Defining Counselling: Part 2 of 3, as featured in Vol 23 No 2 Winter 2022 of the Counselling Australia Journal.

In this second instalment, we talk to doctor-turned-counsellor Vicky Dawes about the importance of counsellors and its distinction from the medical field.

By Larissa Dubecki

After seven years of working as a doctor in emergency medicine, Vicky Dawes had reached burnout. “It’s a really common phenomenon,” she says. “But it’s only recently been spoken about more openly. It’s related to the work environment – very stressful, high pressure, little room for taking a break. Then you can add to that the fact that medicine does attract these high achievers who throw themselves into their careers. The telling thing is that burnout does happen to a massive number of doctors.”

Now a clinical counsellor, Vicky can look back and see certain augurs had anticipated her shift to counselling: “While I was in medicine, I always loved seeing people who essentially needed counselling. The other doctors would say, ‘Vicky, can you go and see this person because I don’t know how to handle this’ – because they didn’t know how to handle it. It’s undervalued how important it is, often with people who are quite distressed.”

Taking the leap from emergency medicine to counselling – with a short-lived stint of psychiatrist training in between – has proven a fortuitous one for Vicky. A graduate of the University of Queensland with a Master of Counselling, she spent five years as counsellor and educator for a not-for-profit doctors’ health service, supporting doctors and medical students with their own mental health and wellbeing.

Now in private practice, Vicky specialises in bespoke therapy for doctors, professionals and university students. “Going from medicine, which is socially held up on a pedestal, to counselling – which in many ways isn’t – has been interesting. But I absolutely love it,” she says. “Giving patients the permission to be vulnerable and responding to shame with empathy is enormously powerful. I really do think that counselling proves, in bucketloads, the importance of the therapeutic relationship.”

From doctor to counsellor:  a cultural shift

Vicky observes from her real-life experience that medicine and counselling are seen in vastly divergent ways, even though both are patient based. “In my former career as a doctor, I had been taught how to efficiently take a history from a patient, examine their body for signs and symptoms, come up with a diagnosis and differentials, and start treatment – based off the best evidence available at the time,” she says.

“As a medical practitioner I was often positioned as expert. Moving into counselling was a complete shift in both mindset and approach. While both roles encourage the doctor or counsellor to approach the patient or client from a position of curiosity and not knowing, in counselling I learned the immense value of deep empathic listening, of recognising the client as expert in their own lives, and of the power of walking alongside someone in their time of need rather than telling them what was ‘wrong’ or jumping in to ‘fix it’. While ‘bedside manner’ is touched upon in medical training, counselling recognises the profound importance of the therapeutic alliance underpinning whatever therapeutic approach is taken.”

Her own professional shift revealed the cultural weight applied to the hierarchies apportioned to the health industry.

Vicky says she was seen to ‘abandon’ the more culturally valued field of medicine. “It was culturally unacceptable, especially to doctors of a certain age who would say things like ‘oh, that’s a shame’ when they found out I was leaving – or to tell me they thought I was throwing it all away.

“Your identity as a doctor is so entwined in your sense of self. While colleagues were generally incredibly supportive, it did reveal to me that there is shame attached.”

Vicky remains active in a Facebook group for medics looking for an alternative route through the profession. “It has thousands of members. Almost daily there’s an anonymous post from someone reporting their experience and saying ‘I don’t know what to do’, and I’ll jump in and say I’m very happy to talk. Without fail I’ll get four or five messages from other people saying, ‘I saw your post, can I please speak to you.’ The number of people getting in touch is staggering.”

A shared experience

In 2016, Vicky graduated from UQ with her master’s degree – where her thesis became the basis for the university’s student-based Mental Health Strategy – and she was struck by the “absolute brain shift” in moving from the medical model.

“You take information, you’re refining it, trying to come up with a differential diagnosis, you’re very much positioned as the expert. It’s a real brain shift to realise it’s not just about the information that you’re getting, it’s not that you’re the expert, because you’re very much not, but it’s just as much the process and the immediacy of what’s happening between you. It’s such a deeply respectful, shared experience. It’s amazing and such a privilege to be able to do that with people.”

Her approach to counselling involves first gauging the individual patient’s needs, and their hopes as to what counselling will provide.

“I often ask people if they have an idea of what they’re looking for. Sometimes they’re looking for strategies, sometimes they just want to talk and other times they want to figure out why they think the way they do,” Vicky says.

“There’s the solution-focused counselling approach, but I think it’s the deep respect for walking alongside someone in the knowledge you’re not there to come up with all the answers. I’m not the expert on their life but I’m facilitating them on their path of exploration.

“When we think about the contrast with medicine, we know that doctors whose patients like them are far less likely to be sued and, if you delve into that, it’s really about people wanting a personal connection. It’s not the person who prescribing antibiotics, it’s the person who makes you feel safe and heard. That’s the power of the interpersonal therapeutic alliance.”

The pedestal effect

Originally from the UK (she completed her medical degree at the University of Birmingham) and then moving to Australia, Vicky has seen a notable difference in attitudes towards counselling between the two countries.

“Sadly, counselling is often undervalued in Australia – potentially due to its unregulated nature, potentially due to psychology positioning itself as expert, and potentially as Australia does not have such a rich and respected history of counselling and psychotherapy – unlike places like the UK, Europe or the US.”

One of the fractures in the way counsellors are seen stems from it being an unregulated profession.

That said, any step to raise the profile of counselling should be taken with careful consideration. She says there are both advantages and disadvantages to trying to get counsellors eligible for Medicare rebates – for instance: “I know many of my doctor clients are deeply suspicious of Australian Health Practitioner Regulation Agency–registered practitioners, due to the fear of mandatory reporting by treating practitioners.”

