In Conversation With a Sigourney Award Winner: The Ububele Educational and Psychotherapy Trust

CLINICAL CONVERSATIONS

The Ububele Educational and Psychotherapy Trust was 1 of 4 recipients of the 2024 Sigourney Award. Psychiatric Times spoke with Anthony Hamburger, the founder of the organization, and Esther Chunga, the executive director of the organization, about their important work in Johannesburg, Republic of South Africa.

Psychiatric Times: Your organization expands the accessibility and efficacy of psychoanalytic treatment in South Africa.Can you tell us a bit about how you founded Ububele? What inspired you?

Ububele: Since Freud’s time, psychoanalysis has been hallmarked by its limitations. Although psychoanalysis has been the originator of the talking cure over the decades, it has been passed in quantity by many other nonanalytic models of psychotherapeutic interventions. In America, psychoanalysis, while having a major impact initially, was limited to the medical profession. Psychoanalysis was also limited by the length of time of the treatment, especially in the modern era where time of treatment determines the payment by insurance companies. A further limitation is the lengthy time required to train and qualify as a psychoanalyst. The cost of training also restricted and limited candidates to those who were young, wealthy, and educated.

So the question arose: Why, with the large choice of simpler models of mental health interventions available, did a nonprofit organization in Johannesburg South Africa choose to use aspects of psychoanalysis as a cornerstone of their therapeutic model?

Ububele is a nonprofit organization very close to Alexandra Township, a large notoriously difficult area with over half a million people. Alexandra has a high unemployment rate, high levels of crime, and is basically poverty stricken. It is over 100 years old. Ububele was started 25 years ago by 2 psychoanalytic psychotherapists, Hillary and Tony Hamburger. They were clinical psychologists and not qualified psychoanalysts, as there was no psychoanalytic institute in Johannesburg nor in South Africa at the time. In 1978, about 40 psychologists who were interested in learning about the application of psychoanalytic techniques and theory into the clinical practice formed a society called Johannesburg Psychoanalytic Psychotherapy Society. These psychotherapists received psychoanalytic input from a range of prominent British object relations analysts who came out to South Africa annually and ran workshops, both theoretical and supervisory.

Ububele holds a unique position where we combine community and cultural ways of being with sound psychoanalytic theory and practice, right on the site of one of the greatest target areas of need in South Africa. Ububele has always had an innovative and strategic perspective, providing a combination of important mental health services, while continuously contributing to grow more skilled people to create multiplier effects throughout the profession and sector.

PT: One of your goals is to give youth and their caregivers the ability to break intergenerational cycles of emotional poverty and mental health struggles, and ultimately succeed in life. What preventative strategies are the most effective? Can you give us an example of a success story?

Ububele: Ububele’s vision for South Africa is that of a nurturing society with secure, well-cared for children, who grow up to be emotionally healthy adults, competent parents, and good citizens. One of the ways in which we achieve this is through our preventative programs, including the Ububele Umdlezane (the postpartum period) first 1000 days program. Research shows that early childhood experiences are the biggest influencers on lifelong development, emotional health, and wellness. The quality of relational experiences and responsive caregiving during the earliest years of life has been shown to predict physical, social, and mental child outcomes. Ububele’s large focus on the first 1000 days is to provide emotional, psychoanalytically-based support to parents during the critical, sensitive, and vulnerable postpartum period. By providing support to parents during this time, they are better able to offer sensitive, reflective care to their infants and children, enhancing optimal outcomes. Ububele believes that investing in parenting in the first 1000 days of life is not only hopeful, but also the most cost-effective way to improve child and family outcomes.

PT: Ububele also helps mothers and caregivers who struggle to overcome historically deficient and discriminatory systems. Globally, what needs to be done to help improve maternal mental health? What would you say are the top issues you see in when helping to treat mothers?

Ububele: Alexandra township is underresourced with critical mental health social services, including family counselling and psychosocial support. The high-density living conditions for over half a million people (combined with intergenerational poverty) places strain on families and in particular parents, who struggle to supplement the historically deficient public health care systems. The environment is volatile and insecure, marked by previous systemic structures of racial violence. Generations of families experience trauma and neglect in various and multiple ways. Parents are overburdened and generally undersupported when it comes to providing psychologically nourishing child support.

In order to improve maternal mental health on a global level, there needs to be an acknowledgement that this is a critical need for parents and infants globally. That if we get this right, at the very beginning of an infant’s life, their life-long prognosis looks hopeful. That if we intervene with culturally sensitive, accessible, and relevant interventions, we catch risk early and hold dyads longer. There must also be a pull to normalize the need for support in nonpathologizing ways. We also need to open our interventions to be more inclusive of men and fathers. Locally, there are high rates of absent fathers, which can be extremely isolating or contribute to further absenteeism.

The use of community-based lay counsellors, as is with the Ububele model, is a way to continue to reach those at risk in a way that is nonthreatening and less stigmatizing. Lay counsellors who are from the community themselves are often seen as reliable, trusted, and regular conduits for information and access, meaning that more families have a chance to raise concerns with people who are able to take action, and there are more opportunities for appropriate referrals and interventions.

The use of low-cost models of care and treatment, including that of groups for psychosocial support and brief interventions such as the Baby Mat to screen and assess are helpful ways to have wider reach and impact.

