Enraged psychologists fighting for an improved mental health system

Enraged psychologistI’ve never met so many enraged psychologists as I have in the last six months. We’re channelling our pent up fury by pounding keyboards, our battle cry is echoing loudly through social media and Members of Parliament (MP’s) are being accosted at every opportunity.

And that goes against everything I know about my usually sedate and contemplative colleagues.

Life of an enraged Psychologist 

Let me tell you a bit about the life of a psychologist. We work with vulnerable people in our community. You can find us in hospitals, schools, unemployment services, domestic violence agencies, substance abuse services, disability services, prisons, rehabilitation clinics, the armed forces, the police service and in private practice. We work with kids and adults.

Most of our days are spent being cool, calm and collected… and teaching others to do the same.

We are a female workforce, 80% of psychologists are female.   I have worked with very few male psychologists. Possibly men don’t join us because it’s a low paid, caring role and we need to change that. You’ll often find a disproportionate number of male psychologists in management, board and director roles. The mental health system is dominated by male psychiatrists. Yes, psychology is low paid. Many psychologists work part-time, juggling family care.

We spend hours exploring trauma, often perpetrated by the hands of others, that has led to the clients’ mental health problems. We sit beside those in debilitating emotional and physical pain. We hold space for gut-wrenching grief. We teach, support, advocate and listen.  It’s exhausting work.

We often don’t have much energy or patience left at the end of the day, but we go home and tend to our families. We are not usually enraged psychologists.

Blindsided Psychologists – Is this a feminist issue?

To our detriment, as female psychologists, we have been so focused on supporting our clients (and our families), that we have allowed our profession to be blindsided, and this has ultimately been detrimental to our clients. Most psychologists (and our clients), not just those who work in private practice, will continue to be disadvantaged unless the Medicare Benefits Schedule Taskforce Review into Mental Health currently underway makes significant changes. (If you are a psychologist who doesn’t work in private practice and you think this has no impact on you… keep reading!)

In 2006, in the dark ages, before we had harnessed the power of social media to build a collective of enraged psychologists, Medicare instigated a two-tier system to assist Australians to access psychological treatment.

I vaguely remember this happening, but I wasn’t working in private practice then, so didn’t pay much attention. I should have!  Behind this two-tier system is a story worthy of a tv drama of political intrigue and deceit. It includes powerful and stealthful lobbying by one group of psychologists and academics, unnoticed by another preoccupied group of psychologists who were focused on their clients (and family) and placed their faith, and money, in the Australian Psychological Society (APS) who vowed to represent them. In my opinion, the APS ruthlessly betrayed the majority of psychologists and the Australian public by failing to advocate for the bulk of their members and failing to advise on an appropriate mental health process for Australians.

The drama also includes the pervasive culture of fear that has been instilled in psychologists, through threats of retribution and ostracism if you are do not hold membership with the APS.  Fearful psychologists question “If I advocate for change will I be audited?”,  “Will I be blacklisted?”

I say viva la revolution!

Why are psychologists enraged? Meet the discriminatory Medicare two-tier system!

The Medicare two tiers are this.

  1. One tier provides access to Clinical Psychologists who are permitted to provide the evidence-based therapy which is best for the client. Clients receive a rebate of $124.50.
  2. The other tier provides access to Psychologists who are only permitted to provide Psychologically Focussed Therapy. This is a limited choice of therapies and may not be the best therapy for the client. Clients receive a rebate of $84.80.

Psychology sessions under the Medicare two-tier system are not free to clients!

Let us do away with that fallacy. Most psychologists can’t sustain a living by bulk billing clients. We have to charge a gap fee.  In general, psychologists providing Medicare services are self-employed, even if we work in a group practice. We must pay for room rental, insurance, professional development, and administration. We do not get paid holiday or sick leave. We are meant to finance our own superannuation, but many don’t make enough to do so. There is no fee for letters to doctors, the phone calls we make and the preparation that takes place before we see clients.  If a client doesn’t turn up, we often don’t get paid.

The Medicare two-tier system misleads clients!

Clients assume that the higher rebate for a clinical psychologist ensures they receive superior therapeutic treatment from a psychologist who is more skilled and experienced than those who are not eligible for the higher rebate.  This is false.

Consider a client with Complex Post Traumatic Stress Disorder as a result of child sexual abuse who requires psychological treatment.  Currently, the treatment options for a client through Medicare may hypothetically be:

  1. A clinical psychologist, with a Masters in Clinical Psychology, with two years’ experience whose previous employment was in a hospital renal ward.  This psychologist is at the start of their career and their professional development has been in pain management and weight loss strategies.
  2. A psychologist, with a Masters in Applied Psychology (Counselling), with 10 years’ experience working with trauma victims in domestic violence and sexual assault services. This psychologist has invested years of professional development in treating child sexual abuse.
  3. A psychologist who completed 4 + 2 pathway (four-year degree + two years’ probation completing a competency-based program under supervision) with 20 years’ experience in sexual assault services, a drug and alcohol community organisation and private practice. This psychologist has invested in years of professional development from leading trauma experts.