Nor is Vicky an advocate of counsellors moving into the area of other allied health professionals by performing diagnostic tests, for instance. “Absolutely we need to be more formalised as allied health professionals,” she says.

“But while the more formalised assessment processes used by psychologists are often positioned as a strength of psychology, counselling’s strength really relies on there being nowhere to hide. We are not reliant on trying to define someone’s experience according to their responses to assessment, but rather on seeing the person as a whole and helping the individual to explore that themselves, taking into consideration all the complex influences that make each individual who they are. We’re less about labelling and reductionist thinking and [more about] seeing the messy, complex whole of a person. I don’t believe counsellors do want to be performing diagnostic tests. There is a risk if you go too far down the traditional diagnostic route that it takes away the power of what counselling is all about.”

The unregulated nature of counselling in Australia creates something of a grey area that can only be policed by individuals. “Legally, ethically and morally, counsellors should not be practicing beyond their area of expertise,” says Vicky. “While some situations will be standardised – for example, legal requirements – others are likely to differ according to the individual counsellor’s experience and training.”

A long and winding road

Vicky uses the concept of ‘planned happenstance’ to describe her unexpected – and entirely rewarding – journey from medicine to counselling. A term used in careers counselling, it counters the traditional narrative of a career as a linear arc, starting at A and winding up at B.

“Particularly when you’re younger you think you need to know where you’re going and what your goal is. But planned happenstance is the idea that there’s real benefit to taking a meandering route, because not only will you gain experience along the way but also you’ll wind up at a place you could never have anticipated at the outset,” she says. “Me as an 18-year-old at med school in the UK could never have anticipated living in Brisbane in my 40s as a counsellor. All of my experiences have been really helpful, and I feel like I’m in the right place now.”

By Philip Armstrong

New figures released last week by the Australian Institute of Health and Welfare paint a dire picture for Australians who are becoming reliant on chemical interventions for their mental health.

• 42.7 million mental health-related medications (subsidised and under co-payment) were dispensed in 2020–21.
• 4.5 million patients (17.7% of the Australian population) filled a prescription for a mental health-related medication in 2020–21, with an average of 9.4 prescriptions per patient.
• 62.3% of mental health-related prescriptions filled were subsidised by the Pharmaceutical Benefits Scheme (PBS)/ Repatriation Pharmaceutical Benefits Scheme (RPBS) in 2020–21.
• 84.7% of mental health-related prescriptions filled were prescribed by GPs; 7.5% prescribed by psychiatrists, 4.9% were prescribed by non-psychiatrist specialists in 2020–21.
• 73.1% of mental health-related prescriptions filled were for Antidepressant medications in 2020–21.

The most disturbing figure is that 84.7% of prescriptions were prescribed by GPs who have minimal formal training in mental health, usually a 20-hour course[1], and have no mandatory requirements to undergo annual ongoing professional development (PD) or clinical supervision. To be fair to GPs, when would they have the time?

The cost to Australians in 2019-20 for government-subsidised mental health-related prescriptions under PBS/RPBS was $566 million[2]. This doesn’t take into account that Australians pay a gap fee up to $42.50 for most PBS medicines or $6.80 if they have a concession card.

Take into consideration a study published in World Psychiatry “The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisons (2013)” concluded that pharmacotherapy and psychotherapy have comparable effects in several depressive and anxiety disorders[3]. With 73.1% of prescriptions being for depression brings into question why the government isn’t making counselling available to the public through the Medicare Benefits Schedule (MBS). Surely giving Australians access to a non-chemical alternative is in everyone’s interest, bar the pharma’s.

What would the annual cost to MBS for 3,000 Registered Counsellors and Psychotherapists to be able to offer ten 1-hour sessions to Australians suffering from depression? Answer: less than $250 million a year. Compared to $556 million for prescriptions alone, which doesn’t consider the added cost of people taking prescriptions who are also seeing a psychologist under MBS rebates.

It’s time Registered Counsellors and Psychotherapists became a part of the Medicare system to give Australians a choice between chemical interventions or equally effective counselling services delivered by humans.

[1] General Practice Mental Health Standards Collaboration (2022). https://mentalhealth.racgp.org.au/guidelines/index/616b4fb1-9755-464b-9b04-30228eb78572.

[2] AIHW (2022). https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/expenditure-on-mental-health-related-services.

[3] World Psychiatry (2013). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683266/.

Defining Counselling: Part 1 of 3, as featured in Vol 23 No 1 Autumn 2022 of the Counselling Australia Journal.

By Larissa Dubecki

When Dr Sophie Lea arrived for her first session as a school counsellor 20 years ago, she found she had been given the cleaner’s storage room as her clinical space.

“I remember it like yesterday. It really does show how they just weren’t understanding the requirements that we need as therapists in the school space,” she says. “I tried to liven it up by putting a pot plant in there and an Eminem poster to appeal to the kids. Not coincidentally, my PhD ended up being on therapeutic space design.”

A Monash University lecturer in Counselling, as well as an adolescent and family counsellor, teacher, education wellness consultant and clinical supervisor, Sophie has witnessed significant changes in the counselling space over the past two decades.

“It was very unusual back then for school systems to even have counsellors, and I could see it was all about having psychologists and being able to do diagnostics and funding applications,” she explains. She has encountered all the myths about counselling over her career – including the view that the counsellor’s job is to ‘fix’ the client – but has cause for optimism after witnessing the profession assert its place in the allied health services while maintaining its own important identity.

“For me the core driver is around the gift and responsibility and privilege of being able to support others in their mental wellness journeys,” she says. “Counselling is a dynamic and courageous exchange with people who are sometimes at their most vulnerable. In my opinion, counselling explores the ‘how’ and ‘why’ of human existence in a safe, accepting and supportive environment. As I say to my students, counselling is all about heads and hearts.”

