Why Should I Join AAPi by
- If you feel that registered psychologists have been 'sold down the river' by the APS (promoting a devaluing of 'generalist' psychologists and a non-evidence based favouring "Endorsed" Clinical practitioners and APS Clinical College members, resulting in the 2 tiers of Medicare rebates.)
- If you are concerned about the 'break-away' APS Clin Psych board members (who are angry with the APS for not promoting them even more than they have, and who are lobbying to have all Medicare rebates to registered psychologists eliminated, with only them being eligible for Medicare rebates)
- If you are concerned that the Federal Government's provision for the recognition of equivalent learning and experience of psychologists (assessments conducted by the APS Medicare assessment team) is operating in a manner which is a corruption of the original intentions - not actually providing a fair assessment of experience/training of experienced psychologists
- Then you need to seriously consider joining the voice of protest which the Australian Association of Psychologists Inc has been created to express.
- The funds generated from registration fees will be going towards a variety of activities to address the issues referred to above.
- Please distribute this information to as many psychology colleagues as you can. Help to get this ball rolling. The aim is to have the AAPi become a peak professional organisation that will represent the interests of registered psychologists with key decision makers (eg. government) and to address the above mentioned inequities.
- Our livelihoods and the public's access to psychological services are at stake.
Click on "My AAPi" and then "Register with AAPi" to complete the registration form.
Now is the time to get involved.
Sunday, April 22, 2018
Elitism and Hubris in Australian Psychology by Dr. James Alexander Ph D.
Elitism and Hubris in Australian Psychology
Dr James Alexander, PhD. Registered Psychologist.
There seems to be something of a media campaign occurring in the last few months in which some 'clinical' psychologists are laying exclusive claims to professional expertise in the mental health arena- this is on top of the APS successfully arguing for a differential of competence (ie. superiority) of their endorsed 'clinical' psychologists. One need only review the comments of many 'clinical' psychologists in the ABC Radio National web page after a Life Matters program in which the current president of the APS and psychiatrist Ian Hickey were interviewed ('look up listeners comments for the 'Psychology Blues' discussion under Life Matters). Further evidence of this attitude amongst some 'clinical' psychologists can be found in the article which featured in The Australian on 12th March (Psychologists quit in row over standards). In this article, a view that 'non-clinical' psychologists are "likely to place patients at risk of harm" is attributed to the 'break-away' 'clinical' psychologists who are upset over the APS not doing enough to promote their supposed exclusive expertise. Clearly, these 'clinical' psychologists believe that only they are well trained in dealing with mental health problems, and only they are able to obtain positive outcomes with clients. It is clear that they believe only 'clinical' psychologists should be able to claim Medicare rebates under the Better Access scheme, as apparently all other psychologists are deemed as somehow 'unsafe', and at the very least inferior. Whether this is an honest and serious belief, or simply an attempt to protect their own academic and clinical careers (vis-a-vis self-elevated status and economics) is a valid question to ask. Surely, they can't be so ill-informed about their own profession? Is there more than innocent ignorance at play?
The critical discussion that follows pertains to the attitudes of those 'clinical' psychologists who share the beliefs referred to above. Obviously, not all 'clinical' psychologists share these views, however an unknown amount do endorse them- if it is a minority, judging by the responses on the Life Matters discussion page, it is a highly vocal and self exulting minority.
Throughout this article, the designation of a psychologist as 'clinical' will appear in inverted commas in order to question the legitimacy of the exclusive use of this terms by some self appointed portions of Australian psychology. So, what is 'clinical' psychology and how does it differ from non-clinical psychology? The term, like the word God, has been so badly misappropriated and misused that I wonder if it wouldn't be better abandoned? In his discussion site Conscience, W.A psychologist Ben Mullings (2010) makes the point that when psychology was beginning to emerge from the universities and into applied settings following WWII, many psychologists were doing the same type of work in public settings and using terms such as 'counselling', 're-education' or 'child guidance' instead of 'therapy'. The term clinical psychology became a preferential term for some psychologists in applied settings, whereas others preferred the term counselling- there was, and remains, little difference between the two.
In the many years since then, the term clinical psychology has become 'colonised' and appropriated in Australia by the APS, so that in order to describe oneself with that term, one apparently needs to be an APS endorsed 'clinical' psychologist. Being a psychologist doing clinical work apparently does not qualify one for to use this now elitist term. How did this colonisation of a descriptive term occur? The push for greater professionalism in all aspects of society must hold part of the answer. The illustrious careers of some academic psychologists, and the self enhancing development of their status must also be part of the problem. The notion of improving the training and skills of psychologists working with clinical problems somehow became associated with certain, selected courses of study to the exclusion of others. Surely, at the end of the day, clinical psychology is the application of a scientific psychology to clinical problems which humans experience. The term 'clinical problems' cover a range of phenomena so well understood that it requires no explanation. Clinical psychology, like 'politics' is an activity- it is what psychologists do in a clinical setting.
The recent comments on the ABC Radio National Life Matters discussion page clearly indicate a range of deliberately false views that are being espoused by some 'clinical' psychologists. These include the statements that 'generalist' psychologists (ie. anyone other than an APS endorsed 'clinical psychologist') are only 3 year trained; are only 4 year trained; have completed no post graduate training or professional development; that 2 years supervised training is an inadequate waste of time; that 'generalist' psychologists have undertaken no training at either the undergraduate or postgraduate levels in psychopathology, psychological assessment or psychological therapies; that 'generalist' psychologists have not undertaken any student placements in their post graduate studies; that 'generalist' psychologists are either of no use in working with emotionally distressed/disturbed people, or are simply dangerous.
Most of these spurious views are easily dismissed in reference to the evidence- some are deliberately untruthful and mischievous, while others are simply ill-informed and misguided. In deciding which is true (ie. either ignorant or mischievous), one needs to consider the boost to APS endorsed 'clinical' psychologists status (as psychology's self appointed 'Brahmins'), not to mention their pockets. Most of them are either now receiving higher Medicare rebates as a result of convincing the Federal Government of their inherent superiority; and if academics, they are advancing their careers by ensuring that more people are channelled into their 'clinical' psych programs due to the financial benefits created for so doing.
