The practice of psychotherapy in Spain (Europe) continues being a reason for doubts, uncertainty, controversy or confusion. The access to psychotherapy is also controversial. To contribute to clarify all this in order to improve quality and minimise risks is the aim of our work.
MethodUpdate of the regulations and legal rules which are applicable in psychotherapy to those graduated in both psychology and medicine.
Results and discussionNeuroscience, clinical psychology and psychiatry develop in a parallel and convergent way. It is necessary to emphasise the risks of pseudotherapies, including pseudopsychotherapies, and pseudosciences in general. The practice of psychotherapy as a psychological treatment necessarily implies the healthcare field both for the private and public sectors. In order to practice as a psychotherapist in Spain, it is necessary to be a psychologist specialised in clinical psychology or a doctor specialised in psychiatry. The figure of the sanitary general psychologist is a regulated profession in Spain at present, but that is not equivalent to be a specialist. The former psychologists who have the required legal qualification are also allowed to act for the public sector in the healthcare field. Other doctors who are not psychiatrists, other psychologists or the nurses specialised in mental health are not allowed to name themselves or act as psychotherapists in any field or sector.
In practice, “psychotherapy” is a word that is often used polysemously. For the Royal Spanish Academy (RAE for its initials in Spanish) of language, which defines the concept, although it does not regulate it, it means the treatment of mental illnesses, psychosomatic illnesses and behavioural problems by means of psychological techniques. And for the same RAE “treatment” means the set of means used to cure or alleviate a disease. Thus, psychotherapy as psychological treatment is the conceptual meaning to be given to that following in this article, as there is currently no standardised and unequivocal definition of competences, training requirements and limits to practise psychotherapy.
As we will see later in the “results” section, in order to accurately apply psychotherapeutic research, one needs to be a clinician with explicit knowledge as a specialist. However, skills acquired through experience alone do not suffice. Despite this, the exclusive practice of psychotherapies by specialised psychology and medicine (clinical psychology and psychiatry, respectively) remains a source of doubt, uncertainty and controversy or confusion and needs to be clarified. The purpose of this paper is to aid that clarification in order to improve quality and minimise the risks arising from inadequate practice. Access to psychological treatment is also sometimes controversial,1 not to mention the nature and type or school of each variety of psychotherapy,2 hindering agreement between professionals.3
Some Spanish associations that consider themselves to be experts assume that they can accredit and train aspiring “psychotherapists”, or they recruit them from health, or from social or human sciences. This is done or permitted in different ways, e.g. by private entities such as the Spanish Federation of Psychotherapists’ Associations, the Spanish Society of Psychosomatic Medicine and Psychotherapy, or the Federation of Associations of Psychologists and Medical Psychotherapists of Spain. And at the international level, the International Society for Emotion Focused Therapy, among many others. It can include, as is happening, a variety of professions, as well as equally diverse qualifications, and is usually supported to the extent that different therapies show comparable efficacy.4 Likewise, as indicated above, there are a multitude of psychotherapeutic orientations that have greater or lesser scientific backing, and there are also integrative perspectives,5,6 or those that claim to be primarily adjusted to the biopsychosocial reality of the moment. Even some self-styled psychotherapists consider the absence of scientificity as an advantage and deny the necessary scientificity of their practice.
Material and methodReview and analysis of the main legal regulations and some of the various provisions regulating psycotherapy in Spain, in addition to the required competences.
ResultsPsychotherapies and university qualifications in psychologyThe competences proposed for a degree in psychology in Spain were detailed in the 2005 White Paper on the Bachelor's Degree in Psychology, published by the National Agency for Quality Assessment and Accreditation (ANECA for its initials in Spanish). The speciality of clinical psychology, which is the only psychological speciality in the country, was created and regulated by Royal Decree (RD) 2490/1998, with content approved and published by Order SAS/1620/2009 of the Ministry of Health and Social Policy. The bachelor's degree does not in itself entitle the holder to practise psychology in the health sector. According to Law 33/2011 General Law on Public Health, partly amended by Law 3/2014, for those who do not hold a degree specifically in the speciality of clinical psychology, a qualification with the corresponding official university master's degree in general health psychology is required as a prerequisite for practising in the health sector. The aforementioned Act 3/2014 stipulates that psychologists who were registered before April 2011 as a care unit or psychology practice in any register of health centres, services and establishments in the country can also continue to practise in the private sector. The same applies to the public sector if they were already working in the sector before that date. See Ministry of the Presidency Order 1107/2002, RD 654/2005 and Law 5/2011 on Social Economy.
