Valuing Psychotherapy and Mental Health Nursing



Mental health nursing is one of the oldest regulated health professions in the  world. It predates the invention of all other allied health professions. At the  core of it's history and practice is psychotherapy. Psychotherapy is a transdiciplinary activity. In my country of residence of Australia, neither psychotherapy, nor mental health nursing are treated respectfully or equitably with other health professions or specialties.


Psychotherapy is often conflated with psychology and mental health nurses are viewed as having few skills in either.  Psychotherapy is the treatment for most problems of living, and has been for most of the 20th century. This page celebrates and promotes psychotherapy as the only effective treatment for many mental health problems, and also mental health nursing as a specialty which is often excluded from practicing this craft in Australia through programmes such as "Better Access".


What particularly distinguishes mental health nurses from others is their post graduate education and capacity to be with people in extreme states of distress or human experience. Many have specific post graduate qualifications in psychotherapy. Mental health nurses have adapted  psychotherapy to work with people with the most complex needs or to very difficult environments and contexts. Sadly they are excluded from working to their potential by current policies. This page highlights the efforts of myself (Richard Lakeman) and many colleagues (particularly Prof John Hurley and  Prof Andrew Cashin) in promoting psychotherapy and  access to the right treatment, at the right time,  by the right person (often Mental Health Nurses), to improve the mental health of Australians. 

What is Psychotherapy?

According to the Psychotherapy and Counselling Federation of Australia "Psychotherapy is a holistic engagement that focuses on the mental, emotional, relational or spiritual health of a human being. It is useful when psychological, developmental, relationship and wellbeing issues arise in life"...

Publications on  Psychotherapy

I and colleagues have written extensively on psychotherapeutic practice. Whilst this site shares some publications on the psychotherapeutic potential of nurses you can read more about psychotherapy below 

The Need for Psychotherapy

Now more than perhaps at any other time in modern history we need psychotherapy and the public need and deserve the services which Mental Health Nurse pyschotherapists can provide. 

The struggle for recognition

In various programmes the psychotherapeutic skills and potential of mental health nurses has not been recognised. This was true in what was known as the Mental Health Nurse Incentive Programme (now abandoned) and Mental Health Nurses have been excluded from accessing the Medicare Benefit Scheme "Better Access" regardless of experience or qualifications.

Sisyphus and the struggle for recognition of Mental Health Nursing

Psychology belongs to everyone, but what about psychotherapy? A discussion of the undervaluing and professional capture of psychotherapy in Australia.



Australia has made a huge investment in mental health through subsidised medical and psychological services in primary care. However, subsidised psychotherapy of any degree of sophistication is rarely available in the right dose, at the right time, or delivered by people that have advanced training in psychotherapy. Indeed, in Australia psychotherapy is not part of the public discourse about treatment and is often conflated with or presumed to be the same as psychology. This paper discusses the Australian funding context and argues that psychotherapy needs to be valued and assume its rightful position as essential ‘treatment’ commensurate with the value placed on medicine and medicines.

Lakeman, R. (2021). Psychology belongs to everyone, but what about psychotherapy? A discussion of the undervaluing and professional capture of psychotherapy in Australia. The Science of Psychotherapy Magazine, Feb 2021, 41-77. https://www.thescienceofpsychotherapy.com/product/the-science-of-psychotherapy-february-2021-2/

Presentations

Lakeman (25-26 November, 2020). The case for equitable access to mental health nurse psychotherapists: improving access and outcomes across the mental health continuum. Paper Presented at the Informa Connect ‘Australian Healthcare Funding Summit. Virtual

The Medicare Benefit Scheme (MBS), ‘Better Access’ program which focuses on providing subsidized focused psychological strategies is out of reach for large sections of the population due to the overvaluing of this service by eligible providers who charge excessive ‘gap fees’. Mental health nurses (whilst eligible through PHN funded programmes to provide services for people with higher level needs or when people can’t afford ‘gap fees’) have been excluded from the MBS. Additionally, eligibility to provide ‘Better Access’ has become the de-facto benchmark to provide other MBS items (e.g. the recent eating disorder Item Numbers) and a criteria for employment in many services such as headspace.

