Mental Health or Behavioural Health? Psychology's Identity Predicament Continues

A comprehensive critique of the National Commission for Allied and Healthcare Professions Bill 2021

Credit: Rashi Trehan

Rarely does it happen that a Bill goes to a Parliamentary Committee for improvement and comes back in a worse form. As far as psychology is concerned, this is exactly what happened in the case of National Commission for Allied & Healthcare Professions Bill 2021.

Let’s recap! On December 31, 2018, a Bill entitled the Allied and Healthcare Professions Bill, 2018 (AHPB 2018) was introduced in the Rajya Sabha by the then Union Minister of Health and Family Welfare Mr Jagat Prakash Nadda. Its objective was “regulation and maintenance of standards of education and services by allied and healthcare professionals and the maintenance of a Central Register of Allied and Healthcare Professionals.”  

Understandably, the AHPB, 2018 was sent to the Parliamentary Standing Committee on Health and Family Welfare for examination and report on January 02, 2019. After more than a year (during which the general elections to the Lok Sabha were also held), the Standing Committee presented its report to the Parliament on January 31, 2020. In light of the Committee’s recommendations, the Government revised the Bill and the Union Minister of Health & Family Welfare Dr Harsh Vardhan introduced the new version as the National Commission for Allied & Healthcare Professions Bill (NCAHP Bill) 2020 in the Rajya Sabha on September 15, 2020.

The NCAHP Bill is a landmark legislation and defines two kinds of professionals: allied health professionals and healthcare professionals. The allied health professional is “an associate, technician or technologist who is trained to perform any technical and practical task to support diagnosis and treatment of illness, disease, injury or impairment, and to support implementation of any healthcare treatment and referral plan recommended by a medical, nursing or any other healthcare professional.” They should have obtained a qualification of degree or diploma with a coursework of minimum 2,000 hours spread over a period of two years to four years.

The healthcare professional “includes a scientist, therapist or other professional who studies, advises, researches, supervises or provides preventive, curative, rehabilitative, therapeutic or promotional health services.” They should have a qualification of degree with a coursework of minimum 3,600 hours spread over a period of three to six years.   

The NCAHP Bill covers ten categories of professions such as medical laboratory and life sciences; trauma, burn care and surgical/anesthesia related technology; physiotherapy; nutrition science; ophthalmic sciences; occupational therapy; community care, behavioural health sciences and other professionals; medical radiology, imaging and therapeutic technology; medical technologists and physician associates; and health information management and health informatic professionals.  

The scope of this article is limited to category number seven: community care, behavioural health sciences and other professionals. Two years ago, in an article on AHPB 2018, I had written that in India, psychology as a discipline had always been in an identity crisis and those conflicts of identity were at the heart of that Bill. The new NCAHP Bill shows us that even worse is possible. Let’s unpack the issues with this Bill one by one as far as the ‘community care, behavioural health sciences and other professionals’ category is concerned:

1.     The first problem is the name of the professional category itself. Instead of the usual term “mental health,” the Bill uses “behavioural health.” In fact, it is stated in its Schedule that “‘Behavioural health’ is the preferred term to ‘mental health’.” It does not tell us why, but I will not go into the conceptual debate. The problem I want to highlight is of more immediate and practical significance: the conflict of this nomenclature with the already existing terminology in law.

In India, we have the National Mental Health Policy 2014 and the Mental Healthcare Act 2017. As it is clear from the names of these documents, they use the term ‘mental health’. Similarly, the National Health Policy 2017 also uses this term. Under the Mental Healthcare Act 2017, the clinical psychologists are ‘mental health professionals’, but under the NCAHP Bill, other psychologists and counsellors are ‘behavioural health sciences professionals.’ Why has the government used different terms for the same discipline? Are the sub-fields drastically different in reality? If yes, what are those differences? Would this not create a conceptual, legal and administrative conflict among professionals belonging to the same discipline? And would it not also confuse the people who avail their services?

2.     The term ‘behavioural health sciences’ is defined, in the Bill, as the “scientific study of the emotions, behaviours and biology relating to a person's mental well-being, their ability to function in everyday life and their concept of self.” This definition refers only to “study” and not practice, the more important part which the NCAHP Bill seeks to regulate. For example, in the Mental Healthcare Act 2017, the definition of ‘mental healthcare’ is the “analysis and diagnosis of a person's mental condition and treatment as well as care and rehabilitation of such person for his mental illness or suspected mental illness.” Although not ideal, this definition does include the practice part also, which is of immediate significance with respect to the patients and their care.

