State of Allied Mental Health Services in Pakistan: A Qualitative Study

State of Allied Mental Health Services in Pakistan: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article State of Allied Mental Health Services in Pakistan: A Qualitative Study Taha Sabri, Uswa Ali Memon, Mariyam Sibghatullah, Ailiya Nooruddin, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9036338/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Allied mental health professionals i.e. clinical psychologists, mental health counselors, and lay counselors, comprise approximately 90% of Pakistan’s mental health workforce. Despite this central role, they operate without licensing bodies, standardized training curricula, or regulatory oversight, creating significant risks for patient safety and persistent barriers to professional development. This study investigated the current state of training, practice, and regulation across these three professional categories. Methods A qualitative descriptive design situated within a constructivist paradigm was employed. Semi-structured in-depth interviews (n = 15) and four focus group discussions (n = 23 participants) were conducted with allied mental health professionals, academics, and policy stakeholders across Sindh, Punjab, Balochistan, Gilgit-Baltistan, and the Islamabad Capital Territory. Purposive sampling ensured variation across professional roles, institutional types, and geographic regions. Data were analyzed using inductive thematic analysis with independent coding and peer review of themes. Results Four themes were identified: (1) inconsistent institute structure and educational training, with wide variation in curriculum quality, internship provision, and supervision standards across institutions and regions; (2) absent licensing mechanisms, with no standardized framework defining scope of practice for any allied professional category; (3) compromised quality of training and supervision, particularly in rural and under-resourced settings; and (4) fragmented collaboration and advocacy, with professional associations lacking enforcement authority and inter-disciplinary rivalries obstructing coordinated reform. Conclusions Significant structural gaps in standardized training, licensing, and regulatory oversight place both patients and allied mental health professionals at risk. A national licensing framework, competency-based training standards, and strengthened inter-agency collaboration are urgently required. These findings offer actionable evidence for policymakers, professional associations, and academic institutions seeking to strengthen Pakistan’s mental health workforce. Allied mental health clinical psychology counseling regulation licensing Pakistan Background Allied mental health services in Pakistan encompass a range of professionals who work alongside psychiatrists to support the mental health system. These include clinical psychologists, mental health counselors, and lay counselors, who differ in education, training, scope of practice, and accessibility [ 1 ]. Clinical psychologists typically hold an MS or PhD in Clinical or Counseling Psychology and are trained in cognitive-behavioral and psychodynamic therapy [ 2 , 3 ]. While HEC-recognized degrees provide legitimacy, no centralized licensing authority regulates their practice. They cannot prescribe medication but are central to non-pharmacological care [ 4 ]. Mental health counselors offer short-term, solution-focused therapy. They often hold a Bachelor's or Master’s degree and a diploma in psychology or counseling [ 3 ]. No standardized certification exists, though some organizations offer training and accreditation [ 5 ]. Lay counselors are community-based workers with basic mental health training, serving particularly in low-resource settings [ 6 ]. They usually complete short-term training from mental health organizations and offer psycho-social support, often as helpline workers or peer counselors [ 5 , 3 ]. Their effectiveness hinges on the quality of training and supervision. Despite being 90% of Pakistan’s mental health workforce, allied professionals face major challenges due to the absence of licensing bodies, affecting both quality of care and professional development [ 1 , 7 , 8 ]. Psychiatrists, in contrast, are licensed through the PMDC and follow a national code of ethics [ 9 ]. The unregulated private sector further exacerbates disparities and ethical concerns [ 10 ]. Fifteen national institutions offer mental health education and research, including programs in psychiatry and psychology [ 7 ]. Many independent centers also provide diplomas in modalities like Humanistic Counseling, EMDR, and CBT [ 11 , 12 , 13 ] However, varying entry requirements lead to inconsistencies. For instance, Therapy Works accepts students with any bachelor’s degree, while CPPD requires a relevant background and emotional intelligence screening [ 14 , 11 ]. Without licensing, individuals with diplomas are often grouped with clinical psychologists, despite distinct training [ 10 ]. Globally, regulation ensures mental health professionals deliver competent care [ 15 ]. In Pakistan, transparency in assessing competency is limited, and policymakers have been reluctant to implement standardized accreditation [ 16 , 17 ]. Organizations like the Pakistan Psychological Association and Pakistan Association of Clinical Psychologists have pushed for licensing frameworks but lack of government support and enforcement has hindered progress [ 18 , 19 ]. The Allied Health Professional Council Act of 2021 aimed to define regulatory structures for allied professionals, but implementation remains pending [ 20 , 21 ]. The absence of a standardized curriculum leads to discrepancies in practitioners’ educational backgrounds and compromises care quality [ 7 , 10 , 22 ]. Efforts by the PPA to introduce national exams have been ineffective due to limited authority [ 18 ]. Although the PPA constitution requires a Master’s for membership, underqualified individuals continue to practice [ 16 ]. The lack of licensing allows unregulated practice, risking patient safety. There is a pressing need for collaboration among academic, policy, and regulatory stakeholders to implement systems ensuring practitioners meet minimum standards [ 16 , 23 , 15 ]. Methods Study design: This study explored the current state of allied mental health services in Pakistan using a qualitative descriptive design situated within a constructivist paradigm. Semi-structured, in-depth interviews (n = 15) and four focus group discussions (n = 23 ) were conducted to capture detailed insights from diverse stakeholders. Setting: Data collection took place across multiple provinces of Pakistan, including Sindh, Punjab, Balochistan, Gilgit-Baltistan, and the Islamabad Capital Territory. Both public and private sector institutions were represented, such as universities, clinics, NGOs, and government mental health facilities. This diversity of settings allowed for a broad understanding of the training, roles, and challenges faced by allied mental health professionals in different contexts. Participants and sampling: Purposive sampling was employed to identify individuals with relevant expertise in allied mental health services in Pakistan. The sample was designed to capture variation across professional roles (clinical psychologists, counselors, lay counselors), institutional affiliations (universities, NGOs, government facilities, and private clinics), and geographic regions (Sindh, Punjab, Balochistan, Gilgit-Baltistan, and Islamabad). In total, the study included 15 allied mental health professionals who were working as policymakers, academics, department heads, faculty, and practitioners, along with students enrolled in advanced training programs who participated through focus groups. Both practitioners and students were included to reflect perspectives from service delivery, training, and policy contexts. Recruitment continued until thematic saturation was reached, at which point no substantially new insights were emerging from additional interviews or focus groups. Inclusion and exclusion criteria: Participants were eligible if they were currently or previously working as a clinical psychologist, mental health counselor, or lay counselor in Pakistan; second if had at least one year of relevant experience or were enrolled in a recognized academic program; and third provided written informed consent to participate in English-language interviews or focus groups. Individuals were excluded if they lacked formal or informal experience in mental health service delivery, declined participation, or were unable to engage in a 60-minute discussion. Data collection: Four focus groups, each comprising 5–6 participants, were conducted alongside 15 individual interviews. A semi-structured interview guide was developed collaboratively by psychologists, psychiatrists, and public health experts to address key mental