Under the current Medicare two-tier system, the clinical psychologist (A) can offer a broad range of therapeutic interventions.  However, psychologists B and C, while trained and experienced in the delivery of appropriate therapeutic interventions are limited to only providing Focussed Psychological Strategies while working under Medicare.  Although, they can provide alternative and more appropriate services to private clients.  Therefore, the two-tier Medicare system limits the client’s access to the most appropriate therapeutic intervention and their ability to choose the most experienced psychologist that would best meet their needs.

The situation becomes even more complex when a client needs to access a service where there is only one (non-clinical) psychologist available, such as in a remote area (most clinical psychologists are found in cities).  That psychologist is then limited, unethically and without evidence, by the Medicare rebate system, to the type of therapy they can provide the client. And, psychologists with clinical endorsement only make up 40% of the psychology workforce.

While I have proposed a hypothetical situation, it reflects my real-life experience of working within psychological services alongside clinical psychologists.  We all do the same work.  I have taken over caseloads when psychologists have resigned, with and without clinical endorsement, and there is no discernible difference between client complexity or treatment plans. All registered psychologists are trained in and can diagnose, assess and treat clients, regardless of whether they are clinically endorsed or not. The example provided demonstrates that depth and breadth of psychological expertise is developed post-university.

This great video by One Psychology  Australia explains it even better.

All psychologists do great work with their clients.

Psychologists working in both Medicare tiers obtain great outcomes with their clients.  There is no outcome difference between psychologists with or without clinical endorsement. Behind the closed doors of the counselling room, we all do the same work.  We all provide the therapeutic treatment that is the best for the client. To not do so, despite the Medicare restrictions, would be unethical.  See Research into Outcomes in Psychology Practice Under Medicare Better Access.

The Medicare two-tier system perpetuates a false hierarchy

The Medicare two-tier rebate system has imposed a false hierarchy within the profession of psychology which is now negatively impacting psychologists’ roles in systems outside of Medicare such as hospitals, schools, Centrelink and the NDIS.  A clinical psychologist is now, falsely, seen to represent a psychologist with more expertise than that of other psychologists. Psychologists, who do not have a clinical endorsement, have been stopped from providing assessments and reports in these systems, despite years of experience and appropriate expertise.  Imagine what its like if you are a parent of a child with autism, who has been diagnosed and treated by a psychologist, with years of experience and training in the field,… but their report is rejected.  However, a newly qualified psychologist with a clinical endorsement, with limited experience, can sign the report. No wonder we are enraged psychologists!

Private practices are recruiting clinical psychologists over other, possibly more experienced and qualified psychologists, simply because they attract a greater Medicare rebate and therefore higher fees can be charged.

In popular usage, the term clinical psychologist refers to a psychologist who works in a clinic. The term is often misunderstood by community members and those that work in the health profession.

The term clinical psychologist represents an area of endorsement with the Australian Health Practitioner Agency (APHRA).  There is an increased number of jobs advertising for clinical psychologists, despite there being other psychologists (who may hold other endorsements with APHRA) who would meet the skills and experience required for the position.

The Medicare two-tier system limits client access to a competent and diverse range of psychologists.

The consequences of this false hierarchy, which is seeping through the profession, is that there are now fewer university courses in Applied, Counselling, Health, Organisational, Education and Developmental psychology.  This narrowing of the psychological field is not a benefit to the mental health and wellbeing of our community. The continuation of the Medicare two-tier model would further support and promote this false hierarchy.

I am a psychologist in a busy Brisbane inner-city practice and our administration team now consists of four psychology students.  They have all discussed the pressure they are under to complete a Masters of Clinical Psychology, despite valuing the diversity of our team, and preferring to take an alternative pathway to become a Psychologist.  They worry that if they do not take the clinical psychology pathway their future employment opportunities will be limited.  They contemplate leaving the profession before they have even entered it.

One Tier – One Rebate

The MBS Taskforce Review into Mental Health initial draft document for public consultation has now been released. The report recommends some improvements including much needed additional sessions for clients with the greatest need, being able to see parents without the child being present and more flexibility to deliver group program.  Unfortunately, the two-tier model remains!

We need One tier – One rebate.  This system will allow the client to access the therapy they need from the most appropriate psychologist… or mental health social worker, or mental health occupational therapist.

Psychologists, let’s continue the rage!

Psychologists maintain the rage!  Speak boldly with your enraged voice, the public debate is urgently required. Do not listen to those that label you a trouble maker, be the instigators of change. Do not be “good” and quiet girls, be strong and powerful women.
We must take time out from client and family care, and stand up for ourselves, and for our clients. We need to become political beasts, meeting with MP’s, writing missives of rebellion to the Australian Psychological Society (who originally proposed an even worse three-tier system to the Taskforce Review see my earlier response to that here!) and joining the Australian Association of Psychologists and Reform APS who provide an alternative viewpoint to the Australian Psychological Society. The profession of psychology cannot be united unless the injustices are addressed.

Keep up the activism, so we have significant input into the final report of the MBS Taskforce Review into Mental Health.

We need consumers and providers of the Australian mental health services to understand the ramifications of maintaining the Medicare two-tier system and act to change it.

One tier – one rebate.

Enraged Psychologists, you can take action.

Mental health advocates and consumers, you can take action