Submission to the Senate Inquiry on the National Disability Insurance
Scheme Bill 2013
Submission to:
Community Affairs Legislation Committee
25 January 2013
For further information contact:
Maria Brett
Chief Executive Officer
PACFA
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Executive Summary …………………………………………………………………………………………………. 1 Background to PACFA ………………………………………………………………………………………………. 4 What is PACFA? ……………………………………………………………………………………………………………. 4 What are Counselling and Psychotherapy?………………………………………………………………………. 4 PACFA Register …………………………………………………………………………………………………………….. 5 Table 1: Specialist supports provided by members of PACFA member associations ……………. 5 NDIS Bill 2012 …………………………………………………………………………………………………………. 6 Access Criteria ……………………………………………………………………………………………………………… 6 Early Intervention …………………………………………………………………………………………………………. 6 NDIS Rules …………………………………………………………………………………………………………………… 6 Table 2: Counselling and psychotherapy interventions recommended for NDIS …………………. 7 General Supports ………………………………………………………………………………………………………….. 8 Reasonable and Necessary Supports ………………………………………………………………………………. 9 Role of Carers and Families ……………………………………………………………………………………………. 9 Registered Providers of Supports ……………………………………………………………………………………. 9 Table 3: Proposed requirements for NDIS registration as a provider of support ………………. 10 Table 4: Costs for counselling or psychotherapy ………………………………………………………….. 11 Conclusions ………………………………………………………………………………………………………….. 11 Appendix 1 …………………………………………………………………………………………………………… 12 Appendix 2 …………………………………………………………………………………………………………… 14 Appendix 3 …………………………………………………………………………………………………………… 15 References …………………………………………………………………………………………………………… 16
Appendices
Appendix 1: Evidence for the efficacy of counselling and psychotherapy
Appendix 2: Counselling and psychotherapy in early intervention services
Appendix 3: Counselling and psychotherapy to support psychosocial functioning and capacity for social and economic participation
Executive Summary
The Psychotherapy and Counselling Federation of Australia (PACFA) welcomes the National Disability Insurance Scheme (NDIS) as an initiative that will significantly improve the level and quality of support provided to people with disability and their carers and families. The principles set out in the NDIS Bill 2012 are welcomed, in particular that people with disability should be supported to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports. PACFA also welcomes the recognition, in the NDIS Bill, of the important role that families, carers and significant others have in the lives of people with disability.
Access to counselling and psychotherapy services for people with disability is important in early intervention, to improve psychosocial functioning and to increase their capacity to participate in employment and community life. Counselling and psychotherapy are professional services with a strong evidence base which assist people to develop greater self-understanding and to make changes in their lives. It is therefore important that short-term counselling and psychotherapy are included in the NDIS as early intervention supports and reasonable and necessary supports for NDIS participants. Counselling and psychotherapy should also be provided as general supports for carers and families to improve their wellbeing and the quality and sustainability of informal supports. The inclusion of counselling and psychotherapy in the NDIS Rules will improve choice for people with disability, their families and carers, by improving their access to these services.
PACFA operates a national register of counsellors and psychotherapists who are qualified, experienced
and ethical practitioners, who must meet ongoing professional development and supervision
requirements to maintain registration. Specialist supports provided by PACFA Registrants are of particular relevance to NDIS participants, including family therapy, relationship counselling, solution focussed counselling, hypnotherapy and creative arts and experiential therapies. PACFA will apply for Registrants to be registered as providers of supports under the NDIS. Registration of counsellors and psychotherapists as eligible providers will be of benefit to NDIS participants, government and the community, due to the cost effectiveness of the services they provide.
Given the importance of the NDIS to people with disabilities and their carers and families, it is important that consultation is undertaken on the proposed NDIS Rules, once developed. Consultation with a range of stakeholders will ensure the Rules meet the expectations of NDIS participants, their carers and families, and the broader community.
Recommendations
PACFA puts forward eight key recommendations which are explained in full in the submission:
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The significant role of counselling and psychotherapy in early intervention should be recognised and the NDIS Rules should enable access to counselling and psychotherapy services as early intervention supports.
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The NDIS Rules should be drafted so as to enable NDIS participants to choose to access counselling and psychotherapy services as part of their NDIS Plans.
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Certain types of non-clinical counselling and psychotherapy services, as outlined in Table 2 of the submission, are appropriate for inclusion as NDIS supports and should be funded and provided through the NDIS.
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Consultation on the proposed NDIS Rules should be undertaken to ensure they meet the expectations of people with disabilities, their carers and families, and the broader community.