The Federal Government has been led to believe that there are two types of psychologists, ie. 'clinical' (according to the APS) and all others- 'generalists' (in which are lumped counselling, health, forensic, educational, sports, organisational psychologists etc). This is many ways a false dichotomy. All registered psychologists share at least 4 years of academic study in which the vast majority are taught common subjects including abnormal psychology, assessment and approaches to psychological therapy/counselling at both the undergraduate as well as the post graduate level. Some psychologists, after these 4 years, chose to undertake even more academic training (masters or PhD's) in a range of sub-disciplines as listed above as well as in clinical psych, whereas others chose to get some applied training in the workplace under 2 years supervised training. Personally, I believe that more benefit accrued to me as a young psychologist by undertaking 2 years of supervised training in an applied clinical setting (conducting assessments, report writing, counselling/psychotherapy) than by undertaking 2 more years of academic training. This reflected my strong desire, after 4 years of academic training, to 'roll my sleeves up and get my hands dirty', doing the real work while under in-house supervision. I recognise that not everyone had the same desire. Some of my post grad colleagues felt not quite ready yet to do applied work under supervision, and chose instead to continue on to a Masters program where they hoped to receive more confidence through more academic training and placements. I never had a problem with this choice of theirs, even though it was different to mine. At the time, I could recognise that there were several paths to becoming a capable psychologist, and if some felt the need for more study, so be it. It never occurred to me (or apparently to many others) that my choice of doing 2 years supervised training was an inferior form of training- in fact, the opposite seemed true as I was doing the work 'for real'. I never felt inclined to diminish the other chosen path of more academic training. Other people made the same choice as me for more economic reasons, ie. their life circumstances required the earning of an income after 4 years of full time study.
Whatever the reasons, it is clear that my training as a psychologist did not end until I had completed my 2nd year of supervised training, culminating in my 6th year of training overall, when I became a registered psychologist in my own right. It also never occurred to me that this new status of a registered psychologist would ever be used in a pejorative sense by my colleagues who had decided on the need for more academic training in a masters program. In summary, to be a registered psychologist is only possible after one has completed 6 years of study/training, whether the final 2 be in the form of an internship or in the form of a masters degree.
For APS endorsed 'clinical' psychologists to state that registered psychologists are under trained is simply promoting their training choice above an alternative training choice. Where is the evidence in favour of their choice? As the APS convinced the Federal Government that a masters degree in 'clinical' psychology demonstrates a higher level of competence, deserving a higher rate of pay, surely there must be some evidence to justify this differential? More broadly, where is the evidence that above a certain level, more academic training produces more effective psychologists or clinicians?
The only research that I am aware of which has addressed this question is now decades old. Do the results still apply? In the absence of any contemporary results indicating the opposite, is there any sound reason to assume they do not? Research conducted by Carkuff (1984) in the 1960's examined the different levels of effectiveness in counselling skills between lay counsellors and academic professional training at the graduate psychology level (perhaps equating to an equivalent level as our masters programs in terms of preparation, workload and level of specialisation). The lay counsellors who he assessed had received some training in counselling skills, but not the higher degree level of the academically trained psychology students. Carkuff (1984) concluded that:-
1. lay trainees function at levels essentially as high or higher (never significantly lower) and engage clients in counselling process movement at levels as high or higher than professional trainees (p.5)
2. lay trainees effect changes on the indexes assessed that are at least as great or, all too frequently, greater (never significantly less), than professionals (p.7)
3. the professional trainees were functioning at higher levels prior to training and at lower levels following training, both in relation to lay trainees and themselves (p.7)
4. While the results of lay programs exhibit trainee gains on those dimensions related to client change, the professional programs exhibit a drop in the level of trainee functioning over the course of graduate training, with the largest drop seeming to occur between the first and second year. Although with experience practitioners appear to recoup some of their losses in functioning, there are direct suggestions that many may never again function at the level at which they did when they entered graduate school. Two follow-up evaluation studies indicate that those who drop out of professional training tend to be functioning at higher levels of facilitative conditions than those who stay in. (pp.9-10)
One possible explanation for these findings was that the lay counsellors were selected for their roles as a result of natural empathy, warmth etc; where as the selection into professional training programmes were dominated by highly intellectual factors, primarily grade point average. Also of interest was the finding that the trainees level of competence tended to converge on the level of functioning of their trainers. The trainees of trainers who were functioning at high levels themselves demonstrated uniformly positive change; those of trainers who were functioning at moderate or low levels demonstrated little, or deteriorative change or none at all. It can be inferred from this finding that the level of functioning of the professional trainer (ie. an academic) may account in large part for the negative results in studies of graduate training.
The most pertinent implication of these findings is that further academic training, beyond a certain point (ie. in the American university system- between year 1 and year 2 of graduate training, perhaps equating with our post graduate/honours level) does not equate with a higher level of skill. In fact, the opposite seemed to be true in Carkuff's research- the more academic training, beyond a certain point, the more de-skilled in counselling the students became. Beyond a level (that equates with our 4th year of study), the more academic training incurred, the worse the counselling skills became.
While these may be somewhat shocking results for professional psychology, and they are admittedly quite old, in the absence of any research demonstrating an opposite finding, then they remain hard to ignore. In our context, these results do suggest that one could in fact be more suspicious of the therapeutic skills of psychologists with higher degree academic training; and more confident in the skills of psychologists with only 4 years of academic training. As Carkuff (1984) demonstrated, the actual level of skills measured usually corresponded with the skill level of the trainers. In a university training system, this generally means academics. Academics, by definition, are people who may have done some applied work (not necessarily so), but have primarily focused more on research, training and education- not developing their applied clinical skills. Carkuff (1984) demonstrated that the less time being trained in therapeutic skills by any academic educator in a university setting was better for the maintenance of pre-existing therapeutic skills. As such, on the face of the evidence, it seems hard to support the notion that completing a masters degree in 'clinical' psychology necessarily equates with superior clinical skills when compared with psychologists who undertook the 4+2 approach. If there is research based evidence suggesting a different conclusion, then please feel free to bring it to my attention- I would be extremely interested.