health issues in Pakistan. Interviews and focus groups were held in Urdu and English (all participants were at least bilingual), each lasting approximately 60 minutes. Researcher reflexivity: The research team had prior experience in delivering mental health services, conducting research, and engaging in policy and advocacy in Pakistan; while this provided useful context, we remained mindful of these positions during the study and prioritized participants’ perspectives in the analysis. Ethics approval: All participants were informed about the purpose of the study and provided written consent. Confidentiality and voluntary participation were emphasized, and participants could withdraw at any stage without consequence. Ethical approval was obtained from the Institutional Ethical Review Committee of the Health Services Academy, Islamabad (Approval No. 7–82/IERC-HSA/2022−54). Data processing and analysis: All interviews and focus groups were audio-recorded with participant consent and transcribed verbatim. Transcripts were anonymized and systematically coded. Using a thematic analysis approach, the team first conducted open coding to capture recurring ideas, then refined and clustered these codes into categories, which were further synthesized into overarching themes. Coding was conducted manually without the use of qualitative data analysis software. To ensure rigor, multiple researchers coded transcripts independently and met regularly to resolve discrepancies. In addition, emerging themes were reviewed with peers outside the core research team for feedback, which helped refine and solidify the thematic structure. Credibility was further enhanced through triangulation across stakeholder groups (professionals, students, policymakers) and team-based interpretation to keep findings grounded in participant accounts. Results The participant sample for this research was stratified across provinces of Pakistan to target the three defined categories of allied mental health services. Perspectives were gathered from field experts, department heads, directors and academics, senior clinicians with years of established clinical practice, students, lay counselors, trainees, early career professionals, and policy makers (refer to Annex 1 for participant characteristics). Institute Structure and Educational Training Clinical psychologists, mental health counselors, and lay counselors each occupy different roles within Pakistan’s mental health landscape, but a common challenge they all face is the inconsistency in training, supervision, and assessment. Mental health counselors' scope of practice is often limited to providing general counseling support, with referrals made for cases that meet DSM-5 criteria for clinical disorders. As one counselor explained, “For such cases, we have been trained to refer clients, because of course we are not psychologists; we are just counselors.” The training process for counselors also varies across institutes. Some institutions have structured, mandatory training programs. One counseling school owner described their approach: “It is a seven-day mandatory training that all participants must attend. As part of the program, we conduct pre- and post-tests to assess their understanding and determine whether they have grasped the concepts taught during the training. The training includes a significant amount of theoretical knowledge as well.” For clinical psychologists, the challenges largely stem from variations in the core curriculum across universities and disparities in internship opportunities. While some institutions offer rigorous coursework combined with practical experience, others integrate psychology into broader social sciences, creating inconsistencies in training. A professor of clinical psychology in Sindh noted: “Different programs have varying requirements for the number and type of assessments and therapeutic sessions students must complete, leading to discrepancies in training quality.” Internships are crucial for clinical psychologists and mental health counselors, providing hands-on experience under supervision. However, opportunities remain limited, particularly in certain regions. Some institutes have managed to sustain structured internship programs with close supervision, typically with a ratio of 5 students to 1 supervisor, offering assessment batteries, therapeutic sessions, and intakes as part of clinical training. These programs also include separate ethics courses, ensuring students are well-versed in ethical and professional practices. However, not all institutes follow this structured approach, leading to inconsistent levels of preparedness among graduates. A psychiatrist from Balochistan highlighted another challenge, emphasizing the regional disparity in internship opportunities: “Trainee psychologists come who do internships with us and then they go on to work in the private sector with good hospitals and organizations outside of Balochistan, all over Pakistan.” This suggests that some regions cannot retain trained professionals due to limited local opportunities. For lay counselors, who may enter the field with diplomas or certifications rather than formal degrees, the primary concern is the lack of clarity for clients regarding credentials. Without clear licensing frameworks, many individuals seeking therapy are unaware of distinctions between clinical psychologists, mental health counselors, and lay counselors. One mental health professional explained: “Most clients don’t even ask about the degree, credentials, or supervisors. This is important information, but they don’t ask.” While some training programs integrate theoretical knowledge with practical experience, the lack of standardization in training and supervision, coupled with regional disparities in opportunities, contributes to inconsistencies in service delivery. Addressing these gaps, whether through more explicit licensing regulations, structured supervision models, or national accreditation systems, could improve the overall quality of mental health care in Pakistan. Existing Licensing Mechanisms The absence of a regulatory body and licensing requirements for allied mental health services in Pakistan has led to significant concerns about the quality of care, professional oversight, and public awareness. Without formal licensing, individuals can label themselves as clinical psychologists regardless of their qualifications, creating confusion for both practitioners and clients. A clinical psychologist from Sindh highlighted the consequences of this gap, "In Pakistan, those who are suffering are because of the lack of proper legislation and a proper regulatory body for mental health practitioners. Because we don't have licensing, many malpractices are happening." This lack of regulation affects clinical psychologists as well as mental health counselors and lay counselors, who operate without a standardized framework defining their scope of practice. As a result, malpractice, inconsistent training standards, and unclear professional roles remain widespread concerns. The Higher Education Commission (HEC) does not provide a clear roadmap for clinical psychology degrees, leading to inconsistencies in qualifications. Individuals with bachelor’s degrees or diplomas in psychology often practice as clinical psychologists despite not meeting the required training hours or specialization. A psychologist from Sindh reflected on this issue, "I don’t have a license, but I still have an HEC degree. I can practice within Pakistan, but if I go to America, I cannot. If I go to Canada, I cannot practice there; I need to get a license there. Even in Pakistan, if there were licensing, anyone from abroad would also need to get Pakistan's licensing. Licensing is necessary..." Additionally, there is no standardized process for clinical supervision, which creates further disparities in training and skill development. Some supervisors lack practical clinical experience despite holding PhDs in research psychology, leading to inconsistent and, at times, ineffective supervision. Another challenge is public misunderstanding of mental health roles. Many individuals seeking therapy or counseling do not differentiate between clinical psychologists, counselors, therapists, or interns. A lay counselor described this issue, "Another very important thing related to this is that our beneficiaries, those who come for therapy or counseling, are not trained enough to know who is actually a clinical psychologist, who qualifies as a counselor, therapist, or intern. Most clients don’t even ask about the degree, credentials, or supervisors. This is important information, but they don’t ask." This lack of awareness contributes to misinformed choices and potential risks for those seeking mental health support. Without proper regulation and client education initiatives, unqualified practitioners can continue to operate without accountability. A long-standing debate exists