3.     The Mental Healthcare Act 2017 includes provisions like informed consent (“consent given for a specific intervention, without any force, undue influence, fraud, threat, mistake or misrepresentation, and obtained after disclosing to a person adequate information including risks and benefits of, and alternatives to, the specific intervention in a language and manner understood by the person”), advance directive (“the way the person wishes to be cared for and treated for a mental illness, and the way the person wishes not to be cared for and treated for a mental illness”) and least restrictive alternative/environment (“offering an option for treatment or a setting for treatment which meets the person’s treatment needs and imposes the least restriction on the person’s rights”).

These provisions put the patients at the centre and recognize their rights. However, the NCAHP Bill does not contain such provisions, depriving the patients of their basic rights in the behavioural health sciences ecosystem. It is possible that the National Commission for Allied & Healthcare Professions would wake up one day and form guidelines about informed consent, advance directive, etc., but the fact is that they would not have the force of an Act made by the Parliament of India. Therefore, these provisions should have been included in the Bill itself.

4.     The NCAHP Bill has excluded clinical psychologists because, the government argues, they are already covered in the Rehabilitation Council of India (RCI) Act, 1992. However, the RCI is under the Ministry of Social Justice and Empowerment, Government of India. The National Commission for Allied and Healthcare Professions is under the Ministry of Health and Family Welfare. It is absurd that one sub-field of psychology — clinical psychology — is regulated by one ministry and other sub-fields would be regulated by another ministry. This makes me wonder if it would be sensible if the psychiatrists were under the Ministry of Social Justice and Empowerment, while all other doctors were under the Ministry of Health and Family Welfare. Moreover, the division of psychologists between two ministries would only create barriers in coordination and collaboration among members of the same profession. In my opinion, it is the government’s laziness and status quoist approach that has led to this bizarre situation.

5.      I hope you have noted that the name of the professional category is ‘community care, behavioural health sciences and other professionals,’ not ‘behavioural health sciences professionals.’ It is primarily for this reason I said in the beginning that the NCAHP Bill went to the Parliamentary Standing Committee for improvement but came back in a worse form.  

In the AHPB 2018, the category was called ‘behavioural health sciences’ and included only psychologists and counsellors. Since many professions were asking for their own independent regulatory councils, the Standing Committee recommended that those Councils should be formed under the overarching National Commission for Allied and Healthcare Professions. It suggested that the similar professions could be clubbed together to form such Councils. Hence, one of the Committee’s recommendations was to group together life sciences professionals, nutrition science professionals and behavioural health professionals to form a Council for Life, Nutrition and Behavioural Health Science Professionals. The Government accepted the idea, but decided to group together community care professionals, behavioural health professionals and “other care professionals” instead. Hence, from both the Government and the Parliament, the psychologists and counsellors got bad deals. Leave alone an independent National Psychology Council, they did not even get their own independent professional category.

Additionally, the category number seven is the only category that includes the term “other professionals.” The government could not even find a proper term for these “other professionals,” because what common label one can put on podiatrists, palliative care professionals and movement therapists (who, in the Bill, include art therapists, dance and movement therapists, and recreational therapists).

6.     The Government of India has adopted International Labour Organization’s International Standard Classification of Occupations – 08 (ISCO-08) for identification and mapping of professionals “so as to allow for global recognition and mobility.” In the Bill, only the names of professions and their ISCO – 08 codes are mentioned, and the definitions of professions are not provided because, as per the government’s argument, “the ISCO document already includes the definition of each profession.”

Herein lies the contentious issue. Only the definition of “psychologist” is provided in the ISCO – 08 and not that of “behavioural analyst,” “integrated behaviour health counsellor,” “health educator,” “disease counsellor,” “clinical social worker,” “psychiatric social worker,” “medical social worker,” etc., which are also included in the behavioural health sciences category. In fact, these professions are not even specifically mentioned in ISCO – 08! What is the difference between a behavioural analyst and an integrated behaviour health counsellor in Indian law? Or the difference between a clinical social worker and a medical social worker? We don’t know!  

