Hot Issues in Mental Health

Psychology Cuts

From Jillian Harrington - The leading comment in an article “Psychology cuts defy expert advice” in The Age on Thursday 29 December 2022, p.27

“Inequity will grow and mental health care will step back several years on January 1, when psychological treatment will be halved to just 10 sessions per year. This, despite every committee or review of the past 10 years recommending more sessions for those with more severe illness. The Albanese government will slash access to psychological treatment under the Medicare Better Access program next week – under the guise of making mental health care “more accessible”. It claims Australians accessing more than 10 sessions have been somehow making it harder for those from low socio-economic backgrounds or regional and remote areas to get the help they need.

What these changes actually do is put effective treatment out of reach for many thousands of vulnerable Australians, ignoring explicit findings from the Medicare Review Taskforce, the Parliamentary Select Committee on Mental Health and Suicide Prevention, the Productivity Commission’s Mental Health Inquiry and the current Better Access Evaluation.

This forces psychologists into uncomfortable decisions: spread appointments out, or aim for a short, sharp burst of more intensive therapy and hope for the best.
Those with money can still pay for evidence-based care, but many families and low-income earners will simply miss out.

The Better Access Evaluation, an independent assessment commissioned by the government, was silent about why a small but significant group – roughly one in six patients who access the program – requires more than the initial 10 therapy sessions a year. Most people do require only five or six sessions, but it is a false economy to deprive those requiring a higher “dose” the extra sessions they need.

In my practice there is one common factor about which the Better Access Evaluation didn’t ask. If it had, it would be the most likely factor to underpin the need for more sessions — and that is developmental trauma. Childhood abuse or neglect leads to much higher instances of almost every mental health condition. The diagnoses vary from depression to anxiety, addictions, personality disorders or post-traumatic stress disorder. It’s politically unpopular, but a significant body of evidence and several clinical guidelines tell us what works to help childhood trauma survivors overcome abuse and neglect: long-term psychological therapy.

Recovery through therapy involves finding solid ground in the here-and-now (at first it might be preventing suicide, then developing safety and stability, and learning to manage big feelings). Then, coming to terms with the past (processing the memories of unspeakable trauma, mourning the losses of a childhood in which much was missed), and finally, orienting to a future with healthier connections, identity, purpose and meaning. This often takes years, not months, and the best outcomes are achieved with continuity of care — long-term work with the same person.

While the private practice “fee for service” model is disparaged by many, it is the most cost-effective and often the only option for long-term care with the same therapist.

The Better Access Evaluation found “those with the greatest levels of need were not only more likely to access Better Access treatment services but also that they were likely to access a greater number of sessions and to pay less for doing so”. When therapy is funded at the right dosage, this system works.

With a promise of experimental alternatives, the Albanese government has left evidence-based treatment accessible only to those who can pay. It is argued that those with more complex or severe mental illness need alternative models of care — something different to individual psychological treatment. The evaluation warned, however, “any new or modified model should be trialled alongside Better Access, with the processes, outcomes and costs carefully monitored before any broader roll-out”.

While the evaluation found that both the number of people seeing psychologists and session usage did increase slightly over the past couple of years, the number of new patients entering the system has held steady. The report found psychologists provided more services.

Anecdotally, we know that many increased work hours to cope with increased demand. Psychologists know that those with higher need have been getting closer to the level of help they need for true recovery. While wait times had initially increased, many practices now report a return to pre-pandemic wait times.

For many thousands of Australians whose mental health issues are underpinned by developmental trauma, a new model is not actually what they want or need. Multi-disciplinary, team-based care instead of evidence-based individual treatment, when both are needed, would be unthinkable in physical health. These cuts make true recovery much less likely, and once again put mental health in the “poor cousin” basket. Physical health treatment is never compromised in this way. We don’t limit Australians to half a course of antibiotics. This cap on necessary services would never happen in cancer care.

When these cuts were announced, the health minister claimed they would help to address the inequity between high and low-income-earners and between the city and the country. Without addressing the shortage of psychologists, nothing in these cuts will solve that problem; they just leave thousands of vulnerable people without adequate care.

To date, the government has refused to extend incentives to lure nurses and doctors to the bush to psychologists and other mental health professionals, or to address other blockages in our university training systems.

Since psychology rebates began in 2006, Australia has led the world in access to evidence-based psychological treatment.