between clinical psychologists and medical specialists regarding professional hierarchy and authority. Some psychiatrists view clinical psychologists as subordinate to them, which has led to tensions within the field. A professor and chairperson of the Department of Applied Psychology in Punjab emphasized the urgency of moving beyond this debate, "They consider that by being a medical specialist, they are a little more superior than a clinical psychologist. They should be over them. Now, we need to bring this debate to a conclusion because if we remain stuck in this, our bill will never get passed. Licensing, legislation, and mental health policy cannot be approved without consensus." This lack of consensus has stalled efforts to pass essential mental health legislation, further delaying the establishment of a national licensing framework. Pakistan’s mental health sector faces systemic challenges due to the absence of licensing, regulatory frameworks, and standardized training models. Without structured oversight, graduates enter the workforce with inconsistent levels of preparedness, further widening the gap between theory and practice. A national licensing framework, clear supervision guidelines, and public awareness campaigns are essential to address these issues. Establishing a formal licensing body would improve service quality and professional accountability and create a clearer distinction between different mental health roles, ensuring that clients receive appropriate and ethical care. Quality of Training and Supervision The training and supervision of mental health professionals in Pakistan suffer from systematic gaps, leading to inconsistencies in the quality of care provided. A significant concern is the outdated curriculum for psychology programs, which fails to equip students with the practical skills necessary for clinical work. While the Higher Education Commission (HEC) sets the curriculum, its implementation varies across institutions, often emphasizing rote memorization over applied learning. Many students feel unprepared for professional practice after completing their degrees. One mental health counselor noted that they lacked confidence in their training: "When I was in my BS, I didn’t have the confidence that I had received the training I should have.” Many psychology graduates enter the field without sufficient hands-on experience in counseling, assessment, and intervention. Despite completing a 16-year education, they are not necessarily prepared to practice as counselors or clinical psychologists. An assistant professor from the Department of Behavioral Sciences in Gilgit-Baltistan highlighted this concern, “ Even after 16 years of education, we cannot call a psychology student a counselor. For that, training and practical exposure are needed... As a result, the ultimate sufferers are our masses, our community.” Supervisory challenges also stem from the fact that many faculty members, while academically qualified, lack real-world clinical experience that cannot be segregated based on who can practice and who cannot. The lack of standardized competency assessments further exacerbates the problem. Without clear benchmarks for clinical proficiency, training quality varies widely across institutions. Some graduates enter the field with strong practical skills, while others lack the necessary preparation, leading to inconsistent care. The level of supervision is also a major concern. A lay counselor described supervision as "very compromised," explaining that while they meet skilled professionals, "there needs to be more transparency in training and mentorship” to ensure a benchmark across the board. Additionally, training opportunities are heavily concentrated in urban centers, leaving aspiring mental health professionals in rural areas with limited access to education and mentorship. A professor and head of the Department of Psychiatry and Behavioral Sciences in Balochistan explained, "If I talk about other cities, for example, in Karachi, there are many programs, and to a great extent, good training is also being provided. However, in remote areas some private programs take advantage of students' desperation, charge them money for a short course, and then those same students go out and treat patients." This severe shortage of qualified and verified services further exacerbates this issue. This shortage directly impacts service availability; as fewer trained professionals mean millions of Pakistanis lack access to mental health care. An academic described that this can be solved by “institutions providing standardized training, and working together.” A competency-based training system that defines clear skill requirements at each level of education (BS, MS, PhD) is needed to address this. Collaboration and Advocacy Efforts Efforts to improve the psychology curriculum in Pakistan are ongoing, with some universities developing new undergraduate programs in clinical psychology. Psychologists have also advocated for a Pakistan Psychology Council to regulate licensing and professional standards. While collaboration between universities and government-led programs shows promise, challenges remain in securing policy-level support for accreditation and professional oversight. Despite these efforts, mental health professionals in Pakistan do not always collaborate effectively, sometimes viewing their work as competitive rather than complementary. A lack of structured interdisciplinary coordination may result in fragmented care, where individuals struggle to navigate mental health services. A lay counselor working in Sindh emphasized the importance of greater professional unity: "We need to work together across disciplines to improve the overall mental health landscape in Pakistan. There is a lot of potential for collaboration if we can set aside our differences" Strengthening networks among professionals across disciplines, such as psychology, psychiatry, and other allied services could improve the overall service delivery and reduce gaps in patient care. The regulation of mental health professionals is another area of concern. Without a national licensing system, there is no standardized competency assessment for practitioners, which has implications for both the quality of care and professional accountability. A professor of Applied Psychology in Punjab emphasized the urgency of policy reform, stating, “Advocacy for mental health policy reform is crucial. Without it, our field will continue to lag behind and fail to meet the growing needs of the population.” The development of a national mental health policy is needed to address the gaps in mental health care and establish a framework for quality services. Discussion This research highlights key challenges faced by allied mental health professionals in Pakistan, such as role ambiguity, inconsistent training, limited regulatory oversight, and obstacles to professional development [ 24 , 25 ]. These challenges reflect broader systemic gaps, including uneven supervision standards and the absence of a national licensing framework [ 26 ]. As a result, variations in professional competency, unequal access to services across regions, and confusion among the public about mental health roles persist [ 3 , 27 ]. Addressing these systemic issues may benefit from learning from international models and fostering stronger institutional coordination. Globally, countries have introduced regulatory frameworks to bring consistency to training and practice in the mental health sector [ 28 ]. In the UK, the Health and Care Professions Council (HCPC) is responsible for credential verification and professional oversight [ 29 ]. The British Psychological Society (BPS) plays a complementary role by setting accreditation standards [ 30 , 31 ]. In India, the Rehabilitation Council of India (RCI) and the more recent National Commission for Allied Healthcare Professionals Act (2021) demonstrate how governance reforms can shape licensing systems and professional identity [ 32 , 33 ]. In Australia, the Psychology Board of Australia, under the Australian Health Practitioner Regulation Agency (AHPRA), monitors national registration and continuing education [ 34 ]. These systems reflect a shared emphasis on centralized oversight, standardization, and public accountability. Pakistan’s current mental health infrastructure differs significantly. Despite the passage of the Allied Health Professionals Council Act in 2022, regulatory mechanisms for allied mental health professions remain underdeveloped [ 20 ]. Mental health professionals often work in a fragmented landscape with limited guidance on professional roles, licensing, and training pathways [ 25 ]. This situation has implications for service quality and professional growth. Recognizing this, there is a growing need to explore how Pakistan might evolve a more structured regulatory environment [ 7 ]. Establishing clearer scopes of practice, formalizing