Psychotherapy is not a new field, beginning over a hundred years ago as the ‘talking cure’ established by Freud.

Today, there are hundreds of types of psychotherapies. Most therapists use a combination of three or more to treat clients for various mental health conditions, which are evidence-based to reduce hospitalisations and lifetime treatment costs.

So, why are qualified mental health nurse psychotherapists feeling invisible when it comes to helping relieve Australia’s burdened mental health system?

Claire Hudson-McAuley, a mental health nurse practising psychotherapy, says despite extensive education in psychotherapy, a wealth of experience and willingness to treat, nurse practitioners and credentialed mental health nurses miss out on vital funding to provide crucial mental health care to Australians.

“A survey of members of the Australian College of Mental Health Nurses this year shows that 92 per cent believe psychotherapy is or should be part of their role.

“Many mental health nurses and nurse practitioners have undertaken extensive post-graduate studies in psychotherapy, work in their own private practice as psychotherapists and offer supervision and training in psychotherapy.

“Despite this, governments have withdrawn or slashed funding for most forms of psychotherapy delivered by mental health nurses and nurse practitioners over the last decade, in contrast to other professions.”

Gender bias, a lack of education on how nurses can provide psychotherapy and systemic inequality in professional practice is at the heart of the problem, according to Ms Hudson – McAuley. 

“Nurses, above all professions, are expected to be particularly noble, silent, caring, and self-sacrificing – roles commonly expected of women, even though many nurses are not female.

“An epidemic of gendered bias in Australia today and the decades-long lack of respect for nurses shown by successive governments means that psychotherapists who happen to be nurses have been routinely silenced and devalued.

“Pointedly ignored and overlooked as a resource, despite extensive research backing their effectiveness, nurse-psychotherapists are frustrated by their exclusion from the current national conversation.

“Their lively, competent, and comprehensive psychotherapy skills appear invisible to politicians and policymakers, despite the desperate shortage of psychological care within the current COVID-19 crisis.”

Leanne Boase, President of The Australian College of Nurse Practitioners, says nurses should be supported and recognised in the field of psychotherapy.

“Nurses train to provide this essential service in the community and often do it unrecognised. They are most certainly underappreciated as part of our health system.

“It’s a natural extension and evolution of nursing care, especially for nurses working in mental health and primary care.”

Opposition to nurses being able to refer for mental health treatment under MBS has centred on alleged ‘fragmentation of care’, explains Ms Boase, but nurses and nurse practitioners de-fragment care, communicating well with all members of the health care team. 

“I know personally, patients that do open up to me often do not want to tell their story over again.

“I have to tell them to find a GP for a referral, and then they’re lost in the system. So, not being able to refer actually fragments care.

“It also delays access to mental health care and costs the system more in duplicate consultations.”

In psychotherapy, not all professionals are equal, according to Ms Hudson-McAuley, but with the pandemic putting further pressure on the mental health system, it’s time to insist on change.

“The COVID crisis is a wake-up call. Now is the time for state and federal governments to show substantiative recognition for our contribution and skills through increased funding for nurse-psychotherapist sessions, including ongoing Medicare and Better Access and group psychotherapy programs.

“For too long, we have tolerated systemic inequality, with some professions more equal than others.

“It’s time for the government to revise its gendered bias towards nurses by immediately initiating equal nurse access to MBS and other forms of funding for psychotherapy, as well as the ability to nurse-refer to all appropriate services.”

If access is simplified and nurses are part of the solution, the community will benefit, and the mental health system will improve, says Ms Hudson-McAuley.

“Simplifying access to mental health services will decrease the logjam in the system and the crisis of mental illness and suicide.

“The crisis is an opportunity for the government to finally treat nurses who are highly skilled psychotherapists with the acknowledgement and respect they deserve.”

A lack of funding undervalues the untapped potential of nurses, according to Ms Hudson-McAuley, and is driven by concern over nurse shortages.

“The MHNIP program was an outstanding example of the talents and broad capabilities of nurses who are psychotherapists, but the Federal Government axed this in 2014, partly because they were afraid too many nurses would leave the public hospital system and work in private practice.

