Therapy by any name

KARACHI:

Noor Mukadam’s heinous murder has left the entire nation reeling. Among the many scandalous revelations, one of the most concerning was that the murderer, Zahir Jaffer, was apparently practicing as a psychotherapist after enrolling in a certification from Therapy Works. This case has laid bare the perils of the country’s regulated mental health service sector.

Therapy Works later issued a statement on their social media accounts. “Zahir Jaffer was enrolled as a student in UK Level 3 from September 2015 to September 2016. After this, he joined UK Level 4 from October 2016 to June 2018. He did not complete his coursework and International Essays, and accordingly was never ever given permission to see clients,” However, an Instagram photo on their page that has since been deleted, features a group of its UK Level 5 candidates including Zahir Jaffer.

The website page of Therapy Works claims that it is affiliated with the Counselling and Psychotherapy Central Awarding Body (CPCAB) in the UK and is a member of the British Association for Counselling and Psychotherapy (BACP). Since Noor’s case raised a lot of speculations regarding its accreditation, BACP via their Twitter have categorically confirmed that Therapy Works is not a member of their organisation and have contacted Therapy Works to remove the BACP logo from their website.

When contacted, CPCAB, which is the UK's leading counselling awarding organisation, explained that their role is to approve the design and assessment methods of training to provide accreditation. That said, they have no say in regulating the clinical services provided by their accredited training centers. They shared the following statement: “The training service ‘Therapy Works’ offers bespoke qualifications which are non-regulated but are accredited through CPCAB’s Tailor-Made qualification route… We are aware that many queries have been raised regarding the operations of both the Therapy Works counselling and psychotherapy centre, and the Therapy Works training service. CPCAB has no affiliation with the Therapy Works counselling and psychotherapy centre, and has no authority over the clinical services of Therapy Works. We are however, pursuing all relevant lines of enquiry which relate to the provision of Tailor-Made qualifications offered under CPCAB accreditation at the Therapy Works training service.”

It is important to note that if some counselling service claims affiliation with a certified foreign counselling or therapy body, the role of that body is only to ensure the quality of training educational material, not the treatment offered by those centers. When this article was written, orders had been issued to seal the Islamabad office of Therapy Works. However this is just a temporary solution in the absence of a centralised regulatory body for mental health services which is the need of the hour.

 

License to treat

When Zubair*, a chartered accountant working for a multinational, felt that his substance use was getting out of hand, he decided to seek professional help and contacted a therapist. He was making progress until he found out that his therapist had revealed details of his issue to one of their mutual acquaintances at a corporate event who also happened to be a colleague of Zubair. The colleague subsequently shared the details with their boss, leading to grave professional consequences for Zubair. Why did the therapist feel comfortable breaking the client’s confidentiality? Why was he gossiping about his clients? All of this stems from no fear of legal repercussions.

The Pakistan Psychological Council Bill, 2020, which was passed in the National Assembly earlier this year and is currently tabled in Senate, aims to establish an international standard council to register psychologists and to recognise institutions and organisations in public and private sectors imparting psychological education. The bill proposes that 16 years of education and 2 years of experience in the field of psychology, applied psychology and behavioral psychology should be the eligibility criteria to be registered as a psychologist. However, the majority of mental health experts are of the view that only those with at least 18 years of education (MS/MPhil in a relevant field of psychology) should be allowed to practice as psychologists.

“Like any profession where service to the public is involved (think medicine, lawyers, nurses) licensing is one way to ensure that only qualified persons enter the profession,” said Dr Rubeena Kidwai, an experienced psychologist with a doctorate in clinical psychology who is also a member of Sindh Mental Health Authority. “Professional licenses are usually conditional upon minimum requirements of education and training so that only qualified persons may practice in a given field.” she explained. “The goal, aside from establishing a standard for professions, is to protect the public from harm. Psychologists often serve vulnerable groups so it is even more important for there to be a licensing body to prevent quackery and malpractice in the name of mental health or psychological services.”

