Abstract

Background. South Africa (SA)’s pluralistic mental health system reflects a coexistence of biomedical and traditional healing paradigms. While this plurality enhances cultural accessibility and patient trust, it also raises ethical and legal uncertainty regarding professional accountability and liability. The absence of harmonised governance between the Health Professions Council of South Africa and the Traditional Health Practitioners Council complicates interprofessional collaboration and increases the risk of professional exposure. Objectives. To explore how psychologists, psychiatrists and traditional health practitioners (THPs) understand risk, liability and accountability in pluralistic mental healthcare, and to identify areas where ethical and legal frameworks could be strengthened to support culturally responsive and legally coherent collaboration. Methods. A qualitative exploratory-descriptive design was employed. Semi-structured interviews were conducted with 19 practitioners, comprising psychologists, psychiatrists and THPs. Data were analysed using Braun and Clarke’s thematic framework to identify shared and divergent understandings of professional responsibility, ethical practice and legal accountability. Results. Three overarching themes emerged: ambiguity in professional accountability, ethical tensions arising from cultural responsibility, and the need for policy and legal reform. Practitioners recognised the value of pluralistic care, but cited an absence of clear ethical guidance, referral systems and shared documentation protocols. Psychologists and psychiatrists expressed concern about malpractice liability, while THPs highlighted marginalisation within formal regulation. Participants emphasised the importance of ethical frameworks that respect cultural pluralism while protecting professional integrity and patient safety. Conclusion. Pluralistic collaboration is an established feature of mental healthcare in SA, but remains ethically and legally underdefined. Aligning the Health Professions Act 56 of 1974 and the Traditional Health Practitioners Act 22 of 2007 through joint policy development would clarify accountability and reduce liability risk. Interprofessional ethics education and formal referral mechanisms are essential to integrate cultural legitimacy with legal coherence.