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Editorial: Adaptation, Integration, and Equity

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Jane Marsden

 

Recently released census data highlight Australia’s increasing cultural diversity (Australian Bureau of Statistics [ABS], 2022c). For the first time, more than half of the population (51.5%) was either born abroad or had a parent born abroad, while almost a quarter (24.8%) speaks a language other than English at home. The number of Australians who identify as being of Aboriginal and/or Torres Strait Islander origin increased between censuses (812,728 people or 3.2% of the total population in 2021 compared with 649,171 or 2.8% in 2016; ABS, 2022a). At least 167 Aboriginal and Torres Strait Islander languages were used at home in 2021. In another first, the 2021 Census permitted all respondents to choose non-binary sex as a third response option for the sex question; however, data about those who identified as non-binary will not be released until September 2022.

The 2021 Census was the first to ask Australians about long-term health issues, with mental health conditions—including depression and anxiety—the most commonly reported. Age increased the likelihood of reporting at least one long-term health condition (62.9% of people aged over 65 compared with 22.1% of people aged 15–34). The National Study of Mental Health and Wellbeing (ABS, 2022b) provides a more granular reading of the nation’s mental health.1 It found that women were almost twice as likely as men to report having an anxiety disorder2 in the 12 months before the survey, which ran from December 2020 to July 2021 (21% compared with 12.4%). Women also experienced higher rates of affective disorders (e.g., a depressive episode; 8.5% compared with 6.2%). Nearly two in five young people (39.6% of those aged 16–24) experienced mental ill-health; of those, almost half were women (46.6%). Of all people identifying as gay, lesbian, or bisexual, or who used a different term such as asexual, pansexual, or queer, 44.7% had an anxiety disorder and 30% had an affective disorder in the year before the survey. People who at some point in their lives had no permanent place to live experienced higher rates of affective disorders than others (17% compared with 6.4%).

These figures corroborate what we already know: that the wellbeing of non-dominant groups is lower than that of dominant groups (Siette et al., 2021; Sisko, 2021). For instance, while 15.4% of Australians aged 16–85 had high or very high levels of psychological distress in 2020–2021, this figure was double (31%) for people identifying as being of Aboriginal and/or Torres Strait Islander origin in 2018–2019 (ABS, 2019, 2022b). This disadvantage of non-dominant groups is compounded by a lack of equity and access to resources, including mental health support (Australian Human Rights Commission, 2022).

Given this timely snapshot of one of the world’s most diverse countries, it seems fitting that four of the articles in this issue of the Psychotherapy and Counselling Journal of Australia (PACJA) highlight the benefits of tailoring psychotherapeutic approaches to specific sub-populations, including those from culturally and linguistically diverse backgrounds (Bertossa et al., 2022; Khawaja et al., 2022), older adults (Sadler et al., 2022), and people who are incarcerated (Denton & Grenade, 2022). Researchers found that their adapted approaches lessened barriers associated with more traditional therapeutic programs and enhanced access, retention, and other outcome measures for clients experiencing marginalisation.

Integrating culturally specific perspectives into evidence-informed practice was a goal for Bertossa et al. (2022), who adapted a behavioural program for Vietnamese Australians experiencing gambling problems in South Australia. A reference committee including Vietnamese Australian health and welfare professionals oversaw the development of the pilot program, and Vietnamese-speaking practitioners and support workers provided language and cultural guidance to non-Vietnamese-speaking therapists. A specialist gambling treatment service’s collaboration with an ethno-specific welfare association, along with in-language promotional resources, aided recruitment. Compared with standard treatment, those in the culturally adapted program attended more sessions and had a significantly higher rate of treatment completion, gambling-related problem resolution, and gambling-associated goal achievement.

Khawaja et al. (2022) also situated their intervention in a community setting to decrease stigma and increase service uptake. Participants were older Bosnian women from refugee backgrounds who the authors hypothesised could benefit from the Tree of Life (TOL) group approach based on concepts from narrative and expressive therapies. This creative and strengths-based intervention is an alternative to cognitive behavioural therapy (CBT) models, which involve more direct exposure to memories, and which the authors argued might be retraumatising. All oral and written communication was assisted by an interpreter. Conducted in Queensland, this qualitative pilot study found that TOL was a feasible and acceptable intervention with therapeutic benefits for older adults from refugee backgrounds.

Addressing another important gap in the literature and a pressing need for non-pharmacological adjunct recovery options for older adults with complex mental health concerns, Sadler et al. (2022) trialled a six-week “Age with ACT [acceptance and commitment therapy]” group for adults over 65 years at a community mental health service in Victoria. All participants had a diagnosis of major depressive disorder, and comorbid psychiatric and chronic medical conditions. While statistically limited by the small sample size, preliminary evidence pointed to improvements in participants’ mood, psychiatric symptoms, life skills, values progress, confidence, awareness, hopefulness, social connectedness, and physical health.