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The ‘general supports’ referred to in section 13 should be further defined in the NDIS Rules to include counselling and psychotherapy services, to be accessible by participants as well as their carers and families.
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The ‘reasonable and necessary supports’ referred to in section 34 should be further defined in the NDIS Rules to include counselling and psychotherapy services where the participant requires these services to improve psychosocial functioning and to participate more fully in social and economic life.
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The NDIS Rules should enable the provision and funding of counselling B services as general supports for families and carers of people with disability to improve to improve their wellbeing and the quality and sustainability of informal supports.
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The criteria for approval of registered providers of supports should enable registration of counsellors and psychotherapists as providers of supports for the NDIS and PACFA-registered counsellors and psychotherapists should be listed as eligible providers.
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Introduction
In this submission, the Psychotherapy and Counselling Federation of Australia (PACFA) reviews the National Disability Insurance Scheme Bill 2012, and focuses on the importance of NDIS participants being able to access support in the form of counselling and psychotherapy.
The terms ‘counselling’ and ‘psychotherapy’ do not refer to particular therapy modalities but are inclusive terms covering a range of different therapeutic approaches and incorporating many different therapeutic interventions. Counselling and psychotherapy are informed by research and have a strong evidence base which has been established over many years.
PACFA supports the principles set out in the NDIS Bill, in particular that people with disability should be supported to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports [section 4(4)]; that reasonable and necessary supports for people with disability should support them to pursue their goals, maximise their independence, and participate in the community and in employment [section 4(11)]; and that the role of families, carers and significant others in the lives of people with disabilities should be acknowledged and respected [section 4(12)].
Much of the crucial detail that will impact on NDIS participants’ capacity to exercise choice is still not
known and will be defined in the NDIS Rules. PACFA therefore submits that it is crucial that our
recommendations, as outlined in this submission, are taken into account in the development of the NDIS Rules. The NDIS Rules should enable participants to seek support from counsellors or psychotherapists, either as an early intervention support, as a general support, or when this is a reasonable and necessary support to enable them to pursue their goals and maximise their independence, and to participate in the community and in employment.
Currently, counselling and psychotherapy are not funded through Medicare as they are not considered by government to be clinical mental health services in the same way that services provided under Medicare by psychologists, social workers and occupational therapists are deemed to be clinical services. In a letter to PACFA in August 2012 from the Honourable Mark Butler, Minister for Mental Health and Ageing, PACFA was advised that:
…the Australian Government recognises that counsellors play a particularly important role in assisting individuals and families during relationship difficulties, in managing grief and loss and in providing assistance in times of personal crisis.
Minister Butler also noted our role in early intervention services:
Counsellors are the target providers for a number of early intervention and support programs…
In some circumstances, counsellors and psychotherapists can and do provide clinical services, for example, providing counselling to clients experiencing high prevalence mental disorders such as depression and anxiety, or longer-term psychotherapy to clients with more complex issues such as trauma, personality disorders, substance abuse and dependence, or other mental disorders for which there is evidence that psychotherapy is effective. These services will continue to be provided by existing clinical service providers (which employ counsellors and psychotherapists as well as other health professionals), or by psychologists, social workers and occupational therapists with Medicare Provider numbers.
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For the purposes of the NDIS, PACFA recommends that certain types of non-clinical counselling and psychotherapy services are appropriate for inclusion as NDIS supports, when provided by counsellors and psychotherapists registered with PACFA. The counselling and psychotherapy services would be short-term with a focus on supporting participants to improve their capacity for social and economic participation [section 24(1)(d)], or their functional capacity or psychosocial functioning in undertaking communication, social interaction, learning, self-care, and self-management [section 24(1)(c)].
These requirements as detailed in section 24 are exactly the kinds of issues for which clients regularly seek support from counsellors and psychotherapists. These services may be needed by NDIS participants experiencing a range of impairments such as cognitive, neurological, physical or sensory impairments, and not only those with impairments attributable to a psychiatric condition.
PACFA acknowledges the need for financial sustainability of the NDIS. We submit that inclusion of counselling and psychotherapy is a very cost-effective way to support NDIS participants. With counselling and psychotherapy not being covered by Medicare as clinical services, people with disability currently have limited opportunities to access counselling and psychotherapy and should therefore have the choice to seek these supports through their NDIS plans.
Background to PACFA
What is PACFA?
