Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697645619374.pdf (Australia)
Select Committee on Mental Health and Suicide Prevention I am writing to respond to two of the Select Committee’s Terms of Reference: • Emerging evidence-based approaches to effective early detection, diagnosis, treatment and recovery across the general population and at-risk groups, including drawing on international experience and directions; • Building on the work of the Mental Health Workforce Taskforce and forthcoming National Medical Workforce Strategy, the roles, training and standards for all health and allied health professionals who contribute to mental health care, including peer workers, that are required to deliver quality care at different levels of severity and complexity, and across the spectrum of prevention, early intervention, treatment and recovery support.
I will first address the second point focusing on the Mental Health Workforce.

I would like to draw the Select Committee’s attention to a sector of the mental health workforce which has until now received limited attention in the various commissions and reviews of mental health in Australia.

I refer to this group as Mental Health Counsellors.

Counselling in Australia has been relatively slow to organise itself as a clearly defined profession, distinct from similar allied health professions.
One of the legacies of this tardy organisational development is confusion about qualifications, levels of registration, and specific expertise within the counselling field.

In my commentary, I aim to differentiate Mental Health Counsellors from other Counsellors and to establish their bona fides as mental health practitioners within the mental health system and therefore their availability as an essential dimension of the mental health workforce.
The two peak Counselling bodies in Australia, the Psychotherapy and Counselling Federation of Australia (PACFA) and the Australian Counselling Association (ACA) under the auspices of the Australian Register of Counsellors and Psychotherapists (ARCAP) have made numerous submissions to various commissions and select committees representing counsellors and psychotherapists.
While such representations have served to draw attention to the qualities and presence of these professions within the wider health system, they have not, to date, afforded the professions of counselling and psychotherapy sufficient and equitable recognition.

One of the many impacts of this inequity has been the obfuscation of professional counsellors serving in the second tier of the mental health system.
As I will clarify further in this submission, there is a substantial workforce already available to be more fully included in the mental health workforce if it is recognised appropriately by government.

As someone who has served on the board of professional counselling associations, chaired standards committees and who is a university educator in counselling and mental health, I am well placed to assess what knowledge and skills counsellors bring to their professional practice.
While I laud the efforts of the authors of the various ARCAP submissions and agree with much of their commentary and claims, I dissent from their views about professional counsellors, in general, as being ready for inclusion as mental health practitioners within the Better Access system, although with one exception.

My claim is similar in kind to that of the professions of Social Work and Occupational Therapy wherein only some members of these professions are classified as Mental Health Practitioners.
Both Social Work and Occupational Therapy are self-regulating professions like counselling, but members in these professions who can demonstrate additional training and competencies in mental health are eligible for recognition as Mental Health Social Workers or Mental Health Occupational Therapists.

The irony is the profession most explicitly trained in the delivery of psychological therapy, Mental Health Counsellors, are not provided the same recognition.
As in the professions of Social Work and Occupational Therapy, there are many professional general Counsellors who would not qualify as mental health practitioners.
However, the training received by the majority of degree-qualified Professional Counsellors is already sufficient to meet the government’s stated mental health Mental Health and Suicide PreventionSubmission 160 Mental Health and Suicide PreventionSubmission 160 Mental Health and Suicide PreventionSubmission 160 Select Committee on Mental Health and Suicide Prevention The problem with this statement is again its double standard in that the Commission also states in respect to the delivery of psychological therapy delivered by psychologist and other mental health practitioners: There is strong evidence demonstrating the efficacy of individual psychological therapy in clinical trials (Lambert 2013, pp.
176, 193).

But there is currently insufficient evidence that any of the three avenues for taxpayer-subsidised psychological therapy are effective as they are delivered.

In other words, it is not clear that they are substantially improving the outcomes of the people using them.

This is concerning, given the dominant role of psychological therapy in Australia’s mental health system (Vol.

2, p. 558).
2, p. 558).

Based on the Commission’s own admission, psychologists and other mental health practitioners deliver mental health interventions via psychological therapies but not on the basis of demonstrated evidence.

