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Enhancing the contribution of clinical psychology: an under-utilised

workforce in public mental health services

Article in Australasian Psychiatry · February 2021

DOI: 10.1177/1039856221992649

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992649 APY Australasian PsychiatryJackson et al.

Australasian
Psychiatric services Psychiatry
Australasian Psychiatry

Enhancing the contribution 2021, Vol 29(4) 446­–449

© The Royal Australian and
New Zealand College of Psychiatrists 2021

of clinical psychology: an Article reuse guidelines:

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DOI: 10.1177/1039856221992649
https://doi.org/10.1177/1039856221992649

under-utilised workforce in journals.sagepub.com/home/apy

public mental health services

Henry Jackson University of Melbourne, Melbourne, VIC, Australia

Caroline Hunt University of Sydney, Sydney, NSW, Australia
Carol Hulbert University of Melbourne, Melbourne, VIC, Australia

Abstract
Objective: Clinical psychologists are practitioners with expertise in mental health, who apply advanced psychologi-
cal theory and knowledge to their practice in order to assess and treat complex psychological disorders. Given their
robust specialised mental health training, clinical psychology is an integral component of the Australian mental
health workforce, but is under-utilised. Recent reviews have identified significant problems with Australia’s men-
tal health system, including unequal access to clinical psychology services and fragmentation of service delivery,
including convoluted pathways to care.
Conclusions: Clinical psychology is well placed to contribute meaningfully to public mental health services
(PMHS). We describe what clinical psychologists currently contribute to team-based care in PMHS, how we could
further contribute and the barriers to making more extensive contributions. We identify significant historical and
organisational factors that have limited the contribution made by clinical psychologists and provide suggestions for
cultural change to PMHS.

Keywords: clinical psychologists, public mental health services, mental health workforce, treatment outcomes,
serious mental disorders

A
ustralia’s public mental health services (PMHS)
are funded to treat serious mental illness, typi-
cally including schizophrenia-spectrum disorders,
bipolar disorders, severe depression and, more recently,
personality disorders. Recent reviews have identified
problems with Australia’s mental health system, includ-
ing fragmentation of service delivery and limited access
to empirically validated treatments.1–4 There is robust
evidence that these patients require more than medi-
cation to overcome their mental health issues and that
psychological treatments addressing symptoms, func-
tioning and quality of life are efficacious.5
Clinical psychologists are evidence-based practitioners
with expertise in mental health (https://acpa.org.au/
what-is-a-clinical-psychologist/). Clinical psychology is
an integral component of mental health workforces in
the USA and UK. Here, in Australia we remain largely an
under-utilised profession. This limits the capacity of
clinical psychology to contribute meaningfully to PMHS.
What roles do clinical psychologists
currently undertake in PMHS?
We have focused our attention on an area of PMHS of
greater need and opportunity for improvement – that is,
adult community-based services, including specialist
and rehabilitation services.
Currently, clinical psychologists employed as specialist
clinical psychologists or case managers are engaged with
people with severe mental illness. Their training prepares
them to provide diagnostic, cognitive and developmental
assessments, formulation and specialist treatment,
Corresponding author:
Henry Jackson, Melbourne School of Psychological Sciences,
University of Melbourne, Level 12, Redmond Barry Building,
Parkville, VIC 3010, Australia.
Email: henryjj@unimelb.edu.au

