British Radio Highlights Flawed Case for Statutory Psychotherapy Regulation
Under the guise of exploring trust within the profession, the BBC’s influential Radio 4 programme Today has highlighted the case for statutory regulation of psychotherapy practice, drawing an analogy with the regulation of medical professions such as radiology.
In a report commissioned by the programme’s guest editor Baroness O’Neill, BBC Radio 4’s Today programme on the morning of 31 December 2004 highlighted the issue of trust within the psychotherapy profession. Observing that trust in medical professions increased greatly when medical practice became subject to statutory regulation, one correspondent expressed amazement that in the United Kingdom, psychotherapy is not subject to any statutory regulation at all. The report went on to suggest that, like radiologists or physiotherapists or other medical practitioners, psychotherapists ought to be professionally regulated.
Unfortunately, the programme’s exploration of the topic overlooked two important facts:
- Psychotherapy is strongly disanalogous to the practice of medicine, and
- Scientific evidence strongly suggests that the types of characteristics typically measured by regulatory schemes (such as academic qualifications and years of experience) are irrelevant to the clinical effectiveness of a psychotherapist.
By the first point above, I mean that the practice of psychotherapy is not at all like the process of manipulating a heart valve: psychotherapy simply is not medicine. A few working in the field might like you to think it is, for their own personal reasons, but it is not. Psychotherapists do not manipulate body parts or mind parts to fix something that is ‘broken’. Nor do they, as a general rule, prescribe medications. (Psychotherapists who do prescribe medications are doing so by virtue of having qualified separately as medical doctors, in addition to their psychotherapy training.) In fact, the overwhelming majority of clinically relevant change effected by the process of psychotherapy is due to factors within the client, not to the efforts of the psychotherapist. (See the review of Hubble, Duncan and Miller at this site for the full scientific background on this point.)
Which brings us to the second point above: clinical effectiveness in psychotherapy has almost nothing to do with the types of characteristics (such as academic qualifications and years of experience) typically measured by regulatory schemes presently in use in some countries. Returning to the medical analogy, someone with a degree in medicine clearly will do a vastly better job of completing a heart bypass operation than someone without that training. Analogous statements for the psychotherapy profession, however, are flatly false — because, again, factors like academic degrees demonstrably have virtually no bearing on clinical outcomes in psychotherapy.
To my mind, marketing to the public a statutory regulation scheme which is based upon characteristics known to be almost irrelevant to the quality of service a potential client might receive borders on unethical.
When proponents of statutory regulation do eventually get around to addressing characteristics like actual clinical effectiveness (not effectiveness spuriously presumed on the basis of qualifications), and when they begin addressing issues of trust with, for example, government-sponsored background checks, I will be one of the first to the front to declare my support. But I will not support the perpetuation of the myth that psychotherapists mechanically fix patients like medical doctors, or that statutory regulation as presently envisioned by major professional bodies will do anything whatsoever to safeguard quality of service. Statutory regulation as presently envisioned might help build trust, but it would do so by misleading the public in a way which I believe is bereft of scientific substance.
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This article was last reviewed by on Friday, 31st December 2004. You can leave a response below.
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http://counsellingresource.com/features/2004/12/31/psychotherapy-regulation/
3rd January 2005
The idea that psychotherapy is not at all analogous to medical practice is an exaggeration.The fact that client variables are more important than treatment modalities is exactly the same as in medicine.In general, the sicker the patient the less likely that there will be a good outcome.Also,the more resistant to treatment,the worse the predicted outcome.It’s the fifteen percent that makes all the difference.Anybody can give a mostly heathy person good medical treatment by advising them for example,to stop smoking and eat more vegetables but only a well trained, experienced surgeon can remove a tumor.Anybody can help a normal adolescent adjust to college but only a well trained, experienced psychotherapist can help a seriously dysfunctional phobic client overcome their disabling condition.Regulating agencies can assure that a psychotherapist has had sufficient supervised experience.To remove my diseased lung I’d choose a licensed physician and surgeon over a psychotherapist or a licensed plumber.To help me overcome my agoraphobia I’d choose a licensed psychotherapist over a surgeon or a licensed electrician.Regulating agencies also can help prevent ethical problems by yanking the license of,for example,a child therapist who thinks it is good treatment to beat and have sex with his clients.I think that’s pretty important.I,in short,think that regulation of psychotherapists is just as crucial and significant to the public as regulation of medical practioners. Kenneth Peiser,Ph.D. Licensed psychologist,codirector Midwest Psychological Healthcare P.C.,coauthor “Beat Your Addiction”,Adams Media.
8th January 2005
Kenneth, thank you for your thoughtful input on this. I find myself both agreeing and disagreeing with some of what you’ve said, and if I’ve understood what you’ve written correctly, I guess I would also want to dispute some of the logical structure of what you’ve suggested — but perhaps you can correct me if I’ve just misunderstood.
You’ve conceded that client variables are more important than treatment modalities but argued that this is exactly analogous to medicine, suggesting this is the case because, for instance, the sicker the patient the less likely there will be a good outcome. However, two important points seem to me to have been lost here… The first is that outcome studies (whether for effectiveness or efficacy) control for differences in parameters like “the sickness of the patient” — in other words, the conclusions of these studies refer to the effectiveness of different treatments given that it didn’t just so happen that one patient was in better health than the other. The second is that the “fifteen percent that makes all the difference” may differ wildly between the professional realms you cite, such as those of psychotherapists, surgeons, plumbers and electricians. If I had to take a wild guess, I would imagine that “plumbing outcome” is pretty close to 95% down to “plumber factors” such as plumber training, plumber choice of materials, etc. Likewise for “electrical wiring outcome”. Medicine broadly understood differs from either of these, because here client variables do emerge pretty noticeably (Hubble, et al. have some interesting material on the placebo effect which bears on this), but outcomes are still largely determined by the practitioner, once we have accounted for things like who was healthier to begin with. Psychotherapy, however, differs far more, because here the impact of specific practitioner variables dwindles to somewhere around the 15% figure you cite.
The argument for registration on the basis of effectiveness, however, really seems to me to come undone on the fact that the variables which typically figure in registration schemes for psychotherapy are almost entirely irrelevant to (and in some cases are inversely correlated with) clinical outcomes. This patently is not the case with electricians, plumbers, or physicians, where the types of skills and knowledge being measured are strongly correlated with outcomes.
Having said all that, I agree with you about the role of regulating agencies in addressing ethical problems. I agree that it’s very important to address the ethics violations you cite, such as beating clients or having sex with clients. Fortunately, I can fully support that specific aspect of regulation and agree with you on its importance — while still rejecting other aspects of arguments commonly put forward in this area that so often spuriously link practitioner variables with outcomes, in outright contradiction with empirical research evidence.