Now, the date of implementation of the MBS changes is just days away and details of how it’s going to work were vague until last Friday.
Dr Judy Hyde, past President of the Australian Clinical Psychology Association, highlighted some of the most pressing issues to me via phone. “We are very concerned that people with severe eating disorders are likely to be seen by people with very little psychological training,” she says.
I don’t think clinicians who haven’t treated these conditions realise how difficult they are to treat.
The MBS changes mark a critical shift in the way mental health care is offered. Under the existing Medicare Better Access to Mental Health Care program, occupational therapists, social workers and registered psychologists are restricted to providing structured Focused Psychological Strategies designed for patients with more common, lower severity mental health conditions. Meanwhile, people with more complex conditions that require advanced therapies can only be treated by clinical psychologists.
Under the MBS changes though, occupational therapists and social workers would be eligible to provide advanced therapies to people with eating disorders. There would be no differentiation between these diverse professional groups who have very different training, apart from the fact that consumers would be eligible for a higher rebate for sessions with a clinical psychologist.
A spokesperson for the Department of Health told me via email that “It is expected that practitioners who are providing services under these items will have appropriate training, skills and experience in treatment of patients with eating disorders.” Yet, there are no details of what training would be required. They also said that “the eligibility for provision of the psychological services are aligned with the Better Access initiative credentialing requirements.” But while it’s true that occupational therapists and social workers can offer mental health treatment, under Better Access that they can’t treat patients with complex needs.
“Eating disorders can be tough to treat,” says Dr Hyde. “Even with a background in it, even with training. I don’t think clinicians who haven’t treated these conditions realise how difficult they are to treat. And they can deteriorate rapidly. Clinicians need a lot of experience and training to understand when a patient may need urgent medical care because of electrolyte imbalances or other physical health issues that can emerge very quickly, with little warning.”
Eating disorders — including anorexia, bulimia, binge eating disorder, and disorders that don’t fit the strict diagnostic criteria of anorexia or bulimia but can still be equally as dangerous (known as other specified feeding or eating disorder or OSFED) — are very serious. They’re among the deadliest of all mental illnesses. People with eating disorders often require long-term therapy, dietician support, medication, as well as treatment for physical complications. Both the disorders themselves and their complications can be deadly, leading to higher risks of suicide as well as heart problems and multiple organ failure.
Ella reflects on her own experiences of the complexities of eating disorders. “It is a mental illness that impacts you physically. It’s very hard to do any deep psychological treatment when you’re malnourished and medically unwell. The eating disorder will make you believe that you aren’t worthy of help, that you aren’t really that unwell and a whole myriad of untruths which you need an experienced psychologist to navigate.”
Although social workers and occupational therapists can play a valuable role in a treatment team, assessing, diagnosing, and treating those with eating disorders in private settings and without supervision is beyond the scope of their training. Those working in the field have expressed concern that providers need a solid foundation in mental health assessment and treatment, as well as extensive eating disorder specific training, ongoing professional development, and intensive clinical supervision to safely assess and treat this complex, high risk population.
Eating disorders are among the deadliest of all mental illnesses.
Eating disorders also go along with a range of complex comorbidities as well as physical health issues. Patients may also have mood, anxiety, or personality disorders, or be affected by relationship issues, substance abuse, or trauma. Dr Hyde is concerned that undertrained clinicians won’t be able to address those issues alongside the eating disorder.
Ella speaks to the importance of working with clinicians who understand eating disorders and their complexities. She has a comorbid bipolar disorder alongside her eating disorder diagnosis — something that wasn’t picked up on until she’d already been in the mental health system for eight years.
“I’m physically recovered with limited psychological eating disorder traits remaining now.” And because her bipolar medication has caused her to gain weight, she says, “I don’t look like the stereotypical eating disorder patient anymore.” Ella has encountered problems working with clinicians who don’t understand the realities of eating disorders, specifically that people can have an eating disorder without being underweight. “I expressed how distressed I was at how much weight I’d gained,” she recounts. Her psychologist voiced surprise that Ella had ever had anorexia, given her weight. “She told me to stop taking the medication that has enabled me to be stable,” citing the health risks of weight gain. “I was horrified, and it was really triggering,” Ella says. This psychologist’s advice was ill-informed and insensitive.
“At best,” says Ella, “someone who isn’t adequately trained in eating disorders won’t help someone. At worst they could cause serious harm and even contribute to a death from an eating disorder.” Access to mental health services is vital, but those services have to be of good quality to be of any use.
Dr Hyde says that one of the issues is that clinicians often don’t refer patients to someone with specialist knowledge of eating disorders when they’re out of their depth. The MBS could financially incentivise clinicians to seek out eating disorders patients, knowing that they could get up to forty rebated sessions. “There is always a risk that some providers may see this as a business opportunity and may overestimate their capacities and underestimate the training required to address the eating disorder and associated comorbid disorders.”
It could be disastrous for people with eating disorders to remain in treatment with someone who’s working beyond the edge of their expertise. And although an evaluation of the changes will be scheduled for twelve months after the changes take place, it’s still unclear how the government will measure treatment outcomes.
A spokesperson for the Department of Health says that “all MBS items are subject to a range of regulatory and compliance processes, including random and targeted audits to minimise risks to patients…The Department will monitor utilisation of the items and consider feedback from the sector to ensure the items are operating as intended for patients and providers.”