Featured letters

It was interesting to review Dr Robin Vines (December InPsych, 2017, p. 33) article about the need to “end Australia’s regional health workforce drought” when a few days before I read it, ABC and SBS TV news reported the “Royal Flying Doctor Service (RFDS) warns rural mental health services in ‘crisis’ ”.

This was also a few days after I’d driven to a non-metropolitan centre to provide telehealth consultations, and not for the first time, I had no telehealth consultation booked.

The situation is not helped by (at least) three “barriers”:

a) The obscenely low Medicare rebates;

b) The rebate being the same if I consult in my metropolitan office or a hired room in a country town, which I’ve spent (non-income generating) time driving to;

c) One of the major employers of doctors in the region advising me “…we provide medical and allied health services where we either don’t charge or charges are well below industry averages, and we maintain this consistency with services provided through third parties onsite.” (I’d enquired about sessional rental of a room in their premises). 

So, while that not for profit (presumably) gets a massive subsidy to provide services in the country, (which allows them to bulk bill clients) a private practitioner seeking to “…increase ease of access to psychological services for a currently underserviced section of the Australian Community” (to quote Dr Vines) gets no subsidy. For example, a higher Medicare rebate for non-metropolitan consultations.

Despite spending considerable amounts of time, money and energy contacting doctors and potential clients (including via targeted advertising on Facebook) I have yet to receive a single telehealth referral.

Considering Dr Vines “workforce drought” and the “crisis” reported by the RFDS I think the situation is not helped when GPs don’t actually make use of the available services. 

Following on from Kristen Keppel’s article (February InPsych, 2018, p. 40), I would like to offer some advice for those contemplating a move to a country practice. For many years I worked in a rural centre, and also in a remote Northern Territory town. Given my experience I have some observations to share that are not really outlined in the APS Code of Ethics or the Ethical guidelines for psychological practice in rural and remote settings. Before you contemplate a move, make an honest assessment of both your professional and personal needs. While a change may sound exciting, distance from family and friends can be debilitating, especially for single people. The lack of cultural and sporting activities can magnify this. Establishing how you might connect to the community before taking up an offer is advisable. This could include volunteering, coaching a junior football club, or running a hobby class. If face-to-face professional development activities and supervision are scarce, take advantage of the APS online resources and Skype.

Seeking the support of non-psychology health professionals is also recommended. With being the inevitable ‘big fish in a small pond’, comes the responsibility of acting professionally at all times. In a small community everyone will get to know you and behaving inappropriately will damage your reputation and that of the profession. Other good advice I was given years ago was to ‘slow down, don’t talk down, and dress down’. Try to take on board the norms of the community into which you are moving.

Another issue is the ‘head office’ mentality of some organisations. They will not always be understanding if a natural disaster such as a cyclone gets in the way of submitting a report on time. You should carefully monitor your self-perception as a practitioner. It is very easy to acquire an inflated sense of self, particularly if you are the only psychologist in town.

Despite potential drawbacks, living and working in a country area can bring many benefits. As Kirsten Keppel said, rural practice can be a refreshing change from the hustle and bustle of the city.

In the February issue of InPsych, Professor Anthony Love described what he sees as a “dilemma of diagnosis” for psychologists. However, he presented only a few of the weakest criticisms of the current dominance of the medical model of psychiatric ‘mental disorders’ within psychology. He also oversold the related benefits, and compared DSM-based diagnosis to no model at all, rather than to psychology’s own alternative – case formulation. His weak criticisms included the dangers of labelling, such as the stigma it can produce, and the confirmation bias that diagnosers can be subject to. But he did not mention much more serious deficiencies such as the complete failure to find even one single biomarker or underlying biochemical defining process among the psychological ‘disorders’. So Professor Love’s analogy of a car mechanic diagnosing an engine problem falls down badly. Mechanics, fortunately, do not announce diagnoses such as “302.10 Underbonnet Clunking Disorder” or “112.23 Slow Acceleration Spectrum Disorder” because, unlike a psychiatric diagnosis, a car mechanic’s assessment will suggest an underlying localised functional problem, and hence a specific repair process.

He also overlooked the fact that psychologists frequently target legitimate ‘clinical psychological problems’ (CPPs) that are not mental disorders. Relationship problems are a case in point. They are relegated in DSM-5 to a few nonclinical ‘V’-codes as there is no way that they can be conceptualised as ‘mental disorders’. But they are a major and legitimate target for clinical psychological intervention. Other CPPs that are not mental disorders are borne by the third to half of all presenting clients whose problems do not fully or neatly match the criteria of any DSM diagnosis. They have variously been labelled as subclinical, subthreshold, or situation-specific (e.g., only happens at work). Should we be turning away people in great distress because they qualify under only three of seven criteria, when DSM-5 specifies that four are required?

Professor Love unfortunately cites as the most important benefit of diagnostics “the contribution a diagnosis makes to treatment decisions”. This is possibly its greatest weakness. Diagnoses have proven to be almost irrelevant to psychotherapeutic intervention decisions, which are made by the majority of psychologists for the majority of CPPs subsequent to a case formulation or functional analysis. This is reflected in the movement toward transdiagnostic theories and treatment modules, as underlying psychological-level processes are belatedly restored as the foci of research and clinical attention.