Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Wednesday, June 3, 2015

Why Should Mental Health Practitioners Be Licensed?

Some weeks ago, when I had written a post about the Oregon psychologist Kali Miller and the revocation of her license (http://childmyths.blogspot.com/2015/03/psychology-license-revoked-become.html), one Robert Plamondon commented with severe criticism of psychology licensing boards and advice that unhappy clients of psychologists should sue the practitioners directly instead of going through the licensing board. I pointed out in response that when children were the patients, they did not have the capacity to sue for personal injury, and if their parents had made the decision to seek the treatment, or even carried out some of the treatment themselves, the parents would probably not bring suit on the children’s behalf (behalves?).

I see now that Plamondon has a web site, www.unlicensed-practitioner.com, which purports to provide resources to help alternative and unlicensed practitioners operate “legally and ethically” in Oregon. As far as I can tell, Plamondon objects to decisions made by the Oregon board of psychologist examiners, but in addition he favors mental health treatment by unlicensed persons in a general sort of way. This may be in part because he himself is practicing as a hypnotherapist.

I would be the first to admit that national professional organizations like the American Psychological Association and the National Association of Social Workers have strong “guild” mentalities and are much concerned about their professional hegemony. The current scandal about the involvement of APA with approval of torture is evidence that focusing on putting the profession forward can interfere with everyday ethical decisions, not to speak of professional ethics. But to my mind these are not reasons to abandon regulation through licensure and other methods.

Why do I think this? What are the advantages to the public of licensing mental health professionals? Why, especially, do the educational requirements for licensure benefit the public? There are two primary reasons for requiring practitioners to meet licensing standards  and to do so through formal education--  and neither of them has much to do with whether the practitioner has learned specific techniques of therapy.

The first concern has to do with education about the nature of evidence and the ways we can test the effectiveness of treatments. Plamondon himself states that the major difference between psychologists and counselors is that psychologists are trained to do scientific research. From the point of view of patients, there is probably no advantage to visiting a practitioner who is doing  actual research (i.e., collecting data systematically), but there is an enormous advantage to going to someone who can read research, which few people are able to do well unless they have studied research methods. Practicing psychologists, social workers, and other mental health professionals should be capable of understanding when research evidence supports the use of a treatment method, when there is no such support, and when a treatment is potentially harmful to patients.  No licensure can insure that practitioners do their homework, but licensing standards can  require that professionals have gone through the formal educational process that should provide them with the skills to understand research evidence.

Unlicensed practitioners may be competent and careful about the evidence basis of the treatments they use, but it appears likely that most of them are not. This point is made by Plamondon’s tendency to refer to “unlicensed and alternative” practitioners. Alternative practitioners by definition use methods that lack evidence of effectiveness; if this were not the case, there would be nothing “alternative” about them. Plamondon himself displays his lack of concern with evidence of treatment effectiveness by his references to such methods as Neurolinguistic Programming (NLP) and sensorimotor psychotherapy. These therapies, which Plamondon apparently finds admirable, are without acceptable research support. It is not illegal to use them, but it would be difficult to argue that such use is demonstrably in the best interest of the public. In some cases, methods used by alternative practitioners are not only ineffective, but potentially harmful—as in the case of “conversion” therapy and the related “holding” therapy.

These facts lead us to a second issue about education required by licensing standards. Licensed mental health practitioners have to show that they have been through educational programs that included study of professional ethics. Unlicensed practitioners may be perfectly ethical people in their daily lives, but may be without training in some of the special issues of professional ethics. For example, in daily life, it is “not nice” but not strictly unethical to tell a juicy piece of gossip that has been disclosed to us; in mental health practice, confidentiality is an ethical obligation  that may be handled well only if someone has been trained to think clearly about conflicting motives and benefits. (Does the psychologist tell a patient’s family member that the patient seems to be considering suicide? ) Similarly, in daily life, it does no harm for someone to socialize with a person he employs or works for; in mental health work, the wearing of “two hats” in dual relationships creates a variety of ethical problems, which may be avoided only when earlier training and practice have alerted a practitioner. No one would claim that all licensed mental health professionals are always able to make the right choices in professional ethics (as any state’s list of disciplinary decisions shows), but a requirement of appropriate education excludes from practice persons who have never received formal instruction about ethical choices.