educational and internship standards, and encouraging inter-agency collaboration could help shape a more consistent framework [ 26 ]. Stakeholders from academia, clinical practice, and policymaking may play a role in these conversations, particularly in relation to credentialing systems and ethical guidelines [ 33 , 35 , 36 ] Efforts to improve training infrastructure and professional development could also benefit from partnerships among universities, private organizations, and hospitals [ 32 , 34 ]. Mentorship opportunities and continuing education might contribute to greater consistency in practice and strengthen the skills base within the profession [ 30 , 34 ]. In this context, fostering public awareness about different mental health roles, such as clinical psychologists, counselors, and lay counselors, could support more informed decision-making among those seeking care [ 24 , 25 ]. Conclusions Ultimately, the variability in training and the absence of standardized licensing systems appear to influence the overall quality of mental health services [ 3 , 4 ]. Gaps in regulation may lead to fragmented care and uncertainty for clients [ 32 ]. Comparative examples from other countries suggest that clearer professional definitions and oversight mechanisms are often associated with improved service delivery and public trust. Understanding these dynamics in the Pakistani context may offer pathways for long-term improvement. Limitations: This study has several limitations. The sample size was relatively small and primarily drawn from urban centers, which may limit the transferability of findings to rural or under-resourced contexts in Pakistan. As a qualitative study, the results are not generalizable but are intended to provide in-depth insights into the experiences of allied mental health professionals. Researcher positionality, shaped by prior involvement in mental health service delivery and advocacy, may have influenced data interpretation, although reflexive discussions and peer review of themes were used to mitigate bias. Finally, the absence of quantitative triangulation limits the ability to compare perspectives with larger-scale data; future mixed-methods research could build on these findings to strengthen policy and program recommendations. Abbreviations AHPRA Australian Health Practitioner Regulation Agency BPS British Psychological Society HCPC Health and Care Professions Council IJMHS International Journal of Mental Health Systems KII Key Informant Interview LMIC Low- and Middle-Income Country PPA Pakistan Psychological Association PMDC Pakistan Medical and Dental Council WHO World Health Organization Declarations Ethics approval and consent to participate This study received ethical approval from the Institutional Ethical Review Committee of the Health Services Academy, Islamabad (Approval No. 7–82/IERC-HSA/2022-54). Consent for publication All participants provided written informed consent prior to data collection. Confidentiality was maintained throughout the study, and participants were assured of anonymity. All participants consented to the publication of anonymized data and quotations derived from the interviews and focus groups. Competing interests The authors declare that they have no competing interests. Funding This article did not receive any funding. Author Contribution TS and MS conceptualized the study and developed the methodology. MS and AN collected the data. UAM conducted the formal analysis. UAM and MS prepared the initial draft. TS provided supervision and critical revision; AM contributed additional critical revisions. All authors read and approved the final manuscript. Acknowledgements We thank the allied mental health professionals and students who generously shared their insights. We are especially grateful to the Health Services Academy (HSA) for ethical approval and institutional support. 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Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 23 Apr, 2026 Reviewers agreed at journal 20 Apr, 2026 Reviewers agreed at journal 17 Apr, 2026 Reviewers invited by journal 17 Apr, 2026 Editor assigned by journal 06 Mar, 2026 Submission checks completed at journal 06 Mar, 2026 First submitted to journal 05 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9036338","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628258356,"identity":"cb672121-a125-46c8-bb02-342e9d343f25","order_by":0,"name":"Taha Sabri","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwElEQVRIiWNgGAWjYFACHgaGD0BKggQNPAyMMxJI1cLMQ5IWe/azBz/b/rCzl2xvPvaAoeKeXQNBW3jykqVzEpITZ/McSzdgOFOcTFgLQ44BUAtzgpxEjpkEY1tCMkGH8fC/Mf5tkVBvLyf//huRWoCGSzMkHGacLcHDBtJiR1jLjTdmlj1pxxNn9qSZSSScSUggqIW9P8f4xg+banuJ44efSXyoSLAnqAUVAK1IbCBRDzCiSNYxCkbBKBgFwx4AADyfNG+Yb1McAAAAAElFTkSuQmCC","orcid":"","institution":"Taskeen Health Initiative","correspondingAuthor":true,"prefix":"","firstName":"Taha","middleName":"","lastName":"Sabri","suffix":""},{"id":628258357,"identity":"204b0d28-c7d4-49da-9bee-654b2658df39","order_by":1,"name":"Uswa Ali Memon","email":"","orcid":"","institution":"Taskeen Health Initiative","correspondingAuthor":false,"prefix":"","firstName":"Uswa","middleName":"Ali","lastName":"Memon","suffix":""},{"id":628258358,"identity":"1b784139-4c00-4a86-ba6b-3e7e5d74a4ad","order_by":2,"name":"Mariyam Sibghatullah","email":"","orcid":"","institution":"Taskeen Health Initiative","correspondingAuthor":false,"prefix":"","firstName":"Mariyam","middleName":"","lastName":"Sibghatullah","suffix":""},{"id":628258359,"identity":"f51ed0b6-a63d-4474-9768-580b05cc8cd6","order_by":3,"name":"Ailiya Nooruddin","email":"","orcid":"","institution":"Taskeen Health Initiative","correspondingAuthor":false,"prefix":"","firstName":"Ailiya","middleName":"","lastName":"Nooruddin","suffix":""},{"id":628258360,"identity":"4ddc96a9-e26a-4759-aada-17d128ff6d18","order_by":4,"name":"Abid Malik","email":"","orcid":"","institution":"Health Service Academy","correspondingAuthor":false,"prefix":"","firstName":"Abid","middleName":"","lastName":"Malik","suffix":""}],"badges":[],"createdAt":"2026-03-05 05:54:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9036338/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9036338/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108006680,"identity":"0f03280e-2013-4a15-805c-db1606e8830a","added_by":"auto","created_at":"2026-04-28 12:56:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":223121,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9036338/v1/9fde6823-0789-4f7e-b40b-07aa4d90d3c4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"State of Allied Mental Health Services in Pakistan: A Qualitative Study","fulltext":[{"header":"Background","content":"\u003cp\u003eAllied mental health services in Pakistan encompass a range of professionals who work alongside psychiatrists to support the mental health system. These include clinical psychologists, mental health counselors, and lay counselors, who differ in education, training, scope of practice, and accessibility [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinical psychologists typically hold an MS or PhD in Clinical or Counseling Psychology and are trained in cognitive-behavioral and psychodynamic therapy [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While HEC-recognized degrees provide legitimacy, no centralized licensing authority regulates their practice. They cannot prescribe medication but are central to non-pharmacological care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Mental health counselors offer short-term, solution-focused therapy. They often hold a Bachelor's or Master\u0026rsquo;s degree and a diploma in psychology or counseling [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. No standardized certification exists, though some organizations offer training and accreditation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Lay counselors are community-based workers with basic mental health training, serving particularly in low-resource settings [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. They usually complete short-term training from mental health organizations and offer psycho-social support, often as helpline workers or peer counselors [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Their effectiveness hinges on the quality of training and supervision.