Marianna Jaross
The world-renowned Adverse Childhood Experiences (ACE) study shows the impacts of ACE scores (calculated from 0–10, one for each trauma experienced) across several domains including abuse (physical, emotional and sexual), neglect (physical and emotional), and household dysfunction (mental illness, incarcerated relative, mother treated violently, substance abuse, and divorce).
The higher the ACE score, the greater chance of poorer health outcomes.
These health outcomes range across the lifespan and include obesity, heart disease, suicide attempts, and stroke. Behavioural outcomes linked to a higher ACE score include increases in smoking, lack of physical activity, drug use, alcoholism and high number of days absent from work. We also know from research that adverse childhood experiences impact brain development at neurological levels.
It is clear that the impact of unaddressed trauma and pain from our early life has widespread and lasting effects on our long-term physical and psychological health. If we combine these impacts with a global pandemic, rising costs of living, and other unpredictable life stressors, it is no wonder we are experiencing a mental health crisis and stretched healthcare system.
As a mental health professional, I believe this knowledge requires a collective pivoting towards understanding and addressing the impacts of trauma on our psychology and physiology, and supporting young people (and others across the life-span) to receive emotional and mental health support at earlier stages, sans stigma. This includes a paradigm shift towards understanding that the emotional wellbeing of a child is going to significantly influence their life trajectory, not just the quality of the curriculum and their education alone.
The next issue is one of access.
Within Australia, our entry point into seeking help in the private sector can be made more challenging via a lack of accessible Medicare rebatable practitioners. When we do try to seek support, we are often met with barriers financially, long wait times in a well-intentioned yet overburdened system, therapists who may not meet our specific needs, and a system that is reliant on a GP-led diagnosis and a 10-session model over the course of a year.
Currently, those who require Medicare rebatable services to make support financially viable are largely limited to referral to psychologists. This means that wait times are high in the private system, anywhere between a couple of weeks to several months; especially since COVID, the financial stressors of daily living, and other life issues that continue irrespective of a pandemic and its impacts.
My contention is that there are other trained and qualified practitioners who sit under professional bodies who may be able to support and alleviate the current mental health crisis.
First, let me take a step back.
Upon entry to seeking support, someone could be assessed within ten minutes as having depression by a well-meaning GP. This could include symptoms of low mood, loss of appetite, and loss of enjoyment of tasks that once brought pleasure. They are sent to a psychologist with a wait time of several months.
Outside of problematic wait times to receive support, this umbrella diagnosis could reveal other issues that are likely not able to be covered in a GP’s office logistically; for example, their spouse has died, they are feeling low because they are experiencing ongoing family violence, relationship changes, resurgence of family of origin issues, or increase in drug and alcohol use. Hypothetically, all (or a combination) of these issues could lead to different healthcare pathways outside of the default of psychologist, who are at the top of the referring hierarchy. In the meantime, there are other public services available such as 1800Respect, Lifeline, and Griefline; who are important wheels in the mental health system, but can’t provide the ongoing treatment/support that can be required for deeper healing.
The issue is not necessarily ‘getting it right’ from the start, but rather normalising the process of therapy and support-seeking as an ongoing process. I know from experience and conversations with my clients that it can take time to find the right fit or match therapeutically, that challenges don’t present in a vacuum, and cross-referral and collaboration can be required to best support a person. (This is why I have favoured multidisciplinary teams across my placements and workplaces).
Yes, there may be some issues that are best suited to a psychologist and a streamlined service. The larger issue is that we don’t give our clients enough time or variety with a clock-ticking ten-session limit, or by impeding cross-referral to other practitioners or specialties that could be required for holistic support.
We are ignoring other mental healthcare workers who may also be qualified or experienced to work with a particular issue or complexity. Given the above referral example there would be a broad range of potential pathways for someone to seek support. I think we could provide clients the choice to receive the service that they want from practitioners that have training/speciality in a particular area, without being blocked by the lack of Medicare rebate and lengthy wait times to get the support that they need. Secondly, opening access would allow for cross-communication between disciplines, specialities, and a collaborative approach.
Given the overwhelming need in the mental health care system at the moment, it might be an idea to draw on existing clinicians.
Though this seems straightforward in some ways, it is a contentious position professionally. I am aware that there is a territorial nature to mental health professions, and a hierarchy in terms of training, which is inevitably linked to whether a service/profession is ‘rebatable’ or not, and how much so.
Personally, I have completed several training programs in Australia. I completed a Master of Counselling and Psychotherapy, as well as a Master of Psychology (Professional). I am now a registered psychologist. However, I couldn’t and can’t unsee how much unhappy discourse was thrown from different camps depending on which degree I was completing, what professional body I would fall under, and where I was working.
There is overlap between trainings, and there are gaps and differences between each: Counsellors, social workers, creative arts therapists, and psychotherapists are all important to our mental health care system, and are currently underutilised in a time of great need nationally. It would be great to open referral pathways to suit a particular client and their specific needs, for clients to have the freedom to make a choice regarding their practitioners, and for practitioners to take time to work together and collaborate.
Furthermore, more and more research has revealed that we should be aligning to and working in conjunction with modalities outside of traditional talk therapy; such as creative arts/expressive therapies, movement-based therapies, and somatic experiencing.
Though there have been considerable moves towards these modalities, we largely haven’t caught up to the fact that body work and self-expression often accompany healing trauma, finding one’s voice, regulating one’s physiological state, and improving well-being and quality of life. Importantly, these can support the healing of the issues people are carrying into adulthood from their childhoods, as well as current life challenges and circumstances. There is an abundance of evidence base behind body based and creative modalities that we tend to skate over and would do well to better integrate into our mental health system.
I would like to suggest that we find a way as a system to work together with the common goal of optimal and client-centered care. This would mean drawing on our different strengths and modalities to best cater to the diverse needs of our clients. (It is important to note that community health services have already implemented utilising a range of practitioners in their services). Broadening access would mean the potential to cross-refer without accessibility depending on the hierarchy of who has traditionally been Medicare rebatable.
Importantly, I am aware that we can’t go handing out accessibility and Medicare rebates without thought, and there is a significant ethical and professional responsibility that accompanies this. I am aware that there would have to be significant overview in ethics, professional competencies, and training in order for other professions to be eligible for Medicare; and that this goes beyond my “why can’t we be friends, work together, and figure this out” ideals and into a thorough evaluation across disciplines towards a sustainable model from a broader systems perspective, which, admittedly, is beyond my scope to map out specifically.
I am also aware that there would be hesitance to open the doors to other practitioners outside of the established norm and referral base. This might occur for several reasons: There is safety in what has already been established and is in place, there are financial concerns regarding other clinicians ‘taking’ clients and the impacts of this, there are concerns about the ethical rigour of other professional bodies outside of AHPRA. However, I think the potential benefits of collaborative care, timely and holistic support long-term far outweigh the costs and headache of further investigation and considered steps towards creating a better model of care. Ethical practice and client centered care is still the objective, and I think we could work towards an outcome that could ultimately benefit the Australian population: More clinicians who can provide timely support.
Overall, I think it would be shame to not draw on existing professions and their experience to shoulder some of the mental health burden.
I would love to see professionals from different disciplines working together, learning from each other, and keeping client outcomes at the centre of our practice; for early interventions to be normalised and implemented; for clients to have choice regarding who they see and freedom to access the evidence-based modality that works for them; all without having to wait months for a first appointment and ten-session limit.
References
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/S0749-3797(98)00017-8
Van de Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking Press.
© Marianna Jaross
Note: This article originally appeared on Medium in 2023 and is independent of my professional association(s) and workplace(s).
ความคิดเห็น