Unregulated mental healthcare

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A heinous murder in Pakistan’s capital city has shaken Pakistan’s middle and upper classes to its core. It has done so because it suggests that even elite privilege cannot quite paper over the cracks of Pakistan’s malfunctioning governance structures, or of social systems whose flaws have been exacerbated by state failure. Of the many revelations that have surfaced in the past week, those relating to the dangers of unregulated mental health services loom especially large.
In order for mental healthcare services to be rights-based, these services must be freely accessible and must offer care based on regulated, scientific protocols. So how exactly is mental healthcare provided in Pakistan?
Except for a handful of psychiatrists trained abroad, the vast majority of Pakistan’s psychiatrists qualify from the country’s College of Physicians and Surgeons. As soon as they qualify, they launch independent practices in both the public and private sectors. There is no regulatory mechanism to check the quality of care being provided or to govern how these services develop in the private sector. Many tertiary care centres cater to hundreds of patients every day, who are assessed and treated by postgraduate students of psychiatry, without much supervision.
A closely related and highly prevalent malpractice in mental healthcare has to do with drug rehabilitation centres. These centres are commercial entities where unqualified staff provides management not just for detoxification from drug use but also for mental disorders. These services are completely unregulated. To provide legitimate cover, many hire qualified psychiatrists who are minimally involved in case management and are paid up to Rs10,000 for each on-site visit.
Undergraduate training in psychiatry is also seriously compromised; taught curricula are grossly outdated and barely cognisant of public mental health needs. Students are hardly ever formally assessed for their knowledge of common mental disorders. The situation in private medical colleges is rarely better; most departments in private medical colleges have only one psychiatrist, no nursing care, and do not meet the 12-bed standard criteria for psychiatric patients.
Another fast-developing discipline is that of clinical psychology. Although many universities in Pakistan offer courses in psychology, there are only a handful of graduate programmes in clinical psychology, which include either an MS or an advanced diploma in clinical psychology. These specialisations are completed after a master’s or a four-year bachelor’s in psychology. Again, upon qualification, there is no regulatory mechanism to govern how these services develop or to check the quality of service being offered. In Islamabad alone, there are over 150 clinical psychologists working in the private sector, all unsupervised and completely unregulated.
Over the last decade or so, a third category of mental health professionals has also emerged in Pakistan — ‘therapists’. Ideally speaking, certified counsellors and therapists are trained, supervised and regulated.
In the UK, the Counselling and Psychotherapy Central Awarding Body is the main awarding body that accredits trainings. It is not, however, a professional association responsible for ensuring counselling standards. In the UK, standard setting remains the responsibility of organisations such as British Association for Counselling and Psychotherapy that have their own ethical criteria. The CPCAB also gives accreditation to training centres outside the UK but it has no role in regulating the clinical services offered by these centres.
CPCAB has a process for awarding unregulated Tailor-Made Qualifications, which has been the case for countless accredited trainings in Pakistan. These qualifications are somewhat different from CPCAB’s UK-regulated qualifications: these do have an external assessment/exam in the same way that regulated qualifications do; CPCAB does not have a role in recruiting candidates into training courses in Pakistan; and there are likely to be vast differences in the training that is provided at a given level in Pakistan to the equivalent level in the UK. A fully trained counsellor in the UK is one who has completed Level 5 training and is working “under close monitoring of an organisation”. Unfortunately, no organisation in Pakistan is equipped to carry out this kind of monitoring and evaluation.
The pursuit for recognition by international accrediting bodies sans efforts to strengthen training or develop local regulatory mechanisms is alarming. One example is that of honorary fellowships by internationally recognised institutions, which are awarded without training or examination. Although well-intentioned, these honorary awards are used to overstate clinical competence.
Yet another example of malpractice is professionals using inaccurate titles for self-promotion without any accountability: for instance, some professionals of repute claim that they are members of a ‘Federal Mental Health Authority’, whereas no such authority exists.
These concerns can only be addressed if Pakistan were to form an effective regulatory mechanism for mental healthcare provision in the country. While the provinces of Sindh, Punjab and KP have enacted mental health legislations, these acts are neither rights-based nor primed for implementation. At the moment, there is no mental health legislation covering the federal capital either, in the absence of which it is practically impossible to monitor complex breaches of ethical code of mental health practice in the city.
One possible solution lies in the Islamabad Healthcare Regulatory Authority, established in pursuance of the Islamabad Healthcare Regulatory Authority Act passed by the National Assembly in 2018. The authority can set standards for registration, licensing and regulation of healthcare professionals and establishments, and service provisions. The scope of this authority extends to mental healthcare facilities. According to a source, the Ministry of Narcotics Control and the Ministry of National Health Services Regulation and Coordination have recently prepared a draft bill for certification and registration of centres providing services and interventions for drug use disorder.
Policy planners must decide whether Islamabad Capital Territory should urgently work towards enacting a single comprehensive mental healthcare legislation to cover the federal capital, or initiate a regulatory mechanism under the purview of the existing Islamabad Healthcare Regulatory Authority. There is no time to waste. Unregulated mental health services are a violation of the basic rights of those suffering from mental health problems, and as established by recent events, can have deadly and deeply tragic consequences.