The practice of counselling and psychotherapy has existed, depending on one’s definition, for many centuries. The earliest expression of what we today would recognise as a form of counselling was the practice of the “care of souls”, a form of pastoral care. Alternatively, if we consider counselling and psychotherapy as a modern phenomenon based on formal organisation and recognition by guilds, then we might consider that it arose in the late 1800s. The emergence of counselling and psychotherapy as professional practices has had an enormous impact on society. However, any practice that has sought to become recognised by society as a profession with its own distinct body of knowledge, skills, ethical principles, and organisation has done so by progressively establishing its distinctiveness and bona fides. While counselling and psychotherapy are well recognised as profession-like practices, in many jurisdictions, depending on how the terms are understood, they have still not gained final status as distinct professions (O’Hara & O’Hara, 2015).
Although many factors have slowed the progression of full professional recognition by our social institutions, one confounding factor has been the problem of distinguishing counselling as a practice conducted by many caring professions and as a profession distinct from other professions. To confound this problem further, especially in the Anglophile world, a long debate has been running regarding whether counselling and psychotherapy are the same or different professions. At any given time, the outcomes of this debate have varied depending on the jurisdiction. Historically, the strengths and weaknesses of the debate have mostly been of interest to those in the field and have not piqued public interest, and largely have only garnered marginal interest by governments. However, in recent years the growing concern of governments for public safety in relation to mental health has drawn attention to the practice of psychological therapy and its regulation. This is evident in the Australian Government’s announcement of its funding of a review of the national standards for counselling (Psychotherapy and Counselling Federation of Australia, 2023).
Over the past three years several royal commissions and reviews of the health system have been conducted, both at the national and state level. These include the Mental Health: Productivity Commission Inquiry Report (Productivity Commission, 2020), the Royal Commission into Victoria’s Mental Health System. Final Report: Summary and Recommendations (Armytage et al., 2021), the Mental Health and Suicide Prevention—Final Report (House of Representatives Select Committee on Mental Health and Suicide Prevention, 2021), and the Inquiry into the Opportunities to Improve Mental Health Outcomes for Queenslanders (Mental Health Select Committee, 2022). Each of these reviews has noted that counselling, unlike psychology and social work, is not directly part of the mental health system, although it is recognised as providing support for wellbeing. While counselling and, by implied inclusion, psychotherapy, are appreciated for their contribution to the health of Australians, there appears in these reports, either through unconscious absence or by explicit statement, a concern regarding the standing of counselling as a recognised profession. This has been so notable that even after multiple submissions by counselling associations to government and these various reviews, there remains limited formal recognition of counselling within the health system. Several reasons may account for this frustrating lack of recognition but probably the most telling factor is evidenced in two statements, one by the Productivity Commission (2020) and one by the House of Representatives Select Committee on Mental Health and Suicide Prevention (2021). The former noted that although a national register for counsellors and psychotherapists exists, namely, the Australian Register of Counsellors and Psychotherapists (https://www.arcapregister.com.au/), it is not convinced that the requirements for registration are associated with more effective outcomes than those experienced by counsellors who are not registered. The Productivity Commission (2020) states,
While the development of a clearly defined and standardised set of requirements is an important step in alleviating some of the concerns about quality control, the Productivity Commission has not been able to find any strong evidence to suggest that those registered and meeting the registration requirements are associated with superior service delivery compared with those who are not. (p. 734)
This comment suggests that while the Productivity Commission approves of the development of professional standards, it does not have confidence in the veracity of these standards and therefore of the outcomes provided by counsellors. This view led the Commission to decline from recommending an extension of Medicare Benefits Schedule (MBS) items in the Better Access initiative to counsellors and psychotherapists. There is some irony in this view since the House of Representatives Select Committee on Mental Health and Suicide Prevention (2021, p. 223), referring to the reliability of outcomes provided by psychiatrists and psychologists, agrees with the view expressed by the National Mental Health Commission (2021), namely, that “the availability of MBS items for psychology and psychiatry is not clearly linked to evidence on their outcomes, effectiveness, and successful ‘dosage’ of treatment” (p. 11). Hence, on the one hand, the Productivity Commission (2020) is not convinced of the effectiveness of training based on the training standards of the counselling associations, while on the other, the House of Representatives Select Committee on Mental Health and Suicide Prevention (2021) and the National Mental Health Commission (2021) are not confident about the outcomes provided by psychiatrists and psychologists but are prepared to offer the Better Access initiative to psychiatrists and psychologists. While the existence of a double standard could be argued here, the key point is that commissioning authorities want to be assured of the standards of training and service outcomes of professionals operating within the mental health sector.
