Freud, Jung ... your cleaning lady?
Globe and Mail, 28 April 2007
ALISON MOTLUK
You
turn to them for marital advice. Or to fight depression. But, as Alison
Motluk writes, anyone from your grandmother to a disgraced MD can hang
out a psychotherapist's shingle. Ontario gets set to rein in the wild
west of mental health
Late
last year, Charles was dumped by his girlfriend. He was surprised by
how severe his reaction was. For weeks, he barely slept or ate. At
work, he couldn't concentrate, couldn't stop crying - and he eventually
took a three-month leave. For a while, he was even afraid to live alone.
His
family doctor recommended professional help. But getting an appointment
with a psychiatrist meant months of waiting in anguish. So Charles, who
asked not to identified to guard his privacy, was left only one obvious
option: a psychotherapist.
But what exactly is psychotherapy?
Anyone at all, without even the pretense of a qualification -- you,
your grandmother, the cleaning lady, a doctor who has been stripped of
his licence for sexual misconduct -- can hang out a shingle and
practise. And when something goes wrong (they use questionable
techniques, say, or cross the line between professional and personal
intimacy), there's not a lot you can do about it.
As it stands,
the onus is on clients to ask about credentials. But clients who are
distraught often decline to press therapists and doctors on their
qualifications or ethics. "When you're in a fog," one female client
says, "you're not thinking about asking 20 questions."
Besides,
what kind of training should a psychotherapist have? Imagine having to
evaluate your cardiologist or nurse this way. Luckily, you don't have
to. They have to be educated at accredited institutions and pass
standard tests. In contrast, your therapist could have trained with
Jung -- or in the school of hard knocks.
This problem has not
escaped the Ontario government's notice. Two years ago, they asked for
guidance in regulating the profession. The Health Professions
Regulatory Advisory Council (HPRAC), an independent government agency,
proposed creating a College of Psychotherapy and setting minimum
training standards for anyone in practice. And last week a standing
committee began examining a bill on the issue. By the end of the year,
it could become law.
The plan is to place psychotherapy
alongside other so-called controlled acts - performing a procedure
below the dermis, administering a substance by injection and sticking a
finger beyond the external ear canal -- and then restrict who can do
it. But psychotherapy is not like jabbing a needle into an arm. In
fact, there's not much agreement about what it is at all.
Right
now, the government's working definition of psychotherapy is "the
assessment and treatment of cognitive, emotional or behavioural
disturbances by psychotherapeutic means, delivered through a
therapeutic relationship based primarily on verbal or non- verbal
communication."
But this doesn't define what those
"psychotherapeutic means" actually are. Some experts think the official
definition of psychotherapy should include words such as "diagnosis" or
"treatment." Others feel this misses the essence. They see it more as a
journey.
"We don't regard most of the things we're dealing with
as illness, but rather how to deal with the human condition - anxiety,
fear, the ghastly experience of a marital breakup," says Philip McKenna
of Toronto's Centre for Training in Psychotherapy.
Psychotherapy
client Valerie Dugale agrees. "Childhood sexual abuse is not a
disorder," she testified to the HPRAC, "nor would I characterize the
discovery of its existence in my past as a 'diagnosis.' "
Part
of the trouble is that practitioners come from across the spectrum.
Physicians, psychologists, occupational therapists and social workers
all do psychotherapy. So do therapists formally trained in specialties
such as cognitive behavioural therapy or art therapy. Others just feel
they have a knack for the talking cure.
As for expertise?
Psychologists must have a graduate degree and thousands of hours of
supervised training to be certified. Many trained therapists also
emphasize doing their own therapy so they don't bring their neuroses
into the room with clients. Any doctor, on the other hand, can practise
psychotherapy - though many medical schools offer "little or no"
training for non-psychiatrists, according to the HPRAC.
Then
there's the debate about whether you need to get to the root of what
makes you the way you are - or whether the important thing is simply
changing unwanted behaviour.
Yet, although no one can quite
agree on what psychotherapy is, almost everyone accepts that, done
wrong, it can cause harm. "...There was extensive evidence of harm
being done by those who weren't competent and didn't have adequate
training," says Barbara Sullivan, chief executive officer of the HPRAC.
Clients
tend to be very vulnerable - they are people suffering from depression,
or eating disorders or childhood abuse. Interventions by people who
don't know what they're doing can, and often do, make their situations
worse. And, as a woman burned by a romantic relationship with her
former therapist testified to the HPRAC, "Clients are re- victimized
when they attempt to deal with their experience of serious
exploitation."
Setting up a college - along the lines of the
College of Physicians and Surgeons or the College of Psychologists -
would provide a legitimate way to pursue grievances and hold therapists
accountable. Importantly, since it can be hard to speak up about
exploitation, it would also force psychotherapists to agree on ethical
standards.
A college would need to establish minimum training
standards too. This will be a fraught process, given the diversity of
psychotherapies out there. Not to mention the fact that many
practitioners already belong to professional colleges (such as doctors,
nurses and social workers) and will be monitored by them.
"We
need a single universal set of standards across the different colleges,
defined and accepted," says Zindel Segal, chair of psychotherapy at the
University of Toronto and part of the HPRAC's advisory committee. He
believes the legislation will be "eviscerated" if all the colleges
don't get on board.
Another concern is how to evaluate all the
people currently practising. Rumour has it that psychotherapists with a
few years of experience might be grandfathered in. This is good news
for satisfied clients, not so good for those worried about incompetence
or abuse.
Douglas Saunders, past president of the Ontario
Psychological Association, says he fears the public may think all
psychotherapists have had training when, in fact, they have not. The
woman who testified about her relationship also stresses that
experience doesn't preclude therapists from manipulating clients.
Then
again, clients such as Ms. Dugale worry that therapy could become too
uniform, that diversity will be lost. "Freedom of choice must not be
sacrificed in an excessive zeal to 'protect people from harm,' " she
says.
Mr. McKenna is also concerned about over-policing the
field. He stresses that since psychotherapy is such a young profession,
with so many different methods and modalities, we have to be open,
careful not to dismiss innovations before they are explored.
Of
course, whether legislation will actually make it easier to figure out
what kind of therapist you are getting remains to be seen. In fact, it
just might make it harder. Oddly, as the bill is currently written, not
everyone with the right to practise psychotherapy will legally be able
to call themselves psychotherapists -- only members of the new college.
Practitioners belonging to other colleges will have to call themselves
something else.
Prof. Segal hopes any new college will be
accompanied by a public-awareness campaign. Mr. McKenna and others have
also been calling for a register where psychotherapists' training would
be disclosed.
So where does that leave clients such as Charles?
As it happens, he was referred to a doctor who works full-time as a
psychotherapist. There was a certain comfort in knowing the man had a
medical degree. But real clarity about just what kind of experience GPs
and other therapists bring to their clients is going to take time.
"That kind of chaos isn't going to be addressed any time soon," Prof. Segal says.
Reining in therapists
Ontario is not the first jurisdiction to grapple with how to make psychotherapy safe and consistent.
Canada:
Quebec and British Columbia are considering regulating the practice.
Alberta has some guidelines for psychotherapists, but the profession is
not fully regulated.
Britain: Psychotherapists are currently self-regulating, but they have a voluntary register and minimum training requirements.
United
States: Anyone delivering talk therapy is supposed to be a licensed
professional of some kind. At the state level, however, requirements
vary.