The general health psychologist is currently a qualified and regulated profession in Spain. However, as established in 2011 by the General Law on Public Health, only psychologists who specifically hold the title of specialist can carry out their activity as such in the National Health System (NHS) and in approved centres, with the aforementioned exception in Law 3/2014. See also Royal Decree 1393/2007, which established the organisation of official university education. Despite this, there is some debate among some people as to whether or not general health psychology7 should be classified as “specialised”, which would contravene the General Law on Public Health with the first option. General health psychology resembles, in short, the widespread but obsolete and unofficial concepts or disciplines called behavioural medicine or psychosomatic medicine, and medical psychology or health psychology, among other denominations.8
In accordance with the provisions of Law 44/2003 on the Organisation of Health Professions and the General Law on Public Health, the general health psychologist is responsible for practising psychological interventions, provided that they do not require specialised care by other health professionals. As far as primary health care is concerned, the 2011 National Institute for Health and Care Excellence (NICE) guidance9 can be consulted to identify adults with common mental health disorders at this level of care and the pathways to care or referral where appropriate. However, this does not mean that “psychotherapies” of any kind can also be provided by the primary care team, instead of psychological interventions adapted exclusively for the adequate counselling and accompaniment of the user. This applies in particular to general health psychologists, who cannot replace specialists, whether the latter are physically located with primary care or specialised mental health teams. This must be the case, even if various “psychological treatment protocols”10 are sometimes promoted from primary health care, although without specifying who is to evaluate them and which could involve non-specialist evaluators.
It should be noted that the use of information and communication technologies in clinical psychology11 is a separate issue, as is the modern provision of video-conferenced psychotherapy in the public sector.12 This is also the case with some personalised interventions for online self-help for functional symptomatic symptoms, which have already shown good results.13
Post-specialisation and specific training areas, also known as sub-specialities, have been officially established for all professionals in the health care specialities. Likewise, post-specialisation accreditation diplomas and advanced accreditation diplomas have been established, described and regulated in RD 639/2015, all of which are temporary. Currently, there are no diplomas in psychiatry (only four specific functional areas have been approved for the entire medical degree) or psychology. Another issue is the practical existence of numerous branches or fields in psychology, but which are not officially considered training areas, nor specialties or sub-specialties.
Order SSI/890/2017 implements RD 640/2014 which regulates the State Register of Healthcare Professionals created for the whole of the NHS in 2012, updated in 2018. The register incorporates data on all healthcare professionals authorised to work in Spain and is freely accessible. It is attached to the General Directorate of Professional Organisation of the Ministry of Health, Social Services and Equality. Graduates with a degree in psychology can register if they are also specialists in clinical psychology, are qualified in the master's degree in general health psychology or have been granted the previous health qualification. According to RD 640/2014, all private healthcare centres in the country must be included in the General Register of Healthcare Centres, Services and Establishments. These centres will have to have their practising healthcare professionals, including those in professional training, registered in the State Register of Healthcare Professionals. See RD 1277/2003 and Law 16/2003 on Cohesion and Quality of the National Health System.
It should be emphasised that registered psychologists (specialists, with expertise and qualified) are authorised to practise in the public and private spheres. However, according to the aforementioned General Law on Public Health and Law 3/2014, the assessment, diagnosis, treatment and rehabilitation in mental health is the exclusive competence of psychologists specialised in clinical psychology. On the other hand, and as mentioned above, psychologists qualified only in the aforementioned master's degree can intervene and perform only preventive psychological functions and related activities. These activities can be carried out in non-health contexts, or in health contexts, but as non-specialists. It should be noted that non-health psychologists cannot work in health care settings.
Another issue is that healthcare activities can be carried out in a non-health centre, but only if they are carried out by qualified healthcare professionals. The definition of healthcare activity is contained in the aforementioned RD 1277/2003. In 2013, the Centre for Legal Studies and Specialised Training of the Generalitat de Catalunya conceived and structured the training of psychologists in the field of penal execution.14 This centre aims to inform and advise judicial or administrative bodies on the psychological situation of persons involved in criminal proceedings, although it has labelled as “specialised” what in reality is only the qualification of experts.
