Is our mental health system disjointed?
- yourlistener249
- Jun 18
- 6 min read
Welcome to the May 2025 edition of the Your Listener Counselling newsletter! This month, we are exploring the issue of how Australia's mental health industry segregates different roles. While to an extent this is functional, treating certain professionals as if they are entirely different from each other potentially has undesirable consequences, limiting the scope of services and placing the industry at risk of becoming insular and disjointed. To begin, let us define the basic mental health roles.
Psychiatrists are qualified in both general medicine and psychology. They can diagnose mental illnesses, provide psychotherapy, advise other practitioners on treatment, provide testimony in legal settings, and unlike the other practitioners, prescribe medicine. A psychologist can not prescribe medicine, but can provide therapy, advise on treatment, and possibly provide testimony and diagnose mental illnesses, depending on their specialisation. "Psychiatrist" and "psychologist" are protected titles, meaning that using them and performing their specific duties requires a licence. Other mental health professions do not legally require qualifications or a licence to practice at a national level, in which case there are usually private organisations that accredit members; there may also be state-level licensing. Counselling (or psychotherapy) is one such profession. Counsellors focus on helping clients but can not diagnose illnesses or use medical treatments. Social workers provide psychotherapy and help clients to work with other systems and seek opportunities in the community to better their wellbeing. A number of newer and less recognised roles exist, usually in public practice and not-for-profit organisations. These include psychosocial recovery coaches (P.R.C.s) and behaviour support practitioners (B.S.P.s) operating under the National Disability Insurance Scheme, psychosocial support workers, case managers, and lived experience workers.
Although not inherently a flaw, it can be a challenge to determine which professionals help with a given problem, as multiple may be appropriate. The choice depends on the severity, the client's needs and preferences, and the practitioner's competence, therapeutic style, and personal qualities — which have a major influence on how well they work with a client. For example, I as a counsellor regularly help clients experiencing problems such as depression, anxiety, and trauma, with which a psychologist or psychiatrist may also help. However, if a client were suffering trauma so severe that they experienced loss of memory or consciousness, I would refer them to a psychiatrist as this would be in need of medical attention.
Separating the aforementioned conventional roles allows professionals to focus on working in particular ways to help different clients, shares the responsibility of delivering services across a broader workforce to make help more available, and facilitates different models of practice to provide clients with choice. A problem, however, is that there is often segregation of (usually newer or less conventional) roles where the essence is similar. I am not questioning the value of the practitioners themselves, but arguing that the roles are wrongly conceptualised. Numerous roles use different frameworks with claims that personnel need experience using those frameworks to perform them as they are fundamentally different from one another. They also often imply that approaches applicable to one role are not applicable to another. These are instances of what is called "reification", meaning that the objective realities of the roles are treated as different by referring to them using different invented concepts and language. This is fallacious; in the domains in which these roles function, helping any client requires a basic understanding of psychology with an accompanying common set of skills, and this knowledge is practically always inherent in the different frameworks, albeit referred to with different language. These frameworks often claim to be distinct due to having certain qualities, when those qualities should be present in any framework for the same purpose. Hence, having this fundamental knowledge would realistically allow someone to adapt to these different roles. Additionally, these frameworks often only address limited domains of functioning.
Let us examine P.R.C.s as an example. P.R.C.s use a "recovery-oriented framework", which defines recovery not as attempting to achieve a complete state of mental wellness, but coping as well as possible given the constraints of illness. They are expected to focus on helping clients to set and achieve goals related to this. While this is an essential component of any mental health care, the implementation is questionable. Much of the aforementioned basic psychology is considered to be "clinical" and out of the scope of the role, hence personnel are not always hired based on it. They encounter the challenge that their clients often do not have the capacity to immediately approach such goals because their symptoms are interfering — which any practitioner should be able to recognise and address first before attempting more challenging goals. Even helping someone according to this framework would be considered psychotherapy or counselling if the practitioner was addressed as such, but the title is used to argue that the practice is different. Additionally, establishing "recovery-oriented" practice as a distinct framework is fallacious as by definition, clients of any practitioner regardless of framework want to find ways to cope with or eliminate problems.
A further problem is staffing. At the lower qualification levels, different roles that essentially help similar types of clients often have different requirements that could only be met if personnel undertake specific training in the given frameworks — yet I am aware of concerns of the scarcity of employers who train in these frameworks. There are also mental health roles in which employers require qualifications which would not be logically associated with the role, or which are arguably superfluous — for example, some intake and case management roles require staff to be licensed nurses, occupational therapists, or psychologists, but counsellors are of no interest, and the roles do not even involve implementing therapy. Hence, it is increasingly difficult for personnel entering the industry to know what courses of study and development to take, and hiring such a narrow range of people in to each type of role means that the workforce is chosen based on how well they have memorised frameworks rather than their broader range of technical and interpersonal skills — which could actually be more indicative of their potential to achieve desirable outcomes.
Too often, especially in public health, clients work with multiple practitioners who each have overlapping areas of practice with accompanying burdensome regulatory requirements, and are forced to repeat answers to the same questions and complete similar activities, while not being able to receive all care from one practitioner because their roles are segregated. One wonders if the demand for services is so great that the industry simply can not source enough personnel competent in general mental health practice, leading to the invention of rigid service models which more personnel can be taught to deliver — yet even these are effectively treated as specialised when the knowledge requirements are so rigid. I recognise the importance of a market in which providers have freedom to introduce their services and innovate, and clients to choose those services. I also recognise the importance of quality control, which is why I abide a strict ethical code and use only evidence-based therapeutic approaches. I criticise not to dismiss the potential of new practices, but to encourage our industry to examine what is ultimately helpful. Our roles exist to help clients overcome problems so that they can live the lives they desire — an endeavour that is not helped by more regulation, superficial frameworks, and inventing new solutions before we have properly understood existing problems.
Rather than relegating individuals with entry-level qualifications to roles that have limited applicability, we should broaden the definitions of titles understood in common English such as counsellor and social worker, and define them not purely based on qualification or accreditation, but on essential purpose and skill. To develop that skill, we should provide opportunities for personnel to learn not just in educational environments working with pure theory, but in the workplace. Rather than treating each other as completely different, we should unify based on our common goal, and recognise that even within a single client population, people with different qualities in addition to the same fundamental skills and knowledge can contribute in equally important ways. We must remember that all the theories and frameworks in the world can only provide a basis to understand problems — we can never dictate the workings of the problems.