At the moment, the provinces of Sindh, Punjab and Khyber-Pakhtunkhwa have Mental Health Acts enacted under which provincial mental health authorities have been formed. “It is the mandate of these bodies to establish and regulate quality standards for mental health services,” Kidwai pointed out. At the moment only psychiatrists are recognised as mental health professionals in these Mental Health Acts. This needs to be amended by including psychologists as well.

“However most of these bodies are in their initial stages, progress in terms of formation of rules and regulations is slow, more so owing to the pandemic, and systems and processes for regulation are still in the works. What can be done is to pressurise provincial governments to speed up the process on an urgent basis so that the Authorities are in a position to set quality standards, develop a system to regulate mental health services and create a system of checks and balances.’

When Senator Dr Karim Ahmed Khawaja, Chairman Sindh Mental Health Authority was contacted to comment on the issue of licensing he shared that various meetings with psychologists have been conducted and those recommendations have been sent to the government but due to COVID, progress has been slow.

 

Rise in tele-mental services

This is ironic because since the pandemic, the demand for mental health services has gone through the roof. A plethora of telecounseling and virtual mental health service providers have cropped up to address the needs. The plus side to this mode of health services is that it is scalable - people living in remote areas or those who are physically or financially challenged now have access to affordable mental health services due to these providers. However, quality assurance of these services remains a looming concern.

Dr Kidwai seems to agree. “Many people are reaching out for virtual mental health services and many individuals with varying levels of training and qualifications are meeting this demand. There should be policies and guidelines for offering mental health services in virtual space.”

Aftab Shah, a forensic psychologist and a lawyer, shared similar views. “Recently, mental health has been monetised due to a spike in demand. Many new organizations have sprung up that offer 6 months, 12 months diplomas after which they claim that their psychotherapists/counselors are on a level playing field with clinical psychologists who have undergone rigorous studies and clinical supervision.” This is completely unfair since a diploma holder lacks the course work and training of a proper clinical degree.” He believes that licensing for psychologists should be made mandatory, but not under the banner of Pakistan Medical Commission (PMC).

He cited cases like that of Farhan Kamrani, which probably would not have occurred in the presence of a strict code of conduct for the mental health sector. For those unaware, Kamrani was an assistant professor at the psychology department of the University of Karachi who in July was sentenced to 8 years imprisonment for harassing a female teacher online.

“It is problematic that while Farhan Kamrani was not yet convicted but out on bail, he was already employed at University of Karachi as a faculty member and his contract continued even when he was under trial. He has now been convicted but due to a lack of a regulatory body, there is nothing stopping him from resuming his clinical practice when he gets out from jail after completing his sentence.”

This indicates the dismal state of affairs that is Pakistan’s mental health services landscape.

 

Colonial hangover?

There is no hiding the fact that the country’s mental health service sector and psychiatric facilities leave much to be desired whether it be state-funded hospitals, large scale philanthropic centers or non-profits.

In the past decade, numerous mental health ventures have sprung up that deviate from the prevailing biomedical model for treating mental health issues and taking a cue from the West’, focus on humanistic centered, positive psychology paradigms. Certifications like the one provided by Therapy Works and CPPD are examples of that. However, there are limitations to the domains in which these certified professionals can work.

A remnant of colonial rule has been an inferiority complex in the general population where anything foreign or imported is deemed superior to its local counterparts. The same goes for certifications and degrees. While no one is arguing the credibility of many foreign certifications, the risk is when inadequately trained, foreign qualified mental health professionals start practicing out of their discipline and when these unethical practices are justified under the pretext of a foreign degree. This does more harm than good for our system.

Mariam*, who had been diagnosed with bipolar disorder shared that she had been getting therapy from an apparently experienced therapist at a popular mental health service provider. Following Noor’s case, she enquired her therapist’s credentials which led to her therapist getting extremely offended. After asking around, Mariam found out that her therapist had no background in clinical psychology, was not qualified to treat psychological disorders and had been ripping her off by charging a hefty fee for each session. Therefore, people seeking therapy also need to be cognizant of the basic domains of psychology as well as their therapist’s qualifications. For instance, a therapist with a degree in organisational or counseling psychology can only provide counseling for mild cases and is not equipped to deal with severe psychopathology unless they have undergone specialized training.

