The Macquarie Dictionary defines psychology as ‘the systematic study of the mind, or of mental states and processes’, suggesting that training in the discipline will teach keen young students about how individuals reason, perceive and react to things, express emotions and behave. This implies that a psychology degree prepares new graduates for jobs in which much of the work is done on a one-to-one basis, in a range of different settings. Psychology is certainly about individuals, and there are many, many psychologists around Australia who are making a massive difference to individuals’ lives. However, we would argue that psychology is about more than this. Training in psychology equips graduates with myriad skills that enable them to influence policy and practice in a way that improves the mental health and wellbeing of whole populations, if they choose to take up this challenge.
We were asked to write an article for InPsych on the role of psychologists in informing initiatives and interventions at the broad population level. We have been shamelessly self-indulgent in our approach, with each of us providing a ‘case study’ that describes how we came to follow this sort of career path and providing an example or two where we believe we have had some sort of population-level impact. At the outset, we should declare that the three of us did honours in psychology together at the University of Tasmania in 1985, and writing this gave us an opportunity to reflect on the professional choices we have made since then. Before we get to our case studies, however, we discuss some of the different roles that psychologists may play that allow them to influence population mental health and wellbeing and the kinds of qualities and skills that they have that equip them for the task. We also make note of particular branches of psychology that may be relevant.
Roles that impact on populations
Psychologists may take on a range of roles that allow them to influence the mental health and wellbeing of whole populations. Some may work in academic settings, conducting research that provides evidence for the effectiveness of large-scale programs designed to promote good mental health or prevent or treat mental illness. Some may be employed in government departments which fund and oversee the roll-out of these sorts of programs, and others may hold community-sector positions that are responsible for developing and delivering them.
Still others may be involved with organisations that promote best practice, building the capacity of others to deliver on optimal mental health outcomes through, for example, training and guidelines. This list is obviously not exhaustive; there are many different and novel ways that psychologists can have an impact on the wellbeing of whole populations.
Often the roles psychologists play in this area are not mutually exclusive. For instance, some academic psychologists conduct their own research into the effectiveness of given initiatives and/or synthesise the effectiveness evidence from studies conducted by others, and then get involved in knowledge translation exercises where they develop and disseminate guidelines based on this evidence.
In addition, these population mental health roles do not preclude psychologists from being involved in individual-level activities, such as seeing clients in a clinical context. In fact, they are often complementary and mutually beneficial. Clinical work with individual clients, for example, can give psychologists a perspective on population-level mental health initiatives that they might not otherwise have.
Skills for population-level roles
From the outset, psychologists are encouraged to think critically, not to take anything at face value, and to question the evidence for given claims. Training in research methodology is core business in any psychology degree, so when psychology students graduate they can recognise a good study design and conduct rigorous research themselves. Communication is valued in psychology, and psychologists are taught how to communicate persuasively in a range of ways with a variety of audiences. Together, these skills mean that psychologists can present the case for particular policy reforms or practice changes and develop programs that will resonate with particular target groups, whatever roles they may be performing and whatever setting they may find themselves in.
Relevant branches of psychology
Much of the theory underpinning psychology relates to behaviour change, and this can be applied to groups and whole populations in the same way that it can to individuals. Certain branches of psychology may be particularly relevant in this regard. As we alluded to earlier, clinical psychology is a case in point.
Clinical psychologists have an in-depth understanding of mental health problems and best practice approaches to treatment. This will be helpful for those who make the shift to population mental health; it will give them the edge in commissioning, designing or deploying large-scale programs. They also understand how others in their profession work, so if, for example, they become involved in guideline development, they will have insights into the ways to frame recommendations that increase their likelihood of being taken up across the board.
The same applies in other branches of psychology in which psychologists deal directly with individual clients, such as counselling psychology and educational psychology. Depending on the client groups with whom they work and the settings in which they are located, they may also be well-placed to inform specific population-based mental health initiatives (e.g., educational psychologists may develop and implement whole-of-school resilience-building programs for children and adolescents). At an even more individual level, the fundamental understanding that neuropsychology gives us about how the brain operates provides new opportunities in behaviour change.
Health psychology and community psychology are other branches of psychology that have much to offer in terms of improving population mental health. Health psychology is concerned with understanding how psychological, behavioural and cultural factors contribute to health and illness. Health psychologists are acutely aware of the interconnections between physical and mental health, and of the social factors that impact on both of these at a population level. Community psychology also considers social, cultural, economic and environmental influences on mental health, and community psychologists empower communities to address these influences in a way that maximises community mental health. Many initiatives that are designed to promote good mental health across the population – e.g., anti-stigma campaigns – are grounded in the theory and practice of health psychology and community psychology.
Social psychology also makes an important contribution, via its emphasis on the impact of people’s social contexts on their thoughts, behaviours, intentions and general equilibrium. Many excellent population mental health interventions work through strengthening social networks, improving circumstances and situations, and addressing other contextual factors in people’s lives.