Photo: Penny Stephen

Counselling literacy

When differentiating counselling from other mental health professions to her students, Sophie asks them to envisage a triangle model.

“I place counsellors at the base of that triangle: we support clients with a wide variety of client issues such as relationships, aspirations of self-actualisation and, of course, mental health and wellbeing. Moving up the triangle, the client intervention becomes more specialised, with social workers and psychologists providing more targeted interventions, assessment and, when required, diagnosis. Finally, at the top of the triangle, we sit in the medical model, with psychiatrists and doctors able to assess and prescribe medication or referral to specialist in-patient settings for clients who require it. But there’s fluidity in that too; health care professionals may have training and experience on more than one level.”

She also draws a distinction between counselling and psychotherapy. “In my experience, the clear definition of counselling and psychotherapy has at times seemed murky – partly because some therapists, such as myself, would view them as interchangeable. The simple distinction I make is that counselling is usually more short-term in its intervention, it supports clients with conscious events and emotions and has a present-day orientation and impact; I see it as more pragmatic in its design. Whereas psychotherapy is a deeper exploration of a client’s life experience, it encourages further self-awareness and understanding of more entrenched patterns of behaviour and delves into uncovering unconscious understanding that empowers the client to facilitate lasting change.”

The road to accreditation

For Sophie and many of her students, counselling is a deliberate choice over psychology. “There is not just depth but also breadth to the work we do, which is one of the reasons I love the work so much,” she says.

A growing awareness and appreciation of counselling as an important part of allied health services is a heartening development for Sophie, but she finds all too often her Master of Counselling students are surprised that anyone in Australia can call themselves a counsellor.

“The lack of regulation in the counselling profession has created such a disservice to our profession over many years. It is something many counsellors have grappled with and been frustrated by. I am very grateful to have a membership to a counselling registration body, ACA, which sets required standards and champions our profession.”

The mental health burden of the pandemic on top of the complexity of the modern era – the corrosive effects of social media, for instance – has added weight to ACA’s call for qualified counsellors and psychotherapists to be included in the nation’s Medicare Benefits Schedule.

“The short-sightedness is what gets me,” says Sophie. “We have people who need support, who are suffering, and who don’t have the means to go private. The bottom line is it’s about humanistic intervention and support. It’s about the responsibility of putting our profession in a space where it’s recognised. There’s also the critical responsibility of doing no harm to our clients … how can we guarantee that without adequate training and being able to adhere to ethical and professional guidelines? It’s a no-brainer for me and it’s completely antiquated.”

Jim Schirmer (pictured), an associate lecturer with the University of Queensland whose research specialises in the professional identity of counsellors and counselling, argues that an advanced mental health system would recognise the complementary strengths of the range of professions involved. “In such a system, I think counselling would bring some distinctive theoretical, philosophical and practical strengths,” he says. “Practically, counsellors not only deal with mental illness, but also are particularly well-trained in non-pathological areas of human difficulty. When I compare counselling training programs to other mental health and human service professions, counselling training includes not only mental health, but also common areas such as grief and loss, relationships and families, crisis counselling, domestic violence and health. In this way, counsellors have the capacity to see clients across a very broad range of human needs.”

Photo: University of Queensland

Clinical applications

This raises the question: should counsellors play a role in hospital and emergency department settings – and conduct diagnostic tests if they are appropriately trained?

For Sophie, the integration of counselling services in healthcare settings makes perfect sense in light of the current mental health crisis. “I think counsellors could play a vital role in this area, triaging clients and working alongside healthcare professionals to reduce the current demand for mental health services and implement much-needed mental health support in a timely manner,” she says. “With the current pandemic, I remain concerned about the wait times clients are experiencing to be able to see allied health professionals. It’s unacceptable, particularly when there are thousands of qualified and experienced counsellors willing and able to play a part in supporting our community.”

Jim, however, cautions that formal diagnostic measures and tests might be at odds with the humanistic strengths of counselling.

“If the question is whether counsellors could conduct formal diagnostic tests, the answer would be a qualified yes. Currently, counsellors are rarely trained to conduct such assessments, but there would be no reason at all why they couldn’t be trained and assessed as competent in any formal diagnostic measure,” he says. “A diagnostic assessment can be valuable for its ability to provide a valid counterbalance to the counsellor’s subjective judgements, as a system-recognised means of accessing support, and as a validating experience for the client’s distress. That said, there are also several arguments for the limitation of diagnosis. Humanistic therapies would caution us from any reductionist account of our clients’ experiences and postmodern therapies would remind us that any discourse is only one socially constructed version of reality. More broadly, though, there would be forms of helping that would be beyond our definition. Something may be helpful or therapeutic but still not be practiced by counsellors. Psychiatric medication would be an obvious example of this. Similarly, a musician or a remedial masseuse may bring about therapeutic ends, but we would not call them counsellors. Therefore, counsellors should be proud of their broad and effective scope of practice, but also happy to know the limits of this and be willing to acknowledge the therapeutic work that others do.”

To the future

Ask Sophie where she would like to see the counselling profession in five years’ time and the answer is simple: “I’d love us to be regulated, number one. I’d love governmental systems to be able to recognise the important role we can play in supporting us through and around these trying times globally … that we have a really strong skillset to offer.”

So how is that achieved? Further resourcing in this space is crucial, enabling clients to access services in a variety of ways that might suit their individual requirements: “Not just in cities but in regional areas as well. Let’s think about the telehealth space and how we can appropriately facilitate that, let’s think about psychotherapists, let’s think about creative arts therapists and animal-assisted therapy as well as counsellors – those different delineations of therapeutic support and intervention.”