The proposed federal government review of national standards for counselling is a positive move and hopefully will begin the process of answering the concerns raised by the various federal and state reviews (Department of Health and Aged Care, 2023). However, I suggest that to do so will require counsellors and psychotherapists to acquire a clearer understanding of their profession. The remainder of this article aims to tease out the issue of professional self-definition. Rather than jumping directly to the often-conflicted demarcation between counselling and psychotherapy, it is important to start with counselling itself.
The question that first needs answering is “What is counselling as a profession?” To answer this question it is helpful to explore what we think the practice of counselling is. There are at least two, possibly three, quite different categorical perspectives. The first (Category 1) is best evidenced in the counselling work most typically offered within the non-government organisation (NGO) sector. NGOs are funded to provide a wide range of services such as parenting programs, alcohol and other drug programs, domestic and family violence support, and general counselling, to name a few. Trained counsellors work in these programs and provide wonderful support to the Australian community. However, for the sake of our discussion, let us only consider the general counselling service offered by NGOs. While it is well understood that people seeking counselling, whether via NGOs, community health, or private practice, may present with any range and severity of life and mental health problems, NGOs do not expect counsellors to work beyond what is commonly referred to as mild to moderate presenting problems. In fact, the conceptualisation of counselling by NGOs is really of a practice of psychological support, not treatment. Whether counsellors are trained to the diploma level, bachelor level, or master’s level, the common NGO expectation is provision of psychological support. For any presenting issue or problem beyond a “general problem in living” (Landsman, 2021; Stupak & Dobroczyński, 2021), it would be expected by NGO management that a referral would be made to a “mental health” professional such as a psychologist or psychiatrist. This approach is consistent with the Commonwealth Government’s promotion of a stepped care structure of health care (Australian Government, 2015). The claim here is not that all counsellors working in NGOs hold this view of their scope of practice, but rather that NGOs hold this view of counsellors’ scope of practice and so, by inference, many counsellors working in this employment sector develop this understanding themselves.
A second counselling perspective (Category 2) is somewhat different from the first. Counsellors who hold this view regard counselling more as a practice that facilitates therapeutic change. Therapeutic change here refers to a psychosocial level of change that enables an internal structural shift within the individual, couple or group, which results in a positive change in the experience of self and consequently of relationship with others. To facilitate such structural changes, counsellors need to have a strong grasp of different theories of psychotherapy, be skilful in establishing and maintaining a therapeutic relationship, and be able to conceptualise and formulate cases, and manage a high level of complexity, thereby enabling ongoing adjustment of strategic interventions to suit the needs of the client. Counsellors working from this perspective may offer both brief and long-term counselling.
It is important to note that I did not include the term “mental health” in this category description. One of the reasons for this is that the terms “mental health” and “mental illness” each have multiple meanings, and counsellors trained in different traditions and theories relate to these terms differently. For example, those grounded in a strong person-centred therapy tradition prefer to view problems in living as existing along a continuum from mild to complex but would not necessarily describe complex issues as mental health or mental illness problems based on the medical model. In fact, both these terms are often thought by many counsellors to be associated with the medical model and therefore quite different from their own conceptualisation of problems in living. Counsellors holding this perspective might even be averse to the notion of gaining inclusion in the Medicare Better Access initiative because it would be thought to align too closely with the medical model. Given the current structure of Better Access, this view has merit since referrals by general practitioners to mental health practitioners are based on the notion of diagnosis. It is important to note that within this second perspective category, counsellors, unlike those in the first perspective category, would view themselves as offering more than psychological support and would highly value their expertise in facilitating therapeutic change. However, within this second category counsellors may not align with the term “mental health practitioner” owing to the different interpretations of the notion of mental health.