On the strength of the above conclusions, it may actually be the case that psychologists who undertook the 4+2 route, and who have then maintained a vigorous professional development program, as we are all encouraged to do, have not been de-skilled of their pre-existing therapeutic skills. This may result because the professional development workshops that contentious psychologists attend are often/usually conducted by applied practitioners, not by academics. These are people who are using on a daily basis the clinical skills that they are teaching in workshops. This may offer some additional benefits above being trained in clinical skills primarily by academics whose main career focus has been research and teaching.
My own experience may or may not be common. I completed a Post Graduate Diploma in Counselling Psychology, which I believe was as good a training as any available at the time. On graduation and commencement of my 2 years supervised training, I managed to put into practice what I was taught (eg. Egans helping skills, CBT, RET, behaviour therapy), however rarely saw results that were terribly impressive- perhaps not unusual for a new graduate at any level. Fortunately, I worked in a counselling centre and had a supervisor who encouraged a broader repertoire than what university exposed me to. I was also encouraged to attend additional training, which I have never ceased to do. Towards the end of my 2 years supervised training, I had managed to 'un-learn' much of what I had been taught, and at that point, I became quite effective as a psychology practitioner. This experience did not reflect a deficiency in my post graduate training, but more a need to find my own way once the basic skills were in place. I do not think this is a unique experience.
Many 'generalist' psychologists (all those other than APS endorsed 'clinical' psychologists) have also undertaken masters degrees and PhD's. The difference is that these people tend not to be presenting themselves as inherently superior psychologists by virtue of their additional academic training; nor have they convinced the government to financially reward them at a higher rate because of their additional study, despite their higher degrees. I have a PhD in clinical health psychology by major research, which I undertook after many years of developing applied psychology skills. I believe that this has improved my knowledge of both the research process as well as of clinical and health psychology in general and my topic area in particular, but I do not insist that it has made me a superior psychologist deserving more payment than others for doing clinical work. My clinical skills were developed in the workplace, under supervision, and in professional development workshops- this is the common experience of 'generalist' psychologists.
Mullings (2010) points out that in America as well as in the UK, there are calls for the distinction between clinical and counselling psychology to be abandoned. No differential in status or income is perpetuated in those countries, whereas in Australia, academic careers have been made on creating such an artificial false dichotomy. This false dichotomy has been heavily promoted by the APS in the discussions leading to Medicare rebates for psychologists; and has been accepted by the Federal Government, now creating a financial reinforcer. On attending an APS workshop as a young psychologist, not long after graduating from my Post Grad Diploma in Counselling Psychology, I asked the workshop trainer, Dr Bob Montgomery to clarify what he meant by clinical psychology (as he was advocating that psychologists needed to get training in clinical psychology). He replied to me that my post graduate training in counselling psychology qualified, to him at least, as clinical psychology. It would appear that in the intervening years, his views on such matters have followed the development of his career as an academic in 'clinical' psychology programs. Dr Montgomery, back in the late 1980's, was clearly aware of the false dichotomy between counselling and clinical psychology. If his use of the term, as in the 1980's, simply means applied psychology skills (assessment, therapy/counselling, report writing), then it is hard to argue that any applied psychologist does not need these skills. Fortunately, the vast majority of applied psychologists obtain such training in professional development and supervision over the course of their careers.
Mullings (2010) also points out "There are some good examples of research comparing clinical and counselling psychology. Brems and Johnson for instance have compared clinical and counselling psychology across a number of areas including training content (1991), publication productivity (Brems, Johnson, & Gallucci, 1996), job-related activity (Brems & Johnson, 1996) and theoretical orientation (Brems & Johnson, 1997) finding very few practical differences. The Association of State and Provincial Psychology Boards in the US, which has overseen standards in specialist psychology since 1961 have conducted a wide-scale practice analysis in recent years, demonstrating that there are no differences between clinical and counselling psychology in terms of the settings they work, the clients they see or the psychological practices they employ." As such, the research would appear to argue against a unique status of 'clinical' psychology- the majority of psychologists do the same activities in clinical settings, whether they be APS endorsed 'clinical' psychologists or not.
Perhaps there is something in the training of 'clinical' psychology in Australia which is unique and clearly superior? The only research cited in PsychInfo on 'clinical' psychology training in Australia was conducted by Pachana, O'Donovan & Helmes (2006). These researchers conducted a survey of all 'clinical' psychology programs being taught in Australia at the masters and PhD levels. Their survey was responded to by 70% of the 'clinical' psychology program directors of programs that were being conducted in Australia in late 2004. Amongst the findings, in relation to 'content of courses', was the result that "The vast majority (84%) of clinical program directors identified their programs as primarily oriented toward cognitive behavioural therapy (CBT), with the rest of the program directors indicating that their programs adopted an integrative approach including theories in addition to CBT. More than half the programs were identified as evidence-based to an average degree; with one third of program directors describing the courses as largely evidence based" (p172).
The implications of this are quite important. Firstly, it clearly demonstrates that the only review of 'clinical' psychology programs in Australia shows that the vast majority train their students in CBT as the main approach to intervention taught, while the remaining 16% of courses train students in CBT and in other approaches as well. As such, 'clinical' psychology training in Australian universities is clearly training in CBT as the therapeutic approach. The APS claims that its 'clinical' psychology members are superior psychologists to 'generalist' psychologists because of their superior training- and the training, for the most part, is essentially CBT. However, where is the evidence that CBT is a superior treatment approach? Academic 'clinical' psychologist at UQ, Robert King (1999), himself a Fellow of the APS, clearly demonstrates in his article "Depression: do we know what we are doing" that there is no evidence that CBT is a superior therapy to other approaches in treating depression- the main condition that people seek help from psychologists for. Research reported this year by Cuijpers, Smit, Bohlmeijer, Hollon and Andersson (2010) demonstrates that the often espoused superiority of CBT disappears when the publication bias has been statistically accounted for. This bias is evident in meta analyses of CBT in that journals have a bias towards publishing research which presents a positive finding, and fail to publish research which presents negative findings. When the publication bias is taken into account with such meta analyses, CBT approaches a level of effectiveness no different to other therapeutic approaches.
