Clinical psychology in a medical setting in Sri Lanka.

It is my observation that Sri Lankan clinical psychologists, contrary to international standards, can, at times, be prevented from independent practice by psychiatric colleagues. This paper suggests reasons for the sometimes strained relations between clinical psychology and psychiatry and discusses the future of the profession in Sri Lanka. An important step would be the establishment of separate departments of clinical psychology in the health system, rather than psychologists being situated within departments of psychiatry.

Sri Lanka (formerly known as Ceylon) is an island lying off the south-eastern tip of India. Its capital is Colombo. The two principal ethnic groups in the country are the Sinhalese and the Tamils. Sinhala is the official language but Tamil is also a national language. English is spoken by about 10% of the population and is commonly used for official purposes. The majority of the population (68%) is Buddhist but substantial minorities are Hindu (15%), Christian (8%) and Muslim (8%).

Sri Lanka’s mental health needs

Sri Lanka has varied mental health needs. The prolonged ethnic conflict, which ended in 2009, affected people physically, psychologically and socioeconomically. In recent times, Sri Lanka has also experienced several natural disasters, the worst of which was the 2004 tsunami, which exposed thousands to trauma, and in addition there have been floods and landslides. Disaster studies indicate serious mental health problems for the survivors of such events and this has been so in Sri Lanka (Wickrama & Wickrama, 2008).

Other than the impact of the ethnic conflict and disasters, Sri Lanka also has other mental health issues. For instance, depression and anxiety are common, with prevalence rates of 2.1% for major depression, 7.1% for other depressive disorders and 0.9% for anxiety-related disorders (Institute of Research and Development, 2007). Further, tobacco, substance and alcohol use and misuse have increased in Sri Lanka and the country has one of the world’s highest suicide rates among adolescents, young adults and those over 70 years (World Health Organization, 2008).

Psychology education in Sri Lanka

Unlike in most Asian countries, psychology education has had a chequered history in Sri Lanka. Only three government universities offer specialised psychology degrees, the first of which was started in the 1990s. A few private institutions, mainly in collaboration with overseas universities, also offer psychology degrees. There are some diploma courses in psychology, which mainly admit non-psychologists; these give a grounding in psychology that students may apply in their own professions. There is only one postgraduate degree in clinical psychology, a Master of Philosophy in Clinical Psychology, which was started in 2008.

Issues in the work setting

A handful of clinical psychologists have been working sporadically in the country since the 1970s. Most of them have been in academic positions, particularly in departments of psychiatry, and at present there are three such psychologists; in lieu of clinical posts, these psychologists practise in teaching hospitals. Other than these posts, the national health system has not, as yet, employed clinical psychologists, although the National Mental Health Policy (Mental Health Directorate, 2005) recommends their provision. Hence, in the government health sector, there are only three clinical psychologists catering for the entire population of the country – some 20 million. Because of the dearth of government employment opportunities, most clinical psychologists are in private work, providing independent out-patient services at non-government hospitals.

In Sri Lanka, the clinical psychologists in the private sector and almost all of those in the government sector practise autonomously. This is in an out-patient context, where direct self-referrals and referrals from psychiatrists and non-psychiatric specialists are taken, for assessment and treatment. Clinical psychologists also provide psychometric services (such as intelligence testing) and forensic psychological services (e.g. evaluations relating to child abuse).

This autonomous practice of most Sri Lankan clinical psychologists in independently assessing, diagnosing and treating patients is in keeping with international practice (Eckleberry-Hunt et al, 2009). However, this has not been without some difficulty. In my experience, although a majority of my psychiatry colleagues have been consistent with these international practices, a minority have resisted, preferring instead to relate in a supervisory mode to clinical psychologists. They appear to be of the view that all patients seeking mental healthcare need a psychiatric and a medical screening and only then can be considered for a clinical psychology referral. If and when a patient is referred to the clinical psychologist, these psychiatrists wish to ‘supervise’ the psychologist’s work, for example psychotherapy or psychometric testing. Some of these psychiatrists have worked in a high-income country as part of their postgraduate training, often in the UK or Australia, but they appear to resist a multidisciplinary approach once they return to Sri Lanka – and work instead in a regressive way.

