I was shocked and appalled to learn of the session cutting provisions of the budget. I have been told that the only possibility of change at this point in time is to lobby the greens, and in particular, the greens' health representative. You are probably aware of this already. Nevertheless, I am passing this information on to you.

I participated in the Medicare survey on the Better Access scheme. Our work came up trumps and this has been ignored. My clients do not like to go to psychiatrists. While there are many reasons for this, I get a lot of unsolicited feedback about the perceived arrogance of psychiatrists and their narrowness of approach. Most outstanding psychiatrists have closed their books as they are swamped with patients. I am sure that we can all work more efficiently than we do but where will our clients go once they have used up their sessions. Most of my clients do not have the funds to access private sessions.

As a private practice psychologist I am sick and tired of having our work undermined by the likes of certain psychiatrist lobby groups who misinform the public. Now we have the indignity of having 2 of our sessions removed to fund other programs making it even harder to choose which area to work on in an often complex presentation. Give us a break our work is hard enough. I have been in the mental health service for many years and have never worked as hard as I do in private practice. I bulk bill 50% of my low income and health care card holders and have a $29 gap for those in employment so I don’t charge huge fees. The majority of my clients have a medium to severe mental health disorder. I have at least 6 or more clients with severe mental health disorders, namely bi-polar disorder, chronic depression and PTSD, whom I see on a long term basis. The therapeutic relationship with these clients is central to their care and has been built up over time. I work in collaboration with their GP who also sees them regularly and we communicate when we have concerns about their mental status. The GP and I feel that this regular care prevents these patients requiring more expensive hospitalisations. Many of my other clients will return over time and may just require a few sessions to get them back on the “straight and narrow”. Many of these clients have young families so the small cost involved in their treatment may well prevent further mental health issues arriving intergenerationally down the track.

This is an unfair strategy by the current government, and once more victims will be the disadvantaged people. When are we going to have competent people running the government?

Thanks for the message Ben. I dont know where Prof Mendoza gets his figures that most sessions under Better Access have not been taken to completion because that certainly is not the case with me or a number of my colleagues. You are right as is APS that with 6 or 10 sessions even the most uncomplicated patients cannot be treated. It is idealogically ironic that it took a liberal government to introduce medicare for psychologists and labor who is supposed to look after the less fortunate now cuts it back by half. I have worked with some extremely complex cases most of which would probably have ended up in either the public or private hospital system if they had not been referred to me. I am not big noting myself because they could also have been seen by one of my colleagues. I am quaified to make this statement because I have worked on psychiatric triage as part of CAT teams for ten years and know the type of patient that would have been admitted. Better access has prevented many hospitalisations therefore saved lost work time and provided timely therapy within the patients' own community setting. This is far less disruptive than admission. I dare say some suicides have also been prevented through the Better Access system. I could give a brief run down of the types of cases I have seen to demonstrate that these are NOT the worried well, far from it. I would sadly predict that over the next 12 months there will be more suicides and hospital admissions plus many other effects from patients unable to afford psychologists services. Fpr what its worth I always bulk bill because most of my patients cannot afford a gap and I see my role in the spirit of providing a needed service to those who can least afford it. That's what the scheme was originally introduced for. We need to lobby hard and fast to have it restored. It really needed to be expanded to more sessions for some very complex and needy cases but far be it for me to even think this now.
michael costa

Hi Ben, I absolutely agree with what you have written about the very puzzling decisions made by the Government, one of which is to curtail the number of sessions able to be accessed per year through Medicare. The decision defies logic! Their own recent research and subsequent report was 'glowing' as to the success of the program. Methinks that the very powerful Social Worker's lobby had something to do with this decision? It's such a pity that we psychologists are divided at the moment through the two-tiered system that has weakened our argument. We no longer stand as one.

What an outrageous statement from John Mendoza! I am shocked at this fellow professional's use of opinion rather than fact. Unacceptable professional behaviour.

I am concerned about my clients who have quite severe mental health issues who are unable to make a co-payment for services, or pay for extra services when the medicare funding for psychology is finished for the year.

I have developed a therapeutic alliance with the clients I have in mind and they have chosen to continue work with me. People with Borderline PD, severe PTSD and women who have been in relationships characterised by domestic violence.

Research repeated shows the therapeutic relationship is the number one factor in good therapeutic outcomes. The work with these people is often hard work, with extra phone calls made between sessions and liasing with other service providers to provide the best outcome for them. They do come back each year, but are making slow progress on the mutiple issues in their lives.

I bulk-bill these people. As a counselling psychologist this is not a lot of money, but I do this because I thought working with this client group is what this scheme was about.

Prior to these cuts, I was making the available sessions stretch as far as I could without underservicing. Now these clients may be taken up with the ATAPS scheme and I may see them through this, but am unsure of the details for this scheme yet, nor whether I would be a preferred provider for this scheme, nor whether clients will have any choice over which professionals they see.

With only 10 sessions in a year, the better access scheme will not allow me to continue working in this way with these clients. I am not in a position to offer further unpaid services to these clients. I now think better access will become a service for the worried well. I will now have to reconsider whether I think these limited sessions will be of adequate benefit for this client group, or perhaps even do harm.