Overall, she hopes to see the counselling profession continue to commit to its professional standards and responsibilities, guided by a scope of practice and ethical guidelines, and not lose sight of the expert skill sets counsellors have in facilitating a safe and purposeful therapeutic relationship with a diverse range of clients.

“That’s where I’d love to see our profession heading and I think we have the training opportunities, experience and passion to do it.”

What are employee assistance programs?

Employee assistance programs (EAP) are a mechanism of support for employees with work-related problems (or personal problems) that may impact on their overall job performance, health and mental wellbeing, and ability to be an effective employee in the workplace.

An EAP provider generally offers employer funded confidential counselling for employees and their family members as well as consultative support for managers and supervisors to address employee and organisational challenges and needs – all in the name of making the workplace more efficient and harmonious.

How does it work?

While some EAP providers deliver the services themselves, many EAP providers will use other practitioners as “subcontractors”. EAP providers will then “refer” the client to Registered Counsellors. EAP Providers will negotiate their rates for services with organisations directly; making their own business profitable while still paying reasonable “subcontractor” fees to Registered Counsellors.

For Registered Counsellors, EAPs represent an opportunity to add a new revenue stream to their private practice as a subcontractor, applying their professional counselling skills on behalf of the EAP provider.

Naturally, there is a business agreement that a Registered Counsellor must comply with before clients are “referred” to the “subcontractor.” Those terms usually cover confidentiality, privacy, client case notes, mandatory reporting, clinical supervision, the scope of practice for practitioners, referral pathways, billing and other key business items. In return, Registered Counsellors will be referred clients and compensated for their time.

All practitioners “on the books” with EAPs must sign an agreement with each EAP provider which includes the terms of business. Terms of business will include how client referrals are handled, fees, client case notes, mandatory reporting, client handling and other important aspects of practice.

Registered Counsellors must register their interest with each different EAP service. The EAP/Provider relationship is “at will”.

EAP Providers will still need to meet their professional registration obligations. Registered Counsellors need to make sure that they meet the terms of business as laid out by the EAP Provider so that they can become a “subcontractor” and begin receiving referrals.

What is an average fee range?

Fees will range between $80/hour and $110/hour, depending on the practitioners’ expertise, location of practice, EAP service and other factors.

What are the advantages of being an EAP subcontractor?

EAP subcontracting can be an advantageous situation for Registered Counsellors in private practice, because it does not require additional marketing to acquire new clients, and clients can access the counselling they may need.

What EAP Providers can I work with?

15 EAP Providers have confirmed that ACA Members are eligible to provide services to employees across the country. To learn more about EAP Providers that can subcontract to you:

1. Log into your membership portal.
2. Click on the ‘Publications & Resources’ tab.
3. Visit ‘Download Documents’ (or click here).
4. Scroll down to ‘Employee Assistance Programs’ and hit download.

How I do register to work with an EAP Provider?

To register your interest for EAP, members must contact each provider directly and individually. Members, you can find EAP providers by typing their name in Google.

This week ACA CEO Philip Armstrong and ILO Elliott Ainley visited our counterparts at the British Association for Counselling & Psychotherapy. During our visit, we discussed our similar domestic challenges and how ACA and BACP can collaborate on developing joint strategies for addressing issues such as stigma, professional recognition, training standards and accreditation frameworks.

We discovered a significant amount of synergy between our organisations, both being the leading entities for the profession in our respective countries. ACA would like to sincerely thank the team at the BACP, particularly Fiona & Caroline from the Senior Professional Standards team, for their hospitality during our strategic outreach program.

We look forward to sharing more about this visit with members.

World Mental Health Day – 10 October – is a day for global mental health education, awareness and advocacy. It is an initiative of the World Federation for Mental Health to raise public awareness of mental health issues worldwide.

The Australian Counselling Association is a proud partner of Mental Health Australia, who are leading the World Mental Health Day campaign in Australia.

This World Mental Health Day – Monday 10 October – the message is simple: “Look after your mental health, Australia.”

1 in 5 Australians are affected by mental illness annually, yet many don’t seek help because of stigma. During the COVID-19 pandemic, prioritising mental health and wellbeing has been more important than ever.

We encourage all Australians to make mindful habits for mental health, not just this October, but always. Here are 10 tips that may help you or someone you know.

Stay active

Exercise increases wellbeing and helps reduce symptoms of common mental health concerns. Your gym may have closed or your fitness groups may be cancelled, but that doesn’t mean you can’t exercise! Yoga, Pilates, HI IT routines – all can be done in a relatively small space and with no equipment. Have a search on the internet for free workout videos and guides.

Eat well

Eating a nutritious diet is great for both your physical and mental health. As much as possible, try and stick to a healthy diet even as your activities and environment change.

Connect with others

COVID-19 may have made connecting with others trickier, but social connection is more important than ever. When many of us faced lockdown, physical distancing, and travel restrictions, we relied on technology to talk to our friends and family. Where possible, try to connect with others by going out for a coffee or meal together, seeing a film, or going to an event. Reach out to your neighbours and community. Share how you’re feeling and invite others to share with you.

Do something you enjoy each day

Do things that make you feel physically and emotionally comfortable, engaging in activities that make you feel safe and calm. Continue to do the things you enjoy as much as possible.

Limit media consumption (and choose trusted sources)

Choose how often you engage with news and social media and be sure to find news sources that are trustworthy and factual. Add in some content that makes you laugh and feel comfortable wherever possible.

Keep to a routine

Keep to your regular routine as much as possible, including exercise, sleep, daily chores, work, recreational activities and connecting with others.

Get an early night

Prioritise getting enough sleep each night to help you feel more energised and focused during the day. Getting enough rest is the foundation to protecting your mental health.