Language barriers, the perceived relevance of conventional therapeutic techniques, and a need for cultural understanding are also applicable to counselling people in incarceration. Denton and Grenade (2022) interviewed 36 counsellors in Western Australian prisons regarding how they established a therapeutic relationship with their clients. About 90% of those incarcerated in Western Australia are men, of whom 38% are Aboriginal or Torres Strait Islander people (Department of Corrective Services, 2017). The study highlighted four practice approaches: gaining a client’s trust, listening, authenticity, and a non-judgemental attitude. The article details the self-awareness, creativity, cultural sensitivity, and other skills and qualities necessary to engage with individual clients in the regimented prison context.

These articles remind us of the Psychotherapy and Counselling Federation of Australia’s (PACFA’s) Code of Ethics, in which practitioners “are responsible for learning about, and taking into account protocols, customs and conventions . . . relating to human diversity and diverse social and cultural contexts” (PACFA, 2017, p. 11). PACFA’s Code of Ethics exhorts practitioners to reflect on their own biases and assumptions in relation to gender, age, culture, ability, lifestyle, sexual identity, spirituality, and values and be aware of how these affect the therapeutic process. These studies provide some guidance on this.

Another topical theme in this issue is the integration of psychotherapeutic models.3 Recognising that “no single set of counselling techniques is always effective in working with diverse client populations” is both pragmatic and client-centred (Corey, 2016, p. 431). While there are many advocates of psychotherapy integration (e.g., Gilbert, 2019; Hofman & Hayes, 2019), evidence on exactly how to do this is still in its infancy, as Takizawa et al. (2022) discuss. Their narrative review of existing literature on five neuroscience-informed psychotherapy models for the treatment of depression and anxiety disorders found that no studies directly compared the efficacy of the models with conventional psychotherapy models. However, their findings on the models’ similarities and differences—including recommendations for focusing on bottom-up regulation before top-down regulation—will be of interest to therapists applying neuroscience in their work.

One of the challenges of developing an integrative perspective is that modalities often draw on different theories and views of human nature, as Penwarden (2022) writes in her account about navigating a critical moment in the integration of person-centred therapy and narrative therapy. She suggests that holding and accepting (or at least tolerating!) theoretical tensions between models, becoming aware of the intention behind using a particular approach with a particular client, reflective journaling, and supervision can all be helpful in becoming more integrated as a practitioner. Her practice example reveals the benefits of approaching not only clients but also herself as a multi-storied therapist with respectful curiosity.

Finally, Philip Chittleborough’s review of 127 More Amazing Tips and Tools for the Therapeutic Toolbox: DBT, CBT and Beyond (2020) by Judith Belmont recommends it as a useful source of client worksheets, other materials, and practical ideas spanning several major modalities (Chittleborough, 2022).

The production of this issue has relied on the outstanding efforts of the research committee, editorial board, peer reviewers, authors, copy editors, typesetter Linda McLaughlan, former editor Rhys Price-Robertson, and outgoing book review editor Kitty Vivekananda. I would also like to thank former acting editor Gávi Ansara for his considerable work towards this issue and his stewardship in shifting PACJA to the editorial standards and style of the 7th edition of the Publication Manual of the American Psychological Association (2020).

As incoming editor, I am excited by the calibre, variety, and creativity of this issue’s articles, the selection of which reflects PACJA’s integrative and inclusive approach. As a counsellor, I am heartened by their applicability to real-world practice. I hope readers will be similarly inspired and perhaps even submit their own feedback, suggestions, or manuscripts that contribute to evidence-informed psychotherapy, counselling, and Aboriginal and Torres Strait Islander healing practices (editor@pacja.org.au).

 

References

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.).

Australian Bureau of Statistics. (2019). National Aboriginal and Torres Strait Islander health survey (Reference period 2018–19 financial year). https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples/national-aboriginal-and-torres-strait-islander-health-survey/latest-release#mental-health

Australian Bureau of Statistics. (2022a). Aboriginal and Torres Strait Islander people: Census  (Reference period 2021).https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples/aboriginal-and-torres-strait-islander-people-census/latest-release

Australian Bureau of Statistics. (2022b). National study of mental health and wellbeing 2020–21 (Reference period 2020–21). https://www.abs.gov.au/statistics/health/mental-health/national-study-mental-health-and-wellbeing/latest-release

Australian Bureau of Statistics. (2022c). Snapshot of Australia. National summary data (Reference period 2021).https://www.abs.gov.au/statistics/people/people-and-communities/snapshot-australia/2021

Australian Human Rights Commission. (2022). Our work. https://www.humanrights.gov.au/our-work

Bertossa, S., Sramek, M. P., Fairweather, K., & Lawn, S. (2022). Meeting the needs of a culturally diverse nation: An evaluation of a behavioural program adapted to treat Vietnamese Australians experiencing gambling problems. Psychotherapy and Counselling Journal of Australia, 10(1), Article 1. 