PACFA is the leading national peak body representing the self-regulating profession of counselling and psychotherapy. PACFA is a federation of 29 member associations which cover a range of counselling and psychotherapy modalities including family therapy, relationship counselling, experiential therapies, expressive arts therapies, hypnotherapy, integrative counselling and solution-focussed counselling.
PACFA advocates for appropriate, accessible health services to meet the bio-psychosocial needs of consumers. Counselling and psychotherapy focus on the prevention of mental illness and the provision
of psychotherapeutic interventions for psychological difficulties, while actively promoting the
development, mental health and wellbeing of consumers.
What are Counselling and Psychotherapy?
Counselling and psychotherapy are professional activities that utilise an interpersonal relationship to enable people to develop greater self-understanding and to make changes in their lives. Professional counsellors and psychotherapists work within a clearly contracted, principled relationship that supports individuals to explore and resolve their difficulties. Evidence for the efficacy of counselling and psychotherapy is included in the appendices to this submission.
The relationship between counselling and psychotherapy is seen as a continuum rather than as a complete demarcation. Counselling focuses more on specific life difficulties such as bereavement and relationships, adjusting to life transitions, and fostering clients’ wellbeing, whilst psychotherapy focuses to a greater extent on achieving change in some aspects of the person’s self or personality structure to reduce repetitive, maladaptive patterns in work and relationships.
Counselling and psychotherapy are interdisciplinary activities provided by a range of professionals, including psychologists, social workers, occupational therapists, nurses, doctors and psychiatrists, as well as counsellors and psychotherapists. Counselling and psychotherapy are not ‘owned’ by any one of these professional groups.
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PACFA Register
PACFA operates a national Register of suitably qualified and experienced counsellors and
psychotherapists. PACFA Registrants are required to belong to one of the 29 professional associations which are members of PACFA as a condition of registration. Registrants must practice according to the PACFA Code of Ethics, as well as the Codes of Ethics of the member associations to which they belong.
Some PACFA member associations focus on certain therapy modalities which will be of particular relevance to participants in the NDIS. Practitioners who specialise in providing these types of supports are identifiable on the PACFA Register by their membership of one or more of these associations, as detailed in Table 1.
Table 1: Specialist supports provided by members of PACFA member associations
PACFA Member Association Supports provided
Australian Association of Family Therapy (AAFT) Family therapy
Australian Association of Relationship Counsellors Relationship counselling
(AARC) Couples counselling
Association of Solution Oriented Counsellors and Hypnotherapy
Hypnotherapists of Australia (ASOCHA) Solution-focussed counselling
Australian Hypnotherapists Association (AHA) Hypnotherapy
Gestalt Australia New Zealand (GTA) Creative arts therapies
Experiential therapy
Melbourne Institute for Experiential and Creative Creative arts therapies
Arts Therapy (MIECAT) Experiential therapy
Music and Imagery Association of Australia (MIAA) Music and imagery therapy
Australian & Aotearoa New Zealand Psychodrama Psychodrama
Association (AANZPA)
Dance Therapy Association of Australia (DTAA) Dance therapy
There are also general counselling and psychotherapy associations with members who provide a wide range of counselling supports is most states and territories throughout Australia:
Counselling and Psychotherapy Association of Victoria (CAPAV) Counselling and Psychotherapy Association of New South Wales (CAPA NSW) Psychotherapy and Counselling Association of Western Australia (PACAWA) Professional Counselling Association of Tasmania (PCA) Counselling Association of South Australia (CASA) Queensland Counsellors Association (QCA) Counselling and Psychotherapy Association Canberra and Region (CAPACAR)
PACFA’s 1,500 Registrants have completed training in counselling and psychotherapy to at least Bachelor degree level or equivalent, and many are trained at postgraduate levels. They have attained the required
level of supervised practice experience and demonstrate that they meet ongoing professional
development requirements.
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NDIS Bill 2012
Access Criteria
PACFA supports the approach taken in the NDIS Bill to access criteria. It is an inclusive approach that will ensure people with impairments that require life-long support will be able to participate in the scheme.
PACFA queries, however, whether section 24(2) sufficiently captures the episodic nature of some mental disorders. It is important that supports can be accessed by participants promptly during times of crisis or serious deterioration in mental health, even though at other times the person’s mental health may stable with few or no supports being required. For these participants, the support should clearly be life long, even though the disability relates to a psychiatric impairment that is episodic in nature.
For example, it is noted that section 30 enables revocation of NDIS participant status where the person no longer meets the early intervention requirements. It is essential that participants with a psychiatric impairment that is episodic will not have their participant status revoked prematurely, and that they will be able to reapply to the NDIS in the future should their episodic illness require further support.