Hence, it is reasonable to question, on what basis those who are recognised to deliver psychological therapies are qualified to deliver such services.

I suggest that it cannot be on the basis that TEQSA has double standards for its approval of masters level qualifications.
My own view is that it is based on professional profiles established through historical longevity, a medical model bias (that is, a bias towards a positivist paradigm of human functioning) and lobbying capacity.

Counselling while actually an old practice, is a relatively young profession, at least organisationally, and this has limited its profile and capacity to inform and influence policy makers.
In my view, counselling in Australia has also not supported the promotion of its own strengths and capabilities by its continued endorsement at least in some corners of the profession, of a range of levels of training, some of which are sub- degree.

This has had the effect of conflating the view in the minds of critical commentators, that counselling is only a practice done by minimally trained practitioners.
As the term ‘Counsellor’ is not protected, the Commission is correct in noting that it holds concerns about verifying standards.

There is absolutely no doubt that a substantial portion of the counselling workforce are highly qualified professionals in mental health.

It is also true that without a protected title which, to some degree, guarantees training quality, it is harder to establish the professional standing of specifically- trained and well-qualified counsellors, although not impossible.
My recommendation is that like Social Workers and Occupational Therapists, those Counsellors who do meet the national mental health competencies should be recognised by government as qualified and available mental health practitioners under Better Access.
Such Counsellors would be designated as Mental Health Counsellors in order to differentiate them from General Professional Counsellors While ARCAP and its representative bodies could be charged with assessing those applying for recognition as Mental Health Counsellors, I propose an alternative model.

This is the establishment of a Mental Health Counselling Association whose single task is the representation, assessment, and validation of Mental Health Counsellors.
The benefit of this approach is that it removes any confusion in the mind of commissioning bodies regarding the qualifications and competencies of Mental Health Counsellors.

Only those who have been validated by this new association would be deemed mental health practitioners.

There are many General Counsellors who work in NGOs and other organisations who do not regard themselves as mental health practitioners and these professionals are well represented by PACFA and ACA.
They are recognised by the government as professionals who provide early intervention and support for people with mild mental health issues.

My proposal is that Mental Health Counsellors are qualified and competent to work with people struggling with moderate to high demand mental health needs such as those accessing support through Better Access.
There is a strong precedent for this proposal in the United States example where the Mental Health Counsellors Association exists alongside the American Counselling Association.

Notably, the US senate recently approved admission for licenced Mental Health Counsellors to their Medicare system.
Mental Health and Suicide PreventionSubmission 160 Select Committee on Mental Health and Suicide Prevention One further option for recognition of Mental Health Counsellors would be the inclusion of such a category designation on the AHPRA register.

If the Parliamentary Select Committee felt that an even stronger regulatory approach was warranted to assure the quality and standards of training for Mental Health Counsellors, it could propose inclusion of Mental Health Counsellors on the AHPRA register.
In my view there are two overarching issues to consider, quality and sufficient provision of well-trained practitioners for the workforce.

Currently there is strong evidence of insufficiency of supply in specific areas of the mental health workforce (Meadows, 2020; Royal Commission into Victoria’s Mental Health System, 2021; Senate Community Affairs Committee Secretariat, 2018).
If the issue of confirming and recognising standards is resolved either through the above recommendation of the establishment of a Mental Health Counselling Association to advocate for and vet the standards of members as mental health practitioners, or through the establishment of a Mental Health Counselling Board within AHPRA, or both, then a significant increase in the mental health workforce can be achieved immediately.
I would like now to turn to the second Term of Reference as stated below: Emerging evidence-based approaches to effective early detection, diagnosis, treatment and recovery across the general population and at-risk groups, including drawing on international experience and directions.

The importance of evidence-based approaches in mental health and psychological therapies has grown in prominence over the past twenty.
Taking a cue from medical sciences, other disciplines have sought to demonstrate the effectiveness of their professional practice through hard scientific evidence.

This notion has warrant because individuals, society as a whole, and certainly funding bodies like governments, want to know that their monies are being well spent.