In his earlier comment, Plamondon suggested that patients who have been injured should bring personal suits against mental health practitioners rather than bringing a complaint to a licensing board. Let me point out that personal injury suits are time-limited and in some states cannot be brought more than a year after the event that caused the claimed injury. Although it can happen that the time limit clock starts when the person realizes that an injury was done, in that case the defense for  a practitioner may be a motion to dismiss the case because the individual “should have known” earlier that there had been an injury caused by a treatment. A number of suits by adults who were harmed by inappropriate mental health practices when they were children have failed because the individuals did not manage to understand that they had been harmed and to find counsel for several years after the 18th birthday. Thus personal injury suits are often ineffective ways to obtain redress for people who have been harmed by alternative mental health practices. Similarly, suits for fraudulent deception are likely to fail either on the ground that an injury or loss cannot be clearly demonstrated, or on the ground that the practitioner believed the treatment would be effective and not harmful. Protection of commercial speech in the United States makes fraud even more difficult to prove.

Because of the difficulties of finding justice for people who have been harmed by alternative or unlicensed mental health practitioners, I would argue that in spite of many and various holes in the system, the best choice for the patient is a licensed mental health practitioner, and the best governmental  choice is to continue and strengthen licensing requirements.      



4 comments:

  1. Jean, thanks for writing your post. Keep in mind that I'm writing from the point of view of someone in Oregon, where there is zero chance at all that the Legislature will start requiring licensing for hypnotists, yoga instructors, aromatherapists, or even counselors. No chance at all. Given the fait accompli, I don't spend much time on building a case for why things should be the way they are. Maybe I should.

    Does licensure help? And if so, under what circumstances, and by how much? No doubt there has been research into this topic. I haven't pursued this line if inquiry because, as I said before, I'm taking the existence of perfectly legal exempt practitioners are a given. But if I were to compare licensed and exempt practitioners, I'd start with a survey of the research.

    (If asked to guess, I'd guess that: (a) exempt practitioners would seem to have the advantage -- not because they're better, but because they don't take insurance, and clients who pay out of their own pocket tend to be better motivated and higher functioning than average. (b) Once you normalize for this, I'd guess that the Dodo Bird Verdict would come into play, with most of the differences between groups of therapists being quite small.

    As for malpractice, most of the lurid cases of mental-health malpractice we've heard about involve licensed practitioners -- but I don't know what that means. I don't have any estimates about the numbers of exempt practitioners, so I don't know what kind of exempt/licensed ratio we'd expect if the two groups were identical.

    I do know, after talking to quite a few legislators recently, that licensing boards in general are considered to be a potent force for trade restriction and monopolistic practices,sometimes become intensely abusive towards their own licensees, are sources of constant complaints from constituents, and are generally seen as a cross the legislature has to bear. Perhaps necessary in some cases, but neither reliable nor efficient.

    They don't say this, however, about other kinds of licensing. For example, drivers' licenses are handled more systematically and efficiency, perhaps because the DMV has no discretionary power. They must issue licenses to anyone who meets the requirements, and they have no power to revoke licenses at all: that's done by a court. Perhaps the separation of powers helps.

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    1. The issue of how well the licensing board does things is just a red herring. The question is whether people who meet the qualifications for licensure have the capacities to practice at a better level than do those who do not meet the criteria. As to whether one group does a better job than the other, I would propose that in addition to the question you ask, we would also need to know which group is more likely to cause indirect harm or direct harm, including the "emotional burden" of treatment, than the other. Indirect harm would include the failure to provide effective treatment when it exists.

      Your example of driving licenses is an interesting one because they go only to those who yes, meet the requirements. The requirements are set by people who know how to drive, and the dangers of licensing those who don't know how are evident to the public at large.

      Mental health professionals' licenses are also available to those who "know how", not only to supply a treatment, but to recognize when there is good evidence for a treatment's safety and efficacy, and to follow guidelines of professional ethics. Whether they know these things is decided by people who do know them, rather than by those who don't, which seems sensible to me. (The licensing board doesn't work perfectly, but then people who are licensed drivers have accidents some times.)

      As for the consequences and possible dangers of allowing unlicensed practitioners to operate, these may be less obvious to the public than the consequences of allowing people to drive without meeting the criteria for a license. Many people assume that either all psychotherapies "work" or that no psychotherapy "works". They forget the losses of resources that occur when people engage in a treatment that is not effective-- and few people have gotten the message that "therapies" can be harmful (this is a fairly recent understanding even among serious professionals).

      By listing various "alternative" treatments on your web site, you demonstrate that you yourself are either indifferent to evidence of safety and effectiveness, or else you don't know how to assess them. You resemble other practitioners of alternative treatments in these ways.

      State licensing boards are comprised of professionals who work without compensation and who are often overwhelmed with the number of cases they must deal with. To improve licensing board functioning, we need to offer salaries and staffing to people who are competent to do the work and who would be part of the board for a limited period of years. (Don't ask me where I think the money would come from; I'm just sayin', here.) But this has nothing to do with returning to the Wild West of unlicensed practitioners that gave us people like Nandor Fodor-- and maybe even your admired Milton Erickson, who advised sitting for hours on disobedient children and feeding them only cold oatmeal.

      As for whether Oregon will deal with unlicensed practitioners: the state removed philosophical exemptions from immunization, right?

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  2. You seem to be arguing that only trained professionals can detect harm. For which I propose two counter-arguments:

    1. This is untrue in general. I'm talking about palpable harm here, not theoretical harm. I don't need to be a mechanical engineer to know that it's bad if the door falls off my new car. Nor does it take a particularly subtle grasp of a given field to compare two groups of mental health practitioners for palpable harm to their clients (deaths, hospital admissions) or proxy variables of presumed harm (lawsuits, complaints, assessments of deterioration).

    2. Even if this were not the case, there's quite a bit of high-quality research coming from the work of research psychologists, who presumably meet your requirements as being from Those in the Know.

    Yes, it's true that Oregon is weird. I hadn't heard that about Milton Erickson, but I agree that he acted like someone born over 100 years ago. But I dont' see what these or any other ad hominem arguments have to do with your point or mine.

    And you're way off when you apply it to me. It's not that I don't have experience with experimental design, statistical analysis, and working a problem from both ends at once -- it's just that my brief survey of the state of the art shows that outcome-based therapy is in its infancy, in a way that reminds me of fields shortly BEFORE major breakthroughs -- the treatment of infections before Pasteur, for example. There were treatments that worked pretty well, but no overarching theory that made sense of the isolated techniques.

    I asked Michael Lambert straight out if any of the outcome research has done much to improve therapeutic effectiveness, and the thing he pointed to, the use of a brief questionnaire with each session, is admittedly more a feedback loop for where the client is at the moment than a contribution to the understanding of how therapy works. The latter is what the researchers really want to find, but they haven't achieved it yet. Or so I'm told.

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    1. About safety of a treatment: you seem to be limiting the possible harm to be done by a treatment to having the patient's figurative door fall off. Most professional discussions of this issue include unnecessary expenditure of family resources, time lost through failure to have effective treatment, and the emotional burden of experiencing distressing but ineffective treatments, as well as increased distress and suicidal or homicidal behavior (or victim-precipitated homicide).

      About effectiveness: You are skipping an essential point when you start to talk about how therapy works. The starting point is to ascertain whether a particular therapy DOES work. To do this requires a lot more than statistical analysis, such as assurance of intervention fidelity, blinded evaluation, etc., all of which there is plenty to read about should you happen to become interested. This sort of evidence has been presented for some treatments, and if it were presented for alternative therapies we wouldn't call them alternative any more.

      My comments about M. Erickson were not ad hominem (though I could have made such about him), and in addition are quite relevant because some alternative psychotherapies are based on his views, just as others are based on other ideas from more than 100 years ago-- e.g. the New Thought movement.

      If you want to make one more statement, I will post it, but I don't see any point in backing and forthing like this.

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