Stein & Lambert (1995) state that "research demonstrating an association between within-program training procedures and the subsequent quality of therapy outcomes is virtually nonexistent" (p.182). In other words, there is simply no evidence that training psychologists in CBT produces superior psychologists. So, if not the approach, what does predict positive outcomes for clients when they receive therapy from psychologists? Lambert & Barley (2001) provide estimates of the contributors to therapeutic outcome that "characterize the research findings of a wide range of treatments, disorders, and ways of measuring client and therapist characteristics. The estimates represent research findings that span extremes in research designs, and are especially representative of studies that allow the greatest divergence in the variables that determine outcome. The percentages were derived by taking a subset of more than 100 studies that provided statistical analyses of the predictors of outcome and averaging the size of the contribution each predictor made to the final outcome".(p 357).
They present a pie chart which shows the following contributions to therapeutic outcomes:-
- Expectancy (placebo effect)- 15%
- Extra-therapeutic change- 40% (eg. luck-changes in circumstances, social support, etc)
- Techniques- 15% (eg. CBT, or EMDR, or Solutions focused brief therapy, etc)
- Common Factors- 30% (ie. client-therapist relationship; interpersonal style, therapist attributes- warmth, empathy, congruence, respect; etc)
"Research has demonstrated clearly that some therapists are better than others at promoting positive client outcomes in general and that some therapists produce better results with some types of clients than others" (p.358)
Where is the evidence that 'clinical' psych members of the APS, by virtue of their training (primarily in CBT) are the most capable of all psychologists in creating the therapeutic relationships that research keeps on showing are essential in creating therapeutic change?
Regardless of the values of CBT or otherwise, it is clear that the practice of this approach is definitely not unique to 'clinical' psychologists. Mullings (2010) cites evidence that, for better or worse, counseling psychologists are just as likely to do CBT as are 'clinical' psychologists. He states that post graduate training in counselling psychology presents a broader skills training than does 'clinical' psychology training in that it tends to not just focus on CBT, but rather encompasses a wider range of approaches.
In terms of implications of Pachana etal's (2006) article, of the Australian 'clinical' psych program directors who responded to the survey (ie. 80% of all Australian programs in 2004), only one third of them described their courses as largely evidence based, and more than half identified them as evidence based to only an average degree. This means that two thirds of 'clinical' psych courses are described by their own program directors as being minimally evidence based; and less than half of them described their courses as evidence based to only an average degree. In light of Cuijper etal's (2010) findings, it is clear that Australian 'clinical' psychology programs could only be training people exclusively in CBT while ignoring the evidence which indicates it to be no superior to most other approaches. In fact, they could only do this because they are ignoring the evidence, rather than having a healthy respect for evidence.
This is a general, broad problem which has seen the APS favour 'clinical' psychologists and convince the Federal Government of the false dichotomy. For a discipline that differentiates itself from others (such as philosophy, social work) with claims to a scientific status, it is remarkable that the self appointed leaders of Australian psychology can have such a robust disrespect for evidence. In the absence of evidence supporting either a superiority of 'clinical' psychologists per se, or a superiority of what they primarily do (CBT); in the absence of any evidence demonstrating a qualitative difference between what 'clinical' psychologists and 'generalist' psychologists do; in the absence of evidence demonstrating that 'generalist' psychologists are unable to conduct clinical work in a safe and effective manner- the APS and the break-away clinical psychologist are surely being motivated by something other than the facts.
In an activity where there is clear, demonstrable differences in standards of performance, no one generally has a problem with differences in both pay and status. As a former amateur Aussie Rules footballer, I can recognize that footballers in the AFL deserve more pay and status than I did (when I had to pay clubs to allow me to play with them in the form of registration fees!). But when it comes to psychology, surely there must be a demonstrable difference justifying differential pay and status?
The break-away APS eligible 'clinical' psychologists merely represent the natural conclusion to notions of superiority that have been fostered and promoted by the APS and accepted by the Federal government. In so doing, they remind me very much of a group of India's Brahmins who several years ago went on a hunger strike as a result of the government policy of no longer recognizing their inherent superiority with guaranteed jobs. Their superiority was self evident to them; however, it was no longer evident to the government and presumably much of the Indian population. The break-away 'clinical' psychologists have reduced themselves to the level of such hysteria and self adulation that they actually bring discredit to our entire profession. As far as a rational basis for making a differential goes, you might as well consult Chinese astrology and say that any psychologist with a 4 in their birthdate is an 'unlucky' (ie. inferior) psychologist who should not be eligible for Medicare rebates. What clinical psychologist are proposing is fanciful, irrational, and so based on vested status and financial interests that one may even consider it to be grubby behavior unfitting of a professional.
Since the advent of the Better Access program, 'generalist' psychologists have provided twice the number of services to the Australian public than have 'clinical' psychologists. People in the most disadvantaged areas, rural and remote, now have 50% more access to psychologists as a result. This breakaway group of 'clinical' psychologists would put an end to this improvement, insisting that only their small club be able to provide these services with a Medicare rebate. If they succeed, the result will be people in the affluent areas of capital cities still getting the same access to clinical psychologists (most of whom are located in areas of affluence), while the rest of the population return to going without. Untold suffering to non-affluent Australians will result; spending on 'down-stream' health services will blow out, but at least the self proclaimed elite of Australian psychology will have secured their incomes and their careers. Better Access to Mental Health will become Worse Access for Most Australians, and none of it will be based on any actual evidence- odd for a profession that aspires to science.