Be kind to yourself

Remind yourself that there is no right or wrong reaction to the uncertainties of the pandemic, or to worrying events. Allow yourself extra grace if your productivity and motivation have been impacted by the changing environment.

Maintain perspective

While this is an uncertain time, try and view these changes with openness and acceptance. Remind yourself of things you’re grateful for and things you’ve learned.

Seek help

It’s normal to experience anxiety and stress resulting from the pandemic. Talking to a Registered Counsellor or Psychotherapist can help you through it. With ACA’s Find a Counsellor tool you can search for a practitioner in your region.

By Philip Armstrong

I recently read an article from The Conversation (click here to read) about Australia’s mental health crisis, titled: We can’t solve Australia’s mental health emergency if we don’t train enough psychologists.

While I certainly agree there is a severe shortage of mental health practitioners in Australia, I must disagree that training more psychologists is the only solution to this crisis.

None of the measures put forward in The Conversation article address the most urgent issue facing the mental health sector today: how can we provide access to mental health services for Australians who need immediate support?

Currently the challenge for mental health providers is how to cope with this surge in demand and ensure that support is provided when and where it is most urgently needed.

So what does this mean in real terms for everyday Australians? And what options are available to help alleviate the pressure?

Unlocking an overlooked workforce

One potential and swift solution to our mental health crisis involves making better use of the thousands of Registered Counsellors and Psychotherapists employed right across Australia today.

Registered Counsellors and Psychotherapists are a qualified, highly trained sector of the mental health workforce, but are currently under-utilised. As counselling specialists, Registered Counsellors and Psychotherapists could significantly reduce the burden on the system, freeing up psychologists to focus on more advanced cases and lowering wait times across the board.

As expert communicators and relational practitioners, Registered Counsellors and Psychotherapists are strong compliments to multidisciplinary teams and should be utilised broadly throughout the workforce.

What’s more, this is a workforce that can be accessed immediately: right now, the Australian Counselling Association has a membership of over 11,500 Registered Counsellors and Psychotherapists that can make a difference.

Safeguarding Australian’s mental health

While there are multiple external factors contributing to Australia’s current mental health crisis, many of which are outside of our control, right now there is an opportunity to alleviate and potentially even reverse the declining mental health of our nation.

It is the strong recommendation of the Australian Counselling Association that Registered Counsellors and Psychotherapists are added to the list of allied health professions in the Health Insurance (Allied Health Services) Determination 2014, which provide Focussed Psychological Strategies under the Medicare Benefits Schedule (MBS) Better Access Initiative (BAI).

There are at least 4,000 Registered Counsellors and Psychotherapists who meet the current criteria for the Medicare Benefits Schedule (MBS), while a further 1,000 could be eligible to register within six months.

Including Registered Counsellors and Psychotherapists into the MBS will significantly increase access to bulk billing services, especially for our nation’s most vulnerable. In the absence of a viable solution from the Government, it presents an appropriate, cost-effective and immediate solution that would ultimately help save lives.

Article from: Counselling Australia Journal: Volume 22: Number 3 – Spring 2021

By Dr Jillian Stansfield

The Diagnostic and statistical manual of mental disorders (DSM-5), published in 2013, refers to autism spectrum disorder (ASD) as an umbrella term and is based on a deficit medical model. The DSM-5 diagnosis of ASD includes the previously separated diagnoses Asperger’s syndrome, Rhett syndrome, pervasive developmental disorder and pervasive developmental disorder not otherwise specified (PDD-NOS), and focuses on traits most often associated with males. The criteria to be met for an ASD diagnosis under the DSM-5 are persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following: socialemotional reciprocity; non-verbal communicative behaviours; and developing, maintaining and understanding relationships (APA, 2013). These symptoms are present from early childhood and limit or impair everyday functioning (APA, 2013). A diagnosis of ASD is also assigned a severity specifier of level 1, 2 or 3, depending on the support required. Therefore, the terms ‘high-functioning’ and ‘lowfunctioning’ are redundant and are not included in either of the diagnostic manuals DSM-5 or International Classification of Diseases (ICD-11) (World Health Organization, 2018). As there is no definitive biological test for determining autism, a process is followed that relies on multiple sources of information, including tests and observations to assist medical professionals with making a diagnosis (APA, 2013).

Diagnoses of females are predicated on the same narrow ASD criteria, which is geared towards the male presentation of autism and is one reason why girls may not receive an autism diagnosis, also referred to as a ‘missed diagnosis’ (Fields, 2020; Stansfield, 2020). A ‘misdiagnosis’ can occur when someone is diagnosed with a mental disorder based on a cluster of traits that overlap with autism. The lack of understanding and research about the female-typical presentation or female autism phenotype is reflected in the disparity of diagnoses between males and females, a ratio of 4:1 (Hull et al., 2020).

However, the use of one term, ‘autism’, has resulted in confusion about where people diagnosed under the range of autistic-like conditions should be placed along the autism spectrum (Bennett & Goodall, 2016). This is particularly problematic when individuals are overlooked or misdiagnosed, particularly females, or when the preconceived view is that the overarching diagnostic term is ‘Kanner-type’ or ‘classic’ autism traits. The words ‘disability’ and ‘disorder’, both of which are used in social discourse, indicate a deficit in ability or that something is wrong. However, some autism deficits could be viewed as strengths or advantages (Goodall, 2015). There is an inconsistency in language about and definitions of autism (Cleaton & Kirby, 2018).

Instead of being considered a disability or disorder, as the formal terms suggest, autism is regarded by some as more of a neurological difference (Goodall, 2015). Throughout this paper, the terms ‘autistic’ and ‘on the autism spectrum’ are preferred when referring to a person diagnosed with an autism spectrum disorder. Neither a ‘person-first’ nor an ‘autism-first’ approach is used because some people in the autism community prefer one term over the other and it is essential for the terms adopted to respect the autistic community (Kenny et al., 2015).