Early Intervention
PACFA welcomes the recognition in section 25 that early intervention supports can mitigate, alleviate or prevent the deterioration in functional capacity; strengthen sustainability of informal supports such as the support provided by carers; and is likely to reduce the participant’s future needs for supports in relation to the disability.
However, it may be problematic for participants to demonstrate, as required by section 25(b), that the provision of early intervention supports is likely to reduce future need for supports when their disability relates to a psychiatric impairment that is episodic. Some further guidance may be required in the NDIS Rules to make it clear how the CEO will assess whether this requirement is met.
It is PACFA’s submission that counselling psychotherapy could play a significant role in the NDIS for early intervention, and they should therefore be included in the NDIS as early intervention supports. Research evidence demonstrates that counselling and psychotherapy are effective for early intervention to reduce the impacts associated with disability (World Health Organization & World Bank, 2011; Vuorialho, Karinen & Sorri 2006) and to promote wellness and prevent mental health conditions (Cuijpers, van Straten, Smit, Mihalopouls & Beekman, 2008; Stevenson, Meares & D’Angelo, 2005; Seligman, 1995). See Appendix 2 for further information on the effectiveness of counselling and psychotherapy as an early intervention for people with disability.
Recommendation 1: The significant role of counselling and psychotherapy in early intervention should be recognised and the NDIS Rules should enable access to counselling and psychotherapy services as early intervention supports.
NDIS Rules
PACFA has identified a number of important details which are still to be defined in the NDIS Rules. In this section, we make recommendations for drafting of the Rules, to ensure that NDIS participants will be able to seek support from counsellors or psychotherapists, either as an early intervention support, a general support, or when this is a reasonable and necessary support.
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The Rules still to be developed are crucially important to ensure NDIS participants will have genuine choice about the supports they can access. Further consultation on the draft Rules is required to ensure they meet the expectations of people with disabilities and the broader community.
In particular, the following matters need to be covered in the NDIS Rules to ensure that participants will be able to exercise their choice to seek support from counsellors or psychotherapists.
Section 9 The definition of early intervention supports in section 9 refers to the supports to be identified in the NDIS Rules. Counselling and psychotherapy should be identified in the Rules as early intervention supports.
Section 27(1)(d) Under section 27(1), the NDIS Rules may be prescribed relating to the and criteria for assessing whether early intervention supports are likely to section 27(1)(e) reduce future need for support and to mitigate, alleviate or prevent deterioration of a person’s functional capacity. It is essential that any criteria to be developed recognise the significant role that counselling and psychotherapy can play as an early intervention. The Rules should enable counselling and psychotherapy to be offered as early intervention supports.
Section 35 (1)(a) The method for assessing, or criteria for deciding, the reasonable and necessary supports or general supports that will be funded or provided under the NDIS should enable counselling and psychotherapy services to be funded and provided.
Section 35 (1)(b) Counselling and psychotherapy should not be prescribed by the NDIS Rules as reasonable and necessary supports or general supports that will not be funded or provided under the NDIS as this would restrict participants’ capacity to exercise choice.
Section 35 (1)(c) Particular participants or groups of participants should not prescribed as
being unable to access counselling and psychotherapy services as
reasonable and necessary supports or general supports.
Recommendation 2: The NDIS Rules should be drafted so as to enable NDIS participants to choose to access counselling and psychotherapy services as part of their NDIS plans.
Counsellors and psychotherapists provide a wide range of supports using different therapy interventions. PACFA has identified a list of counselling and psychotherapy interventions which are appropriate supports for NDIS participants and others such as carers and family members. It is suggested that these should be identified in the NDIS Rules.
Table 2: Counselling and psychotherapy interventions recommended for NDIS
Counselling & psychotherapy Details intervention Brief therapy Support to find solutions to specific problems Cognitive-behavioural therapy Support to change dysfunctional thoughts and behaviours Couples therapy Support with the primary relationship with a spouse or partner Creative arts therapies Support to improve psychosocial functioning through creativity Family therapy Support to improve relationships with family and carers Group therapy Support to develop and improve social and communication skills
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Hypnotherapy Support to increase motivation or change behaviour using hypnosis Integrative counselling Support for a wide range of issues using a range of interventions which are selected according to client needs and preferences Mindfulness-based therapies Support to develop awareness and acceptance of present experience Motivational interviewing Support to build motivation for behaviour change and reduce resistance Person-centred counselling Support to develop a stronger sense of self to help clients make changes Psycho-education Support to develop a wide range of psychosocial skills Relationship counselling Support to improve relationships with family, carers, friends and workmates Solution-focussed counselling Strengths-based support to assist clients to find solutions for specific problems and develop positive self-identity Supportive counselling Support with all aspects of functioning
Recommendation 3: Certain types of non-clinical counselling and psychotherapy services, as outlined in Table 2 of the submission, are appropriate for inclusion as NDIS supports and should be funded and provided through the NDIS.
