A Dilemma of Ethics

Following ethics can stimulate a wide range of reactions since the practice
of psychotherapy is complex, multifaceted – and uncharted.

By Zara Maqbool | December 2020


Psychotherapy is picking momentum in Pakistan. More and more people from all age groups but mostly between the 20s and 40s are becoming significantly aware of mental health issues and how critical it is to maintain a healthy state of mind and its impact on their healthy functioning lives. Currently there is an unprecedented rise in mental health issues in the young population.

Over 15 million people in Pakistan are suffering from some form of mental illness, according to latest new report. However, for a population of 220 million, only 400 trained psychiatrists and clinical psychologists and roughly around a 100 therapists /counselors work in Pakistan.

All hospitals have psychiatry units for in-patients and out patients. There are also many clinics operating, some in collaboration with medical services, which only cater to psychological issues. There are also addiction counseling centres or rehabilitation centres and marital counseling and depression/anxiety clinics in major cities.

Psychiatry is the most recognized and the oldest medical profession, followed by clinical psychology, in Pakistan. Practitioners in both these fields are qualified to prescribe medicines and deal with all kinds of mental and personality disorders as well as conditions like depression, anxiety, emotional imbalance, etc. It is also important to know that along with giving medication, they should offer counseling to the patients too.

The Pakistan Medical and Dental Council regulates medical professionals but surprisingly not mental health professionals.

The Pakistan Medical and Dental Council regulates medical professionals in the country but surprisingly not mental health professionals. There is no equivalent licencing body for therapists and counselors.
Psychotherapy is not recognized formally in Pakistan and there is no board of ethics that could hold these psychotherapists responsible for the quality of services rendered or the ethics that they need to follow. Psychotherapy is more like free-lancing and it is up to the individual therapist to maintain a safe practice for his or her clients.

All psychotherapists in Pakistan are foreign-qualified professionals, holding masters degrees or diplomas that permit them to work as independent practitioners. There is no local awarding body or program that trains therapists in the country. Most of these therapists follow various international counseling and psychotherapy boards for ethical guidance. There is also no local board that discredits therapists for malpractices.

There are many unethical practices that occur in psychotherapy, relating to breach in confidentiality, ethical violation and misconduct, but there is no body where psychotherapists can be reported or accounted for. Some basic ethics require that each therapist has been engaged in personal therapy for a significant number of minimum hours so that they are deemed fit to see clients. They also need to be under regular supervision; the supervisor is even more important for practitioners in Pakistan as he or she is someone who the therapist refers his work to and seeks guidance from.

Some unethical practices include therapists charging high fees from their clients and, more importantly, varying their fees according to the client’s financial status. Giving a session time of 50-minutes is another key element and a time bracket of less or more than that regularly is also considered unethical.

Also, a therapist cannot prescribe any medication as he is not licenced to do that. The most important factor is maintaining confidentiality of the client and that is the backbone of this field as earning trust is what the relationship between patient and therapist is all about. This includes not giving any information to any family or friend of the client. It is also unethical to forge reports for court or any other purpose in exchange for huge sums of money.

Another very crucial thing is not having any relationship outside the counseling room for a minimum of six months. This also means not seeing a friend or family member as a client as its tantamounts to a dual relationship and is counter-productive for therapy to work.

As far as mental health clinics are concerned, one hears of malpractices every now and then. But again the alarming thing is that there is no check and balance to see if the service is okay. For example, drug addiction rehabs employ untrained staff, use methods like physical restraint on patients, recommend inappropriate medicines and do not give sufficient psychological support. It is also a common malpractice to accept people who don’t require admission in rehabs.

Another unethical practice is the way psychiatrists do not listen to patients’ issues properly and focus on writing a prescription within two minutes of the interaction. The pharmaceutical industry influences such unethical practices. This also includes not referring clients to appropriate specialists or claiming expertise that the therapists are not trained in, such as hypnosis.

One hopes the Pakistan government gives attention to mental health as a top priority. A regulatory body is essential to ensure safe practices in mental health treatment. A mentally healthy individual certainly contributes more to the collective mental health of society.