration resulted in inadequate opportunities for student supervision and the development of contextually relevant professional skills (Ferreira-Correia 2016; Truter et al. 2017). Furthermore, student exchange programmes and research collaboration disproportionately favour the global north, further perpetuating the marginalisation of African voices in academic discourse and training (Kissani & Naji 2020).
Regarding the desired direction for transformation, the overall goal is to take the shared input of staff, students, community members and other stakeholders and use it to align neuropsychological training with a social justice agenda. Hence, transformation of training programmes must centre on enhancing cultural relevance and improving inclusivity. The first of these is, as noted earlier, a non-negotiable element of a decolonised and transformed training programme. Uncritical appropriation of knowledge systems from the global north often creates an epistemological dissonance and, consequently, clinical services that lack applicability to the African context (Adetula et al. 2022). Training programmes often overlook the inclusion of indigenous practices to foster decolonial praxis (taking the form of, for instance, cultural competence, humility and responsiveness) in assessment and intervention. Relatedly, training that emphasises continuous adaptation to and alignment with evolving community needs is critical for ensuring that assessments and interventions are derived from contextually relevant frameworks (Cockcroft 2020).
Inclusivity might be enhanced by increasing training opportunities for individuals from historically marginalised communities. One might use a tiered approach to provoke such an increase: firstly, establish more practicum training opportunities, secondly, more internship positions, and thirdly, more mandatory community service posts (Bush et al. 2023). Such systemic shifts in training pathways require not only pedagogical reform, but also transdisciplinary collaborations among universities, healthcare providers, community organisations and governmental agencies.
Other opportunities for collaboration, and hence for increased inclusivity, should be sought on the African continent. Historically, South African neuropsychology has shown little appetite for engagement with other African nations. This lack of exchange represents an underutilised opportunity for fostering research and clinical advancements through a more inclusive and regionally informed approach.
The practical factors that might hinder these efforts towards transformation include limited resources, a lack of professional capacity and intrinsically Euro-American curricula. Although training programmes do not have the means to address chronic and nationwide resource constraints directly, academic staff and students can play a vital role in advocating for policy reform by disseminating evidence-based research that exposes the inequalities in neuropsychological training and service delivery across South Africa. Such work on resource allocation gaps and exclusionary policies can further inform the development of decolonial training frameworks and may help promote new models of care grounded in local communities.
Addressing the lack of professional capacity (i.e the relatively small number of fully trained and registered neuropsychologists in a country that faces a high burden of disease) is a long-term project that requires intense collaboration by, among others, universities, government health departments, public and private hospitals, and non-governmental organisations. This collaboration should focus on the development of sustainable training programmes by implementing, for example, scaffolding strategies such as online instruction, satellite campuses and mobile clinics as a means to expand educational and instructional possibilities across the country.
Finally, there is the critical matter of changing intrinsically Euro-American curricula. Here, we envision a multipronged strategy that includes:
- Training programmes adopting a community-based approach centred on prevention, rehabilitation and neuropsychoeducation; this approach can help re-orientate training from a purely functionalist model towards one that values relational engagement and social responsibility (Garton et al. 2022; Joosub 2019).
- Academic staff within the programmes acknowledging the changing role of students from passive recipients of knowledge to dynamic collaborators in teaching and learning (Van Zyl et al. 2020).
- Students and staff cooperating in an active process of curriculum (re)development.
- Students and staff adopting professional roles that exemplify the values of decolonial praxis and social justice in their practice; in practice, these values would lead to an advocacy for more resources and structural support by networking with policymakers and healthcare organisations and by raising awareness of the need for more inclusive and culturally responsive training.
Conclusion
Globally, the teaching and practice of neuropsychology, as well as its research methods and research foci, tend to operate within a framework that is rooted in Western, individualistic and androcentric ontologies. In South Africa and other LMICs of the global south, this Euro-American framework has marginalised indigenous epistemologies and healing practices and discouraged wide-reaching and inclusive participation in the delivery of clinical services, production of research knowledge and advocacy for healthcare policy formulation.