Given that the development of the NDIS rules is such an important element of the legislation that will impact significantly on the capacity of participants to exercise choice, PACFA believes further consultation on the Rules will be required once they have been drafted.
Recommendation 4: Consultation on the proposed NDIS Rules should be undertaken to ensure they meet the expectations of people with disability, their carers and families, and the broader community.
General Supports
In section 13(1) will be useful if it enables carers and family members who are supporting a person with a disability to access support, which could be provided by counsellors and psychotherapists. However, it is not clear who will be targeted to receive general supports, or to what extent this will be possible in practice. Also, the reach of the NDIS is potentially very expansive if people with disabilities who are not participants are also able to access general supports through the NDIS.
In section 13(2)(a), it is not clear how the general supports would be provided by the Agency. The provision reads as if the general supports would be provided directly by the Agency. As the criteria for deciding what general supports will be funded are still to be defined in the NDIS Rules [section 35(1)], it is difficult to envisage what kind of services the Agency would be providing under section 13(2)(a), and whether these services would be better delivered and funded through section 14. This may be a more appropriate way for these services to be delivered as it would give those receiving the general supports greater choice in accessing the services they need.
Counselling and psychotherapy will potentially be of great value as general supports for non-participants in the NDIS such and carers and family members of people with disability. (See section below for details).
Recommendation 5: The ‘general supports’ referred to in section 13 should be further defined in the NDIS Rules to include counselling and psychotherapy services, to be accessible by participants as well as their carers and families.
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Reasonable and Necessary Supports
The requirements detailed in section 34 provide comprehensive guidance as to the type of supports that will be funded through the NDIS. It appears that, in theory, many types of supports could be allowed, including counselling and psychotherapy which certainly meet the section 34 requirements.
Importantly, PACFA does not see section 34(f) as a barrier to participants seeking support in the form of counselling and psychotherapy. Counsellors and psychotherapists do not have Medicare numbers to provide clinical services, so they are not part of government’s universal service obligation [section 34(f)]. Also, based on the limited levels of counselling services accessible to people with disabilities in the community sector, it cannot be argued that counselling and psychotherapy are more appropriately funded or provided through other general systems of service delivery. Access to counselling and psychotherapy services is quite limited, particularly for those on low incomes who do not have the means to pay for private counselling or psychotherapy.
As already detailed above, the NDIS Rules which may be prescribed under section 35 will have a significant impact on the ability of participant to exercise real choice. If the Rules are too restrictive, they will take away the choice that section 35 enables. It is important that the Rules enable NDIS participants to choose to seek support from counsellors and psychotherapists, where the participant requires these services to improve psychosocial functioning and to participate more fully in social and economic life.
Recommendation 6: The ‘reasonable and necessary supports’ referred to in section 34 should be further defined in the NDIS Rules to include counselling and psychotherapy services where the participant requires these services to improve psychosocial functioning and to participate more fully in social and economic life.
Role of Carers and Families
For many people with disabilities, the informal supports provided by carers and family members are of central importance to their functional capacity and their social and economic participation. Sometimes, professional support - such as the support provided by counsellors and psychotherapists - is essential to help family supports work effectively and to be sustainable, and to help people cope with the stresses, conflicts and difficulties that can arise within families when caring for a family member with a disability. Family therapists and relationship counsellors are uniquely placed to support NDIS participants who need to improve their relationships with carers and family members and the quality of the informal support they receive from them.
Recommendation 7: The NDIS Rules should enable the provision and funding of counselling and psychotherapy services as general supports for families and carers of people with disability to improve to improve their wellbeing and the quality and sustainability of informal supports.
Registered Providers of Supports
PACFA intends to apply under section 69 for PACFA Registrants to be registered as providers of supports to NDIS participants. The criteria for approval as registered providers of supports are still to be defined in the NDIS Rules. PACFA recommends that the Rules should be drafted so as to enable registration of counsellors and psychotherapists as providers of supports.