Our new prime minister has famously said “short-term thinking is the greatest enemy of good government”. For developmental trauma survivors, this short-term policy reaction is the enemy of what Whitlam aspired to – adequate care for all, regardless of their place in society.”

Jillian Harrington is a clinical psychologist, a director of the Australian Psychology Accreditation Council, and president of the Applied Neuroscience Society of Australasia. Her comments were echoed next day on page 4 in another article, by Lisa Visentin, titled “Peak mental health group blasts cuts”.

“The chair of Mental Health Australia questions whether the Albanese government has dropped reform of the system as one of the nation’s top priorities, in a powerful intervention ir1to the debate over the decision to halve the number of Medicare-funded psychology sessions. The change, which takes effect from January 1, will result in subsidised psychology sessions dropping from 20 per year back to the pre-pandemic maximum of 10.

It has alarmed mental health advocates and experts, who are urging the government to address the lack of supply of psychological and psychiatric services in Australia.

They also warn that the return to pre-COVID funding arrangements should not be taken as a sign that the pandemic’s hidden impacts are over — a plea which aligns with fresh statistics from Lifeline showing unusually high demand for help may be the “new normal”.

Chair of peak advocacy body Mental Health Australia Matt Berriman said the cut to Medicare-subsidised psychology sessions had raised broader concerns about the mental health system. He challenged the government to reveal its longer-term plan.

“We need added services and action yesterday, not less,” Berriman said. “The new government should make mental health a key priority, which has seemed to have been lost since taking power.”

Health Minister Mark Butler will host a forum on January 30 with experts and advocates on how to make Medicare-backed mental health services more sustainable and equitable.

On December 12, Butler announced the government would not extend access to the 10 additional Medicare-backed sessions, introduced by the Morrison government as a temporary measure during the pandemic. They were always due to expire at the end of 2022. He has defended the decision based on the findings of a Melbourne University evaluation which found the system was “serving some groups better than others”. The report found that only about 15 per cent of people accessing treatment had taken up at least one additional session, and may be limiting new patients’ access to treatment But the evaluation ultimately recommended the 10 additional sessions be retained and targeted towards those with complex needs. ‘

“The scheme is called Better Access, but the additional sessions made access worse,” Butler said. He said the evaluation was not conclusive about how the extra sessions could be targeted, and that was why the government was convening a forum to canvass options.

He said the government was “committed to expanding the range and supply of psychological services for everyone”, and flagged this would involve “building the mental health workforce and developing new digital and direct models of service.”

However, the decision to scrap the additional sessions has divided medical and mental health experts, with psychologist groups in particular opposed to the change.

Professor Caroline Hunt, the president of the Australian Clinical Psychology Association, said the decision was premature given it would likely take years to roll out specialised services to target the “missing middle” cohort of people.

Professor Patrick McGorry, a psychiatrist and executive director of Orygen, the centre for youth mental health at the University of Melbourne, said he broadly supported the government’s decision but stressed the focus must shift to funding specialised treatment programs for people with complex health needs. Crisis support service Lifeline has reported a 20 per cent rise in daily calls since the pandemic began.”

One Response

  1. MHYFVic supports continued extension of the rebate scheme for psychological treatments of mental disorders. The argument that it has impaired access by needy people is a nonsense. It is political spin, based on the observation that waiting times transiently increased under the pressure of work, but that is only because of insufficient numbers of trained therapists. That, itself, is a failure of planning. It is no argument to say that one failure justifies another.

    Governments need to grasp the nettle of providing rebates for mental health just as they do for physical health. The reason they are reluctant is because it costs money. There is no free lunch. If the service is needed it must be paid for, and the public must pay through our health insurance. The current levy is totally out of keeping with actual costs. The public is right to demand the service but must also be willing to bear the cost. The solution to this issue is to legislate a Medicare levy that actually reflects the costs, which must surely be “politics free”.
    One way that governments and health care professionals could simplify the burden would be to adopt the “Zero Waiting List” approach advocated by MHYFVic. This is described in our
    Guide to Best Practice PE7a paper

    It involves an immediate assessment and formulation of a management plan followed by therapeutic triage. The majority of cases would be managed within a short-term package of ten sessions, but some would be seen, at the initial assessment, to need longer-term therapy. This triage would allow longer-term therapy at a lower rebate rate for as many sessions as required (with the option of a gap fee). Allowance could be made for people in financial difficulty. That is what government is for.

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