Licensing Would Not Guarantee Quality Psychotherapy

Licensing Would Not Guarantee Quality Psychotherapy
By Dan Hogan, JD, PhD
Instructor of Psychology
Harvard Medical School
(The writer’s publication’s include“The Regulation of Psychotherapists.“)

The issue of how best to regulate psychotherapy is particularly vexing and complicated. Judy Foreman’s June 19 article cites with apparent horror the fact that Dr. Peter Gills Cambridge Psychotherapy Institute in Newton includes therapists who are neither licensed nor possess any academic credentials (Psychotherapy in Massachusetts virtually unregulated”).

In commenting on the allegations of harm caused by the institute, she presents the traditional argument of the profession that strict regulation is needed to protect the public from the danger’s of unlicensed practitioners. Such regulation would, among other things, require all therapists to hold advanced academic degrees.

In the name of such quality control, she mention that Blue Shield is limiting the number of reimbursable assistants to three. A good argument can be made, however, thitherto these restrictions actually do more harm than good.

That is the conclusion I have come to after years of intensive research on the subject, begun when I was a Research Fellow to the Department of Psychology and Social Relations at Harvard University. My analysis suggests that most licensing laws are counterproductive, . Briefly put, the argument runs as follows:

First licensing does not do what it is supposed to do. Although meant to ensure that only competent professionals are admitted to practice, little evidence exists that current entrance requirements, especially academic credentials, bear any relationship to performance. While opinions abound, the unfortunate truth is we simply do not know what makes someone a good therapist. What little we do know suggests that intangible qualities like empathy are particularly critical; but theses are nearly impossible to measure. Joseph Darla’s excellent review in “Psychological Bulletin “ examines 42 studies directly comparing relatively untrained and uncredentialed practitioners with highly skilled, doctoral level professionals. In 28 cases, the paraprofessionals performed as well as the pros, and in another 12 they actually outperformed their professional counterparts. In only two instances were the tables reversed.

This was the case over a wide variety of client populations, including a substantial number of psychiatric outpatients and hospitalized in patients. It was also true over a wide variety of out come measures that were not limited to superficial changes.

Evidence on disciplinary endorsement reveals a woefully inadequate system in which licensing boards rarely take action against licensed practitioners who are unethical or incompetent. To give but one example, several years ago, 33 states revoked no medical licenses. Does anyone really believe that physicians are that good? Even the prevention of unlicensed practices is generally spotty, often being aimed at eliminating competition, not incompetence.

Second, even if licensing laws do ensure competent practitioners, the price may not be worth it. The increased cost of services, the shortages, the misdistributions of supply lead to direct harm through the inability of he poor and other disadvantaged groups to afford or find any practitioner at all. Frequently such persons resort to injurious self help.

Quite apart form these most obvious costs, the entry requirements of licensing laws have a tendency to discriminate against the poor, the aged, women, and minorities, as well as inhibiting important innovations in the methods of organizing and delivering professional services.

Third, even if the net benefits of licensing outweigh the costs, equally beneficial but less expensive alternatives may be available. In addition, other factors than licensing may be far more influential in determining the quality of service ultimately received by the public; and it is these factors that should be looked to if sound regulation is desired.

The president of Massachusetts Blue Shield claims that limiting the number of assistants will improve the quality of services delivered. I believe that the only improvement will be in Blue Shield’s ability to control costs. That a practitioner can only do a good job supervising three assistants seems patently absurd. It depends on the nature and amount of the assistants’ work. If Blue Shield were truly interested in quality control, why did it not focus on the number of hours and the nature of supervision provided?

As for restrictive state licensing. It is my opinion, based on current research, that we would be better off with a law requiring all psychotherapists simply to register with the state. In such a system, they would not have to possess any academic degrees, but should be required to disclose their background and other relevant information for all clients. They would also lose their right to practice of found guilty of harmful or unethical activity.

Although I wish it were otherwise, the paucity of our knowledge make it inadvisable to adopt more restrictive regulatory alternatives.