History of autism

The history of autism is confronting, with an evolving line of thought that includes many misconceptions and perspectives: from perceptions that people on the autism spectrum have ‘refrigerator mothers’, to people being labelled as ‘rain man’ or as having an ‘extreme male brain’ (Silberman, 2015). Due to the pathologising of traits and to stigma, today’s knowledge and understanding of autism is still in its infancy and it appears people are some way off from understanding and accepting this different way of thinking (Stansfield, 2020).

Child psychiatrist Leo Kanner identified the ‘classic’ model of autism towards the middle half of the last century (Kanner, 1943, 1944; Silberman, 2015; Singer, 2017). Kanner used the term ‘autism’ from the Greek word for self (autos) to describe this cluster of traits, as these children “seemed happiest in isolation” (Silberman, 2015, p. 5).

At the same time, Asperger’s syndrome, commonly known as Asperger’s, was first identified by Dr Hans Asperger, who noted some similar characteristics among children in his paediatric practice (Attwood, 2004; Silberman, 2015). Although Asperger referred to his patients as “little professors” due to their abilities in math and science (Silberman, 2015, p. 6), this more positive aspect of his work is tainted by his link to the Nazi era: he is said to have been among the doctors who had the power to decide the fate of children who did not meet certain physical and mental abilities (Sheffer, 2018; Szalai, 2018). Although the origin of autism and the term ‘Asperger’s syndrome’ are tainted by this unsavoury narrative, Asperger’s work was the starting point for discourse on autism (Stansfield, 2020).

When Lorna Wing, a psychiatrist, had a daughter who was diagnosed with Kanner’s classic autism in the 1960s, it was almost unheard of for a female to receive an autism diagnosis. Following the realisation that her daughter had autism, Wing made it her quest to seek out the supports available to families of children like her own (Silberman, 2015). Wing (1981) found that many children did not fit the mould of Kanner’s rigid traits and set out to expand the definition of autism, proposing that it was a ‘continuum’ and later adopting the term ‘spectrum’ (Silberman, 2015, p. 353). Despite Wing’s work, several decades later the connection between autism and girls remains relatively undiscovered and far more is known about autism in males (Tomlinson et al., 2020).

Background of autism spectrum disorder

The DSM-5 is becoming a somewhat outdated source for determining a diagnosis, and controversy surrounds the umbrella term ‘autism spectrum disorder’ in the last update. One point of contention is the use of the word ‘disorder’, because autism is becoming more accepted, particularly in the autistic community, as a neurotype or condition rather than as a mental disorder (Stansfield, 2020). The view that autism is a disorder that can be cured is reflective of the medical model approach, and lags behind anecdotal and clinical observations of the female autism phenotype (Marshall, 2014). No specific changes appear to have been made to DSM-5 diagnostic criteria to reflect this in the foreseeable future.

Silberman (2015) posed the question, “[A]fter 70 years of research on autism, why do we still seem to know so little about it?” (p. 15). People on the autism spectrum are beginning to demonstrate that ‘‘‘neurotypical’ is not the only way to be, or even the best way to be” (Singer, 2017, p. 1195). Over time, autism has become recognised more as a neurotype (neurological type) that differs from a ‘neurotypical’ brain, which is a dominant neurotype, and which Singer observes is “a term coined to sideline [people, like] the word ‘normal’” (2017, p. 404). Neither one is better or worse than the other; the neurotypical brain is “designed to facilitate socialisation” and the autistic brain is designed “to focus on understanding the world around us” (Castellon, 2020, p. 31).

The cluster of deficit-based traits for ASD identified in the DSM-5 are oriented toward males (Ranson & Byrne, 2014), leaving girls undiagnosed or misdiagnosed when their collective autistic traits are misinterpreted and categorised as a mental illness rather than as autism (Carpenter et al., 2019). According to the traditional definition of autism, identified as a male syndrome, the number of children diagnosed with ASD has risen over the last decade (Sproston et al., 2017). The higher rate of diagnoses does not mean the number of people who have been born with the condition has risen; rather, it is illustrative of a better understanding of autism due to ongoing research, education and awareness (Carpenter, 2017). Further research on girls and autism is likely to see the number of female diagnoses increase, shrinking the gap between males and females.

The lack of knowledge about girls and autism due to a dearth of research leaves many girls unsupported, misdiagnosed and misunderstood, even though they may receive a diagnosis as an adult (Carpenter et al., 2019; Cook et al., 2017; Mademtzi et al., 2017). The later diagnoses of women may be one reason why ASD is, according to statistics, diagnosed four times more often in males than in females. Other reasons include ASD presenting differently in males (APA, 2013; Mademtzi et al., 2017; Moyse & Porter, 2015) and diagnostic tools derived from the DSM-5 being skewed towards male traits and characteristics of autism (Ranson & Byrne, 2014). A further reason frequently cited for missed or late diagnoses in females is their ability to mask traits associated with autism (Cook et al., 2017; Ranson & Byrne, 2014). Females are better at masking or camouflaging their symptoms through strategies such as mimicking and scripting (Myles et al., 2019). Due to being able to mask their inadequacies and mimic others, females on the autism spectrum are perceived as ‘normal’, with the result that many autistic girls ‘fly under the radar’ and suffer in silence during their primary years (Attwood, 2006).

Social model and medical model of disability

The medical model versus social model debate is frequently highlighted in the literature on autism (Alsharif, 2019; Liu et al., 2018; Manago et al., 2017; Pickard, 2019; Singer, 2017) and is included in this overview to acknowledge how far our thinking has come in terms of what autism is or is not and how it presents in everyday life. The medical model, with a deficit focus on ASD according to the DSM-5, insinuates a stigma associated with the term ‘disorder’: that it is something ‘wrong’ that requires ‘fixing’, even when the perceived negatives could be strengths or unique abilities (Angulo-Jiménez & DeThorne, 2019).