PT: You have gone on to create several esteemed psychological training programs for health care professionals, social workers, and teachers. What advice would you give to psychiatrists or mental health clinicians looking to found programs of their own?

Ububele: Ububele was founded with the intention of offering support to the distressed community of Alexandra. The support would come from various mental health interventions offered by trained clinicians, as well as by training residents of Alexandra as lay counselors. In fact, that is not an unusual objective, to use folks from the community. However, the training model became more complicated in that it decided to not have a cognitive behavioral or counseling structure. The founders were clear that the depth of the social problems in the community required a psychotherapeutic model to be able to plumb those depths. In other words, psychoanalysis. But clearly, and obviously, psychoanalysis was out of the question to use in such a setting. But rereading about Freud’s early work in Vienna and Anna Freud’s use of psychoanalytic concepts during the war with the Hampstead, nurseries led to a consideration what of psychoanalysis could be, attempted to become a central important aspect of the training and therapeutic model of Ububele. What from psychoanalysis could be used and integrated into the training of the lay counselors?

Some notes about the counselors: Firstly, the language spoken or rather the languages spoken in Alexandra range from isiZulu, Sepedi, or Sesotho, which are not usually spoken by the initially White professional staff. While seeming to be a problem, it in fact turned out to be surprisingly useful. Neither trainer nor trainee could count on the fact that the discussed emotion would be automatically understood. To say one is sad or hopeless or angry is at a distance from the actual emotion. If there is a challenge to find a metaphor, example, or description to illustrate the emotion being used, this seems to lead to a greater emotional experience of what is being dealt with.

Recently, in supervision between a therapist or a counselor and their supervisor, there has been a conscious attempt to get the presenter of the case to note when people use which language. In one case, for instance, it was found that when an English-speaking African reverted to their home language to express something, it seem to be more alive and authentic and valuable in the room.

A central foundation of psychoanalysis that distinguishes it from all other models of psychotherapy and counseling is the concept of the unconscious. The idea that they could be aspects of behavior and thought which were beyond the conscious knowledge of a person and which would play a major role in the behavior and conscious life of a person. The challenge for training is how to make the unconscious paradoxically a reality. In psychoanalytic training, this awareness of the unconscious and its power is discovered by the practitioner in their own training analysis. During the training of our lay counselors, the trainer constantly questioned the learner’s feelings about whatever they were dealing with. For example, when a counselor visited a new mother in a maternity ward, the supervision of that session would concentrate predominantly on the counselor’s experience and that would lead to exploration of the inner world of the mother. So the emphasis in training was on the counselor and not initially on the patient.

This led to the use of the second psychoanalytic concept: transference. Again, by utilizing transference between the scholar themselves or between scholar and trainer, the transferential experience began to be integrated into the future counselors’ abilities. Wilfred Bion emphasized that learning took place mainly through experience. This became a central aspect throughout the work of Ububele.

Ububele has various programs and interventions ranging from work with parents and children, mothers, and babies and attachment theory (first thousand days as a vital developmental period). South Africa has a significant number of children who must deal with absent fathers, which leaves stressed mothers and grandmothers. Attachment theory, which is in harmony with psychoanalytic knowledge, holds that secure, caring mothering are vital factors in emotional development. In time of poverty, financial hardship coupled with emotional stress leads to parents—especially mothers—not always being able to offer their child the necessary emotional stability required.

When one considers that South Africa has 60 million people, 11 official languages, and a painful and damaging period of apartheid and colonialism, the extreme levels of mental illness and mental anguish are almost impossible to tackel with the resources available. Ububele is working in a restricted corner of Johannesburg and South Africa, and part of our role is to be a training center—a mental health laboratory where mental health interventions can be replicated and reproduced in other places in the country and the world. This is especially important when one is trying to introduce and work with uncommon psychoanalytic concepts, techniques, and methods.

PT: Is there anything else about Ububele you would like to share with our audience?

Ububele: Ububele has a long track record of survival and has the added advantage of our milestone 25-year anniversary this year. By virtue of the combination of theory and practice, Ububele is a unique organization that not only provides services to families but also ensures the sound education of professionals who can continue to increase these services offered. Much of the work is analyzed further into academic papers and masters research dissertations in collaboration with local universities.

In addition, Ububele provides opportunities for university students to learn with internship placements and provides highly qualified supervision and trainings in the form of workshops and one-on-one sessions with highly qualified psychologists and psychoanalysts who work part-time and often at extremely reduced rates in the interests of providing psychoanalytic support.

In 2021, Ububele won the International Psychoanalytic Association President’s Award for Psychoanalytic work in Communities. The International Psychoanalytic Association gave us a grant to research "The nature and impact of Psychoanalytically-Informed Interventions in Alexandra Township" in 2024. The American Psychoanalytic Association gave us a grant to process M&E data from 4 interventions and 4 trainings in 2024, and for a communications campaign to "Shar[ing] the value of Psychoanalytically-Informed Interventions and Trainings for South Africa."

The work being done by Ububele has credible and external verification and we are always hoping for new partnerships and avenues of support to continue to meet the needs of the marginalized community of Alexandra township.

PT: Thank you!

Mr Hamburger is the founder of the Ububele Educational and Psychotherapy Trust. Ms Chunga is the executive director of the Ububele Educational and Psychotherapy Trust.