In Europe, each regulation regulates the practice of psychology as a profession to the best of its ability, and there are no rules establishing common requirements for practising in the field of health. As an example of contrast with regard to the authorised health professionals in our country, the European Federation of Psychologists’ Associations, which is a private entity and which only represents its own members, has declared itself to be partly ignoring the current legislation in this respect. To the surprise of many health professionals, this federation has the collaboration of the General Council of Official Colleges of Psychologists. In fact, this Council refers indistinctly to psychotherapeutic treatments as “interventions” and vice versa, as we will comment again later. Other so-called experts seem to support a certain psychologisation of everyday life15 and, therefore, irrespective of whether or not psychopathology exists. On the other hand, there are authors who would also like to include nurses from public mental health teams in psychotherapeutic training16 and not only as the necessary counsellors or collaborators that they are. In any case, there seems to be no doubt that “psychotherapies” can become a business17 conditioned in the private sphere simply by the market.
Psychotherapies and university qualifications in medicineFor their part, the competences of a degree or diploma in medicine18 are obviously those of the health sciences. Their contents are detailed in the White Paper on the Bachelor's Degree in Medicine, ANECA 2005. For doctors there is the European Directive 93/16/EEC of the Council of the European Union of 1993, aimed at facilitating the free movement and mutual recognition of their diplomas, certificates and other qualifications. This Directive sets common objectives and content for all countries of the European Union. The current law on the Organisation of Health Professions establishes that: “the possession of the title of specialist shall be required in order to expressly use the title of specialist... and to occupy jobs with this title in public and private centres and establishments”.
Mental health is a particularly diverse field of care. Consequently, the fields of action of psychiatry in Spain were formally defined in Order SCO/2616/2008, which approved the reform programme for the speciality. RD 183/2008, which was amended in part by RD 639/2014, determined and classified the specialities of health sciences and developed certain aspects of the specialised healthcare training system. The General Public Health Act also amended in part both the General Health Act 14/1986 and the National Health System Cohesion and Quality Act 16/2003, and provides for the amendment of RD 183/2008. At present, specialised health training in the field of mental health in medicine has included resident interns or MIRs since 1976, in psychology the resident interns or PIRs since 1998 and in nursing the resident interns or EIRs since 2005. RD 640/2014 will in the near future require the MIR system to be restructured. For specialised health training by residency in Catalonia see Decree 165/2015, as published in the Official Journal of the Generalitat de Catalunya.
In the age of neuroscience, psychotherapies have to be well and necessarily integrated with the professional identity of psychiatry.19 Psychiatry is officially concerned with psychotherapy, as specified in the core training programme of the speciality. Indeed, psychotherapies comprise a large proportion of the clinical practice of medical psychiatrists20 as well as specialist psychologists. Other professions and professionals, whether they are health professionals or not, are not officially qualified to carry out psychotherapeutic treatments, even though there are numerous training courses and master's degrees that are easily accessible to almost any interested person. Having said this, from the essential bioethical perspective,21 the principle of primum non nocere (first do no harm) must always prevail in all “psychotherapy”, since any health intervention can cause harm that must be assessed and avoided.
Pseudotherapies and pseudosciences. Valid consentNeuroscience, clinical psychology and psychiatry are and will continue to evolve in parallel and converge. In this sense, the Research Domain Criteria framework was proposed to better systematise the evidence on mental disorders and to improve therapeutic outcomes.22 In practice, there is a remarkable popular receptivity to accept various pseudotherapies.23 In an attempt to combat intrusiveness and, in particular, pseudosciences and pseudotherapies, in 2018 the Spanish Ministries of Health, Consumer Affairs and Social Welfare and of Science, Innovation and Universities approved the Plan for the Protection of People's Health against Pseudotherapies. The plan follows the path initiated at the end of 2011 by the Ministry of Health, Social Policy and Equality against so-called natural therapies. Pseudo-psychotherapies must obviously include pseudo-psychotherapies or psychotherapies lacking adequate scientific backing, whether they are provided by health professionals or by self-styled pseudo-psychologists or alternative psychologists.
Once again, in a manner that is ambiguous and inexplicable to the qualified health professionals in Spain, the General Council of Psychology or General Council of Official Colleges of Psychologists, which is statewide, assured in January 2019 in the digital magazine InfocopOnline that some pseudotherapies “can have contrasting benefits for the health of patients when they are used correctly by professional psychologists”. Furthermore, the Collegi Oficial de Psicologia de Catalunya stated on the web on 21-12-2018 that it shared the contributions of the Consejo General de la Psicologia de España to the Plan de Protección de la Salud frente a las Pseudoterapias of the same year, and proposed three additions to the text of this plan by the Ministries of Health and Science, as did other private entities such as the Andalusian Sociedad for the Advancement of the Scientific Study of Behaviour).