One of the difficulties though with the idea of evidence-based practice is its positioning within the hard sciences.
One certainly wants to know that the surgeon’s knife is going to be placed in the right part of the body.

In the physical sciences this idea works well.

However, while not irrelevant, it does not work so well in the human and social sciences.

The reason for this is that the human psyche is not as amenable to mechanistic measurement as is the physical world.

People often recover from a range of mental health issues when simply listened to in a professional, attentive, caring way.
This is not to say that specific interventions and psychological strategies are not required.

It does, however, highlight that we cannot simply apply an approach or measures suited to one paradigm to another.

One of the emerging paradigmatic shifts in the mental health system over the last twenty years is what is often referred to collectively as a person-centred, recovery approach to mental health practice.
The impetus for this approach originally came from service users who were dissatisfied with the type of care they were receiving.

The type of care was based in a medicalised psychological form of care founded on positivist assumptions.

Simply put, this is the view that, if we can identify symptoms of a problem and measure it, we can solve it.

Again, this approach at times has merit, but it also reduces the human psyche to the status of a machine.
Not surprisingly, service users have found that this approach does not work.

Thankfully, the recovery model has championed a more humanistic, whole- of-person conceptualisation of mental health and recovery.

Practitioners who work from this paradigm prioritise client-cooperative case formulation and strategic interventions which are tailored for the individual.

Interestingly, it is this very approach that is recommended in the Commonwealth’s mental health strategy.
Unfortunately, the approach is greatly lagging in real-world application due to the dominance of the medical model mindset.

One of the outworkings of the medical paradigm is the privileging of certain therapeutic approaches.

The argument is that only selected treatment approaches are evidenced-based.

The difficulty here Mental Health and Suicide PreventionSubmission 160 Select Committee on Mental Health and Suicide Prevention centres on what is meant by evidence, an issue rarely questioned.
The evidence in this paradigm is always measurable but only on certain supposedly objective criteria.

This has translated into certain therapeutic approaches being privileged over others but not on the basis of the whole available evidence, rather on narrowly defined evidential criteria.

The approved list of psychological therapies currently available under Medicare’s Focused Psychological Therapies which are largely cognitive and behaviourist in design, is evidence of this fact.
A strong critique of this paradigm is championed by the British Psychological Society (BPS) who suggest that reducing human suffering to the category of mental disorders (a disease model) is nonsensical and does violence to our understanding of the human condition.
Instead of a reliance on diagnosis of mental disorders as the entry point for government supported care, the BPS recommends a non-labelling approach to psychological and social problems based on cooperative problem formulation (Kinderman, et al., 2017; Johnstone, et al, 2018).
This approach is highly consistent with the practice of Mental Health Counsellors and other mental health practitioners who prioritise understanding human suffering as a natural aspect of the human condition, rather than as an organic-like disease condition and therefore do not automatically apply narrowly defined ‘evidence-based’ manualised treatment protocols designed largely to alleviate symptoms.

My critique of the evidence-based paradigm is not one which is anti-evidence.
Evidence for effective professional practice is essential.

The problem lies in the narrow definition of what constitutes evidence.

Rather than an evidence-based approach, many scholars propose evidence-informed practice and practice-based evidence as better alternatives.

These complementary perspectives value a more comprehensive approach to evaluating evidence.
Support for the effectiveness of less- pathologising approaches to understanding and caring for those suffering mental health problems under this more comprehensive view of evidence is widely available (Laska, et al, 2014; Leichsenring & Klein, 2014; Norcross & Wampold, 2011).
Given the strong evidence for the efficacy of a more inclusive range of therapies beyond those already sanctioned, it is recommended that a review be conducted of therapies included in the Focused Psychologies Therapies approach within the Australian Mental Health system but on the basis of an expanded approach to evaluating evidence.

I hope that my information and recommendations aid the committee in its deliberations on how best to provide care for the mental health of all Australians.
I thank the committee for its consideration.

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Mental Health and Suicide PreventionSubmission 160