This brings us to what might be a third category perspective (Category 3). We might call this the category of “mental health counsellor”. Interestingly, PACFA has a registration category which accommodates this designation, that is, “mental health practitioner”. This registration category was established originally to align with the Better Access initiative in a similar manner to that developed by social workers and occupational therapists (Australian Association of Social Workers, 2019; Occupational Therapy Australia, 2023). Members of these two professions can upgrade their qualifications by gaining the mental health competencies outlined within the National Practice Standards for the Mental Health Workforce 2013 (Victorian Government Department of Health, 2013), thus gaining inclusion in Better Access. It was originally thought by PACFA that the designation mental health practitioner might set the foundation for PACFA members who meet the mental health competencies for inclusion in Better Access. This, of course, has not so far eventuated.
Now, it is important to turn to the notion of psychotherapy and the question “What is psychotherapy as a profession?” As noted earlier, how both counselling and psychotherapy are understood depends on several factors, of which two are prominent: training and jurisdiction. The most obvious difference in delineation of the term psychotherapy is between Anglophile countries and other countries, especially those of continental Europe. In Europe, there is little reference to counselling as a profession. When referred to, counselling is understood as a practice rather than a profession. Alternatively, psychotherapy is understood to be an identifiable profession (Category 4) but the pathway to it varies depending on the country. In some European countries, psychotherapy is a specialisation for medical practitioners or psychologists. In fact, Austria is one of the few European countries where psychotherapy is not directly attached to post-medical or psychology qualifications and is in itself a standalone profession.
This approach is quite different from those of countries influenced by the English experience. Some of these countries prefer to align with the European perspective wherein psychotherapy is understood to be a standalone profession or at least an additional specialisation to a medical or psychology foundation. Another view is that psychotherapy is a specialisation that is an extension of a counselling foundation (Category 5). Hence, one might start one’s career as a counsellor and add further study to become a psychotherapist. The notion of advanced studies sometimes refers to studies in a particular theory of psychotherapy such as psychodynamic, cognitive behavioural therapy or gestalt, while it may also refer to specialisation by virtue of working with a particular population, for example, clients presenting with personality disorders, attention deficit hyperactivity disorder or trauma. The key distinction here is that psychotherapy is thought of either as a profession completely distinct from counselling or a further development along a counselling continuum, as outlined in Figures 1 and 2.
To increase these definitional challenges, many psychotherapists would regard themselves as mental health practitioners by definition because of their specialised training. However, others would prefer not to use the term mental health practitioner, along the lines noted earlier, that is, they would not wish to be aligned with the medical model.
One final view is that counselling and psychotherapy can be thought of principally as a practice rather than a standalone profession(s). In other words, any helping profession may counsel or offer psychotherapy because it is the practice of psychological care. Interestingly, within the research literature the term used for research in counselling and psychotherapy is most commonly “psychotherapy” no matter the profession providing psychotherapy.
So, why is this important in the context of the federal government’s proposed review of counselling standards? I think it should be obvious that how one understands the nature of one’s profession fundamentally influences the expectation one has of training in that profession. Therefore, since each category has training and practice implications, will the government’s review of standards focus on counselling (Category 1), counselling (Category 2), mental health counselling (Category 3), psychotherapy (Category 4) or psychotherapy (Category 5)?
As already noted, different jurisdictions manage this issue differently. In the United States, while the language varies slightly between states, the dividing line tends to be between counselling (Category 2) and mental health counselling (Category 3). In 2021 the United States Congress distinguished between counselling and mental health counselling by approving financial rebates for clients of mental health counsellors (Mental Health Access Improvement Act, 2021–2022). Reflecting a somewhat different view, counselling and psychotherapy associations in the United Kingdom recently signed an agreement that recognised a developmental scope of practice depending on training, supervision, and experience similar in intent to the professional continuum model identified above (Association of Christian Counsellors et al., 2022). New Zealand has taken a different approach akin to the separate professions perspective, granting financial rebates to clients of psychotherapists but not counsellors.