“Nurse psychotherapists have done this anyway, as the public mental health system tends to want nurses to simply ‘medicate, monitor and manage’, which is a gross underuse of nurse psychotherapy skills and capabilities and a lack of respect for nurses.

“For nurses to practice as psychotherapists, it is becoming increasingly necessary for them to leave the public and private health system and set up their own private practice.

“Yet in other countries like the UK, nurses are encouraged to utilise these skills within public health.

“Not all nurses want to leave the public system, but in truth, the system stifles the skills and capabilities they have with respect to psychotherapy.”

Mental health nurse practitioner Sian Pritchard says the holistic nature of care provided by nurse-led psychotherapists is vital to addressing the health care crisis.

“Psychological care is incomplete without whole-of-person care. Current research shows that the physical health care needs of people living with severe mental illness are poorly addressed, leading to a 15-to-30-year reduction in life expectancy.

“Mental health nurses and nurse practitioners are key health professionals with the skills to address both the psychological and physical health care needs of our community.”

The ability to prescribe, manage health conditions, interpret pathology, and refer to other health professionals makes a case for nurse-led mental health care powerful.

“Nurse practitioner psychotherapists have extensions on practice that allow us to prescribe or adjust psychotropic medications, to manage or reduce metabolic issues and other adverse effects.

“We can order and interpret investigations such as pathology tests for physical health monitoring of people living with mental illness and offer diagnostic assessments and a referral to psychiatrists.”

Ms Hudson-McAuley agrees, saying, “nurse psychotherapists generally offer more humane and whole-of-person care. As well as psychotherapy, we can assess physical health status, offer case management, and help with advocacy.

“We can work with people with the highest vulnerability, complexity, and risk, such as suicide risk, homelessness, addictions, or self-harm, and with people and families at all ages and stages of life.”

What is psychotherapy?

Psychotherapy is a group of therapies used to treat mental or emotional disorders and behavioural and adjustment problems through therapeutic communication (talk therapy), which explores feelings, thoughts and behaviours.

“Today there are hundreds of types of psychotherapies from top-down cognitive-based therapies like CBT to bottom-up somatic therapies like sensorimotor psychotherapy, and mixed therapies like EMDR, which arguably are both top-down and bottom-up,” explains Ms Hudson-McAuley.

Psychotherapy also encompasses “neuroscience, such as Porges Polyvagal Theory, a type of therapy that teaches people how to calm anxiety and lift depression without medication.”

However, it’s the type of therapist that determines successful recovery via psychotherapy, explains Ms Hudson-McAuley. 

“Common factors research shows that the quality of the relationship with the therapist is one of the strongest indicators for recovery, far more important than the type of psychotherapy used.

“The process of recovery starts with creating and building a safe therapeutic alliance.

“Nurses are especially good at building relationships with consumers who are highly distressed and dysregulated and can build the therapeutic alliance well.”

How is psychotherapy different to psychology?

While a psychotherapist can be a psychiatrist, psychologist, mental health nurse or other mental health professional, the self-regulation of the field of psychotherapy makes it confusing for consumers, explains Ms Hudson-McAuley.

“Psychologists may call themselves psychotherapists …[but] the seven-year training of psychologists currently appears to offer little more than cognitive behavioural therapy training and is heavily invested in the biomedical model’s assessment, diagnosis, and treatment plans.

“Some psychologists do go on to study many forms of psychotherapy and become excellent psychotherapists.

“So, there is a wide variation in the degree of psychotherapy skills and training among psychologists, and consumers should enquire about the training of any psychotherapist they want to see, regardless of which profession they belong to.”

Training to be a nurse psychotherapist

The Australian College of Mental Health Nurses will soon release modules and courses to encourage nurses to explore psychotherapy.

“We will be offering some exciting new psychotherapy modules next year. We hope to help new and aspiring psychotherapists from all disciplines to start the journey of developing skills as psychotherapists and develop skills through experiential learning.

“We want to inspire those who are interested in relational psychotherapies to gain more skills and confidence within a caring community of practice and learning,” says Ms Hudson-McAuley.