Mental health nursing is one of the oldest regulated professions, most trusted, and with a strong history and tradition of providing psychotherapy to those with the most complex needs. Surveys of mental health nurse psychotherapists in Australia indicate that they are highly trained (generally with Masters level qualifications specifically in psychotherapy) and often have decades of experience providing psychotherapy to vulnerable groups.

The public have been unfairly excluded from being able to access a subsidized service from Mental Health Nurses who may be the most experienced and able providers; MHNs have been unfairly discriminated against in primary care by being unable to earn a living providing skilled services in competition with often less skilled yet subsidised practitioners.
Granting immediate eligibility to MHNs to claim the MBS will address a serious skills shortage in primary care across the continuum of stepped care without the need for any further investment in training or education of health professionals

Sisyphus and the struggle for recognition of Mental Health Nursing

Sisyphus and the struggle for recognition of Mental Health Nursing


Albert Camus used the myth of Sisyphus to illustrate his philosophy of the absurd. Having scorned the Gods, Sisyphus was destined to roll or carry a rock up-hill each day, and then watch it roll back down, repeating this struggle each day for eternity. This myth captures the ongoing struggle that mental health nurses (MHNs) have in realising any meaningful recognition of the skills they possess or even that they exist at all. This opinion piece is part reflection on the past year which commenced with catastrophic bushfires which was followed by COVID and an unprecedented need for a psychotherapeutic response from competent practitioners skilled in psychotherapy. MHNs were excluded by the Australian Government from providing subsidised psychotherapeutic services. These challenges facing MHNs are entwined around recognition of the psychotherapeutic capabilities of MHNs, the instrumental relationship of nursing to medicine and the challenges of working in a hierarchical and highly coercive care system, and lastly how entrenched managerialism and the trend towards centralised and protocol driven practices has impacted on professional autonomy. Mental health nursing as a specialty faces an existential crisis which will not be resolved until their psychotherapeutic potential is recognised and MHNs have parity of access to the medicare benefits scheme as often lesser skilled practitioners currently do.


Lakeman, R. (2020). Sisyphus and the struggle for recognition of Mental Health Nursing (Feature Article), Summer News 2020, Year in Review. The Australian College of Mental Health Nurses, p.3-9, Online: https://www.flipsnack.com/acmhn/acmhn-yearinreview.htm

Unlock the potential of Mental Health Nurses

Unlocking the potential of Mental Health Nurses by enabling access to the MBS

Credentialed Mental Health Nurses (MHNs) in Australia are highly skilled, and educated Mental Health Professionals. All have postgraduate qualifications and many are experts in the provision of psychotherapy including working with those with the most complex health issues (see: 1, 2, 3). Successive Governments have failed to recognise the expertise or potential of MHNs. What was formerly known as the Mental Health Nurse Incentive Programme (MHNIP) offered some of the most vulnerable in the community access to medium to long term psychotherapy (see: 4,5) despite this not being officially recognised (see: 6). The MHNIP was handed to the Primary Health Care Networks (PHNs) as part of their flexible funding pool and any reference to the therapeutic capability of MHNs removed from the guidance notes on 'Stepped Care' (see: 7). Some PHNs have prevented MHNs from continuing to provide care to those in need. MHNs have been locked out of providing care under the Medicare Benefit Scheme including COVID-19 funding for tele-health measures (see: 8, 9). MHNs should have full access to the MBS, and their therapeutic skills recognised by all funders of mental health services.

Meet some Mental Health Nurse Psychotherapists

What characterises all these talented individuals is vast experience, advanced qualifications and ineligibility for their clients to receive a subsidised service under the Medicare Benefit Scheme,  'Better Access'

Richard Lakeman

Dr Richard Lakeman

Richard trained as a nurse when psychotherapy was still the main paradigm of psychiatric treatment in many psychiatric facilities in New Zealand over 30 years ago. He published with Wayne Froggatt one of the first e-therapy resources based on Rational Emotive Behavioural Therapy called "Understanding and changing self-defeating beliefs". In 1999 he contributed a chapter on Cognitive Behavioural Therapy in a book called "Talking Cures" edited by his mentor, psychotherapist and Professor of Mental Health Nursing, Phil Barker.