The Liberal government that brought in the Better Access program had the right idea in leaving a clause which allowed for 'generalist' psychologists to demonstrate their equal level of competency. Unfortunately, they left it up to the APS to evaluate a psychologist's education, training and experience. This was like leaving the wolf to guard the sheep- they have a vested interest in keeping their club small as it will increase the chance that when the budget axe inevitably falls, only a small group of the elite will be able to continue receiving Medicare rebates. It has been a common report for highly experienced and well trained psychologists to have applied for eligibility of the APS College of Clinical Psychology only to be rejected on spurious grounds. Many of these psychologists also have masters degrees and PhD's in other areas of psychology as well as in research of clinical issues. The vast majority of them have years and years of professional development training, much of which would equate to several masters degrees of training. The standard advice to such people from the APS has been to undertake and APS approved masters degree in 'clinical' psychology. Again, this issue is political, not scientific. It ensures lucrative academic careers in 'clinical' psychology as there is now a financial incentive for people to study their higher degrees rather than in counselling, educational, forensic psychology etc. What is occurring is a homogenization of Australian psychology which will damage the profession's overall reputation and creditability.
There are many viable alternatives to the current system. These need to be thoroughly explored by Australian psychologists, and not left up to the vested interests of the APS or break-away 'clinical' psychologists. The Australian Association of Psychologists has been formed to represent Australian psychologists in our attempt to negotiate for mutual respect amongst psychologists, equity in status and remuneration, acknowledgment of competencies and a genuine better access to psychological services for the Australian population.
References: Carkhuff, R.R. (1984, orig 1969) Helping and Human Relations (2 volumes): Human Resource Development Press. Amherst, MA
King, R (1999) Depression: do we know what we are doing? Psychotherapy in Australia. Vol 5, No3. May.
Lambert, M., & Barley, D (2001), 'Research summary on the therapeutic relationship and psychotherapy outcome'. Psychotherapy, Winter edition, No4.
Mullings, B (2010) Conscience: the critical issues in Australian Psychology. http://www.psyber.net.au/
Pachana, N., O'Donovan, A., & Helmes, E .(2006) Australian clinical psychology training program directors survey, Australian Psychologist, Nov 41(3): 168-178.
Wednesday, May 12, 2010
The Drugging of Australia by Dr. James Alexander PhD
The Drugging of Australia
Although the Howard government hoped the program (Better Access to Mental Health) would result in a decline of taxpayer-subsidised antidepressants, the number of prescriptions written in Australia for these drugs since 2006 has increased by 382,738 to more than 12 million last year (Editorial- The Age, June 20th 2010). Clearly, the problem is getting worse, not better.
My involvement with GPs dramatically rose with the introduction of Medicare rebates for psychologists introduced in November 2006. Suddenly, more than half of my private practice case load were GP referrals, as GPs are the gate-keepers to these rebates via mental health care plans. Prior to this, most of my clients were either self-referred, or referred by Employee Assistance Programs as part of employee entitlements. As such, most of my previous case load was with people who had not come to me via a medical pathway, however since late 2006 at least half of my case load derives from a GP referral. This increase in GP referrals has given me more experience in what appears to be conventional medical responses to such issues as depression and anxiety. It has also given me the opportunity to work more closely with many GPs and to see that for the most part, these are caring professionals who are genuinely well intentioned. This has created something of a dilemma for me in that it would be easier to take a critical stance of medical responses to mental health issues were I able to disregard the motives of physicians as being paternalistic power plays- my experiences have helped me to sincerely believe that this is not the case. What, then is going on?
While not maintaining any statistics on the issue, my estimate is that around 75% of people referred to me by GPs come already having been placed on antidepressants, usually SSRIs, and often benzodiazepines or mood stabilizers in addition. The overwhelming majority of these people present with symptoms which clearly suggest either the early stages of negative side effects, or an established pattern of the same, depending on how long they have been on the drugs. Naturally, I am aware that I see a biased sample, i.e those whose distress is resistant enough to medical treatment to justify a psychology referral. My assumption, based on the occasional client that I see as well as figures presented by David Healy, Professor of Psychiatry at Cardiff University, is that a portion of the population either appear to do well on SSRIs, or at least they are doing no worse. For the most part, I do not get to meet these people. Around 60% of people placed on antidepressants find the side effects so intolerable that they do not continue on them beyond the initial few weeks (Healy 2004). The other 40% may fit the category of doing well on these drugs, or at least no worse- or they continue with the medications even though their lives are spiraling downwards. They typically present with many of the following symptoms, eg. worsening depression, anxiety and panic attacks; increases in suicidal ideation, and sometimes self-harming behaviour; psychological as well as physical agitation, and often increases in substance use to counter this; mania and hypomania, reflected in reports of out of control behavour that just isnt me; sexual dysfunctions; insomnia as well as lethargy; nightmares and terrors; electric shock like sensations in the head, as well as a myriad of other odd physical sensations, including new chronic pains (medically inexplicable), nausea, dizziness, headaches, tinnitus, bowel and digestive system abnormalities.
Many of the 40% of patients who remain on these drugs have been suffering on them for years, lacking the confidence to defy their physicians recommendations and withdraw. This lack of confidence is usually bolstered by experiences of failed attempts to withdraw themselves, often cold turkey or at least too quickly, resulting in terrifying withdrawal effects. To compound the problem for these sufferers, they tend often to respond to medical cues and invitations to view these symptoms as resulting from a worsening of their condition, eg. depression, rather than attribute them to the symptoms of the drugs. When a sincere and respected physician authoritatively tells a patient that the drugs can't be creating these symptoms, a significant part of the population are prone to believe them, now more vulnerable due to their increased suffering. People who are suffering tend to be vulnerable to the influence of those in credible positions of authority, even if just out of sheer desperation. The greater the suffering, the greater the vulnerability to this influence. As such, the sense of despair and hopelessness deepens and a vicious downward spiral can be created.