Coming back to the definition of a psychologist, the ISCO – 08 actually includes all sub-fields of psychology. Since the NCAHP Bill excludes only clinical psychologists, are we supposed to assume that it includes all other kinds of psychologists including, for example, educational psychologists and organizational psychologists? The plain reading of the Bill indeed suggests so.

7.     The ‘community care, behavioural health sciences and other professionals’ category includes environmental protection officers, ecologists, occupational health and safety officers (inspectors), podiatrists and palliative care professionals also. In the ISCO – 08, the environmental protection officers and the ecologists are categorized as Life Science Professionals. The NCAHP Bill also has a category, in fact the very first, with the same name. Why, then, these professionals are included with mental health, sorry, behavioural health professionals?

Similarly, in the ISCO – 08, the occupational health and safety officers (inspectors) are classified under ‘environmental and occupational health inspectors and associates’ along with food sanitation and safety inspector, pollution inspector and product safety inspector. Going ahead, the podiatrists, art therapists, dance & movement therapists and recreational therapists are categorized as Health Professions Not Elsewhere Classified (2269). The palliative care professionals are mapped under Health Associate Professionals Not Elsewhere Classified (3259). Following ISCO – 08, why did then the government not take all these professions and formed a separate ‘others’ category? Why were these professions forcefully clubbed together with the behavioural sciences? Is it because the government thought that the psychologists won’t notice, or even if they did, then won’t speak against it? If so, I admit that it is a very good reason, but unfortunately not a lawful one.

It is important to mention here that the ISCO – 08 code for occupational therapists is also 2269 (Health Professions Not Elsewhere Classified). Why do then all professions with code 2269 — the podiatrists, art therapists, dance & movement therapists, and recreational therapists — are not grouped together with occupational therapy professionals? Is it because the occupational therapy professionals wanted their own independent category and nobody else to be included with them? Again, an excellent reason, but it destroys the government’s argument that the ISCO – 08 has been strictly followed to recognize and club professions.

8.     The usual higher education structure in psychology consists of a bachelor’s degree of three years, a master’s degree spanning two years, a two-year MPhil, and a PhD (minimum three years). Within the discipline, there is usually no place in the job market for those who hold only a bachelor’s degree. An MA/MSc is necessary. Still, as of today, to be qualified as a registered psychologist and have better career prospects, an MPhil is required. For academia, the PhD is a must (some exceptions can be found here and there though).

As per the NCAHP Bill, the allied health professionals should have a degree or diploma with a coursework of minimum 2,000 hours spread over a period of two years to four years. A BA/BSc would come in this, but from career point of view, it doesn’t have much value in psychology. Hence, the healthcare professionals’ qualification becomes of practical importance who should have a qualification of degree with a coursework of minimum 3,600 hours spread over a period of three to six years. It’s not clear whether the entire coursework has to be covered in one degree or can be covered in more than one degree.

Assuming that it can be covered in two degrees (it would have to be allowed otherwise almost everyone holding bachelor’s and master’s in psychology would be disqualified), the psychologists and counsellors under this Bill would have five years of coursework, whereas the clinical psychologists currently have to undergo seven years of coursework. Does this mean that the behavioral health science professionals would be considered inferior to the mental health professionals? Even if in future, the maximum six years of coursework is made mandatory for other psychologists, it would still not be equal to that of clinical psychologists. It appears that with its poverty of thought, the government has created an unnecessary hierarchy of psychologists. In my view, it has occurred primarily because the government has attempted to impose the realities of medical professions on psychology. [Also, to be noted here is the case of psychiatric social workers: under the Mental Healthcare Act 2017, they need a two-year MPhil (hence seven years of education in total). Under the NCAHP Bill, the maximum course time is six years. So, would there be two kinds of psychiatric social workers?]

9.     There are many psychology professionals in India, who received their education through distance learning mode. The NCAHP Bill states that the allied and healthcare qualification has to be obtained through regular mode only. While I completely support this provision, the care should have been taken to include, in some way, those who already possess distance learning degrees and have accumulated significant work experience. To begin with, these professionals would not be able to provisionally register under Section 38 of this law, which states that “every person who offers his services in any of the recognised categories on or before the commencement of this Act shall be allowed to be provisionally registered under the provisions of this Act.”

Another question is about the continuation of distance learning courses in psychology. Would universities like IGNOU no longer be able to offer degrees in psychology? And if they would be allowed, what would be their degrees’ value in the eyes of National Commission for Allied and Healthcare Professions?