Chittleborough, P. (2022). [Review of the book 127 More Amazing Tips and Tools for the Therapeutic Toolbox: DBT, CBT and Beyond, by J. Belmont]. Psychotherapy and Counselling Journal of Australia, 10(1).

Corey, G. (2016). Theory and practice of counseling and psychotherapy (10th ed.). Cengage Learning Australia.

Denton, D., & Grenade, L. (2022). Connecting with clients: Building therapeutic alliances with people who are incarcerated. Psychotherapy and Counselling Journal of Australia, 10(1), Article 4.  

Department of Corrective Services. (2017, March quarter). Adult prisoners in custody quarterly statistics. https://www.correctiveservices.wa.gov.au/_files/about-us/statistics-publications/statistics/2017/quarterly/2017-quarter1-adult-custody.pdf

Gilbert, P. (2019). Psychotherapy for the 21st century: An integrative, evolutionary, contextual, biopsychosocial approach. Psychology and Psychotherapy, 92(2), 164–189. https://doi.org/10.1111/papt.12226

Hofman, S. G., & Hayes, S. C. (2019). The future of intervention science: Process-based therapy. Clinical Psychological Science,7(1), 37–50. https://doi.org/10.1177/2167702618772296

Khawaja, N. G., Murray, K., & Sadeed, S. (2022). Tree of Life: Acceptability and feasibility with older Bosnian women of refugee background. Psychotherapy and Counselling Journal of Australia, 10(1), Article 2.

Penwarden, S. (2022). Clarifying a muddy pond: A Pākehā therapist’s account of navigating a critical moment in the integration of narrative therapy and person-centred therapy. Psychotherapy and Counselling Journal of Australia, 10(1), Article 6.

Psychotherapy and Counselling Federation of Australia. (2017). PACFA code of ethics. http://www.arcapregister.com.au/wp-content/uploads/2018/08/PACFA-Code-of-Ethics-2017.pdf

Sadler, P., Gardner, I., Hart, S., Aradhye, S., & Nolan, J. (2022). Age with ACT: A pilot acceptance and commitment therapy group for older adults receiving a community mental health service. Psychotherapy and Counselling Journal of Australia, 10(1), Article 3.

Siette, J., Seaman, K., Dodds, L., Ludlow, K., Johnco, C., Wuthrich, V., Earl, J. K., Dawes, P., Strutt, P., & Westbrook, J. I. (2021). A national survey on COVID-19 second-wave lockdowns on older adults’ mental wellbeing, health-seeking behaviours and social outcomes across Australia. BMC Geriatrics, 21, Article 400. https://doi.org/10.1186/s12877-021-02352-1

Sisko, S. (2021). Key principles for multicultural perspectives and responsiveness in counselling and psychology. In V. Hutton & S. Sikso (Eds.), Multicultural responsiveness in counselling and psychology: Working with Australian populations (pp. 287–296). Palgrave Macmillan. https://doi.org/10.1007/978-3-030-55427-9_11

Takizawa, Y., Murray, J., Bambling, M., Matsumoto, Y., Ishimoto, Y., Yamane, T., & Edirippulige, S. (2022). Integration of clinical neuroscience into psychotherapy: A narrative review of neuroscience-informed psychotherapy models for the treatment of depression and anxiety disorders. Psychotherapy and Counselling Journal of Australia, 10(1), Article 5.

Footnotes

1 A comprehensive analysis of the National Study of Mental Health and Wellbeing (ABS, 2022b) is beyond the scope of this editorial. It must be acknowledged, for instance, that certain groups may be less likely than others to report mental health conditions for a variety of reasons. Readers and researchers are encouraged to further interrogate the data.

2 Use of the term “disorder” reflects words used by the ABS. It is acknowledged that diagnostic labels can be associated with stigma and stereotypes. The ABS (2022b) “recognises people who have a lived experience of mental ill-health and that having—or not having—mental ill-health does not define a person” (para. 3).

3 Integration is used in the sense of “attempts to look beyond and across the confines of single-school approaches to see . . . how clients can benefit from a variety of ways of conducting therapy” (Corey, 2016, p. 429). The important distinction between integrative and eclectic practice, unaddressed here, deserves further discussion.

 


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