446
Jackson et al.
research, social skills training, family therapy, group ther-
apy and staff training. For patients with highly complex
presentations, clinical psychologists also undertake assess-
ment and treatment of comorbidities or secondary mor-
bidities, such as depression, substance abuse/dependence
or social anxiety. Other foci are improvement of function-
ing, relapse prevention and treatment compliance.
To be more specific, examples of evidence-based psycho-
logical treatments of value to PMHS are: motivational
interviewing/motivational enhancement therapy (sub-
stance abuse); schema-based therapy, mentalisation, and
dialectic behaviour therapy (DBT) for borderline personality
disorder (DBT); prolonged exposure and response preven-
tion (OCD), prolonged exposure and cognitive processing
(PTSD); structured social skills training, cognitive-behaviour
therapy (CST) for positive psychotic symptoms, cogni-
tive remediation and family psycheducation (schizo-
phrenia); and CBT for mood disorders (https://div12.
org/psychological-treatments/)
What could clinical psychologists
do more of and what could be
done differently?
Innovative practices in many specialist services (e.g. for
personality disorder, early psychosis or trauma) high-
light a way forward for the design of more effective com-
munity-based programmes for PMHS patients with
complex mental health presentations. Services such as
Project Air, Spectrum Personality Disorder Service,
Orygen (Youth Health) and psychiatric rehabilitation
disability services (PDRS) routinely offer thorough assess-
ments and empirically validated psychological treat-
ments. Clinical psychologists in these services play
leading roles in delivering specialist individual, family
and group treatments, as well as leading research pro-
grammes and providing staff training in their area of
specialisation.
Outcomes for patients of community-based mental
health services, including those in inpatient and reha-
bilitation programmes, could be substantially improved
by the widespread delivery of the clinical psychology
services outlined above. Non-clinical psychology staff in
these programmes would be assisted by training and
supervision in evidence-based practice relating to, for
example, better recognition and treatment of co-mor-
bidity, deeper assessment of the role of personality and
personality disorders, and treatment thereof, especially
borderline personality disorder, treatment adherence
and dealing with treatment resistance. Clinical psychol-
ogists can assist colleagues in mental health teams by
delivering training and supervision focused on improv-
ing clinicians’ understanding of assessment, mental
state examinations, comprehensive formulation and
cognitive behavioural interventions. Furthermore, clini-
cal psychologists can deliver interventions for families
and carers.
What are the barriers that prevent
clinical psychologists from fully
contributing to PMHS?
1. The first issue concerns the public profile of clini-
cal psychology in Australia and lack of advocacy
for clinical psychologists in PMHS. Historically,
clinical psychology in Australia has suffered from
a lack of recognition as a specialist profession and
relative to other developed countries, high-qual-
ity professional training took some years to
emerge.6 Prior to Better Access (BA) in 2006, large
numbers of clinical psychologists sought posi-
tions in PMHS. Critically, currently and in the
past, clinical psychology has little or no indus-
trial clout. Clinical psychologists lack strong pro-
fessional unions/societies advocating to
governments for increased funding for specialist
clinical psychology services in PMHS. Indeed, the
key Australian psychology organisations have
largely focused on the concerns of private prac-
tice psychologists, in particular, increased fund-
ing for BA. This might be taken as a signal that
clinical psychologists are better situated in pri-
vate practice than in PHMS. It might also be
interpreted that people on low incomes and with
severe mental illness are undeserving of appropri-
ate psychological treatment, which can be pro-
vided only to those with high prevalence
disorders in fee-paying private practice (and for
those who can afford it).
2. The allied health issue: clinical psychologists, social
workers and occupational therapists, amongst oth-
ers, are grouped under the ‘allied health’ label. The
label encourages the view that there are few or no
meaningful distinctions between professions, their
training, their specialist skills and their relevant
scopes of practice. Rosenberg and Hickie7 note
that ‘. . .disciplines are deemed interchangeable,
perceived as serving the same generic population
needs. . .’ (p. 3). To take one example, the Interim
Report Summary of the ongoing Royal Commission
into Victoria’s Mental Health System2 included a
recommendation for expanding the mental health
workforce with the addition of 120 nursing places
and 60 ‘allied health places’ (p. 19). This Report
remains silent as to the types of ‘allied health places’
and numbers allocated to each and takes a Noah’s
Ark-type approach to the hiring of staff. In this and
other reports,1,2,4 there is the implicit assumption
that all (mental) health professionals conduct
identical assessment, formulation and treatment,
whereas only clinical psychologists – through their
training in psychological science – are able to draw
upon a deep understanding of the psychological
factors contributing to clinical presentations
and the mechanisms underlying psychological
treatments. This homogenising approach undervalues
447
 Australasian Psychiatry 29(4)

Table 1. The total number of psychologists registered by the Psychology Board each year from 2010/11 to 2018/19
(Column 2) and clinical psychology providers of Medicare-subsidised mental health-specific services for those
periods (Column 3)

Year No. with clinical endorsement No. of clinical psychologist providers of

Medicare-subsidised mental health-specific services
2018/19 9000 6385
2017/18 8495 6055
2016/17 7931 5666
2015/16 7481 5370
2014/15 7028 5018
2013/14 6716 4716
2012/13 5965 4288
2011/12 5151 3810
2010/11 4523 3313