10.  Another major drawback of the NCAHP Bill is the under-representation of psychologists in the Commission and the Professional Council. Every category mentioned in the Schedule of the Bill would have a Professional Council. The President and a member of the Professional Council would be part of the overarching Commission. Now, the President of Physiotherapists’ Professional Council would always be a physiotherapist; that of Nutrition Science Professional Council would always be a dietician or nutritionist; that of Occupational Therapy Professional Council would always be an occupational therapist and so on, but the President of Community Care, Behavioural Health Sciences and Other Professionals’ Council would not always be a psychologist. There would be many times when both the President and the representing member would not be psychologists. (In fact, I am willing to stick my neck out and say that a psychologist would never be appointed as the Chairperson of the Commission.)

Even within the Professional Council, which can have four to twenty-four members, the mental health, sorry again, the behavioural health sciences would never be in focus all the time. The physiotherapists can focus only on physiotherapy and the nutritionists can focus only on nutrition, but the psychologists and counsellors would share time and resources of the Council with podiatrists and ecologists among others. How much impact would it have on behavioural health priorities? It is anybody’s guess.

This under-representation and rejection of psychologists has happened earlier also. For instance, in the Mental Health Policy Group — formed to design the National Mental Health Policy (released in 2014) — there was no practising psychologist. There was hardly any consultation with the psychologists during the drafting of Mental Healthcare Act 2017. Even during the drafting of this Bill, there was virtually no consultation with the psychologists. No psychologist was called by the Parliamentary Standing Committee as expert witness. In short, whenever the government has formed any major law or policy for psychology, the psychologists have never been consulted.

11.  The Clause 11(1)(g) provides for a “uniform entry examination with common counselling for admission into the allied and healthcare institutions.” It is not certain if there would be only one entrance exam for all the professions. I hope not because I do not see why and how a psychology aspirant would take the same entrance exam as the one taken by, say, a future nuclear medicine technologist.

In the earlier version, the AHPB 2018, there was also a provision for “a uniform exit or licensing examination,” which, in NCAHP Bill, has been changed to “exit or licensing examinations.” If we were to read between the lines of this change, then it is likely that there would be only one entrance examination for all categories, but separate exit/licensing examinations. Again, only time will tell how this would pan out.

12.  A point which is applicable to all professions: the NCAHP Bill does not state the minimum period of practical training necessary for qualification as an allied and healthcare professional. The definitions state the total duration requirements only. In my opinion, if it was stated in the law itself, it would have been better.

Also, the functions of the Professional Councils are not defined in the Bill. Hence, their powers and responsibilities have been left at the whims and mercies of the Central Government and the Commission.

To summarise, as far as psychology is concerned, the problems in the NCAHP Bill start from the name of the profession itself. The inadequate and incomplete definition of the professional category, absence of patient centric provisions like informed consent and advance directive, division of psychologists between multiple legislations and ministries, clubbing of other professions with behavioural health sciences category, lack of clarity on definitions and scope of individual professions, creation of an unnecessary and imaginary hierarchy between behavioural health sciences professionals and mental health professionals, no provision for degrees already obtained under distance learning mode, acute under-representation of psychologists, and uniform entry examination are some of the issues which would continue to keep the discipline of psychology stagnant and in a perpetual identity crisis.

Finally, I am restating what I have stated earlier elsewhere also. This Bill is primarily for the medical community. The inclusion of psychologists seems like an afterthought. Many psychologists, of course, work in healthcare settings but not all of them. However, the Bill seems to include all kinds of psychologists, even the ones who do not deal with health. My fear is that the National Commission on Allied and Healthcare Professions would focus primarily on medical and related specialties thereby resulting in continued negligence of students and practitioners from the behavioural health sciences category.

Here we are talking of a discipline which has always been on the margins. Despite its more than a century long existence, the growth and contribution of psychology to Indian society is negligible. The government’s budget allocations to this discipline are minuscule; its members are treated not more than the medical support staff in hospitals; and its identity crisis is so deep that some years ago, the University of Delhi decided to award a BTech in Psychological Science! The fundamental question is essentially this: for how long can the neglect of psychology in India continue? Or a slightly more important question would be: for how long the psychologists would stay silent and allow their neglect to continue?

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