Table 3 set out PACFA’s recommendations for the requirements that should be established in the Rules for registration of counsellors and psychotherapists as providers of supports. In accordance with section
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73(1)(d), these recommendations will ensure that only suitably qualified practitioners are recognised, and that safeguards and quality assurance standards and procedures are met.
Table 3: Proposed requirements for NDIS registration as a provider of support
Requirement Details
Registration with PACFA as a PACFA Registration includes requirements to:
counsellor or psychotherapist Maintain professional indemnity insurance
Undertake annual supervision and professional development requirements Comply with PACFA’s Code of Ethics and the Codes of Ethics of PACFA member associations to which Registrants belong Competence to provide one or more The interventions recommended by PACFA are all evidence of the counselling and psychotherapy based interventions which are relevant to the support required interventions recommended by by NDIS participants in accordance with the NDIS disability PACFA for the NDIS scheme requirements
Recommendation 8: The criteria for approval of registered providers of supports should enable registration of counsellors and psychotherapists as providers of supports for the NDIS and PACFA registered counsellors and psychotherapists should be listed as eligible providers.
Cost effectiveness of counselling and psychotherapy
The need for the financial sustainability of the NDIS is an important principle in the NDIS Bill that PACFA supports. Short-term counselling and psychotherapy represent cost-effective supports which will be more accessible for people with disability if made available through the NDIS.
Currently consumers are not able to access counselling and psychotherapy services under Medicare and these services do not receive GST exemption. Very limited private health fund rebates are available. The only option for people with disability to access these services is through community health centres or non-government agencies, where there are limited services available, frequently with long waiting lists. Whereas consumers who are in paid employment have the option of accessing counselling and psychotherapy services privately, this is not a viable option for most consumers who live with a disability and have very limited financial resources.
The counselling and psychotherapy services which PACFA proposes to be provided by PACFA Registrants are short-term interventions to support clients with their communication, social interaction, learning, self-care and self-management, as well as supporting clients to be able to participate in community life, both socially and economically.
Compared with psychologists, counsellors and psychotherapists provide cost effective counselling and psychotherapy services. While fees charged by counsellors and psychotherapists vary considerably, it is reasonable to state that the fees charges by psychologists are in general higher per session than those charged by counsellors and psychotherapists. Counsellors and psychotherapists generally charge between $70 and $130 per session plus GST, with $90 to $110 per session being average fees.
Psychologist consultation fees also vary greatly. It is quite common for psychologists to charge between $120 and $160 per session, although the fee recommended by the Australian Psychological Society is much higher at $222. It should be noted that some psychologists bulk bill when providing Medicare funded services for which the fee would be lower at $83.25, or $122.15 for clinical psychologists. Psychologists’ fees do not attract GST. 10
Research evidence shows that effective outcomes can be expected from one to twelve sessions of counselling or psychotherapy. 60 to 65% of people attending counselling experience significant reduction in their presenting issues after one to seven sessions (Miller, Duncan, Brown, Sorrell & Chalk, 2006). Table 4 compares the costs of one to twelve sessions of therapy at different hourly rates.
Table 4: Costs for counselling or psychotherapy
Number of sessions $90 per $100 per $110 per $120 per
session session session session
1 session $90 $100 $110 $120
2 sessions $180 $200 $220 $240
3 sessions $270 $300 $330 $360
4 sessions $360 $400 $440 $480
5 sessions $450 $500 $550 $600
6 sessions $540 $600 $660 $720
7 sessions $630 $700 $770 $840
8 sessions $720 $800 $880 $960
9 sessions $810 $900 $990 $1,080
10 sessions $900 $1,000 $1,100 $1,200
11 sessions $990 $1,100 $1,210 $1,320
12 sessions $1,080 $1,200 $1,320 $1,440
- Sessions are between 50 minutes and 60 minutes If the NDIS Rules include counsellors and psychotherapists as service providers, PACFA will establish a schedule of recommended fees. A maximum schedule fee of $100 is proposed, which would result in a cost of $1,200 for 12 sessions of counselling, or $1,320 where GST is charged.
Conclusions
The NDIS represents a tremendous opportunity for people with disability, their carers and families, to exercise choice about the supports they access, leading to greater participation of people with disability in the social and economic life of the community.
As the leading peak body for counselling and psychotherapy in Australia, PACFA advocates for inclusion of counselling and psychotherapy as early intervention, general, and reasonable and necessary supports that should be delivered and funded through the NDIS. PACFA has developed a list of non-clinical counselling and psychotherapy interventions that it recommends are appropriate to be provided and funded under the NDIS.
