How can therapy be regulated in Pakistan?

In 2018, I had just returned from grad-school in New York. As if having to give up on free-refills and ubiquitous central heating wasn’t bad enough, I found myself existentially adrift in a particularly viscous quarter-life crisis.

Someone suggested I see a therapist – which is how I found myself at a place called Therapy Works. Convinced that mine were knots too complex to liberate, I was ready to sabotage the whole thing to prove my point. That proved unnecessary.

After opening by telling me that this was just a part-time gig, the genial lady from across the little cabin unloaded an entire magazine of stock-advice at me. Many people get married against their will, drugs are bad, parents are good. What she lacked in ability to discern that this was of no relevance to me, she made up for in pulmonary capacity. If she took a breath, I didn’t catch it.

After the end of an hour that felt like an instant and an eternity, she asked “Sahi ho gaya na masla? Aur kuch?” I told her that would be all.

I didn’t expect to interact with Therapy Works, ever again. But then, it made national news. Zahir Jaffer – discovered all alone with Noor Mukadam’s mutilated dead body – had allegedly managed to provide therapy sessions through its facilities. The facts were murky but we were told that, in any case, Pakistan does not have the legal setup to do anything about it.

This isn’t exactly true. Yes, there are gaping chasms. But they are punctuated by little islands of law.

Now, let’s say that we want to bridge them. Where do we begin? Because ‘healthcare’ is a provincial subject in Pakistan, each province must pass its own legislation on it. Meanwhile, as the ‘medical profession’ is a federal subject, any legislation passed by the federal government on this will have to be followed by all the provinces. The difference is subtle but important.

Take the case of doctors – who, in Pakistan, include psychiatrists, but not psychologists or psychotherapists. The body that regulates the medical profession is the Pakistan Medical Commission. Because a federal body regulates this, a doctor in Landi Kotal doesn’t stop being a doctor in Layyah.

The PMC regulates the medical profession in two ways: it guards the entry of people into it, and also keeps them accountable for professional (mis)conduct. It conducts the entry test to medical colleges, and accredits the colleges themselves. Only after you fulfill the PMC’s requirements are you licensed to practice, and even then, that licence can be cancelled or suspended. You’ll note, though, that the PMC isn’t regulating the hospitals and clinics through which these doctors provide their services. These ‘healthcare establishments’ fall under the broader category of ‘healthcare’, not the ‘medical profession’.

Now let’s say you find that your therapist may be a murderer (to use ‘therapist’ as a loose, umbrella term). What, in a properly functioning regulatory regime, would your options be?

For starters, there would be a body regulating therapists, individually – like the PMC. That body would only let certain people into the profession, and publish a list of those people. It would also create a code of conduct which, if violated, would lead to removal or suspension from that list. Additionally, it would vet the institutes that train such people, to begin with.

Simultaneously, you would have a parallel regime regulating the institution through which such people were providing their ‘services’. That institution, too, would have a licence that could be cancelled or suspended – in addition to other possible penalties.

Now let’s get rid of the training wheels and see what we actually have. First, regulation of Therapy Works: this is where we do have law. Each province has passed its own, but they all share the same purpose and structure. In Islamabad, this is the Islamabad Healthcare Regulation Act of 2018. While this is the only law that mentions ‘psychologists’ explicitly, the rest are still phrased broadly enough to include them.

The Act creates an Islamabad Healthcare Regulatory Authority, which issues licences to places like Therapy Works. Supposedly, it also maintains a register of all such places along with the people working with them and the exact services they provide – though such a list doesn’t seem to be readily publicly available. The IHRA also has the power to conduct inspections that may even lead to cancellation and suspension of a licence, in addition to fines and jail time.

As it turns out, Therapy Works is not only registered with the IHRA, but the Act also provides recourse for many of the allegations against it. If Therapy Works was, indeed, using the logo of the BACP (a UK-based counselling association) without authorisation, this could lead to suspension of their licence under Section 26(2), in addition to penalties under Section 29. (Oddly, the only way the licence can be revoked altogether seems to be if it was obtained by fraud, to begin with.) 

If it turns out that Zahir was not an employee, but gained access to ‘patient data’ then, if appropriate regulations exist under Section 47(m), those might come into play. If it turns out that he was an employee and that Therapy Works fell short of ‘minimum safety standards’, this, too, could lead to suspension of their licence.

But what of Zahir, himself? Well, here things get complicated. While part of the IHRA’s job is to regulate ‘quackery’ – an offence that can lead to seven years in prison or a two million rupee fine – the definition of a ‘quack’ is tricky. Under the Act, this is someone who is either providing healthcare services without being registered under the ‘respective Council’, or without authorization under ‘any law’.

This is an odd situation to be in. Since there is no law explicitly authorising such people to perform these services, no one would be able to provide any kind of counselling or therapy. In any case, the general principle is that as far as private persons go, they are allowed to do what the law doesn’t prohibit – not the other way round.

And as far as the ‘Council’ goes, that doesn’t exist either. There is a council to regulate doctors, a council to regulate engineers, a council to regulate lawyers (in theory at least), and even a council to regulate hakeems. But there is no ‘relevant Council’ for the likes of Zahir Jaffer.

After previously fizzling out in 2013, a Bill to create such a council is, once again, before the Senate. If passed, the law will establish a national regulatory body for psychologists in Pakistan. The Pakistan Psychological Council will – amongst other things – license psychologists through a ‘certificate of registered psychologists’; maintain a record of all such persons; and also accredit the institutions that train them.

Curiously, there is no express provision for suspension or revocation of a ‘certificate’, once issued – even though the council is to create guidelines on ‘ethical practices’. Because the council is to have ‘any other functions deemed necessary’, this power will hopefully be read into the law. But as is, the law does not prescribe fines and jail time the way the law for doctors and dentists does.

Another important point is that it seeks to regulate only ‘psychologists’. In Pakistan, while psychiatrists are regulated by the existing PMC, psychotherapists and ‘counsellors’ would still operate in a vacuum.

All of this is to say that, for now, even alleged murderers can provide mental health services without bothering about a licence or the threat of losing one. The IHRA could attempt to impose some kind of ad-hoc criteria or the kinds of people a place like Therapy Works might hire, but in the absence of any other law, that would effectively veer into regulation of the profession – something it doesn’t have the power to do.

This is a highway where even a toddler can get behind the wheel and floor the pedal (just so long as they can reach it). Which makes it clear where the road needs to go. There may be countries where the market regulates itself through voluntary third-party accreditation, but Pakistan is not one of them.

The Senate needs to recognize the importance of the Bill that is before it, and plug all these gaps. Provincial bodies like the IHRA need to frame comprehensive regulations to control the wider aspects of healthcare establishments. And those who approach these facilities at their most vulnerable need to be made aware that there are – even now – ways to ensure their protection.

And all of this needs to happen quickly. Because until it does, there is really only one thing ensuring that your bad experience is a well-meaning but inept lady, and not a literal murderer: pure chance.

The writer is a lawyer. He tweets @brainmasalaar and can be reached at [email protected]

This article originally appeared in the August 7, 2021 edition of daily The News. It can be accessed here.