If this is all so apparent to me as a psychologist, why is it not so apparent to intelligent and conscientious GPs? This question has puzzled me greatly. To date, I have settled on the explanation that when many of the current crop of mid-career physicians were embarking on their careers in medicine, the SSRIs were being heralded as the new wonder drug. Commencing my own career in psychology during the same era, I remember wondering if I had not just been made redundant by this advance in pharmaceuticals. This concern was only stemmed by my reading in the early 1980s of Peter Breggins book Psychiatric Drugs and their brain disabling effects. The marketing of the SSRIs drugs in the late 80s was so effective that few members of the public could have remained ignorant of them, and they had not yet been around for long enough for the industry claims of no SSRI side-effects to have been proven false. The promise of relief from emotional suffering was now as close as the doctors prescription pad. Due to the effective marketing and the plethora good news stories in popular media, the placebo effect was in full force. (The placebo effect was most recently demonstrated yet again by Kirsch, Deacon, Huedo-Medina, Scoboria, Moor & Johnson, 2008). The pharmaceutical marketing reinforced everyones confidence, especially the prescribing doctors confidence, that the ultimate answer, in the shape of a pill had been found.
Placebo effects are one matter, with the evidence in regards to the SSRIs calling into question the legitimacy of the very term antidepressant. Were the SSRI story to end there, merely with the placebo findings, one may conclude that they were relatively harmless. The issue of psychological and physiological damage is quite another matter however. It can take years for reports of adverse reactions to filter through to authorities in such numbers that demand attention. On a clinical level, it appears that many physicians (even those who both I and their patients view as being the most caring and attentive) are more attached to the promise of SSRI safety and effectiveness than they are to an open minded receptiveness to their patients reports of deterioration of their condition. This appears to be a psychological need of the physician. It is an anomaly that I can only understand in relation to the marketing successes of pharmaceutical companies and the construction of depression as a medical illness. My view is that depression and anxiety are not illnesses requiring medical attention. Our culture used to have a term which covered most of these experiences- it was called life. Some experiences in life can be entirely problematic - Thomas Szasz wisely referred to them as problems in living. Fortunately, most of the problems in living which are currently being treated with SSRIs and other antidepressants tend to be resolvable with:- genuine care, concern and support from professionals or friends; problem solving strategies (perhaps involving legal, economic, social and interpersonal solutions); and with brains that are not being further compromised with introduced neurotoxins in the form of drugs, either illicit or medically prescribed. And this is perhaps the most tragic part of the situation to me- that so much of the apparent damage being caused to people with the mass prescribing of such substances is unnecessary- viable alternatives exist, and are now financially accessible via Medicare rebates. Unfortunately, it seems that allowing GPs to play the role of gatekeepers to psychological services has only ensured that through the required medical contact, the amount of scripts for antidepressants has radically escalated.
Anti-depressants and the problematic 50% Professor Allen Roses (2008), Drug Discovery Institute of Duke University and former Senior Vice President for Genetics Research at GlaxoSmithKline, states that more than 50% of drugs dont work in more than 50% of people. According to Andrew Somogyi (2008), Professor of Clinical and Experimental Pharmacology at the University of Adelaide, this estimate has stood up to the test of time. Why would we assume that psychiatric drugs could be any different? One of the reasons perhaps is that most GPs have experience with the non-problematic proportion of people who do appear to benefit from these medications- such outcomes are bound to make almost any health care professional an enthusiast. It is surely rewarding to see such people improving as the result of ones intervention, and many of these patients are genuinely grateful for the help which has been provided. However, the fact that around 60% of people prescribed anti-depressants do not take them for more than 2-3 weeks as a result of adverse side effects (Healy 2004) suggests that Professor Roses estimate also applies to psychiatric drugs as much as to those used in general medicine. Moreover, of the 40% that do remain on the drugs, it is possible that a significant proportion do so while experiencing adverse side effects and a deteriorating condition. In regards to these patients, a selective medical bias can develop whereby these people are seen as suffering from a deterioration of their original condition (eg. depression), and not as suffering from adverse side effects. It is perhaps difficult to believe that a drug so helpful to one patient could be so harmful to another, but this is Professor Roses main point- an enormous variation in response exists to all drugs.
This possibility is borne out each day in my clinical work as a psychologist where a significant amount of the clients I am working with present with an adverse side effect profile, typically in response to SSRI anti-depressants. Around 10% of the Australian population is currently on SSRIs, meaning that if Professor Roses is correct in his estimate, a possible 500,000 people may at any one time be doing badly on these drugs in varying degrees. Some of those who do not benefit from SSRIs present with few adverse side effects other than perhaps a failure to get better. That is, they defy the statistical norm which sees the vast majority of depressive episodes resolving within around 3 months (Jureidini, in Beddoe 2007). As such people can remain somewhat depressed for many years, or even for decades whilst on anti-depressants, it is reasonable to conclude that the drug is not working for them. Other people can present at the more extreme end of the SSRI adverse effect profile, with symptoms as described earlier.
Why is there such an apparent variation in response to SSRIs? If humans share 99.9% of genetic make-up, it falls to the remaining 0.1% of genetic difference to account for differing responses to all medications (Mitchell 2008). There is no reason to assume that this would be any different for anti-depressants. Any of the 10 million genetic mutations, referred to as single nucleotide polymorphisms (SNPs), can create different responses to the same medications, from the life saving to the life destroying. It is estimated that around 7-10% of the Caucasian population lack liver enzyme P450 CYP2D which plays a key role in breaking down many kinds of medications, including SSRIs (Breggin 2001). These poor metabolisers have around one ninth of the normal ability to degrade and eliminate drugs from their body, resulting in severe reactions to even routine doses of drugs like the SSRIs. In addition to this genetic vulnerability, some drugs, including SSRIs can inhibit the activity of one or more of the P450 enzymes. As a result, the metabolism and elimination of the drug is being inhibited by the drug itself, again resulting in toxicity to both the SSRI and other medications. Breggin (2001) states that all SSRIs can inhibit the functioning of one or more liver enzymes.
As can be seen from the above, there are biological reasons for the different responses to SSRIs. It is hard to object to the use of such drugs when the patient is reporting a positive improvement, although Breggin (2001), himself a practising psychiatrist, expresses concerns about the potential for adverse reactions to occur over time as a result of their enzyme inhibiting functions- toxicity can accumulate. As with all other forms of treatment, informed consent is the ethical corner stone, enabling patients to decide for themselves if the experienced benefits outweigh the potential risks, either in the short or the long term.