Richard completed a Masters in Mental Health (Psychotherapy) at the Univeristy of Queensland. He practiced psychotherapy primarily in the public sector, whilst also working in assertive community treatment. After a few years in Ireland and completing a doctorate focusing on mental health recovery, suicide and vicarious trauma in the homeless sector, he returned to Australia. There as well as academic and clinical jobs (largely with people with complex needs) he practiced psychotherapy under the mental Health Nurse Incentive Programme, ATAPs and entirely privately. He has done further study and supervised practice in Eye Movement Desensitisation and Reprocessing (EMDR) and has written about adapting psychotherapy to psychosis, working with recalcitrant clients and advanced empathy.

Richard presently coordinates SCU Online Master of Mental Health programmes and teaches psychotherapeutic skills across a range of programmes. You can visit his practice at working4recovery.com.

Elaine Ford

Elaine Ford

I am a knowledgeable, enthusiastic, and dedicated mental health Nurse Practitioner with over 40 years of experience in health service delivery, and extensive clinical experience in caring for and optimizing health care delivery for adolescents, adults, and older people with various mental health conditions. I am experienced in providing evidence-based, person-centred care, and working within collaborative frameworks within the National Standards of Mental Health care.

I have had formal supervised training in a variety of therapies, including CBT, DBT, Existential and Psychodynamic Psychotherapy, and EMDR. I particularly like helping people who have experienced trauma, disorders of self, grief and death, emotional distress, and interpersonal conflicts.

I am committed to safeguarding and promoting the welfare of people with mental health problems and helping them recover from their illness or come to terms with it in order to optimise their life potential.

Adjusting to the challenges of life can impact upon our physical and emotional well-being. Having someone assist in adapting to such challenges can be very beneficial. My style of therapy aims at applying evidence-based practice that helps the person understand their experience and explore avenues to bring about change.

Unfortunately I cannot provide a subsidised service under 'Better Access'. However, please visit my service ESF Therapy Centre - Counselling & Psychotherapy

John Hurley

Professor John Hurley

John is a Professor of mental health, a credentialed mental health nurse of 20 years and he has worked in the mental health field for nearly forty years. He trained for four years and qualified as an experiential psychotherapist in the 1980’s and then in a degree in problem solving counselling in the 1990’s. He took these psychological therapy skills and knowledge and used them in daily clinical practice for 16 years, first as a senior clinician and then to lead crisis and home treatment services in Sydney, Cairns and the UK. He worked exclusively with those with the most complex mental health needs, integrating experiential psychotherapy, counselling and psychiatric nursing capability to best meet the high level needs of consumers. He has over subsequent years trained in family systems therapy, behavioural based emotional intelligence and suicide prevention, as well as cognitive behavioural therapy and solutions focused therapy. In addition to his academic role John has for the past decade worked clinically at Headspace where he has been utilised as the clinician to send young people with the most complex needs. John is also a registered general nurse, has three post graduate diplomas, a science master’s degree and a PhD. He has well in excess of 100 international peer reviewed publications, has written multi-disciplinary post graduate mental health courses and has been invited to inform the Victorian Royal Commission into improving metal health services. His work has informed practice standards in the EU and here in Australia he is on the national board of directors for the ACMHN.

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Some selected publications on the potential of mental health nurse psychotherapists

For others please visit Richard Lakeman's Professional Pages

Making the case for clinical mental health nurses to break their silence on the healing they create: A critical discussion

Hurley, J., & Lakeman, R. Making the case for clinical mental health nurses to break their silence on the healing they create: A critical discussion. International Journal of Mental Health Nursing, n/a(n/a). https://doi.org/https://doi.org/10.1111/inm.12836

