What makes regulation of psychological practice difficult?

One day, my fiancée hit me with a question that really got me thinking:

"How do you even know if your clients are getting better?"

So, being the psychologist I am, I walked her through my usual spiel – using objective outcome measures, checking in with other stakeholders, and, of course, directly asking the clients.

Then, she dropped another bomb:

"If you can collect all of this data, why is it so tough to spread the success around in your field?"

Now, her corporate lingo was on point, and it made me ponder.

Why are we struggling to make our great work as contagious as a viral cat video?

This brings me to the ongoing tussle for regulating psychological practice in Singapore. It's a real puzzle given the current state of our practice.

But here's the kicker – many of us just stop at acknowledging the difficulty. Let's dive deeper.

What exactly makes regulation so darn difficult?

Mental health awareness is on the rise, and even the government is hopping on the bandwagon. Yet, we're still grappling with this challenge.

So, I'm here to spill the beans, things we might not love talking about but need to. And that's precisely what this newsletter is about – facing the tough questions together.

Here are some thoughts which I think could explain the difficulty to regulate psychological practices, and I'm sure there's more we can uncover together:

1. Lack of standardization within the profession

The multiplicity of titles within the mental health profession mirrors a chaotic orchestra where each instrument plays a unique tune. While diversity is our strength, a lack of standardization can lead to confusion among clients and even within the professional community.

Drawing a parallel with engineers specializing in distinct fields, it becomes evident that standardization doesn't stifle individuality but rather provides clarity and coherence. Let me make it simpler; it takes every engineer to build a city. If we can have that understood for the field of engineering, I struggle to see that logic isn't applied in our field.

As of now, it's not an easy task to ask even ourselves, the insiders to explain exactly the difference between clinical psychologist, educational psychologist, counsellor, and psychotherapist. And I don't see how that's going to be possible for general public, when we find it challenging.

While I understand certain overlaps, there has to be distinctions to what we do, so that we can better collaborate and support our clients to the fullest. If I know that's beyond my scope of work, I can then provide better support by referring to the right professional to do the task.

The last thing we want is to hoard clients simply because WE THINK THAT WE CAN DO EVERYTHING AND ANYTHING.

By establishing clear distinctions and specializations, we create a roadmap for both professionals and those seeking mental health services.

2. Lack of standardization within the practice

Celebrating the uniqueness of each therapeutic interaction is a cornerstone of our profession. However, envisioning a field without any standardized practices is akin to an artist creating without brushes or a musician without notes.

It's about finding the delicate balance between allowing creative expression and adhering to a shared set of guidelines.

Another example I can provide that may resonate with all of us: Take a look at all the international airports. While they may all look different from one another (i.e., their interior design, facilities and even customer service), they should all share a similar structure in terms of having air control, distance of runway etc. Basically, regardless of which country we are heading to, the pilots will know how to land a plane, BECAUSE THEY SHARE THE SAME GUIDING PRICINPLES.

Similar to our field, the existence of said guidelines can act as a compass, helping practitioners navigate the vast sea of individualized approaches while offering a common foundation to learn from and build upon. In essence, they provide the scaffolding for innovation within a structured framework.

3. Limited utility of objective outcome measures

The subjective nature of "feeling better" underscores the need for a more objective yardstick in gauging therapeutic progress. Imagine a painter without colors – the richness of their art is lost without a diverse palette.

Or specifically, imagine if every client just reports "feeling better". How would we know if that is due to our effectiveness as clinician, or is it solely based on slight change in the environment that our client has no direct control over?

While subjective reporting is essential, therapists need a comprehensive toolkit that includes objective outcome measures.

These tools not only enhance the therapist's ability to assess progress but also provide a more nuanced understanding of the client's journey. This shift towards a more objective evaluation ensures that the therapeutic process aligns with the client's well-being rather than relying solely on subjective sentiments.

4. No measurable outcome, no replicability

For those who have been following my posts, you would have seen me speaking much about the improtance of having data especially in the scientific field like mental health.

Everything shouldn't be just tied to "feeling", especially not when it comes to documentation of improvement and betterment.

Let's see from it this way; it's not possible for any organization to invest a large amount of money to a project that has ZERO REPLICABILITY over its success.

Similarly, it's going to be difficult for government (any) to implement any regulation when many practitioners out there are operating solely based on how they think their clients are getting better. What are the numbers? Where are the data? How do we know if they are actually imporiving aside from their subjective reporting?

Don't get me wrong, exactly like any other clinicians out there, I would love for the regulation to put in place RIGHT HERE AND NOW.

However, from a realistical standpoint, it's not going to be an easy task to rely solely on the government to do so, WHEN WE DON'T oversee and be mindful of what we are doing, which could potentially lead to further problems in the field.

5. Outcome measures tied to credibility

The fear of confronting stagnation in client progress is a genuine concern tied to a psychologist's credibility.