My concern is more for the patients who are displaying a deterioration of their condition since being on an SSRI. Unless the physician is open to the prospect of adverse reactions as relatively common experiences, the course of treatment is often to increase the dosage levels, and/or to introduce additional drugs such as minor tranquilisers, mood stabilizers and even neuroleptics as the condition worsens. The health professional needs to undertake a thorough assessment of the patients subjective experience in relation to the timing of medication and the worsening of their condition. Although the pharmaceutical companies promote the notion that SSRIs take 2-3 weeks to be effective, the concentration of serotonin reaches a maximum level within 24-48 hours of commencing an SSRI (Beddoe 2007). It is during the times of dramatic changes in serotonin levels (as per introduction, increase or decrease of an SSRI) that patients can experience the most intense adverse reactions. These reactions can include an increase in both depressive symptoms and akathisia. Healy (2004) states that this increase in agitated depression manifests in an observed seven fold increase of suicidal ideation and the doubling of completed suicides for people on SSRIs (when compared to equally depressed people not on SSRIs). The reader who finds these figures hard to believe, as they are so at odds with the data provided by the pharmaceutical manufacturers, is urged to read Healys book, Let them eat Prozac for a detailed presentation of the clinical trial datum.
Are these catastrophic reactions due to the natural history of the condition, or to the medication? Healy (2004) attempted clarify this by conducting a well group study, whereby a sample of 20 healthy people with no psychiatric histories were placed on one of two anti-depressants (one being an SSRI) for two weeks. Healy (2004 p.180) reports two-thirds of the group felt significantly worse on one of the two drugs- not simply by virtue of inconvenient side effects...but in terms of being depressed or disturbed. Two participants in the study became actively suicidal for the first time in their lives after only a couple of days on the drugs. Many well group studies conducted by the SSRI companies have found similar results, however these are rarely published. Only twelve out of fifty three studies relating to Prozac, and fourteen out of thirty five well group studies have been reported on. One can only conclude that the unreported studies are as unfavourable to the antidepressants as was Healys study.
Physicians are generally dependent on drug marketing from pharmaceutical companies and peer reviewed journal articles for information on the efficacy and warnings related to medications. While company marketing efforts are easy to identify as a biased source of information, professional literature is less suspect. However, Healy (2004 p.117) reports that by 2000, around 50% of the scientific literature in pharmacotherapeutics was ghost written within companies, or was published in non-peer reviewed supplements to journals.
Professor Healy (2004), also a practising psychiatrist and former enthusiast of SSRIs, makes the point that anti-depressants have only been found useful for people who experience episodes of major depression. Psychiatrist and Head of Psychological Medicine at Adelaide Womens and Childrens hospital, Jon Jureidini (in Beddoe 2007) states that there is now general agreement that antidepressants are no more effective than placebo for treating mild depression. As few as 3% of those receiving antidepressants from GPs suffer from severe depression. As such, the vast majority of scripts for anti-depressants (that is, 97%) are prepared for a condition (mild to moderate depression) for which there is no proven efficacy. There are viable alternatives to medication for most depressed patients. While there are debates within psychology as to which therapies have the most demonstrated efficacy in treating depression (see King 1999), most forms of conventional psychological approaches will assist with most episodes of depression, generally depending on the practitioners years of experience and subsequent quality. It has also been clearly demonstrated by Mynors-Wallis, Gath, Day, Baker (2000) that GPs are able to assist depressed patients, achieving the same results as anti-depressant medication, utilising a simple Structured Problem Solving approach- there is, obviously, no risk of adverse side effects. In addition, Mynors-Wallis et al (2000) found no additional benefit to adding anti-depressant medication to the Structured Problem Solving. Where GPs learn this model, referrals to psychologists for more complicated, non-drug alternatives are usually not required.
When patients report that they are suffering the type of adverse effects described, the use of a withdrawal protocol, as devised by Professor Healy (2008) is indicated. To not use this approach, or at least a very gradual approach (eg. the 10% reduction method) often results in adverse withdrawal effects, including worsening depression, anxiety, panic, agitation, suicidal ideation, and a range of disturbing physical symptoms. The overall result is that the physician and patient alike conclude that these withdrawal effects constitute evidence that the patient is unable to withdraw at all, condemning them to the prospect of life-long dependence- itself, a depressing thought.
It is possible that around 50% of patients on SSRIs are able to tell the physician what the drug companies are not willing to- that SSRIs clearly do not work for all people, in fact they do not work for a significant part of the population; many people will actually get worse as a result of SSRI treatment in that a range of psychiatric conditions can escalate. Psychiatric drugs are unlikely to be exempt from Professor Roses observation that 50% of drugs dont work for 50% of the population. All health care professionals need to listen intently to peoples reported experiences when they are placed on medications that have the potential to help or to harm. Careful and regular monitoring is required, especially in the early stages of treatment and/or when dosage levels are altered to ascertain whether a patient is actually improving or getting worse. An empirical observational approach is necessary when deciding whether a particular patient is benefiting or not- all health professionals need to adopt this empirical stance in preference to their own preconceived views as to how a patient should respond to treatment. A patients actual reported experience is far more important than a professionals view that psychiatric drugs are inherently helpful, or harmful. As detailed earlier, the high range of variability to these drugs precludes a prejudice, either for or against drugs, with any given patient. All health practitioners, medical or otherwise, need to remain open to the evidence presented to them in the form of their patients actual experiences.
I have found Professor Healys (2008) SSRI withdrawal protocol to be an extremely effective approach to helping people restore some balance and sanity in their lives, however I would prefer to be spending my time helping people with problems that were not iatragenic in nature. Unlike the American public, the Australian public maintains a healthy skepticism towards such wonder drugs. The current epidemic of prescriptions for antidepressants could be called 'the American disease', which pharmaceutical companies and GP's seem to be intent on inflicting on our unwilling culture. My observation is that in addition to physicians, there seems to be as many psychologists, nurses and social workers as duped by the myth of antidepressants. I have heard through clients of psychologists in my area who refuse to see depressed clients unless or until they are on an antidepressant.