\u003c/p\u003e \u003cp\u003eDespite being 90% of Pakistan\u0026rsquo;s mental health workforce, allied professionals face major challenges due to the absence of licensing bodies, affecting both quality of care and professional development [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Psychiatrists, in contrast, are licensed through the PMDC and follow a national code of ethics [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The unregulated private sector further exacerbates disparities and ethical concerns [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFifteen national institutions offer mental health education and research, including programs in psychiatry and psychology [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Many independent centers also provide diplomas in modalities like Humanistic Counseling, EMDR, and CBT [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] However, varying entry requirements lead to inconsistencies. For instance, Therapy Works accepts students with any bachelor\u0026rsquo;s degree, while CPPD requires a relevant background and emotional intelligence screening [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Without licensing, individuals with diplomas are often grouped with clinical psychologists, despite distinct training [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGlobally, regulation ensures mental health professionals deliver competent care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In Pakistan, transparency in assessing competency is limited, and policymakers have been reluctant to implement standardized accreditation [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOrganizations like the Pakistan Psychological Association and Pakistan Association of Clinical Psychologists have pushed for licensing frameworks but lack of government support and enforcement has hindered progress [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The Allied Health Professional Council Act of 2021 aimed to define regulatory structures for allied professionals, but implementation remains pending [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe absence of a standardized curriculum leads to discrepancies in practitioners\u0026rsquo; educational backgrounds and compromises care quality [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Efforts by the PPA to introduce national exams have been ineffective due to limited authority [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although the PPA constitution requires a Master\u0026rsquo;s for membership, underqualified individuals continue to practice [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The lack of licensing allows unregulated practice, risking patient safety. There is a pressing need for collaboration among academic, policy, and regulatory stakeholders to implement systems ensuring practitioners meet minimum standards [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design:\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThis study explored the current state of allied mental health services in Pakistan using a qualitative descriptive design situated within a constructivist paradigm. Semi-structured, in-depth interviews (n\u0026thinsp;=\u0026thinsp;15) and\u003c/span\u003e four \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003efocus group discussions (n =\u003c/span\u003e 23\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e) were conducted to capture detailed insights from diverse stakeholders.\u003c/span\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSetting:\u003c/h3\u003e\n\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eData collection took place across multiple provinces of Pakistan, including Sindh, Punjab, Balochistan, Gilgit-Baltistan, and the Islamabad Capital Territory. Both public and private sector institutions were represented, such as universities, clinics, NGOs, and government mental health facilities. This diversity of settings allowed for a broad understanding of the training, roles, and challenges faced by allied mental health professionals in different contexts.\u003c/span\u003e \u003c/p\u003e\n\u003ch3\u003eParticipants and sampling:\u003c/h3\u003e\n\u003cp\u003ePurposive sampling was employed to identify individuals with relevant expertise in allied mental health services in Pakistan. The sample was designed to capture variation across professional roles (clinical psychologists, counselors, lay counselors), institutional affiliations (universities, NGOs, government facilities, and private clinics), and geographic regions (Sindh, Punjab, Balochistan, Gilgit-Baltistan, and Islamabad). In total, the study included 15 allied mental health professionals who were working as policymakers, academics, department heads, faculty, and practitioners, along with students enrolled in advanced training programs who participated through focus groups. Both practitioners and students were included to reflect perspectives from service delivery, training, and policy contexts. Recruitment continued until thematic saturation was reached, at which point no substantially new insights were emerging from additional interviews or focus groups.\u003c/p\u003e\n\u003ch3\u003eInclusion and exclusion criteria:\u003c/h3\u003e\n\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eParticipants were eligible if they were currently or previously working as a clinical psychologist, mental health counselor, or lay counselor in Pakistan; second if had at least one year of relevant experience or were enrolled in a recognized academic program; and third provided written informed consent to participate in English-language interviews or focus groups.\u003c/span\u003e \u003c/p\u003e \u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e Individuals were excluded if they lacked formal or informal experience in mental health service delivery, declined participation, or were unable to engage in a 60-minute discussion.\u003c/span\u003e\u003c/p\u003e\n\u003ch3\u003eData collection:\u003c/h3\u003e\n\u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eFour focus groups, each comprising 5\u0026ndash;6 participants, were conducted alongside 15 individual interviews. A semi-structured interview guide was developed collaboratively by psychologists, psychiatrists, and public health experts to address key mental health issues in Pakistan. Interviews and focus groups were held in Urdu and English (all participants were at least bilingual), each lasting approximately 60 minutes.\u003c/span\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResearcher reflexivity:\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe research team had prior experience in delivering mental health services, conducting research, and engaging in policy and advocacy in Pakistan; while this provided useful context, we remained mindful of these positions during the study and prioritized participants\u0026rsquo; perspectives in the analysis.\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthics approval:\u003c/h3\u003e\n\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e All participants were informed about the purpose of the study and provided written consent. Confidentiality and voluntary participation were emphasized, and participants could withdraw at any stage without consequence. Ethical approval was obtained from the Institutional Ethical Review Committee of the Health Services Academy, Islamabad (Approval No. 7\u0026ndash;82/IERC-HSA/2022\u0026minus;54).\u003c/span\u003e\u003c/p\u003e\n\u003ch3\u003eData processing and analysis:\u003c/h3\u003e\n\u003cp\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003e All interviews and focus groups were audio-recorded with participant consent and transcribed verbatim. Transcripts were anonymized and systematically coded. Using a thematic analysis approach, the team first conducted open coding to capture recurring ideas, then refined and clustered these codes into categories, which were further synthesized into overarching themes. Coding was conducted manually without the use of qualitative data analysis software. To ensure rigor, multiple researchers coded transcripts independently and met regularly to resolve discrepancies. In addition, emerging themes were reviewed with peers outside the core research team for feedback, which helped refine and solidify the thematic structure. Credibility was further enhanced through triangulation across stakeholder groups (professionals, students, policymakers) and team-based interpretation to keep findings grounded in participant accounts.\u003c/span\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe participant sample for this research was stratified across provinces of Pakistan to target the three defined categories of allied mental health services. Perspectives were gathered from field experts, department heads, directors and academics, senior clinicians with years of established clinical practice, students, lay counselors, trainees, early career professionals, and policy makers (refer to Annex 1 for participant characteristics).\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eInstitute Structure and Educational Training\u003c/h2\u003e \u003cp\u003eClinical psychologists, mental health counselors, and lay counselors each occupy different roles within Pakistan\u0026rsquo;s mental health landscape, but a common challenge they all face is the inconsistency in training, supervision, and assessment.