The social model proposes more than one perspective, but essentially asserts that autism is a social construct whereby society determines what is a disability and ability and how they are approached (Mitra, 2006).

The social and medical models are in opposition to one another – the latter focuses purely on disability, whereas the social model draws attention to autism as a spectrum and showcases abilities. Although the social model exposes the social inequalities encountered by people on the autism spectrum, it acknowledges that it is not the person with the disability who needs to change, but society that needs to change its perspectives on autism (Shakespeare & Watson, 2002).

The neurodiversity paradigm for understanding autism is sometimes considered an ‘outgrowth’ of the social model in that it acknowledges the need for support (Angulo-Jiménez & DeThorne, 2019, p. 570).

Disassociating autism from the notion of being a mental disorder and moving towards a more holistic view of how it manifests in the real world means that the strengths inherent in this different way of thinking are not ignored. A different way of thinking simply means autistic people will learn about the world in a different way (Sherratt, 2005).

What the medical model identifies as deficits, the social model may identify as strengths. Focusing on a social model, whereby autism is identified as a neurology, will enable a better understanding of autism in females, not only in a schooling context, but also in the medical milieu where diagnosis takes place. This holistic view of autistic strengths and challenges, rather than just deficits, will allow for better understanding and earlier identification of females on the autism spectrum.

Mediation is needed between the social and medical models to reframe how society views disability, reduce stigma and promote acceptance. One model that is emerging from this binary view is the neurodiversity paradigm, which stems from the social model (den Houting, 2019). Singer (2017) is credited with coining the term ‘neurodiversity’, and did so in the belief that “we need to go beyond the dichotomy of the medical model vs. social model” (p. 615).

Given the history of autism, the medical and social models, people’s lived experiences and the adoption of the term ‘neurodiversity’ within autism discourse, Silberman’s (2015) modern view of autism as a “different operating system” is a favourable one (p. 471). The neurodiversity paradigm began to emerge in the late 1990s (Angulo-Jiménez & Dethorne, 2019; Silberman, 2015) to explain the concept that there is not just one type of ‘normal’ brain.

Identifying the female autism phenotype

As girls on the autism spectrum grow older, they are more likely to be misdiagnosed with mental health issues (Myles et al., 2019). Misdiagnosis can have devastating long-term effects, as undiagnosed females may be medicated, develop limited survival strategies and are often left to navigate a challenging world as ‘misunderstood’ individuals, leading to a plethora of problems in their adulthood (Holliday Willey, 2012). Teachers are often the first to recognise when a student may need a referral to a specialist health professional so that these students receive the appropriate support and intervention in the early years.

As autistic females are underrepresented in the research, ‘female stories’ are often shared to gain insights (Jarman & Rayner, 2015). Jarman and Rayner presented themselves as case studies and shared their personal stories and knowledge of being on the autism spectrum. Temple Grandin’s Asperger’s and girls (2006) and Wenn Lawson’s Girls and autism: Educational, family and personal perspectives (2019) are examples of the autistic voice. They highlight the importance of listening to the voices of autistic females by adding an element of authenticity to the academic discourse. There are also well-known autistic women presented in the media, Greta Thunberg (Swedish environmental activist), Susan Boyle (Scottish singer) and Hannah Gadsby (Australian comedian) who openly share their diagnosis and talents, and challenge ideas of what autism ‘looks like’. Jarman (2013) proposed further case studies on school-aged females on the autism spectrum to enhance understanding and recognise their unique challenges and characteristics. As research often lags behind clinical and anecdotal observations (Marshall, 2015), Jarman’s (2013) work was important for advancing our understanding of the relatively new medical term ASD.

There are many anecdotal and clinical observations on the female profile of autism in the form of checklists and online stories about ‘lived experiences’. These can be a resource for females who have been misdiagnosed, have a missed diagnosis or are seeking answers to explain their differences (Craft, 2016; Marshall, 2016; Starlight and Stories, 2018; The Little Black Duck, 2018). Tania Marshall is an Australian psychologist, specialist and prolific writer on autistic girls and women, who has published numerous books and blogs on the female presentation of autism, including I am Aspien Girl and I am Aspien Woman. Marshall (2019) explored the many traits of girls on the autism spectrum, as well as themes such as masking, anxiety, perfectionism, emotion and high achievement, acknowledging that many of these traits make it difficult to identify and support autistic females.

A communication tool, CASSIE, was recently developed from evidence-based research, and focused on the female autism phenotype in the early years of schooling (5–8 years of age). The CASSIE tool, which is presented in the form of a wheel, can assist with identifying autistic girls in the early years’ classroom and help teachers to better manage girls’ learning and social experiences (Stansfield, 2020). The CASSIE tool further informs the literature about the traits and characteristics that pertain to the female autism phenotype. There is no single way to categorise the traits and characteristics of girls on the autism spectrum, and CASSIE incorporates communication, academic, sensory, social and identity aspects (Stansfield, 2020). Stansfield (2020) found several reasons why girls are ‘invisible’, meaning fewer girls are diagnosed than boys: they have masking traits; they are social, but more so with adults; traits vary between males and females; they are capable but this is not always shown in their work; there are misconceptions that autism is a ‘boy’ condition; and deficits are seen as strengths and vice versa. These reasons support the DSM-5 (2013), which states that females go unrecognised due to “subtler manifestations of social and communication difficulties” (APA, 2013, p. 57).