While at this stage we do not know how the federal government will design the counselling standards review process, it will involve detailed advice and negotiation with counselling and psychotherapy associations, stakeholders, and government. What will be the advice provided by the associations? Will, for example, PACFA’s view and the Australian Counselling Association’s view be the same? All the category perspectives discussed above have merit and reflect an important service provided to the Australian community. However, as the initiative for a review of standards indicates, Australian governments are pursuing formal recognition of counselling as a profession and potentially, by inference, psychotherapy. The central issue is “How will we in the profession position ourselves?” While we can consider this question from the perspective of qualifications, that is, a minimum of an undergraduate degree, what informs the core curriculum of such a degree, or postgraduate degree, largely depends on how we define ourselves. Are we predominantly suppliers of psychological support or therapeutic change agents inside or outside of the mental health system? Of course, whatever is the eventual outcome of the government review, individual practitioners will always define their own professional identity, but the identity recognised by the health system will, ultimately, depend on the determinations of the federal and state governments.
Recommendations
Having set the scene as best I can, I would now like to offer my own views about a preferred structural organisation of the profession. To my mind, the best outcome is recognition of counselling and psychotherapy by government through one of the two following approaches. The first is inclusion in the Medicare Better Access initiative and, along with it, inclusion in a raft of government commissioning opportunities such as the Primary Health Networks. This approach would ensure a considerably more equal playing field for counsellors and psychotherapists who provide many of the same services offered by psychologists, social workers, and occupational therapists. This approach has several benefits, in particular, greater opportunity for financial remuneration and thus sustainability of the profession; greater recognition by the community; and the option for counsellors and psychotherapists to opt in or out of Better Access and therefore the medically focused model, if they so choose, while not forfeiting the other benefits of increased employment and recognition.
The second approach would advance recognition further by recommending inclusion in the Australian Health Practitioners Registration Agency (AHPRA) along with inclusion in Better Access and various commissioning opportunities. The main difference between this option and the former is that recognition and registration of counsellors and psychotherapists would be managed by a government agency and not by professional associations. Both options have strengths and weaknesses. The strength of this second recommendation is the benefit of recognition by a government registration agency. A potential limitation is that external registration regulations are typically more rigid in nature and less flexible and amenable to change. Another limitation is that for those who do not wish to be identified with the mental health system, this option, depending on the constituting objects of an AHPRA Board of Counselling and Psychotherapy, would be at odds with their view of the profession.
It is highly likely that both these approaches would either by inference or by regulation establish a two-tier system of recognition. As noted earlier, in the first approach, those working in NGOs or whose training is more limited would not gain inclusion in Better Access, and in the second approach, would not be able to register with AHPRA. A professional group that primarily provides psychological support within the community would still have strong demand. However, under the above recommendations it is envisaged that the employment landscape would become more clearly demarcated.
Before concluding my reflections, I should comment on how I understand the terms counselling and psychotherapy from the perspective of the categories discussed earlier and how alternative views might affect registration either with government backing or without. I have always preferred to regard counselling and psychotherapy as existing along a continuum rather than as discrete and separate professions. In saying this, I do not mean to imply that the work is identical. I do believe that psychotherapy requires additional training and experience, whether that be in a particular theoretical model or by means of a focus on a particular population. However, I am convinced that the foundations of knowledge, skills, and processes instilled by counselling training, which both counsellors and psychotherapists share, provide the requisites for more formal government recognition. Those who have had additional training and who value the designation of psychotherapist, in my view, would benefit from government recognition along with counsellors via the above recommendations. Like the current organisation of the psychology profession, a psychologist is first recognised as a registered psychologist and then further recognised by specific college endorsement after additional training. The same approach would benefit counsellors and psychotherapists and would not harm the professional recognition of either.
My aim in this article has been to clarify a range of perspectives that are not often made explicit and to open the discussion within our profession to increase our self-awareness and ready ourselves for forthcoming discussions with government and other stakeholders. There may well be other category perspectives I have not presented in this paper, but I hope the foregoing discussion adds some clarity to the issues we face.