This discursive paper aims to clarify what roles mental health nurses identify as being within their scope of practice in clinical settings. It also aims to highlight any consumer benefits arising from these roles. Role theory and its relationship with identity are critically discussed as a framework to explain how contemporary mental health nursing roles are poorly understood and undervalued within mental health services. In order to meet the aims of the paper literature written in the last five years by clinical mental health nurses reporting their roles, and outcomes of those roles were searched. This literature was then considered through the lens of social constructionism that premises truths are accessed and then constructed though relationship based language. Six core mental health nursing roles were identified across international settings. The MHN is a psychotherapist. The MHN is a consumer advocate. The MHN is a physical health therapist. The MHN is a psycho‐pharmacological therapist. The MHN is a relationship focussed therapist and finally the MHN is an aggression management therapist. While European and American nurses reported consumer benefit emerging from these roles those from Australia and the United Kingdom did not. The roles reported on were largely instrumental ones that offered little clarity towards the identity of our profession, nor its worth to consumers or funders of services. Mental health nurses will only have their true breadth of clinical capabilities recognized where there is a consistent construction emerging from clinicians in clinical settings on the efficacy of their clinical work.

The psychotherapeutic practice and potential of mental health nurses

Lakeman, R., Cashin, A., Hurley, J., & Ryan, T. (2020). The psychotherapeutic practice and potential of mental health nurses: an Australian survey. Australian Health Review, 44(6), 916-923, doi.org/10.1071/AH19208

Objective: Mental Health Nurses (MHNs) have an under recognised long history of engaging in psychotherapeutic practice across the spectrum of mental illness and mental health problems, including those with serious mental health problems. There is a need for a psychotherapeutic response for people with complex or serious mental health problems within the stepped care model. This project sought to identify the educational preparation and self-reported competency of MHNs to clinically undertake psychotherapy with people.
Methods: Situated within a larger mixed method study exploring how MHNs practice psychotherapy, adapt it to routine care and envisage the future, this paper reports the findings from survey of MHNs regarding their educational preparation, experience and competence in modalities of psychotherapy and the application of psychotherapy with specific clinical groups.
Results: 153 MHNs responded to a request to participate. In this cohort, eighty-seven per cent of nurses had postgraduate qualifications specific to psychotherapy. Ninety-five per cent had worked for over 10 years in the mental health field and had hundreds of hours of training in psychotherapy. There was a high level of self- reported competence in working with people with serious mental health problems and ‘at risk’ or vulnerable groups.
Conclusions: Currently, MHNs are not recognised in federal funding arrangements to procure psychotherapeutic intervention for members of the Australian population who require it. MHNs ought to be recognised as independent providers based on both the psychotherapeutic skills that they possess and their specialist clinical skills of working with people across the spectrum of mental health problems. Appropriately qualified MHNs need to be funded to employ their skills in psychotherapy via access to appropriate funding arrangements such as Better Access and the National Disability Insurance Scheme.

The remarkable (Disappearing Act of the) mental health nurse psychotherapist

Hurley, J., Lakeman, R., Cashin, A., & Ryan, T. (2020). The remarkable (Disappearing Act of the) mental health nurse psychotherapist. International journal of mental health nursing, 29(4), 547-750. Doi:10.1111/inm.12698

The aim of this Australian based qualitative study was to better understand key drivers for mental health nurses to undertake training in psychotherapy, and how these capabilities are integrated into their clinical practice. Open ended reposes from a national survey of 153 mental health nurses were supplemented with data from 12 semi‐structured interviews of nurses with rich experience of integrating psychotherapy and mental health nursing capabilities. Key findings emerging from the thematic analysis were that mental health nurses are providing uniquely holistic psychotherapeutic services to consumers with often complex conditions, despite overtly hostile clinical and policy contexts. These often very well qualified mental health nurse psychotherapists are different to the traditional identity of either a nurse or psychotherapist. Recommendations from the findings of this study are that where appropriately qualified, mental health nurses be granted eligible provider status for existing Medicare funding items. Finally, training and building foundational capabilities in psychotherapy is highly recommended for all mental health nurses.