The development of the CASSIE tool is beneficial not only to teachers and parents, but also to the wider support network. It can help identify autistic females and support them, regardless of whether they are diagnosed (Stansfield, 2020). Ongoing research on the female autism phenotype, such as the contributions of Jarman (2013) and Stansfield (2020), may assist in reducing the number of missed diagnoses or misdiagnoses of autistic females.

Conclusion

There is a continuing need for acceptance of autism in the general community. Sharing knowledge brings about greater understanding, and highlighting the female autism phenotype with a focus on strengths is a positive way of reducing stigma and increasing acceptance. Over time, education will change community perspectives on autism and how it presents in females. People on the autism spectrum are beginning to demonstrate that “‘neurotypical’ is not the only way to be, or even the best way to be” (Singer, 2017, p. 1195). Over time, autism has become more recognised as a neurotype that differs from a neurotypical brain, a dominant neurotype (Singer, 2017). Neither one is better or worse than the other.

References 

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Carpenter, B., Happé, F., & Egerton, J. (2019). Where are all the autistic girls? In Carpenter, B., Happé, F., & Egerton, J. (Eds) Girls and autism. Educational, family and personal perspectives. (p.3-9). Routledge. 

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Goodall, C. (2015). How do we create ASD‐friendly schools? A dilemma of placement. Support for Learning, 30(4), 305-326. https://doi:10.1111/1467-9604.12104 

Holliday Willey, L. (2012). Safety skills for Asperger women: How to save a perfectly good female life. Jessica Kingsley Publishers.  

Hull, L., Petrides, K. V., & Mandy, W. (2020). The Female Autism Phenotype and Camouflaging: a Narrative Review. Review Journal of Autism and Developmental Disorders. doi:10.1007/s40489-020-00197-9 

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Jarman, B., & Rayner, C. (2015). Asperger’s and Girls: What Teachers Need to Know. Australian Journal of Teacher Education, 39(2), 128 -142. https://doi:10.1017/jse.2015.7 

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Mademtzi, M., Singh, P., Shic, F., & Koenig, K. (2017). Challenges of Females with Autism: A Parental Perspective. Journal of Autism and Developmental Disorders. doi:10.1007/s10803-017-3341-8 

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Article from: Counselling Australia Journal: Volume 23: Number 2 – Winter 2022

By Melissa Marino

Counsellors are critical gatekeepers in the prevention of suicide, says Dr Nicole Hill, a leader in youth suicide prevention research in Australia.

It is, therefore, integral they and other health professionals receive suicide-specific training and operate as part of a healthcare network with families, educators, community organisations and social systems to identify risk and respond in a timely manner.

Dr Hill says her work shows that one in two young people who die by suicide had a suspected or known mental health diagnosis at their time of death. This is important for counsellors to know as it indicates there are opportunities within the health system to make a difference.

The initial response someone receives when reaching out for help can determine how likely they will be to seek future support, she says. With often weeks-long waiting lists for therapy, it is critical that adequate interim support and information is provided to keep people engaged.

“There’s a duty of care to inform young people of strategies or resources they can use to help bridge that waiting period,” she says.

Crisis helplines, such as Lifeline, “can really help during the fleeting suicidal crisis”, she says. And new peer support programs such as one being trialled by SANE Australia could be valuable.

For young people who have disclosed suicide ideation and have a specific plan, best-practice strategies such as means-restriction counselling and safety planning can be very effective. “The research shows that in the general population, safety planning can reduce the risk of suicidal behaviour by up to 50 per cent – so that’s a really important one,” she says.

Culturally informed care is also critical to ensure LGBTIQA+ young people and others who are marginalised have a safe space to go, she says. “It’s as much about addressing the mental health concerns of young people as the social and cultural contexts and stresses that they face.”

Training more counsellors would help address the issue of mental health in young people but, in the long term, changes to the system to ensure young people could access coordinated, ongoing support are required,  she said.

As a keynote speaker at the International Association for Suicide Prevention conference, Dr Hill says such events are important for upskilling, exchanging ideas and learning about evidence-based best practice. On a personal level, it is also invaluable to meet others working in the “significantly underfunded” yet critical field,  she says.

“The work is hard. We’re dealing with suicide, which is a very difficult topic and has a personal cost. But being able to connect with others who are dealing with the same challenges is really good for our own wellbeing as well.”

Matching job seekers to employment opportunities

The ACA Careers Centre is a central hub where employers can advertise current job vacancies to the right candidates and job seeker can find suitable employment opportunities within the counselling industry. In August 2022, over 200 jobs were posted in to the ACA Careers Centre! These jobs spanned all Australian States and Territories with a range suitable for new graduates to experienced practitioners, and across all levels of membership.

The ACA Careers Centre is an information service, not a recruitment service.

How does the ACA Careers Centre work?

What are the benefits to the ACA Careers Centre?

As a job seeker:

Members can quickly and easily find jobs in their area and desired field, that are specific to Counselling and Psychotherapy.

• Only accessible to ACA members.
• Ability to filter searches by state, city, speciality and work type.
• All job listings are linked to the advertiser’s original ad, so there’s no need to manage any additional accounts.
• Setup email notifications to advise you of any new job listings.

As an employer:

Job vacancies that are listed on the ACA Career Centre provide increased opportunities for suitable candidates to find your job listings.

• Get your ad in-front of the largest network of Counsellors and Psychotherapists in the country.
• Easy to use process that links your ACA Career Centre job listings to your current Seek ad so there’s no double handling.
• Free to post as many ads as you like!

What are the most frequently posted jobs on the ACA Careers Centre?

Often, the positions available to Counsellors and Psychotherapists will not be titled “Counsellor” or “Psychotherapist”. The Counselling industry is wide-reaching and diverse. There are more opportunities out there for counsellors than we realise. Here are some of the common terms and positions advertised: