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 18^th 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.      

Why Can't They Tell Which Patient Will Kill Somebody?

Recently, someone commenting on a post on this blog asked me to explain why I had said that diagnosis of mental illness in research did not have to be, or at least was not, as accurate as was needed in treatment of an individual. The writer pointed out that therapists may make a diagnosis not so much because it is accurate but because it allows particular treatments or services to begin. This is certainly true, and it’s also true that psychosocial treatments are often directed at specific symptoms that are troubling rather than at some underlying condition that has been diagnosed. That’s a good idea in many cases, especially when the proposed condition, like Reactive Attachment Disorder, does not necessarily have the causes that are posited for it.

My remarks were not about how things actually are, or about the best they can be in light of various social and political pressures. Instead, I was thinking about the kinds of questions researchers and therapists are asking, and the ways these questions differ from each other. Researchers are almost invariably asking whether one group of people is different from another, or about what will happen to a group given one treatment, as compared with a group given another treatment. They expect some variability within groups and would be surprised and even suspicious if everyone in a group acted the same way. They also accept the fact that diagnostic measures vary in their accuracy.

Therapists, on the other hand, want to know what will be the effect on a particular person of a treatment or experience. They have much less wiggle room than researchers do, especially in cases where a patient may or may not behave violently. We are all aghast every time we read that a formerly violent patient was allowed a weekend pass from a hospital, went home, and chopped up his mother with an ax. “Why didn’t they know that would happen?," we demand.

A useful article in Science (“What is the question?, by Jeffrey Leek and Roger Peng, 20 March 2015, pp. 1314-1315) provides some ways of thinking about these issues. Leek and Peng even give a great flowchart, and I am going to shamelessly follow their description of making decisions about the kinds of questions that are being asked by researchers, therapists, and lots of other people.

The first question Leek and Peng ask about how people think about information they have available is, “did you summarize the data?” If this hasn’t been done--  for example, if there are only anecdotes or testimonials in use—there is no data analysis, and no prediction can be done. (For example, about whether a particular treatment produced a better outcome than another did. )

If the information was summarized, but reported without any interpretation, this was a descriptive approach, but again no prediction can be done.

What if the information was not only summarized, but interpreted—but there was no attempt to decide whether the patterns seen would be repeated in other circumstances? Work of this kind is exploratory. Whatever patterns or connections exist between factors (like treatments experienced), they still need to be confirmed by more work.

Did the study quantify the differences observed and calculate the probability that they would be repeated? If so, there are further questions to be asked. The first one is whether someone is trying to figure out how the average of one measurement affects another measurement. If this is not being done, the next question is whether the goal is to predict measurements for individuals. No? Then the study is an inferential one, which just looks for relationships between factors. Yes? The study is a predictive one. It attempts to predict what will happen with a single individual--  but without being able to understand how or why effects occur, and therefore without real certainty.

Suppose there is an effort to find out how changing the average of one measurement changes another? This may be a study that is causal in nature. It can demonstrate that a group of people receiving a treatment do better on average than a group receiving a different treatment, but is not able to predict which people will do well or poorly—only the average change in risk or benefit is calculated. Leek and Peng give the example of smoking as a risk factor for lung cancer. As we all know, some people who smoke will be very badly affected, and others affected very little, but the whole group of smokers will be more likely to have lung cancer than the whole group of non-smokers (some of whom will get lung cancer too). To take a psychological example, we have the evidence that of depressed people taking antidepressants, many will do better than a matched group without the medication, but some in both groups may kill themselves.

The highest level of explanation involves a deterministic or mechanistic analysis. In this case, the evidence shows that changing one measurement is reliably and exclusively followed by a specific change in another measurement. As Leek and Peng put it, “Outside of engineering, mechanistic data analysis is extremely challenging and rarely achievable.”

When researchers are working on psychological changes in groups as a result of treatments or experiences, they may be working at anywhere from an inferential to a causal level, but their concern is still about average changes in groups. If therapists are trying to be predictive, they may not be able to do a good job of prediction if (as is common) they really do not understand how or why certain results are brought about. Without understanding what events lead to the patient chopping up Ma with the ax, predicting that event is hard; it may be right most of the time, and most weekend passes do not lead to mayhem, but the predictive failure makes it clear that the cause of the behavior is not well understood. However, the more accurate the information is—for example, the better the diagnosis—the better the chances that the individual prediction will be correct.

But human behavior rarely involves a single event that is always and exclusively followed by another specific event. Instead, a broad range of events work together to bring about most outcomes, even those that seem quite isolated, like an ax murder. In aeronautical engineering, factors like wing design can directly affect air flow, but human behavior probably has few factors that are the sole cause of an event. Predicting individual human behavior is much more like meteorology, in which a broad range of factors can determine thunderstorms (does that cold front keep moving or not?) or ax murders (does Ma take the opportunity to tell the patient who his real father is?).  Not all of these are known—or even can be known—at the time of the prediction.