Counselling and psychotherapy have a significant role to play in early intervention and this is supported by research evidence. There is also significant research evidence on the effectiveness of counselling and psychotherapy in general, and to support people with disability to improve psychosocial functioning and to achieve full social and economic participation.
This submission includes eight recommendations which, if adopted, will ensure NDIS participants and their carers and families have the genuine capacity to exercise choice about the supports they access and to achieve fuller participation in social and economic life. PACFA’s recommendations will also go some way towards improving service access for people with disability, who currently have very limited opportunities to choose counselling and psychotherapy for their support.
Importantly, the NDIS Rules have not yet been drafted and further consultation will be needed on the Rules once they are drafted to ensure they meet expectations of NDIS participants, their carers and families, and of the wider community.
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Appendix 1 Evidence for the efficacy of counselling and psychotherapy
There is a strong evidence base for the efficacy of psychotherapy and counselling. PACFA endorses the American Psychological Association’s definition of evidence-based practice as ‘the integration of the best available research evidence with clinical expertise in the context of patient characteristics, culture and preferences’.
In 1977, Smith and Glass published a meta-analysis of studies that compared outcomes for people who had received psychotherapy interventions with those who had not. They found a consistent, positive and substantial treatment effect, regardless of treatment approach or client group. While controversial at the time, these core conclusions have survived a further 45 years of research and continue to be supported in recent reviews of the effectiveness of counselling and psychotherapy.
We also have more than 20 years of knowledge concerning client experience of counselling and psychotherapy. A 1990 study by Scott and Freeman compared GP treatment, psychologist treatment, medication, and counselling treatment provided by social workers. All treatments achieved similar results for similar costs, however clients rated counselling more highly as the social workers spent more time with their clients.
Seligman (1995) undertook a large Consumer Reports study to discover the experiences of people who had undergone counselling or psychotherapy. The study was in effect a consumer satisfaction study of the kind that might be conducted with respect to any product or service. He concluded that there were substantial benefits for people in psychotherapy; that psychotherapy without medication produces the same effects as psychotherapy and medication; that no one model produces better outcomes than other models; and that psychotherapy is effective regardless of the practitioner’s occupation, for example as a psychologist, psychiatrist or social worker.
These findings are supported by research into the common factors underlying the effectiveness of counselling and psychotherapy (Duncan, Miller, Wampold & Hubble, 2009) which has found that all types of therapy achieve broadly similar client outcomes and that the strength of the client-therapist relationship is a key determinant of therapy outcomes.
Recently, outcome data for Medicare’s Better Access initiative indicates that similar outcomes are achieved from the counselling and psychotherapy services provided under the scheme regardless of whether treatment was provided by psychologists, social workers or occupational therapists. The level of psychological distress decreased from high or very high at the start of treatment to moderate by the end of treatment (Pirkis, Harris, Hall & Ftanou, 2011), regardless of the occupation of the practitioner delivering the service.
Counselling and psychotherapy have been demonstrated to be efficacious treatments for health in a number of ways. The contribution they make to health is both remedial and preventative.
Mental health
There is widespread evidence for the contribution of counselling and psychotherapy - of various
orientations - to the effective treatment of mental illness. A pertinent example is the provision of counselling services for high prevalence disorders such as depression and anxiety. Where aspects of personality functioning are a factor in mental health, psychotherapy has a particular role to play. There is
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also strong evidence for the contribution of counselling and psychotherapy to the prevention and treatment of mental illness, including depression, anxiety and trauma (Cuijpers et al., 2008).
Once mental illness develops and becomes severe, specialised clinical services, hospitalisation and a higher level of case management are required. A Cochrane review comparing psychosocial and pharmacological treatments for deliberate self-harm found the most effective treatment for females with Borderline Personality Disorder using self-harm is longer term psychotherapy (Hawton, Townsend, Arensman, Gunnell, Hazell, House, & van Heeringen, 1999). This group is at higher risk of completed suicide than the general population. There is evidence from an Australian clinical trial with a 5 year follow up (n = 150) that regular participation in psychotherapy for people with personality disorders reduced the rate of hospitalisation, incidents of self-harm and violence, reduced drug use and improved work history (Stevenson, Meares & D’Angelo, 2005).
Family therapy also has a strong level of evidence for effective interventions with adolescent anorexia nervosa, for example the Maudsley model which views parents as a resource for recovery (Le Grange, 2005). The evidence indicates that family therapy is more effective in the treatment of adolescent eating disorders than individual therapy. Recent systematic reviews have also shown that couple counselling and family therapy are more effective than individual treatment for treating substance abuse, and result in increased abstinence, reduced incidence of interpersonal violence and improved relationship functioning (O’Farrell & Clements, 2011; Ruff, McComb, Coker, & Sprenkle, 2010).