When will health professionals of all types catch up with the inherent sense of the general public who we are meant to be serving? Surely, listening to people when they report adverse side effects or worsening of their problems post-drugging is a sensible starting point.
Dr. James Alexander, PhD.
Psychologist in Private Clinical Practice.
References: Beddoe, R (2007) Dying for a cure: a memoire of antidepressants. Misdiagnosis and madness. Random House, Australia.
Breggin, P. (2001) The Antidepressant Fact Book. Da Capo Press, MA.
Healy, D (2004) Let Them Eat Prozac. New York University Press, NY & London
Healy, D (2008) SSRI Withdrawal Protocol: http://www.benzo.org.uk/healy.htm
Mitchell, N (2008) Personalised medicine- why drugs donï¿½t always work. ABC Radio National Health Report,
Mynors-Wallis LM, Gath DH, Lloyd-Thomas AT, Tomlinson D. (2000) Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. British Medical Journal; 320:26-30 (1 January )
Roses, A (2008) Personalised medicine- why drugs donï¿½t always work. ABC Radio National Health Report,
Somogyi, A (2008) Personalised medicine- why drugs donï¿½t always work. ABC Radio National Health Report,
Thursday, June 24, 2010
Back to Bedlam by Paul J. Stevenson OAM President AAPi
Back to Bedlam
By Paul J. Stevenson OAM President Australian Association of Psychologists.
Contrary to common belief, Britains first Psychiatric Hospital was a place of rest and tranquillity. Paralleled by the famous Dhtel de Militarire in Paris around the same time, it provided a solace for the mentally ill in an environment of respect and dignity, in the hope that positivist treatment might lead to recovery. In our so-called more sophisticated era, we would do well to revisit these traditional ideals in our care of the mentally ill.
Last week, after disposing of Kevin Rudd, Julia Gillard announced a new Mental Health Initiative. Did she realize her predecessor (along with his predecessor) had already spent 7.2 billion dollars on this over the past four years? Tony Abbott retaliated with a new plan of his own (as if he just happened to have one in his pocket). Neither government, though, has allocated a single new bed to the argument.
At the recent National Mental Health Summit (24th-25th June 2010), a six point plan was announced to improve mental health facilities around the country, but still not one single new bed was part of it. What makes us think that mental illness doesnï¿½t warrant a bed in a General Hospital Ward?
After nearly forty (40) years as a mental health professional, I am aghast that we still consider mental illness to be a second rate disease. After witnessing the failed deinstitutionalisation programs of the 1970s, the failed Community Support Services of the 1980ï, the total lack of all services of the 1990s, and the hypocrisy that we really care for the mentally ill in the 2000s, I am wondering what it is going to take for the authorities to come round to the realization that we really did get it right back in the 1960s.
Prior to 1975, mentally ill patients were able to take time out of the community to get well in a real hospital. Sure, they were primitive and unsophisticated asylums, some more cruel than caring. But, with what we know now about medications, psychotherapy and civil rights, I am sure we could do it better today. What we had then was somewhere to go when the illness became uncontrolled. Now we have nowhere.
If a diabetic patient goes into a keto-acidosis state, he/she is hospitalized until stable. If a cardiac sufferer has a stroke or a heart attack, that warrants a hospital bed. Likewise, if an asthma sufferer has an attack, the hospital admission is available. All of these diseases are treated in the community, where people live and work, until there is a problem. Then the hospital is open to admitting them. When treated, they are discharged. They return home to manage their illnesses with outpatients appointments, pharmacists and physicians. Similarly, the mentally ill can be treated very effectively in the community, with regular outpatients appointments, pharmacists and physicians. But, when there is a problem, the hospital admission is harder to arrange than fitting a Camel through the eye of a needle. What is the difference? An acute illness attack of any kind warrants a hospital bed. Why not mental illness?
The mentally ill are admitted to hospital in the ratio of 1:15 (National Mental Health Summit, 2010). That compares with 9:10 for diabetes, heart disease and asthma. Floridly psychotic sufferers of mental illness, by contrast, account for 60% of all admissions to Police Watchouses and Remand Centres.
The AAPi supports a return to hospital based care for the mentally ill in the same proportion to acute sufferers of other major diseases.
Wednesday, September 01, 2010
Increase in the use of antidepressants not surprising by Dr. James Alexander
Increase in the use of antidepressants not surprising
A Board Member of the Australian Association of Psychologists inc, (AAPi) James Alexander today said that his organization was not surprised by the substantial increase in the number of prescriptions being written for antidepressants since the Howard Government introduced the Better Access program in 2006.
The Howard government set up the Better Access Scheme in the hope that it would reduce government expenditure on subsidised antidepressants.
Well, by putting GPs in the position of gatekeeper to the services, they made the biggest mistake possible. Despite the lack of evidence that antidepressants are helpful for anyone other than the small proportion of extremely depressed people Australian GP's prescribe them hand over fist to anyone who complains of anything remotely emotional James Alexander said.
AAPi are of the opinion that the vast majority of scripts for antidepressants are made out to people for whom there is simply no evidence that they are effective.
Furthermore anywhere between 30-60% of people will suffer adverse side effects, many of which are also psychiatric in nature, eg. worsening depression, worsening anxiety, agitation, increases in suicidal ideation, feelings and behavior, mania and hypomania.
Under the current system, for a distressed person to get access to a psychologist with Medicare rebates (a financial necessity for most people), they first have to meet with a GP who is habit bound to prescribe antidepressants. Many of these people (30-60%) will simply get worse as a result of taking them.
Making GP's the assessor and referral source for access to psychological services has just created another bureaucratic layer and huge expense for the taxpayer, at the same time as it has increased the amount of Australians on antidepressants as well as the amount of people suffering adverse side effects of these.
The Better Access scheme needs to be revised without GP's as the gatekeeper for psychological services. Most GPs are not trained in psychology, in mental health issues or required treatments. Dr Alexander said
Contact: Dr James Alexander Ph D
Australian Association of Psychologists inc. Board Member
Phone: 0410 836 690
115 Keen St, Lismore.