\u003c/p\u003e \u003cp\u003eMental health counselors' scope of practice is often limited to providing general counseling support, with referrals made for cases that meet DSM-5 criteria for clinical disorders. As one counselor explained, \u0026ldquo;For such cases, we have been trained to refer clients, because of course we are not psychologists; \u003cem\u003ewe are just counselors.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThe training process for counselors also varies across institutes. Some institutions have structured, mandatory training programs. One counseling school owner described their approach: \u003cem\u003e\u0026ldquo;It is a seven-day mandatory training that all participants must attend. As part of the program, we conduct pre- and post-tests to assess their understanding and determine whether they have grasped the concepts taught during the training. The training includes a significant amount of theoretical knowledge as well.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eFor clinical psychologists, the challenges largely stem from variations in the core curriculum across universities and disparities in internship opportunities. While some institutions offer rigorous coursework combined with practical experience, others integrate psychology into broader social sciences, creating inconsistencies in training. A professor of clinical psychology in Sindh noted: \u003cem\u003e\u0026ldquo;Different programs have varying requirements for the number and type of assessments and therapeutic sessions students must complete, leading to discrepancies in training quality.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eInternships are crucial for clinical psychologists and mental health counselors, providing hands-on experience under supervision. However, opportunities remain limited, particularly in certain regions. Some institutes have managed to sustain structured internship programs with close supervision, typically with a ratio of 5 students to 1 supervisor, offering assessment batteries, therapeutic sessions, and intakes as part of clinical training. These programs also include separate ethics courses, ensuring students are well-versed in ethical and professional practices. However, not all institutes follow this structured approach, leading to inconsistent levels of preparedness among graduates.\u003c/p\u003e \u003cp\u003eA psychiatrist from Balochistan highlighted another challenge, emphasizing the regional disparity in internship opportunities: \u003cem\u003e\u0026ldquo;Trainee psychologists come who do internships with us and then they go on to work in the private sector with good hospitals and organizations outside of Balochistan, all over Pakistan.\u0026rdquo;\u003c/em\u003e This suggests that some regions cannot retain trained professionals due to limited local opportunities.\u003c/p\u003e \u003cp\u003eFor lay counselors, who may enter the field with diplomas or certifications rather than formal degrees, the primary concern is the lack of clarity for clients regarding credentials. Without clear licensing frameworks, many individuals seeking therapy are unaware of distinctions between clinical psychologists, mental health counselors, and lay counselors. One mental health professional explained: \u003cem\u003e\u0026ldquo;Most clients don\u0026rsquo;t even ask about the degree, credentials, or supervisors. This is important information, but they don\u0026rsquo;t ask.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eWhile some training programs integrate theoretical knowledge with practical experience, the lack of standardization in training and supervision, coupled with regional disparities in opportunities, contributes to inconsistencies in service delivery. Addressing these gaps, whether through more explicit licensing regulations, structured supervision models, or national accreditation systems, could improve the overall quality of mental health care in Pakistan.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eExisting Licensing Mechanisms\u003c/h2\u003e \u003cp\u003eThe absence of a regulatory body and licensing requirements for allied mental health services in Pakistan has led to significant concerns about the quality of care, professional oversight, and public awareness. Without formal licensing, individuals can label themselves as clinical psychologists regardless of their qualifications, creating confusion for both practitioners and clients. A clinical psychologist from Sindh highlighted the consequences of this gap, \u003cem\u003e\"In Pakistan, those who are suffering are because of the lack of proper legislation and a proper regulatory body for mental health practitioners. Because we don't have licensing, many malpractices are happening.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThis lack of regulation affects clinical psychologists as well as mental health counselors and lay counselors, who operate without a standardized framework defining their scope of practice. As a result, malpractice, inconsistent training standards, and unclear professional roles remain widespread concerns.\u003c/p\u003e \u003cp\u003eThe Higher Education Commission (HEC) does not provide a clear roadmap for clinical psychology degrees, leading to inconsistencies in qualifications. Individuals with bachelor\u0026rsquo;s degrees or diplomas in psychology often practice as clinical psychologists despite not meeting the required training hours or specialization. A psychologist from Sindh reflected on this issue, \u003cem\u003e\"I don\u0026rsquo;t have a license, but I still have an HEC degree. I can practice within Pakistan, but if I go to America, I cannot. If I go to Canada, I cannot practice there; I need to get a license there. Even in Pakistan, if there were licensing, anyone from abroad would also need to get Pakistan's licensing. Licensing is necessary...\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAdditionally, there is no standardized process for clinical supervision, which creates further disparities in training and skill development. Some supervisors lack practical clinical experience despite holding PhDs in research psychology, leading to inconsistent and, at times, ineffective supervision.\u003c/p\u003e \u003cp\u003eAnother challenge is public misunderstanding of mental health roles. Many individuals seeking therapy or counseling do not differentiate between clinical psychologists, counselors, therapists, or interns. A lay counselor described this issue, \u003cem\u003e\"Another very important thing related to this is that our beneficiaries, those who come for therapy or counseling, are not trained enough to know who is actually a clinical psychologist, who qualifies as a counselor, therapist, or intern. Most clients don\u0026rsquo;t even ask about the degree, credentials, or supervisors. This is important information, but they don\u0026rsquo;t ask.\"\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThis lack of awareness contributes to misinformed choices and potential risks for those seeking mental health support. Without proper regulation and client education initiatives, unqualified practitioners can continue to operate without accountability.\u003c/p\u003e \u003cp\u003eA long-standing debate exists between clinical psychologists and medical specialists regarding professional hierarchy and authority. Some psychiatrists view clinical psychologists as subordinate to them, which has led to tensions within the field. A professor and chairperson of the Department of Applied Psychology in Punjab emphasized the urgency of moving beyond this debate, \u003cem\u003e\"They consider that by being a medical specialist, they are a little more superior than a clinical psychologist. They should be over them. Now, we need to bring this debate to a conclusion because if we remain stuck in this, our bill will never get passed. Licensing, legislation, and mental health policy cannot be approved without consensus.\"\u003c/em\u003e This lack of consensus has stalled efforts to pass essential mental health legislation, further delaying the establishment of a national licensing framework.\u003c/p\u003e \u003cp\u003ePakistan\u0026rsquo;s mental health sector faces systemic challenges due to the absence of licensing, regulatory frameworks, and standardized training models. Without structured oversight, graduates enter the workforce with inconsistent levels of preparedness, further widening the gap between theory and practice.