Relationship difficulties The nexus between fulfilling and rewarding personal relationships and both physical and mental health is well documented by research. For example, a large Canadian population study showed that 12% of people who separate become depressed, and adult males in particular were six times more likely to become depressed after a relationship breakdown than men who remain married (Rotermann, 2007). Research supports counselling and psychotherapy as the indicated treatment for relationship difficulties and adjustment to separation.
Physical health and disease It is recognised that the response of patients to interventions aimed at ameliorating or healing various
physical conditions will be influenced by emotional and psychological factors. Examples include
treatments for cancer, chronic conditions involving a degree of impaired functioning, and immune disorders including HIV/AIDS. Counselling and psychotherapy have a growing role as an adjunct to medical interventions in these situations.
There is also evidence that many physical ailments have a psychological component and vice versa. For example, recent research from the Australian Institute of Health and Welfare (2010) found that 1.8 million people experiencing back problems in 2007 to 2008 were 2.5 times more likely to experience mood disorders such as depression, 1.8 times more likely to suffer from anxiety and 1.3 times more likely to report a substance use disorder, compared with people without back problems. The provision of short term counselling and psychotherapy is a sound, evidence-based response to concurrent physical and mental conditions.
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Appendix 2
Counselling and psychotherapy in early intervention services
There is a strong relationship between disability and inequality. The World Report on Disability (World Health Organization & World Bank, 2011) found that women with disabilities are more disadvantaged through the combined effects of gender and disability, and that people with mental health conditions or intellectual impairments are more disadvantaged than those with other forms of disability.
Counselling and psychotherapy services provide early intervention to address the impacts associated with disability. Early intervention reduces or prevents the impact of disabling conditions, and contributes to slowing deterioration in every aspect of the lives of people with disability (World Health Organization & World Bank, 2011).
There is strong evidence that counselling and psychotherapy promote wellness and prevent mental health conditions in people experiencing stress and life transitions. Life transitions and stress provide
additional layers of disadvantage for people with disability. Counselling is found to increase the
consistent use of physical aids and taking prescribed medication by people with disability (Vuorialho, Karinen & Sorri 2005; World Health Organization & World Bank, 2011). Counselling also assists people injured in the workplace to return to work (World Health Organisation & World Bank, 2011).
Counselling and psychotherapy provide effective treatment for high prevalence mental health conditions such as depression, anxiety and trauma (Cuijpers, van Straten, Smit, Mihalopoulos & Beekman, 2008). A large consumer reports study found consumers prefer counselling and psychotherapy to other professional treatments, because it is client focused and empowers people to make changes in their own lives (Seligman, 1995).
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Appendix 3
Counselling and psychotherapy to support psychosocial functioning and capacity for social and economic participation
People with disability are more likely to be excluded from participation in everyday life (World Health Organization & World Bank, 2011). Many people with disability face “disabling barriers” (World Health Organization & World Bank, 2011, p. 9) in accessing counselling and psychotherapy services through lack of financial resources, poor coverage of public services and the need for assisted referrals. Counselling is one of the unmet needs for people with disability and their carers, the World Report on Disability (World Health Organization & World Bank, 2011) found. Lack of access to much needed services further contributes to the social exclusion of people with disability.
Mental health consumer and carer speakers at two major counselling and psychotherapy forums, the World Congress of Psychotherapy held in Sydney 2011, and the PACFA Conference held in Melbourne 2012, supported by funding from the Mental Health Council of Australia, emphasised the helpfulness of counselling and psychotherapy in restoring their health and dignity and supporting their recovery from mental health conditions.
Supportive counselling contributed to consumers’ participation and inclusion in work and community activities. They were more able to be independent and to not over-rely on family and friends.
Carers were better able to support and advocate for family members with disability by having their own socio-emotional needs attended to within a therapeutic relationship. Family counselling is an aspect of rehabilitation. The World Report on Disability recommends the provision of counselling to improve carers’ wellbeing (World Health Organization & World Bank, 2011).
Counselling also improves the participation of people with disabilities in the workforce. A five year outcome study on psychotherapy provided to people with personality disorders with related symptoms of depression and anxiety found reduced hospital admissions and absences from work, and fewer disruptions to family relationships (Stevenson, Meares & D’Angelo, 2005).
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