Mental health nurse psychotherapists are well situated to improve service shortfalls in Australia

Mental health nurse psychotherapists are well situated to improve service shortfalls in Australia

Hurley, J., Lakeman, R., Cashin, A., & Ryan, T. (2020). Mental health nurse psychotherapists are well situated to improve service shortfalls in Australia: findings from a qualitative study. Australasian Psychiatry, 28(4), 423–425. https://doi.org/10.1177/1039856220924326

Objective
This paper reports the capabilities of mental health nurse (MHN) psychotherapists in Australia and their perceptions on how to best utilize their skills.
Method
An MHN is a registered nurse with recognized specialist qualifications in mental health nursing. One hundred and fifty three MHNs completed an online survey; 12 were interviewed.
Results
Three themes were derived from a qualitative analysis of the aggregated data: psychotherapy skills of MHN psychotherapists are under-utilized; these nurses bridge gaps between biomedical and psychosocial service provision; and equitable access to rebates in the primary care sector is an obstacle to enabling access to services.
Conclusions
MHN psychotherapists are a potentially valuable resource to patients in tertiary and primary health care. They offer capacity to increase access to specialist psychotherapy services for complex and high risk groups, while being additionally capable of meeting patients’ physical and social needs. Equitable access to current funding streams including Medicare rebates can enable these outcomes.

The Mental Health Nurse Incentive Programme

For mental health nurses this was the first opportunity to branch out and provide what they were good at in primary care. Many nurses did and continue to do some astounding work in this space. However, the programme was flawed in that it did not recognise the psychotherapeutic expertise of nurses.
Click below to read:
Lakeman, R., Cashin, A., & Hurley, J. (2014). Values and valuing mental health nursing in primary care: what is wrong with the ‘before and on behalf of’ model? Journal of Psychiatric and Mental Health Nursing, 21(6), 526-535.

Some selected publications on the Mental Health Nurse Incentive Programme

Please also visit the Australian College of Mental Health Nurses.
Please click on the PDF icon to view the publication. These and others may be found here.

Lakeman, R. (2013). Mental health nurses in primary care: Qualitative outcomes of the Mental Health Nurse Incentive Program. International Journal of Mental Health Nursing, 22(5), 391-398

Lakeman, R. & Bradbury, J. (2014). Mental health nurses in primary care: quantitative outcomes of the Mental Health Nurse Incentive Program, Journal of Psychiatric and Mental Health Nursing, 21(4), 327-335

Hurley, J., Browne, G., Lakeman, R., Angking, D. and Cashin, A. (2014). Released potential: A qualitative study of the Mental Health Nurse Incentive Program in Australia. International Journal of Mental Health Nursing, 23(1), p. 17-23

Psychotherapy belongs to everyone!

Nurses have no monopoly on psychotherapy. However, they do have a unique skill set which means they have the capacity to develop empathic relationships with people in extreme states of distress and human experience. This capacity to empathise is I believe pivotal in helping people with the most complex needs.

Advanced empathy: A key to supporting people experiencing psychosis or other extreme states


The capacity to be empathic and communicate empathically are foundational skills of counselling and psychotherapy, if not all interpersonal helping endeavours. Empathy requires the capability, inclination and capacity to take the perspective of others, appraise and understand their experience without being overwhelmed, and communicate this understanding in a helpful way to the other person. This paper reviews and highlights the importance of this interpersonal capability and describes a form of ‘advanced empathy’ characterised by the capacity to take the perspective of others experiencing extreme states, making sense of this experience and conveying an understanding of that experience in a way which is useful to the person. The capacity for ‘advanced empathy’ is a foundation for any kind of therapeutic work with people who may express delusional or disturbing ideas and will be helpful for anyone needing to develop or maintain a relationship with people in extreme states. These ideas have been tested in practice and with a wide variety of audiences. This synthesis and summary might therefore be useful for training, supervision or reflection by those who hope to build alliances with people who may be in crisis, experience psychosis or are ‘out of step’ with people around them. This paper argues that empathy is useful in most helping relationships but is essential to effective mental health care.

Lakeman, R. (2020). Advanced empathy: A key to supporting people experiencing psychosis or other extreme states. The Psychotherapy and Counselling Journal of Australia. 8(1), Available: http://pacja.org.au/?p=5394

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