Population mental health endeavours also often draw on organisational psychology. Sometimes this is because organisations are delivering programs to members of their own workforces, often reaching significant numbers. On other occasions, it is because large organisations – often non-government organisations – are responsible for delivering mental health related interventions to the wider community, via a network of providers. In these circumstances, organisational performance is paramount, and the principles and practice of organisational psychology come to the fore.
Case studies
Jane
I was always very interested in how particular health issues play out in the general population. If health psychology had been an option when I was studying in the 1980s, I would have leapt at it. Instead, I studied clinical psychology and later complemented this with further studies in epidemiology. Career-wise, I went down a research path fairly early after a very brief period working in educational psychology. I have been at the University of Melbourne since 1996 and I have been the Director of the Centre for Mental Health there since 2013.
I have been lucky enough to be involved in a range of projects that have had direct or indirect impacts on population mental health. A lot of these have involved evaluations of large-scale mental health reforms, like the Access to Allied Psychological Services (ATAPS) program and the Better Access program. However, the example I am going to describe here is the development and evaluation of a three-part documentary called Man Up, which explores the relationship between masculinity and suicide.
Man Up arose because my team (which includes a number of other psychologists) and I had become concerned about the fact that males account for three quarters of all suicides. We had conducted research that showed traditional masculine norms like stoicism and self-reliance were associated with heightened levels of suicidal thinking in men. This led us to wonder whether a highly visible documentary might be able to shift entrenched societal views, change behaviour and ultimately reduce male suicide across the population.
We partnered with Heiress Films and pitched the idea to Movember who were keen to fund it. The title deliberately challenges the conventional use of the phrase ‘man up’, which encourages men and boys to suppress negative emotions and try to deal with problems on their own. Man Up is hosted by commercial radio announcer Gus Worland. Gus is a typical ‘bloke’ but he is also comfortable expressing his emotions and talking about mental health issues. He is also personally invested in the cause, having lost his friend and mentor, Angus, to suicide. During the documentary, Gus tries to understand what is driving Australian men to take their lives. He speaks to everyday people in the street, meets farmers, ex-servicemen and construction workers in their own environments, and learns about men’s mental health from a range of experts.
Man Up is underpinned by psychological conceptualisations of how behaviours develop and can be changed. Throughout the show, dominant masculine norms are questioned, and expression of emotion and help-seeking are normalised. Many of the men Gus meets model positive behaviours, such as talking about personal problems. The show culminates in Gus creating a campaign ad with the tagline ‘Man Up, Speak Up’ to raise awareness about the damage caused by men bottling things up.
As good psychologists, we wanted evidence that Man Up could make a difference. We conducted a randomised controlled trial of the show before it went to air. We recruited just over 350 men and randomised them to watch Man Up or an unrelated documentary called Test Your Brain. Those who viewed Man Up demonstrated significant increases in their help-seeking intentions, whereas those who viewed Test Your Brain showed no change. We took this as evidence that Man Up increased the likelihood that men would seek help if they were facing tough times (King et al., 2017).
The positive findings from the trial were pivotal in the ABC deciding to screen Man Up in prime time in 2016, repeat it three times in 2017–18 and retain it on iView since then. We tracked its performance, and at the end of 2018, the show had been watched by more than 2.6 million people and Gus’s ad had had over 56 million views on social media. We like to think that the evidence of effectiveness demonstrated in the trial multiplied by this high level of reach equates to a fairly sizeable population mental health impact.
Andrea
During my undergraduate degree, I was torn between sociology and psychology as I thought that both provided an important perspective on what makes us tick as human beings. Truth be known, I was drawn more to sociology as a discipline but could see a clearer career path in psychology and chose to go down that route. Those early influences remain though, and throughout my career as a clinical psychologist, I have always been mindful of the family, social and cultural context of individuals presenting for psychological care as well as the context of the service system within which the care is provided.
This broader perspective was probably also influential in the decision I made several years ago to move away from an exclusively clinical role, to a role with Phoenix Australia. As the national centre of excellence in posttraumatic mental health, Phoenix Australia undertakes research, training and workforce development, alongside policy and service development work with government and industry. Work at Phoenix Australia offered the potential to influence systems of care as well as influence the policies and practices of organisations whose staff can be exposed to trauma at work, and government departments responsible for delivering trauma-informed services to people with a background of trauma. This work with population-level interventions has allowed me to have an impact on the wellbeing of many more people than I could have done intervening solely at the level of the individual client.
Perhaps the best example of this is my role in leading the development of the National Health and Medical Council approved and Australian Psychological Society endorsed Australian Guidelines for the Prevention and Treatment of Acute Stress Disorder, Posttraumatic Stress Disorder (PTSD) and Complex PTSD (Phoenix Australia Centre for Posttraumatic Mental Health, 2020).
Having worked in the trauma field for several years, I am acutely aware that it is a field in which practitioners often feel out of their depth in knowing how to best help their clients. Myths abound about the rights and wrongs of trauma-focused treatments and new ‘miracle cures’ are always on the horizon. When I moved to Phoenix Australia, I continued to provide treatment to individual clients through a small private practice, but also had a role in increasing the uptake of evidence-based treatment for PTSD amongst practitioners across Australia through the training and supervision of hundreds of psychologists and other mental health practitioners. However, my role in developing the guidelines has enabled me to have an even greater reach, at the population level.
