Freud, Jung ... your cleaning lady?

Globe and Mail, 28 April 2007

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.