With so few clinical psychologists per head of population, this mental health profession should be carefully used. Its over-use, misuse and underuse should be curtailed. Such ‘supervision’ of clinical psychologists by psychiatrists runs contrary to international practice and is disrespectful to the profession. It is also a misuse of scarce resources – if these patients wish to consult a clinical psychologist they have no choice but to be seen by a psychiatrist instead – burdening an already overworked system. Further, it erodes goodwill between the two professions. Fortunately, relatively few psychiatrists are of this view: the majority accept clinical psychology as an equal partner in mental health delivery.

Initiating change in medical settings tends to be a slow and, at times, a painful process (Eckleberry-Hunt et al, 2009). This is due in part to the complexity of competing interests. This is seen not only in Sri Lanka but also in countries such as the USA, where the relationship between clinical psychology and psychiatry has often been and continues to be a struggle. General economic trends, along with expansions in the extent of practice by professional psychologists, have and will increase competition and conflict between the two professions (McGrath et al, 2004).

Regulation of clinical psychology

At present, it is the Sri Lanka Medical Council (SLMC) that licenses clinical psychologists. There are about 15 so registered, while a smaller number are not registered, largely because they are not clinically active. I have observed that most Sri Lankan clinical psychologists would prefer to be regulated by a psychology body rather than the SLMC, as is the case in many other countries. The reason for this is that in the SLMC procedure there is no clinical psychologist on the committee that assesses the qualifications of an individual requesting a clinical psychology licence. In fact, until 2000, most clinical psychologists were unaware that they were regulated by the SLMC, until a newspaper article proclaimed the fact. Indeed, internationally, it is unusual for clinical psychology to be regulated by a medical body, because, although it is closely associated with medicine, it is a distinct discipline. Nonetheless, in the absence of a psychology body regulating clinical psychology, the SLMC has done a service in licensing clinical psychologists and preserving the integrity of the profession. However, once a Sri Lankan psychology body is formed, it will naturally take over from the SLMC the governance of its own discipline.

The future of clinical psychology in Sri Lanka

In most parts of the world, clinical psychologists are routinely granted a broad range of hospital privileges (Dörken et al, 1982) and the historic systemic barriers, particularly from psychiatry, that had prevented clinical psychologists from practising independently, fully consistent with their postgraduate level of education and clinical training, appear to have been surmounted. Clinical psychologists have emerged as active players in the healthcare arena, broadening the range of populations they serve, from their earlier exclusive mental health focus. Worldwide, they practise in nearly all hospital departments. In fact, in the USA, even in the 1940s, clinical psychologists worked not only with psychiatrists but also with other medical specialists, who directly called upon their expertise for assistance with the management of medical and even surgical patients. Thereafter, liaison psychology services fast gained momentum.

In Sri Lanka, too, I envisage such a trend. Although, at present, academic psychologists are attached to departments of psychiatry within teaching hospitals, it is important that clinical psychologists expand their horizons by working alongside other medical specialties too. In fact, clinical psychologists should be placed in a separate department of clinical psychology rather than within psychiatry (Goodman, 2000). In order to pave the way for a separate department, clinical psychologists should first form collaborative relationships with non-psychiatric specialists, as they are likely to be supportive. Such collaborations, although in their infancy, are not uncommon in Sri Lanka. A significant barrier for expediting such separate departments is the country’s dearth of psychologists to staff these units. Hence, the country first needs to establish more postgraduate degree courses to train clinical psychologists.

Clinical psychology in Sri Lanka needs to see an improvement in the profile of the profession and this could be best achieved through the establishment of a national psychology association. Such an association would additionally provide continuing professional development for its members. Forming such an association is an urgent need, not only for the specialty of clinical psychology but also for other specialties, such as organisational and forensic psychology.