The guidelines are intended to improve outcomes for all Australians impacted by trauma, through guiding the treatment provided by mental health practitioners, helping people with lived experience of trauma to be informed consumers and ask the right questions about the treatment that they are receiving, and setting the standards of care for those responsible for the provision or funding of services. The guidelines are underpinned by systematic reviews of the highest quality clinical trials of psychological, pharmacological and other interventions for the prevention and treatment of acute stress disorder and posttraumatic stress disorder in children, adolescents and adults.
A Guideline Development Group, made up of leading trauma researchers, multidisciplinary health practitioners and people with lived experience of trauma, considered the research evidence and made recommendations for treatments that are relevant and applicable in the Australian healthcare context. In recognition of the importance of the context of trauma exposure, the guidelines include information for practitioners working with clients of different backgrounds – Aboriginal and Torres Strait Islander peoples, refugees and asylum seekers, older Australians, military and ex-military personnel, and emergency services personnel.
They also cover different types of trauma, including disasters, sexual assault, crime, intimate partner violence, and motor vehicle accidents and other traumatic injury. These sections of the guidelines highlight for practitioners the importance of understanding the interpersonal, organisational, social or political context in which psychological injury has arisen, and the need for cultural competence when working with particular client groups.
Even more important than the development of the guidelines is their effective dissemination and implementation. Not one to miss an opportunity, I am pleased to let you know that the guidelines are available for reference and free download from the Phoenix Australia website: www.phoenixaustralia.org
Mark
Growing up in a family that believed in social justice, community services and chaplaincy for vulnerable and disadvantaged people, I was always destined to do something in the social services.
Psychology looked like the right option when I was at the University of Tasmania. Jane and Andrea and I were lucky to be taught by an amazing group of academics in a generalist school that combined sound clinical, experimental, methodological and community psychology influences. In my case, this set me up for a varied career in which I would say I have always been a psychologist but rarely called that by title.
As a psychologist, most of my individual work was in industrial settings at the Commonwealth Employment Service and as an army psychologist. My career took a distinct turn when I joined a market research company in Perth, Western Australia. This is where I first began to realise that I could use my skills to change the behaviour of many people, not just three or four in a day.
I conducted evaluation studies which gave me a direct input into the policies and practices of my clients, who ranged from political parties to pie-makers! I was often able to give feedback to government departments on how the expenditure of (often large sums of) public money was able to achieve outcomes – and sometimes on how this expenditure failed to achieve what it set out to, or even had outcomes that were undesirable.
I moved into the disability and justice sectors and ended up managing young offender programs in Western Australian prisons, a role that made me realise that systemic responses are the necessary underpinning of individual therapeutic work. Without both working together, it was common that neither provided lasting change for the individual.
I returned to Tasmania in 2007 where I was able to support changes in youth justice that moved practice away from a welfarist to forensic model. Psychology training gives you a natural focus on evidence which is the foundation to good policy and practice. A direct outcome of this work resulted in changed Court processes where magistrates moved from looking at episodic offending (i.e., offence by offence) to complete offending trajectories and introduced psychologically evidenced-based assessment in the form of the Youth Level of Service/Case Management Inventory (YLS/CMI) (Hoge & Andrews, 2011).
We also worked with a not-for-profit organisation to move a small amount of justice funding to supporting youth on bail at a pre-sentence time (an area justice services normally stay away from due to the presumption of innocence). This allowed the young people to be supported and often diverted from further offending and being drawn deeper into the forensic services. With additional recommendations about how youth were dealt with while on bail, we rapidly halved the number of youths in detention in Tasmania.
I now run Nexus, a disability service in Hobart. Under the National Disability Insurance Scheme (NDIS) there has been a monumental shift in disability services. This has provided greater support for building individual capacity and expanded the scope of disability services, both in terms of the numbers of people served and the range of needs addressed. Over the past six years, our services at Nexus have moved from providing traditional group homes to a much wider array of services.
One of the most satisfying changes has been our ability to offer a trauma-informed model to a range of young NDIS participants who have moved through either the child safety or youth justice systems, often ending up as adults with a formal diagnosis of borderline personality disorder. For an organisation, this client group is highly rewarding to work with in terms of the outcomes that can be achieved, but it also presents challenges in terms of potential staff and organisational risk.
My training as a psychologist has allowed me to combine an understanding of clinical practice, policy, and governance to give my Board sufficient confidence to support this client group. We now support over 40 of these clients, many of whom have achieved outcomes like re-engagement in education, reduced substance use, stabilised housing and reduced justice contact.
Being part of the big picture
If you had asked us how we thought our careers might pan out when we were doing honours, none of us would have had a clue. We would have looked up from the electric typewriters we were using to crank out our theses and scratched our heads. But 35 years on all of us agree that studying psychology equipped us well for the roles we have played in influencing mental health and wellbeing at a population level. We would definitely encourage the younger generation of psychologists to think about the big picture when making career decisions. The options are limitless.
Contact the first author: [email protected]