“The purpose of psychotherapy is to set people free”

— Rollo May (American psychologist)

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“The purpose of psychotherapy is to set people free — Rollo May (American psychologist)

A few years ago, the administrator of my children’s school approached me at a parent-teacher meeting. After having practiced as a psychiatrist for more than 20 years, when people randomly approach me and start unburdening themselves, I just smile and listen for a couple of minutes and then suggest gently that perhaps we should have this conversation later (when I will have more time to listen attentively) in another place (where they can talk without fear of being overheard or judged).

But the school administrator, Shireen (not her real name), wanted to discuss something a little different. She had recently gone looking for a psychotherapist and heard about someone connected to an organization which a lot of her friends seemed to know about. She called for an appointment, went to see the therapist there and had a couple of sessions with them. Then the therapist suggested that she should join their ‘course’ (for a hefty fee) where she would get the help she needed and could also learn to be a therapist. She did the course for a few months and after taking a few cursory ‘exams’ was told she was now a ‘therapist’ and should start seeing people for ‘therapy’.

What she wanted to discuss with me was how utterly unprepared she felt despite her ‘diploma’ at the prospect of trying to help people with mental health problems. She asked if I could help. I had known about this ‘therapist factory’ for a while.

I told Shireen that if she wanted to ask around and find a few more people who were in the same situation as her, I could perhaps arrange a class or some formal supervision for them although all of my psychiatry and psychology colleagues that I reached out to vehemently opposed being affiliated in any way with what was obviously a thinly veiled scheme for making money and churning out minimally qualified ‘therapists’ that were then let loose on an unsuspecting public.

Shireen’s dilemma highlighted a bigger problem: with the increasing demand in mental health services and a critical shortage of appropriately qualified and trained mental health professionals to provide those services, it is no wonder that unqualified people, quacks and shysters, are stepping into the void to offer whatever snake oil they can sell? In addition, the complete lack of any licensing or regulation in Pakistan of the entire field of ‘psychotherapy’ (and its even murkier cousins “life coaching” etc) has made it impossible to tell who a troubled person can turn to in times of need. This problem is poised to intensify manifold in the wake of the explosion in Covid-related mental health problems which are already upon us and will only multiply in the coming months and years.

The problem exists in the US and other countries as well. More than a decade ago, when I was practicing in the US, I had become a member of the American Society of Psychopharmacology. I had sent them $100 and they had sent me an official looking certificate which I framed and put on my office wall. But I never used it as an educational qualification in my CV, on my business card or in any dealings with patients or employers (because it was not a ‘degree’ that I had obtained after a formal course of education and appropriate exams from an accredited institution). The fake-degree scandal in Pakistan a few years ago laid bare these educational scams and of course, the internet has just made these shady operators that much more savvy and harder to catch.

So where should a person turn if they need help for stress, anxiety or depression or more serious issues like severe substance abuse, bipolar disorder, schizophrenia or suicidal ideation? Is there any way to differentiate actual, reliable, qualified therapists and mental health practitioners from the products of ‘therapist factories’ (sometimes also called ‘diploma mills’) such as the ones mentioned earlier?

Yes, there is. Look for therapists who are affiliated with (or are graduates of) reputable institutions in your city or abroad. In Lahore, the oldest institutions of learning such as Punjab University, Government College University or my own alma mater (and the place where I currently teach) King Edward Medical University, all have reputable undergraduate and post-graduate programmes in psychology and psychiatry. Most colleges and universities in large and medium sized cities will have such programmes. Graduates of these programmes will have, at the very least, minimal adequate training in mental health work including psychotherapy. In Western countries, other related disciplines such as social work, rehabilitation counselling and substance abuse counselling are also established fields of study so before you commit to seeing a therapist, demand to see their qualifications and inquire about their experience of working with people with problems similar to yours. Avoid using the many ‘helplines’ that have sprung up in recent times, especially since Covid, unless you can verify the credentials of the people running the organization and the helpline.

Use word of mouth referrals and ask your friends and family about whether they have had any experience with a therapist (and then cross check their qualifications as mentioned above). When you actually go see a therapist, ask lots of questions (about their education, qualification, area of expertise etc) and walk away if they are evasive or defensive. If you see or experience anything egregiously wrong, you can consider filing a complaint with the Punjab Healthcare Commission. Efforts are currently under way to standardise psychotherapy and other mental health services and develop oversight and regulation both at the provincial and federal levels (although this may take time).

In addition, since the shortage of qualified mental health professionals continues to grow, the Government of Pakistan in collaboration with provincial governments and national organisations like the Pakistan Psychiatric Society has started efforts to provide mental health services which can be provided to large numbers of people at low- or no-cost. These include simple interventions like the evidence based ‘Psychological First Aid’; a useful App called “PFA Mobile” for this can be downloaded on Google Play/Apple store. The World Health Organization-approved Mental Health and Psychosocial Support programme is also designed for population level interventions but needs government support at both provincial and national levels to make it functional.

While there continues to be a shortage of good quality psychotherapy (and psychiatry) services all over Pakistan, there are ways you can seek out and obtain high quality psychotherapy services if you are willing to put in some work. This is essential because a ‘therapist’ who is unqualified and incompetent can do much more harm than good to a vulnerable, emotionally fragile person with already existing problems. Regulations, oversight and accountability are being developed but will take many more years to become effective. In the meantime, “Caveat Emptor” (“Buyer beware”).