Sources: Column 2: Australian Health Practitioner Registration Agency – Annual Reports https://www.ahpra.gov.au/
Publications/Annual-reports.aspx
Column 3: Australian Institute of Health and Welfare (AIHW, 2018/19). Medicare Benefits Schedule Data (AIHW analyses).
https://www.aihw.gov.au/reports-data/health-welfare-services/mental-health-services/data. For specific file, see Medicare-
subsidised mental health-related services 2018–19.
Note. The data in this table are taken from Table MBS.17.

evidence-based psychological treatment within registrars without working in PMHS, resulting in a

PHMS.
3. The case manager issue: a related problem is the
widespread employment of clinical psychologists
as generic case managers. The reduction in spe-
cialist positions for clinical psychologists has
impeded delivery of evidence-based psychological
interventions in PMHS, partly due to the plethora
of time-consuming generic tasks. Moreover, psy-
chologists working in case manager positions
report that their specialist skills are often under-
utilised and undervalued.8,9 Table 1 presents the
number of endorsed clinical psychologists for
yearly periods from 2010/11 until 2018/19.10
Table 1 shows the implementation of government
funding via BA has resulted in over two-thirds of
clinical psychologists now operating in full-time
or part-time private practice.11
Psychologists working under BA provide usually
short-term psychological services to those with
high prevalence disorders. Many concerns have
been voiced about BA.1,12,13 The lure of BA has
resulted in an exodus of senior clinical psycholo-
gists from the PMHS, with many remaining senior
staff working in fractional positions. Although pri-
vate practice has a number of benefits, such as
autonomy, flexibility in determining hours and
location of service, this exodus has left a less-expe-
rienced PMHS workforce.13 Further, clinical psy-
chology graduates directly enter private practice as
narrowed experience of service provision for many.
4. The impact of BA.
Conclusions: how can we retain
clinical psychologists in the PMHS?
Despite these challenges, many PMHS clinical psy-
chologists demonstrate a genuine social justice inter-
est and commitment to work with other members of a
team to achieve positive outcomes for those with
severe mental illness by utilising well-validated treat-
ments. At their best, PMHS teams offer stimulating
learning environments that facilitate world-class clini-
cal research as well as exchanges of ideas via seminars,
case conferences and other professional development
opportunities.13
Nevertheless, clinical psychologists being viewed within
‘allied health’, widespread employment in ‘case manager’
roles, and the impact of BA have contributed to the under-
utilisation of the profession within PMHS. Recognition of
the specialist skills of clinical psychologists through the
development of well-defined PMHS roles will contribute
to improvement in the quality and effectiveness of treat-
ment provided to patients and carers.
Clinical psychologists can occupy a more prominent
role in the PMHS given their training and expertise in
evidence-based practice with serious mental disorders.
Our further recommendations include a review of career

448
 Jackson et al.
and salary structures with pathways that allow advance-
ment within PMHS, and increased clinical psychologist
specialist and leadership positions. Paid psychology reg-
istrar positions like those that exist for psychiatry regis-
trars would assist the skill development and retention of
clinical psychologists in PMHS, and benefit service pro-
vision. Additionally, we underscore the importance of
using the expertise of clinical psychologists to provide
consultation, training and supervision to PMHS staff
and facilitate their contribution to research and the
implementation of innovative treatments.
Authors’ Note
All three authors are Fellows of the Australian Clinical Psychology Association (ACPA), but the
views expressed in this article do not reflect the official views of ACPA. Also, all three are
senior clinical psychologists and currently or in the past have directed university postgraduate
clinical psychology training programmes.
Acknowledgements
We thank Ms Sarah Borg, Dr Jennifer Jackson-Simpson and Ms Jessica O’Connell for their
valuable contributions to this paper.
Disclosure
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of the paper.
Funding
The authors disclosed receipt of the following financial support for the research, authorship
and/or publication of this article: Henry Jackson currently receives research funding from the
National Health and Medical Research Council. Caroline Hunt and Carol Hulbert have no fund-
ing conflicts of interest to declare.
ORCID iD
Henry Jackson https://orcid.org/0000-0002-0022-7315
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