What if after 20 sessions, our client is still not improving (both subjectively and objectively)?

Then the question would be if it's due to our inefficacy.

Understandably that it will tie to how we view ourselves as clinicians. However, reframing this fear as an opportunity for professional growth transforms outcome measures from potential threats to valuable tools.

Picture it as a sculptor refining their masterpiece – the process may be challenging, but the outcome is a testament to their dedication and expertise.

By dissociating outcome measures from self-esteem and embracing them as catalysts for improvement, psychologists can foster a culture of continuous learning and refinement.

6. Lack of cross-checking

In a world where transparency is paramount, our profession's absence of a robust cross-checking system is akin to writing a story without an editor.

A medical diagnosis undergoes rigorous examination; similarly, session notes and reports should withstand scrutiny to ensure authenticity.

Let's be honest here: how many of us here would actually allow other professionals to go through our notes or even what we discuss in the sessions? for this example, let's remove the nuance of client's confidentiality for a moment.

In the above example, it's a rare occasion unless summoned by court order, where we have no choice but to present our sessions notes. With that said, how can we ensure what we do is actually helpful or effective, if there's no cross-checking?

Wouldn't it be a pure he-say-she-say situation?

Or even, who is there to ensure that we are on the right track?

Introducing a system for cross-checking not only validates the veracity of professional documentation but also empowers clients, offering them a voice in the dialogue. It transforms the therapeutic process into a collaborative effort, ensuring ethical standards are maintained and bolstering the profession's credibility.

7. The overemphasized need to distinguish from the medical field

The persistent emphasis on distancing ourselves from the medical field has been a longstanding narrative within the mental health profession.

While the intention behind this endeavor—to advocate for viewing mental health beyond a mere disease model—is commendable, it's crucial to still recognize the utility that the medical model holds.

Within this model, there's a clear distinction between a problem and a disorder.

With effective treatment plan derived from accurate assessment and diagnosis, the success as measured by standarized outcome measures (e.g., body tempature, blood pressure hemoglobin level etc) can be documented, monitored, and REPLICATED across the field.

However, this has been a uphill battle in the field of mental health, especially with the overemphasis that MENTAL HEALTH (especially in the recent trend of neurodevelopmental disorders) IS ALL PART OF A SPECTRUM.

While the intention (I hope I get it right) is helpful as it tries to allow the public to accept the importance of mental health, but we have to be clear that not everything neatly fits onto a spectrum.

We have to be clear that certain criteria are essential to identify when someone is grappling with a mental health condition.

Let's ponder a question: would we ever accept Alzheimer's and dementia as part of a broad spectrum? The resounding answer is a firm "NO" due to the profound impact on both physical and mental well-being.

Similarly to mental health, there has to be a distinction to what makes a disorder. That doesn't mean that there's no intervention needed just because it's not disordered. On a contrary, what it simply means is that it creates level of risks and urgency for stakeholders to act upon (and of course they are multiple reasons to do so, this example may not cover all).

It's akin to knowing what to do when we have an individual with minor fever, and another one losing few bags of blood after a severe car crash.

This is pure common sense, and I fear that it's lacking nowadays.

TO SUM:

The above are some of my reflections to hopefully depict the difficulties as to why regulation is difficult to achieve with what we haven now.

While my points may seem to favour medical field, it's done with a specific reason because that's an established field of which WE CAN DEFINITELY LEARN FROM.

There's no need to villianize any field (that includes any possibility where psychologists or any mental health professionals being seen as "less important"), in order to make ourselves shine.

We can always learn from the legal field, engineering field, heck, we can even learn from history if that helps. The key is that we refer to what makes these fields successful, and we do within our capacity with those references to make ours work too.

It's as simple as that.

While the awareness of this field has been done well, or shoudl I consider it as advanced for many of our Asian counterparts, however, the tapestry of challenges woven through the mental health profession in Singapore DEMANDS a careful and collaborative reevaluation.

As we contemplate the lack of standardization within the profession, the absence of standardized practices, and the critical need for objective outcome measures, we find ourselves at a crossroads.

It's not merely a question of regulating the profession but of fostering a culture that embraces both individuality and a shared commitment to excellence.

The hurdles presented call for introspection and proactive solutions.

While it may seem hard to achieve, but I assure you, that if we start by engaging in open dialogues, addressing uncomfortable truths, and advocating for a nuanced approach to regulation, we can collectively propel the mental health profession in Singapore towards a future marked by clarity, accountability, and the effective delivery of diverse and impactful therapeutic interventions.

These hurdles I've highlighted aren't exhaustive, and I urge you to join the conversation. Let's collaborate to turn the dream of regulation into a reality.

It's taken years to get to where we are. It's going to take years to make this better.

Let's start with you and me.

2 cents.

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