It is also important to consider the preliminary 2019 ministerial report on publications related to techniques with purported health purposes, as well as the “#coNtest” publicity campaign. The conclusions of this report are that more than half of the techniques analysed in Spain do not have any scientific support with a sufficiently solid methodology to evaluate their safety, effectiveness and efficacy, and can therefore be classified as pseudo-pseudotherapies. In particular, not many psychologists practising “psychotherapies” (mainly non-specialists) are well acquainted with techniques that are based on evidence, according to a current limited random sample.24 The above-mentioned Plan for the Protection of People's Health against Pseudotherapies and the subsequent ministerial report of 2019 have not pleased everyone.25 even though they mainly try to protect people who are quite vulnerable. To help in this respect, the observatory of the General Council of Medical Associations currently exists in our country. The aforementioned plan against pseudo-psychotherapies is valid for the public and private spheres, but it still lacks legal regulation, so that it is not possible today to force the closure of places where pseudo-psychotherapies are offered as if they were health care.
Another quite different matter is the importance of knowing that valid or legitimately manifested consent to receive psychotherapy26 should always be given, especially to minors. This must be in accordance with “Law 41/2002 Básica Reguladora de la Autonomía del Paciente...”. See also Circular 1/2012 of the State Attorney General's Office on... “and other medical interventions on minors in cases of serious risk”. Finally, Law 26/2015 on the modification of the system for the protection of children and adolescents reformed Law 41/2002 and incorporated the criteria set out in the aforementioned circular of the Public Prosecutor's Office. Similarly, the need for consent to receive psychopharmacology or medical treatment has been proposed for any patient, whether a minor or an adult.27
It should be borne in mind that the minor is considered to have sufficient maturity at the age of 12, and at the age of 16 years or for those who are independent minors, the so-called legal age of majority is legally recognised. If they are under 16 years of age, without prejudice to the fact that they must be heard, the absence of capacity is presumed. Having said this, the Spanish Civil Code establishes, unless there is a court ruling to the contrary, that “parental authority shall be exercised jointly by both parents or by one only with the express or tacit consent of the other”. This is consistent with the European Convention on Human Rights and Biomedicine (“Oviedo Convention”), in force since 2000.
To complete the reference to consent, the Civil Code is much more conclusive than the current 2010 code of ethics of the aforementioned General Council of Official Associations of Psychologists, which is ambiguous in this respect and limits itself to stating that in the case of psychological “interventions” on minors or legally incapacitated minors, only “their parents or guardians shall be informed”. Nor does the code specify whether it considers such “interventions” only as provided for in 2003 in the Law on the Regulation of Health Professions. Furthermore, it does not even mention the necessary and obligatory consent to receive psychotherapy on the part of those who have the appropriate legal capacity, as is the case for any other non-urgent treatment. And, finally, neither has this code of ethics pronounced itself on the frequent professional use of “psychotherapies” that are not based on scientific methods.
ConclusionsThe field of psychotherapy has evolved enormously in the last few decades and there are many contributions from different psychotherapeutic options,28 but the empirical evaluation of their effectiveness has become a fundamental issue. Another thing is the absurd competitiveness between some psychotherapies and others, although it is well understood that the practice of psychotherapy is already a very important feature of medical care and is becoming more and more so in psychological care.29–31 To practise psychotherapy in Spain, as defined by the RAE, it is necessary to be a psychologist specialising in clinical psychology or a doctor specialising in psychiatry. In particular, other psychologists who have been duly and formally authorised by the competent authority can also act in the health field, although most cannot be psychotherapists if they do not have the speciality or have been authorised. Neither can other doctors or nurses practise psychotherapy. This applies to both the public and private sectors, which may be contrary to many of those involved. In any case, it is primarily a matter of protecting and guaranteeing the highest quality, efficacy, effectiveness and safety for the user, regardless of any preferences or opinions.
FundingThis research did not receive any specific grant or funding from public, commercial or non-profit sector agencies.
Conflict of interestThe author has no personal or financial relationship with other institutions.
To M.ª Pilar Colilla Rubio for reviewing the text in her capacity as philologist.