\u003c/p\u003e \u003cp\u003e A national licensing framework, clear supervision guidelines, and public awareness campaigns are essential to address these issues. Establishing a formal licensing body would improve service quality and professional accountability and create a clearer distinction between different mental health roles, ensuring that clients receive appropriate and ethical care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQuality of Training and Supervision\u003c/h2\u003e \u003cp\u003eThe training and supervision of mental health professionals in Pakistan suffer from systematic gaps, leading to inconsistencies in the quality of care provided. A significant concern is the outdated curriculum for psychology programs, which fails to equip students with the practical skills necessary for clinical work. While the Higher Education Commission (HEC) sets the curriculum, its implementation varies across institutions, often emphasizing rote memorization over applied learning. Many students feel unprepared for professional practice after completing their degrees. One mental health counselor noted that they lacked confidence in their training: \u003cem\u003e\"When I was in my BS, I didn\u0026rsquo;t have the confidence that I had received the training I should have.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eMany psychology graduates enter the field without sufficient hands-on experience in counseling, assessment, and intervention. Despite completing a 16-year education, they are not necessarily prepared to practice as counselors or clinical psychologists. An assistant professor from the Department of Behavioral Sciences in Gilgit-Baltistan highlighted this concern, \u0026ldquo;\u003cem\u003eEven after 16 years of education, we cannot call a psychology student a counselor. For that, training and practical exposure are needed... As a result, the ultimate sufferers are our masses, our community.\u0026rdquo;\u003c/em\u003e Supervisory challenges also stem from the fact that many faculty members, while academically qualified, lack real-world clinical experience that cannot be segregated based on who can practice and who cannot.\u003c/p\u003e \u003cp\u003eThe lack of standardized competency assessments further exacerbates the problem. Without clear benchmarks for clinical proficiency, training quality varies widely across institutions. Some graduates enter the field with strong practical skills, while others lack the necessary preparation, leading to inconsistent care. The level of supervision is also a major concern. A lay counselor described supervision as \u003cem\u003e\"very compromised,\"\u003c/em\u003e explaining that while they meet skilled professionals, \u003cem\u003e\"there needs to be more transparency in training and mentorship\u0026rdquo;\u003c/em\u003e to ensure a benchmark across the board.\u003c/p\u003e \u003cp\u003eAdditionally, training opportunities are heavily concentrated in urban centers, leaving aspiring mental health professionals in rural areas with limited access to education and mentorship. A professor and head of the Department of Psychiatry and Behavioral Sciences in Balochistan explained, \u003cem\u003e\"If I talk about other cities, for example, in Karachi, there are many programs, and to a great extent, good training is also being provided. However, in remote areas some private programs take advantage of students' desperation, charge them money for a short course, and then those same students go out and treat patients.\"\u003c/em\u003e This severe shortage of qualified and verified services further exacerbates this issue. This shortage directly impacts service availability; as fewer trained professionals mean millions of Pakistanis lack access to mental health care. An academic described that this can be solved by \u003cem\u003e\u0026ldquo;institutions providing standardized training, and working together.\u0026rdquo;\u003c/em\u003e A competency-based training system that defines clear skill requirements at each level of education (BS, MS, PhD) is needed to address this.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCollaboration and Advocacy Efforts\u003c/h2\u003e \u003cp\u003eEfforts to improve the psychology curriculum in Pakistan are ongoing, with some universities developing new undergraduate programs in clinical psychology. Psychologists have also advocated for a Pakistan Psychology Council to regulate licensing and professional standards. While collaboration between universities and government-led programs shows promise, challenges remain in securing policy-level support for accreditation and professional oversight.\u003c/p\u003e \u003cp\u003eDespite these efforts, mental health professionals in Pakistan do not always collaborate effectively, sometimes viewing their work as competitive rather than complementary. A lack of structured interdisciplinary coordination may result in fragmented care, where individuals struggle to navigate mental health services. A lay counselor working in Sindh emphasized the importance of greater professional unity: \u003cem\u003e\"We need to work together across disciplines to improve the overall mental health landscape in Pakistan. There is a lot of potential for collaboration if we can set aside our differences\"\u003c/em\u003e Strengthening networks among professionals across disciplines, such as psychology, psychiatry, and other allied services could improve the overall service delivery and reduce gaps in patient care.\u003c/p\u003e \u003cp\u003eThe regulation of mental health professionals is another area of concern. Without a national licensing system, there is no standardized competency assessment for practitioners, which has implications for both the quality of care and professional accountability. A professor of Applied Psychology in Punjab emphasized the urgency of policy reform, stating, \u003cem\u003e\u0026ldquo;Advocacy for mental health policy reform is crucial. Without it, our field will continue to lag behind and fail to meet the growing needs of the population.\u0026rdquo;\u003c/em\u003e The development of a national mental health policy is needed to address the gaps in mental health care and establish a framework for quality services.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis research highlights key challenges faced by allied mental health professionals in Pakistan, such as role ambiguity, inconsistent training, limited regulatory oversight, and obstacles to professional development [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These challenges reflect broader systemic gaps, including uneven supervision standards and the absence of a national licensing framework [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. As a result, variations in professional competency, unequal access to services across regions, and confusion among the public about mental health roles persist [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Addressing these systemic issues may benefit from learning from international models and fostering stronger institutional coordination.\u003c/p\u003e \u003cp\u003eGlobally, countries have introduced regulatory frameworks to bring consistency to training and practice in the mental health sector [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In the UK, the Health and Care Professions Council (HCPC) is responsible for credential verification and professional oversight [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The British Psychological Society (BPS) plays a complementary role by setting accreditation standards [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In India, the Rehabilitation Council of India (RCI) and the more recent National Commission for Allied Healthcare Professionals Act (2021) demonstrate how governance reforms can shape licensing systems and professional identity [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Australia, the Psychology Board of Australia, under the Australian Health Practitioner Regulation Agency (AHPRA), monitors national registration and continuing education [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. These systems reflect a shared emphasis on centralized oversight, standardization, and public accountability.\u003c/p\u003e \u003cp\u003ePakistan\u0026rsquo;s current mental health infrastructure differs significantly. Despite the passage of the Allied Health Professionals Council Act in 2022, regulatory mechanisms for allied mental health professions remain underdeveloped [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Mental health professionals often work in a fragmented landscape with limited guidance on professional roles, licensing, and training pathways [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This situation has implications for service quality and professional growth.