Counsellor, psychologist or psychiatrist: who does what in Australia

Almost everyone who calls me has spent time on this question already, usually at eleven at night, usually with eight tabs open. The titles sound interchangeable. They are not, and the practical differences come down to three things: training, what they are allowed to do, and whether Medicare pays.

I will say upfront that I am a counsellor, so I have an obvious interest here. I have tried to write the version I would want a friend to read, which means it includes the situations where a counsellor is the wrong choice.

The short version

Psychiatrists

A psychiatrist is a medical doctor who then specialised in mental health. That medical training is the thing that sets them apart. They can prescribe and manage medication, they can diagnose, and they are the right people for conditions where medication is a serious part of the picture.

You generally need a referral, and in most of Australia there is a wait. If someone has told you that you need a psychiatrist, that is not a judgement about how bad things are. It is usually about medication or about a diagnosis that needs a doctor's authority behind it.

Psychologists

Psychologists are registered with AHPRA, the same national body that registers doctors, nurses and physiotherapists. They are trained in assessment and in structured therapies, and they can carry out the formal testing that produces a diagnosis.

They are also the main route to a Medicare rebate for therapy. Under the Better Access initiative, Medicare benefits are available for up to 10 individual and 10 group sessions each calendar year, delivered by psychiatrists, psychologists, and eligible social workers and occupational therapists. Your doctor is the usual starting point for arranging it.

Counsellors

This is where the confusion sits, so let me be exact rather than flattering.

Counselling in Australia is self-regulated. There is no AHPRA registration for counsellors. Instead the profession regulates itself through two peak bodies, PACFA and the Australian Counselling Association, which jointly maintain a public register called ARCAP. Members have to meet training standards, work to a code of ethics, and complete continuing professional development every year. The higher membership tiers, Certified Practising and Registered Clinical, carry an annual formal supervision requirement on top of that. There is a complaints process, and anyone can use it.

That is meaningful, and it is not the same thing as government registration. Anyone in Australia can call themselves a counsellor. Nobody can call themselves a PACFA Member without being one, which is precisely why the membership is worth checking rather than taking on trust.

So which one do you need?

Start with a doctor if

• You think medication might be part of the answer, or you are already taking something and it does not feel right
• You want a formal diagnosis, or you need one for work, study, insurance or the NDIS
• Something physical might be involved, such as sleep, thyroid or a medication side effect
• Cost is the deciding factor and the Medicare rebate is what makes therapy possible

A psychologist is likely the right fit if

• You want assessment and a diagnosis, or a structured programme for a specific condition
• You are seeking treatment for something you have already been diagnosed with
• You need the Medicare rebate and can wait for an appointment

A counsellor may suit you better if

• What you are carrying is a situation rather than a condition. A death, a separation, a move, a job that stopped fitting
• You want to start soon rather than join a waitlist
• You would rather not have a diagnosis attached to this, and you do not need one
• You want to work in a language other than English, or you want your culture and background to be part of the conversation rather than background detail
• You have used your ten Medicare sessions and want to keep going

What this costs, realistically

A psychologist with a Medicare rebate still usually involves a gap payment, and the size of that gap varies a great deal. Bulk billing exists but is not common. Counselling has no rebate, so what you see is what you pay. My sessions are $150 for an hour, which I put on the website precisely so nobody has to email to find out.

Some private health funds offer a rebate for counselling under their extras cover, and it is worth ringing yours rather than assuming either way. Ask specifically whether they cover a PACFA registered counsellor.

When I say no

I refer people on more often than you might expect, and I would rather say this here than in a first session.

If someone needs a diagnosis, an assessment, or medication, that is a doctor, psychologist or psychiatrist and I will say so on the free call. If someone is in acute crisis, they need a level of care I cannot provide on a Thursday afternoon. If what someone is bringing sits outside what I am trained and supervised in, taking them on would be a breach of my own code of ethics, not just a poor fit.

I keep a list of practitioners I trust in Brisbane, including people who work in other languages, and I make the referral properly rather than handing someone back to a search engine.