The South African context is marred even further by the lingering scars of the apartheid era. During that era, non-European cultural practices were pathologised as indicative of societal dysfunction, intellectual inferiority and mental illness, reinforcing systematic marginalisation and cultural erasure. Today, the reverberations of those historic injustices persist. Black South Africans continue to be under-represented as both staff and students in training programmes and the population of practitioners and, as patients, they have relatively restricted access to private healthcare, tending instead to rely on the failing infrastructure of the public system. Moreover, academic collaborations tend to favour partnerships from the global north rather than intercontinental and regional relations.
We encourage neuropsychology training programmes in South Africa to participate actively in rejecting these epistemic and historic injustices. Although cross-cultural neuropsychologists have long acknowledged the need to adapt local practices to align with cultural understandings and ecological validity, few have framed their proposals within strong theoretical frameworks or described precise methods for change. We advocate for a decolonial approach, allied to a convivial attitude and task-related practices a la Osmer. Training programmes transformed following those approaches, attitudes and practices will not only benefit staff, students and clinical professionals, but will also ensure that the field of neuropsychology in South Africa is more equitably accessible and relevant and can make meaningful contributions to individual and societal health and well-being.
We end with a cautionary note. This article is a conceptual piece that critiques the current state of the neuropsychology training programmes (and, by extension, the current state of the discipline) in South Africa. We add to the dialogue regarding decolonial approaches to the transformation of higher education in this country, and offer practical suggestions for how to effect socially just changes in what has been, to this point, an unchecked area of the academy. This article is not, however, intended as a static blueprint for how to transform South African (or African, or LMIC) neuropsychology training programmes. A crucial tenet of decolonial approaches is that they are sensitive to context, and context changes not only spatially but also temporally. Areas we may identify as being in need of transformation now may not be as relevant to neuropsychologists in other countries, or in future times. Their approach may therefore be different to ours. Nonetheless, we urge all who are involved in these training programmes to invest in multiple ways of learning and knowing, to prioritise cultural sensitivity, and to resist complacency by continuing to engage critically with apparently entrenched perspectives.
Acknowledgements
Competing interests
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
K.G.F.T. is a co-chair of the African Neuropsychology Network (ANN). He contributed to the article’s overall conceptualisation and structuring, wrote portions of the manuscript, and was senior editor of the final version. L.E.S. is a co-chair of the African Neuropsychology Network (ANN). She contributed to the article’s overall conceptualisation and structuring, wrote portions of the manuscript, and assisted in editing the final version. N.M. contributed to the article’s conceptualisation (particularly related to sections on decolonial theory), wrote portions of the manuscript, and assisted in editing the final version. K.-L.R. wrote portions of the manuscript and acted as the language and formatting editor for the final version article. She prepared the manuscript for submission and submitted the article on behalf of the authorship team. Core members of the African Neuropsychology Network (ANN) participated in theoretical discussions and brainstorming ideas around the transformation of neuropsychology in South Africa. The foundations of the contributions made in the current article were informed by group discussions among these members of the ANN. K.S.v.W, N.J., W.N., and N.C. contributed to the article’s conceptualisation and wrote portions of the manuscript. All named authors read and approved the manuscript ahead of submission.
Ethical considerations
The current article, ‘Transforming neuropsychology training programmes in South African higher education settings’, qualifies for an ethics waiver given that it is non-human and non-animal subject research, and is instead conceptual and theoretical in nature. The data reported in the article were publicly available information from university websites.
An Ethics Review Committee of the Faculty of Humanities at the University of Cape Town determined that a formalised waiver was not necessary in this case. The reference number is PSY2025-019.
Funding information
The authors received no financial support for the research, authorship and/or publication of this article.
Data availability
Data sharing is not applicable to this article, as no new data were created or analysed in this study.
Disclaimer
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.
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Footnote
1. Disparities in service delivery and racially-based healthcare inequalities that were established during the apartheid era continue to affect black South Africans disproportionately: They have significantly less access to mental healthcare services, despite being exposed to more adverse life experiences and higher levels of personal, community and political violence (Harriman et al. 2022; Sorsdahl et al. 2023).
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