Again, thank you Ben for your timely comments and quick response to these matters.
Barbara Dickson
Counselling Psychologist

The Government agenda:

I don't know why anyone would be surprised. Government's overriding objective is similar to the current small and large Corporate Companies' objective. They subscribe to a 19th century economic model of growth (it is both out of date and simply wrong in terms of realistic models of growth that are sustainable). That is their current aim is a strictly linear one. According to that model a business (or government) is good if profits increase at least linearly in a positive direction or even better if the growth is exponentially positive. These beleifs are enshrined in Corporate and Company Law which supports Directors making decisions primarily in favour of shareholders. If we transfer the model to government, they seem to believe that they need to satisfy the shareholders (of power) by making decisions in their favour. The most powerful group in Mental Health (the shareholders) are psychiatrists. The biggest threat to psychiatrists are psychologists.

This government has been spooked by the claim of Liberals ( untrue though it might be) that Labour governments are poor fiscal managers. That is a media and community belief, which never changes despite that Labour governments can do at least as well as Liberal governments when it comes to managing money. The evidence on political decision making in the community is that people hold baises one way or the other and they seek evidence to support the opinion they already hold. So, in that sense, it does not matter what this government does to try to prove their fiscal responsibility.

Effects on practice:

The government's decision to allow 10 sessions as a maximum (if that is the decision) should not be too much of an issue in private practice. The average number of sessions clients tend to use, when it is affordable and easily available to them, is 3-4. Most experienced and effective practitioners would find they have a handful of clients who attend less than three or four times, the bulk who attend between 4- 10 times and another two or three who might require more than 10 times.

Isssues:

The only issue I can see with the restriction is with the very few clients who have accessed a practitioner in the community (in private practice) who require relatively intensive attendance over a longer period of time. I have one such client at the moment. I bulk bill that client and I am concerned about what will happen with that client. The other community mental health services will not take that person and that person has already had the experience of regular changes of practitioners within the government mental health services. One of this clients primary health needs is stability.

The government has only managed to make the issues for clients at this end of the scale even worse. I have not had the opportunity to look at the review of the medicare system yet, but I wonder what percentage of psychologists clients access more than 10 sessions currently. If they do, and I have personal experinece of a practice where sessions were booked ahead weekly when a client made their intial appointment. The culture in that practice became one of seeing the clients weekly (regardless of whether that was really required). It may have been an administrative practice initially, that is , to manage ongoing client availability, but it seemed to become an implied clinical practice.

If their are a critical number of practices operating in that fashion then they may have created an issue for those clients in the gap (such as the one I mentioned). I might add that that type of management of clients seems to result from the manualised approach to practice that comes from higher degree training.

I must say, I am absolutely shocked by the upcoming restrictions.

For many years research has provided evidence that professional counselling and psychotherapy is extremely cost effective - in fact counselling is a lot cheaper for the society than doctor hopping, high numbers of sick days etc (e.g. Grawe, Klaus et al, Psychotherapie im Wandel,1994. 885p)

Please allow me to take the opportunity to share some thoughts about Clinical Counselling and Psychotherapy in Australia from my perspective as a German trained Clinical Psychologist.

Just for the sake of comparison, let me map out some details about psychotherapy in Germany.
Specialist status of Clinical Psychologist (German: Psychologischer Psychotherapeut) since late 1999.
Full payment of clinical psychologist's services (treatment) for either Cognitive Behavioural Therapy or Psychodynamic Therapy (Systemic Therapy and Client Centered Therapy are acknowledged as evidence based, but no cost coverage for those available).
In Germany, the following numbers of CBT (!) treatment sessions are paid for by health funds (after approval by an independent senior certifier).

25 considered short term therapy
45 considered standard long term therapy (e.g. to treat a medium complex, medium severe depression)
to be extended by 15 sessions to a total of 60 sessions
to be extended by another 20 sessions to a total of 80 sessions (in certain, exceptional circumstances)

Accordingly, for psychodynamic therapy the steps are 25 (short term), 60 sessions (standard long term), 80 sessions extended, 100 sessions in exceptional circumstances.
This is, since 2000.

12+6 sessions per calendar year were already challenging for some of my clients, say about 1/3. Needless to mention numerous GP visits, often with a questionable value. Another burden rather than "Better Access".

The reduction of hours even makes it worse - issues come to the surface but can't be resolved.

A slap in the faces of clients. Also, a slap in the faces of psychologists, highly trained for proper treatment. A slap in the face of all who struggled and put energy into integrating psychology into the health care system.

This ridiculous reduction further supports a drug based, old style medicine, neglecting the fact that 70% of GP visits are a result of lifestyle problems, i.e. behaviour problems (eating, low excercising etc) and with the huge motivational and emotional baggage that comes with it.

The regulations to become or maintain to be a registered Psychologist, including PD requirements and the Code of Ethics aims at protecting the public from harm by psychologists.
Which regulations protect the public, including psychologists, from the damage done by incompetent government staff?

The referral system as such is anachronistic and devaluing the specialist status of clinical psychologists (as if a GP judgement on the mental state of a client is more valid than that of a Clin Psych).

I suggest to promote direct access to qualified psychologists, and a medical check that clients have to undertake before they start psychological therapy.

REgards,
Frank Breuer, Clinical Psychologist