George Wills: Greater equality in the funding of professional psychology

An argument in support of greater equality in the funding of professional psychology:

The Better Access to Mental Health Care initiative has emerged because of past lobbying by The Australian Psychological Society and serves as an important plank in the provision of mental health services in Australia. Over time, however, it has become apparent that the initiative, in its present form, discriminates against the clients of counselling psychologists because of the larger Medicare refund provided for clinical psychologists and because of a widespread assumption that services provided by other psychologists are not of equivalent value. In the interests of fairness to patients, to encourage better collaboration among psychologists and as a way of expanding the effectiveness of mental health care, I’d ask members of the Board more actively to support the work of counselling psychologists with patients referred from the general community by advocating for equal levels of Medicare funding for equivalent work.

As a counselling psychologist, it’s especially relevant, and ironic to me that at a number of Australian universities and possibly even secondary schools, directors of counselling services (usually non-psychologically educated managers) are now licensing private clinical psychologists to provide a fee-for-service practice under the Better Access system. Based on advertising on Psychexchange, there appears to be a preference for clinical psychologists, and it would seem reasonable to assume this is to take advantage of the higher Medicare rebates for their services and is a marker of the gradual erosion of counselling psychology as a profession within the discipline. I cannot support the evolution of beliefs within the Society that counselling psychology does not have a positive contribution to make to our professional work and I resent the contraction in tertiary training programs that has occurred in the past ten years because of greater strategic representation of clinical psychology in relation to Medicare funding.

My main contention is that specialist programs, such as counselling psychology, have empirically supported, legitimate, complementary approaches to clinical work, therefore it is justified for our professional society to be proactive in support of them. In particular, inspection of the syllabi of counselling psychology programs in Australia will show that attention is given to comprehensive methods for assessing development, personality, intelligence and pathology. In addition, counselling psychology programs give strong attention to relationship issues that can arise for couples and in groups, so such knowledge and skills have wide application to both clinical and non-clinical settings. This view had clear support in a recent contribution to a counselling psychology conference in Melbourne by Prof. Mick Cooper when he spoke of the balanced way that counselling psychologists provide assessment and treatment of individuals, together with a focus on meaningful processes among people in complex living and work environments. To my mind, there is a spectrum of approaches to clinical work within counselling psychology that define counselling psychology as “humanist existential” in nature.

I studied in probably the first counselling psychology program in Australia which was set up by Ron Greig at Melbourne University in 1965. His was a response to the increasing adoption of the scientist-practitioner model of psychology at that university and which has come to dominate professional psychology. It was his view and it has remained my own, that over-emphasis on behavioural variables fails to attend to phenomenological ones that are equally important and there is an assumption that psychological nous and relationship qualities can be taken for granted as existing in professional people in spite of little attention being given to them in education programs.

Members of the Board will know that there is a spectrum of approaches to humanist-existential ways of working, from the minimalism of Carl Rogers to the more complex and group-oriented work of Gestaltists and Psychodramatists yet, what they have in common is the effort to assist clients to engage subtle thinking-feeling processes at the edge of consciousness. In this regard, humanist-existential methods attend to so-called unconscious processes and because they are process focussed there is more reliance on discovery learning and less on expert interpretation.

Within the humanist-existential way of thinking, there are programs that are highly operationalised (the work of Gerry Egan, Robert Elliott and Les Greenberg are examples) but the operational detail is about processes used to assist clients to explore problems, and studies of the relationships between process variables and client outcomes have been tightly controlled and informative of the worth of working in these ways.

In the forthcoming sixth edition of the Bergin and Garfield handbook there will be a chapter included that proves that there is no evidence of superior outcome for those methods I would refer to as “positivistic” over those that are “humanist-existential”, therefore any assumption that difference indicates relative worth is false according to published data. In addition, APS guidelines for conducting research in a respectful way with indigenous Australians is largely supportive of post-positivist methods and, therefore, reflects genuine openness within APS to a wider range of methods of establishing meaning with medically diagnosable people. Such open-mindedness needs to be extended further, if only for the sake of consistency.

As I alluded earlier, failure to recognise and support contributions is divisive and interferes with collaboration. Medical and legal specialists don’t seem to argue for the essential superiority of one specialism over others and, in the process, their professions advance in the outside world. There is no assumption that an urologist ought to be paid less than a neurologist or a paediatrician from government health funding for equivalent service. A sense of divisiveness was my primary reason for writing to the Board in the first place since the supposed distinction among those of us providing psychological therapy seemed specious in the extreme. I was dismayed by the anger and alienation expressed at the meeting of counselling psychologists I attended late last year and I’m sure it was the result of knowing that they are treated by health authorities as if their work is less valid and useful than that of clinical psychologists and the outrage is amplified when there is silence from The Australian Psychological Society in response.

It would seem from the document on the APS position on the Better Access Medicare rebate structure, that if my arguments thusfar are seen to have merit, the main stumbling block to equal remuneration would be related to the topic of “specified supervision”. In this regard I want to make three points:

  • The first is that in the early years of the B.Ed (Counselling) program that I set up at La Trobe University, which eventually became master and doctoral degrees in counselling psychology, there was initial acceptance of our students in hospital and similar settings but, as consolidation of clinical psychology programs proceeded, our students were eventually not permitted to be supervised in them. To my mind, this was based on decisions of a political nature at the time, since no evidence existed about limitations in the performance of my students in medical agencies.
  • The second is that as such discrimination became institutionalised within psychology, mutually advantageous structures were scrapped in favour of narrowly defined approaches to the practices of clinical psychologists and pathways to mutually beneficial collaboration were lost.
  • Finally, as a consequence, I believe that the APS has a responsibility to face up to the essentially political effect of excluding counselling psychology students from medical settings and redress this either by acknowledging the real limits embedded in the reality of such presumptions or to act to provide realistic paths for counselling psychologists to bridge the presumed gap. My own view is that we could usefully learn from each other and a collaborative professional development program could be developed in order both to deal with outside perceptions about such a “problem” and as a way of repairing harm that has been done by past practices within our ranks.

I am conscious of the hard work that has been carried out in the past ten years by senior people in APS to challenge the dominance of the medical profession in the provision of psychological health services to Australians and I think I have some understanding of the strategic decisions that had to be made on the run, which can distort outcomes. Nonetheless, I want to ask members of the Board to consider how much more could be achieved if there were harmonious relationships among all psychologists working in health-related areas – research, education, training and political representation – and see if they could work out a way of making this happen. A two or multi-tiered system discriminates against the clients of counselling and clinical psychology colleagues and perpetuates a false analogy that counselling psychologists equate to medical general practitioners and clinical psychologists to medical specialists, when the distinction is false.

Finally, I want to make the point that it is the role of APS to defend against political forces that would seek to establish discriminatory criteria and, in spite of the fact that hard-ball politics is currently being played with health and education, I have seen no evidence of political desire to discriminate among the work of counselling and clinical psychologists as a way of saving money, they are simply calling in expenditure in a rather pathetic attempt to hold on to an earlier, now failed, promise of a budget surplus.

George Wills (B.A. Dip Psych., M.A. [Psych.], PhD, FAPS.

March 2013