Monday, September 21, 2009

Myths about Licensure and Expertise in the Mental Health Profession

There has been a great deal of buzz on the Internet over the past several months about licensure vs. people who are not licensed and yet are critics of the mental health profession. What is being claimed, in essence, is that people who are not licensed are inferior in knowledge to those who are licensed and should not be viewed as credible. This is a myth and a completely unwarranted conclusion, so I thought I'd take these opportunity to list a few myths about licensure and so-called "expertise" in the mental health profession and outline what it does and does not entail. Here is what it means to be licensed:

  • The person has attained the level of education required for their state to be eligible for licensure (for example, in psychology, most states require a Ph.D. or PsyD in clinical psychology or an EdD from an accredited institution and for licensure in social work, most states require a Masters in SW from an accredited institution). There are exceptions -- in some states, for example, masters level people can be licensed in psychology and bachelor's level people, in SW.
  • The licensed individual has passed an exam of some sort. These also vary from state to state but usually consist of a 2-3 hour multiple choice exam and in some states, an oral examination.
  • The licensed individual has undergone a period of supervision by another licensed professional -- in most states this is around 2 years of full time, supervised work. There is no guarantee that the interventions done were evidence-based. Any licensed person can be the supervisor, and that would include people such as Roger Callahan, who as a licensed psychologist in California, would qualify to sign off on a person's supervision hours for practicing TFT, just to give one possibility.
  • The person has to subscribe to and abide by the code of ethics for the profession (the APA code of ethics for psychologists, and NASW for social workers). The person need not be a member of either of those organizations to be licensed, however.
  • Licensure provides a mechanism for people to complain to state boards if there have been ethical violations.

And that's pretty much it. Is it valid to assume that an unlicensed person is less qualified to evaluate a particular therapy and the research evidence that exists to support it? No, not necessarily. There is nothing that says that a person who is unlicensed has less education, less knowledge or less capacity for critical discernment than those who are, or even inferior interpersonal skills, since there are plenty of ways to develop such skills outside formal mental health training.

In psychology, people with non-clinical degrees (e.g. developmental, social) are often much more research-oriented. While some clinical psychology programs are also very rigorous, not all are research oriented. In fact, many of the PsyD degrees given from free-standing, non-university affiliated schools have little emphasis on research. There are, of course, exceptions and not all PsyD degrees are from free-standing schools and a few free-standing schools are better than some of the university programs, but I point this out just to give people an indication that just because someone has a PsyD, an EdD or even a PhD we cannot assume that they have received good training in research, or kept up with the latest in research evaluation. All their licensure requires is that they get continuing education credits, but usually those courses are clinical, not about how to evaluate research and claims about interventions. Moreover, many of the clinical courses are not even truly evidence-based.

Recently we have witnessed some people who claimed to be licensed mental health professionals waving their licensure around in a very unprofessional manner and trying to claim that this in some way makes their evaluation of various therapies more credible than people who are not licensed. Again, not necessarily at all. On the contrary, there are plenty of licensed individuals who have displayed very poor judgment about selecting interventions and have chosen interventions that lack research evidence over those that have research evidence. There are even licensed mental health professionals who practice interventions that have been shown to do more harm than good and there is no official prohibition against practicing such interventions.

So what is the difference between a licensed and unlicensed individual? The criteria I listed above. Licensed individuals are not necessarily superior in their critical thinking skills or ability to evaluate research. The only thing unlicensed cannot do that licensed people can do is see clients under the professionally protected title (e.g. social worker, psychologist, marriage and family therapist). A person does not have to ever have seen a client to be able to examine and evaluate research that supports or does not support a particular approach. In fact, a practicing clinician might well be more prone to bias, in that such individuals often become attached to particular interventions that they become known for and become financially and emotionally invested in their degree of acceptance.

The bottom line here is buyer beware, and that people need to examine the actual quality of the evidence, rather than assuming that because something is being endorsed by a licensed individual, it is valid. That is a highly unwarranted and dangerous assumption.

The same applies to "experts". The mental health profession is unfortunately full of examples of "expertise" that is based on nothing more than tradition and authority, not scientific evidence. In the 1950s, for example, "experts" believed that Schizophrenia and autism were caused by a person's mother. There was never any scientific basis for this assumption, but people trusted the experts when in fact they were doing great harm to their patients by assigning the wrong cause and inducing undeserved guilt and suffering in the parents.

More recently, we had the recovered memory craze of the 1990s that resulted in false memories and families that were destroyed. Today, we have other fad diagnoses, such as "attachment disorder" that go far beyond the diagnosis of Reactive Attachment Disorder in the DSM IV and even that is on very shaky ground. Just because something is in the DSM does not make it valid and it is subject to revision, as the lengthy DSM V debates are demonstrating. Again, the point is to question authority.

While sometimes people who lack relevant knowledge and education do need to trust experts, that doesn't mean they have to blindly trust. Find out not only about licensure, but ask what the basis is for their opinions. For example, here are some questions I have for one PsyD who has asserted that he is an expert but has yet to provide scientific references for the prone restraint procedure he recommends in his self-published book. These are the sorts of questions prospective clients ought to be asking rather than trusting assertions from authority.

Find out if there has been any criticism and ask proponents about this. If the proponents attack the critic as being "unlicensed" or use other appeals to authority or personal attacks, instead of giving solid evidence, be very suspicious. This has happened recently when proponents of Ronald Federici and Arthur Becker-Weidman's therapies have attacked critics as being "unlicensed" even when two widely-published critics have research-oriented PhDs and are highly qualified to determine degree of evidence. People who are on solid ground do not need to attack their critics in this way.

There is a false dichotomy proponents of unsupported therapies are trying to sell, which is that people who demand evidence and are critical are cold, uncaring people who have no interpersonal skills. We can see this right here on this blog in Jennifer Molinari's comments to me. Eileen Gambrill has called this the fallacy of hard headed, therefore hard hearted and soft headed, therefore soft hearted. In other words, people who are hard headed and rigorous about evidence are hard hearted, uncaring people when in fact this isn't necessarily so. A person can be hard headed and soft hearted, or they can be soft headed and soft hearted (the compassionate person who nevertheless is highly gullible and uncritical of therapies they practice). What is neglected by people who make this unwarranted assumption is that it is entirely possible to be hard headed and rigorous, yet still be soft hearted and compassionate, and have excellent interpersonal skills.

People who boast about their great interpersonal skills and "compassion" and yet ignore criticism of approaches they use that lack empirical support are the very people mental health consumers need to be the most careful about. Right now, as a Google search on my name will reveal, there is a very active campaign by these so-called "professionals" against people who seek to question and challenge their authority. While there are, of course, many responsible mental health professionals who are open to criticism and do not attack critics, beware of those who do.