Kanza Asad, a certified psychiatric rehabilitation practitioner, shared how she has witnessed unethical behaviour during her professional career. “I have seen the malpractices happening countless times in a way that people with some 3 to 4 weeks or months diploma/ with bachelor's degree in psychology claims and strongly believes that they are authorized to practice and actually get in touch with the clients to do the therapy which is quite threatening because as a mental health professional I firmly believe that not everyone has that particular ability to empathise and connect with people and facilitate the clients in their recovery journey.” She added that these incidents jeopardise the people's faith in the mental health system.

 

Mind sciences

Recently, there has been another addition to the proliferating field of mental health, which are purported by practioners to be ‘mind sciences’. Mind sciences go beyond the realm of orthodox psychology into the obscure science of Parapsychology and Metaphysics. Hypnosis, Neuro Linguistics Programming (NLP) and Reiki come under this sphere.

Neuro-linguistic Programming, NLP, is especially gaining popularity in the country with many organizations boasting of having NLP coaches and therapists on their panel. While there are some organizations providing proper NLP training, it should be noted that someone with only a NLP certificate and no prior training in the field of psychology cannot be referred to as a NLP therapist. Ideally, a NLP therapist is someone who is already a mental health professional with a relevant degree who chooses to gain additional NLP certification through workshops and accredited certifications.

 

Safeguarding client rights

Conflicting sources are reporting that Jaffer was diagnosed with substance abuse issues for which he sought help from Therapy Works before enrolling in their certificate course. If true, that raises pertinent questions about whether that is an ethical practice and should people currently under treatment for severe mental health issues be allowed to practice as a therapist.

Claiming that one is a psychotherapist or psychologist without proper accreditation provides access to the most vulnerable and at-risk groups in society, a gap that could be exploited by those with predatory or manipulative tendencies. Aisha Sanober Chachar, a child and adolescent psychiatrist who has also worked as a college psychiatrist at AKU, asserts that this is why it is imperative that mental health professionals stick to practicing within their area of expertise. They must clarify their clinical skills and limitations when treating clients or working with the public at large.

She opines that since their professional judgments affect the lives of others, mental health professionals must factor in elements that might lead to misuse of their influence. Therefore, training-based supervision and peer supervision post-training at an institutional level - mandated by a centralized governing body – is compulsory. At the moment, “reporting any violation of ethical compliance and professional conduct becomes a barrier in the absence of a centralised regulatory body. Hence, there is a failure to protect the rights and welfare of clients/patients who are at a vulnerable spot.”

 

Know your therapist

The terms counselor, therapist, psychologist are usually used interchangeably. Therein, lies the confusion. It is a client’s prerogative and a mental health professional’s duty to be transparent about their credentials so that their clients can make an informed decision.

Dr Uzma Ali, Director Institute of Clinical Psychology, University of Karachi explains the difference. “There is a dire need to distinguish between Psychologist and Clinical Psychologist, i.e. Clinical Psychologist is the one who can do clinical practice and do psychological assessment, counseling and psychotherapy (in which they are trained) to treat mental health problems /disorders after getting their degree in MS/.Phil and PhD in Clinical Psychology. That requires intensive, at least two to three years specialised training in the field of clinical psychology under the supervision of PhD clinical Psychologist only from those Institutes /Universities that are recognized by Higher education commission in Pakistan/or equivalent.

She further added that although counseling can be used to treat mental illnesses, including the most pervasive ones like mild cases of anxiety and depression, licensed counselors or therapists wouldn’t typically diagnose or handle the most severe cases themselves. Instead, if they suspect a client is suffering from something like clinical depression, they would refer the patient to a clinical psychologist.

This is the gray area where most malpractice takes place in Pakistan. Many organisations employ people who are not qualified like those with degrees in counseling, organizational or educational psychology are assigned to deal with severe psychopathology that goes against the healthcare principle of non-maleficence meaning doing no harm.

Until a regulatory body and rigorous licensing procedures come into effect, the onus falls on mental health professionals on maintaining absolute transparency regarding their area and level of expertise. The general population should be educated on the various domains of mental health services so that they can make an informed decision.

 

*Names have been changed to hide the identities of certain sources