\u003c/p\u003e \u003cp\u003eRecognizing this, there is a growing need to explore how Pakistan might evolve a more structured regulatory environment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Establishing clearer scopes of practice, formalizing educational and internship standards, and encouraging inter-agency collaboration could help shape a more consistent framework [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Stakeholders from academia, clinical practice, and policymaking may play a role in these conversations, particularly in relation to credentialing systems and ethical guidelines [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eEfforts to improve training infrastructure and professional development could also benefit from partnerships among universities, private organizations, and hospitals [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Mentorship opportunities and continuing education might contribute to greater consistency in practice and strengthen the skills base within the profession [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In this context, fostering public awareness about different mental health roles, such as clinical psychologists, counselors, and lay counselors, could support more informed decision-making among those seeking care [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eUltimately, the variability in training and the absence of standardized licensing systems appear to influence the overall quality of mental health services [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Gaps in regulation may lead to fragmented care and uncertainty for clients [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Comparative examples from other countries suggest that clearer professional definitions and oversight mechanisms are often associated with improved service delivery and public trust. Understanding these dynamics in the Pakistani context may offer pathways for long-term improvement.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eThis study has several limitations. The sample size was relatively small and primarily drawn from urban centers, which may limit the transferability of findings to rural or under-resourced contexts in Pakistan. As a qualitative study, the results are not generalizable but are intended to provide in-depth insights into the experiences of allied mental health professionals. Researcher positionality, shaped by prior involvement in mental health service delivery and advocacy, may have influenced data interpretation, although reflexive discussions and peer review of themes were used to mitigate bias. Finally, the absence of quantitative triangulation limits the ability to compare perspectives with larger-scale data; future mixed-methods research could build on these findings to strengthen policy and program recommendations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAHPRA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAustralian Health Practitioner Regulation Agency\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBPS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBritish Psychological Society\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHCPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth and Care Professions Council\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIJMHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInternational Journal of Mental Health Systems\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKII\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKey Informant Interview\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow- and Middle-Income Country\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePPA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePakistan Psychological Association\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePMDC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePakistan Medical and Dental Council\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study received ethical approval from the Institutional Ethical Review Committee of the Health Services Academy, Islamabad (Approval No. 7\u0026ndash;82/IERC-HSA/2022-54).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003e All participants provided written informed consent prior to data collection. Confidentiality was maintained throughout the study, and participants were assured of anonymity. All participants consented to the publication of anonymized data and quotations derived from the interviews and focus groups.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis article did not receive any funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTS and MS conceptualized the study and developed the methodology. MS and AN collected the data. UAM conducted the formal analysis. UAM and MS prepared the initial draft. TS provided supervision and critical revision; AM contributed additional critical revisions. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eWe thank the allied mental health professionals and students who generously shared their insights. We are especially grateful to the Health Services Academy (HSA) for ethical approval and institutional support. We also acknowledge the psychologists, psychiatrists, and public health experts who contributed to tool development, and the research team whose efforts were vital to this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data underlying this study contain sensitive information about research participants and cannot be shared publicly due to ethical restrictions and concerns about participant confidentiality. De-identified excerpts of transcripts relevant to the study\u0026rsquo;s findings are available from the corresponding author upon reasonable request, contingent on approval from the Institutional Ethical Review Committee at the Health Services Academy (Approval No. 7-82/IERC-HSA/2022-54).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eThompson AM, Saleem SM. Closing the mental health gap: transforming Pakistan's mental health landscape. Front Health Serv. 2025;4:1471528. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/frhs.2024.1471528\u003c/span\u003e\u003cspan address=\"10.3389/frhs.2024.1471528\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChadda RK, Prashanth R. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://onlinecounselingprograms.com/become-a-counselor/counseling-licensure/how-to-become-a-counselor-in-michigan/\u003c/span\u003e\u003cspan address=\"https://onlinecounselingprograms.com/become-a-counselor/counseling-licensure/how-to-become-a-counselor-in-michigan/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-mental-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jmhs","sideBox":"Learn more about [International Journal of Mental Health Systems](http://ijmhs.biomedcentral.com/)","snPcode":"13033","submissionUrl":"https://submission.nature.com/new-submission/13033/3","title":"International Journal of Mental Health Systems","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Allied mental health, clinical psychology, counseling, regulation, licensing, Pakistan","lastPublishedDoi":"10.21203/rs.3.rs-9036338/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9036338/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAllied mental health professionals i.e. clinical psychologists, mental health counselors, and lay counselors, comprise approximately 90% of Pakistan\u0026rsquo;s mental health workforce. Despite this central role, they operate without licensing bodies, standardized training curricula, or regulatory oversight, creating significant risks for patient safety and persistent barriers to professional development. This study investigated the current state of training, practice, and regulation across these three professional categories.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA qualitative descriptive design situated within a constructivist paradigm was employed. Semi-structured in-depth interviews (n\u0026thinsp;=\u0026thinsp;15) and four focus group discussions (n\u0026thinsp;=\u0026thinsp;23 participants) were conducted with allied mental health professionals, academics, and policy stakeholders across Sindh, Punjab, Balochistan, Gilgit-Baltistan, and the Islamabad Capital Territory. Purposive sampling ensured variation across professional roles, institutional types, and geographic regions. Data were analyzed using inductive thematic analysis with independent coding and peer review of themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFour themes were identified: (1) inconsistent institute structure and educational training, with wide variation in curriculum quality, internship provision, and supervision standards across institutions and regions; (2) absent licensing mechanisms, with no standardized framework defining scope of practice for any allied professional category; (3) compromised quality of training and supervision, particularly in rural and under-resourced settings; and (4) fragmented collaboration and advocacy, with professional associations lacking enforcement authority and inter-disciplinary rivalries obstructing coordinated reform.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eSignificant structural gaps in standardized training, licensing, and regulatory oversight place both patients and allied mental health professionals at risk. A national licensing framework, competency-based training standards, and strengthened inter-agency collaboration are urgently required. These findings offer actionable evidence for policymakers, professional associations, and academic institutions seeking to strengthen Pakistan\u0026rsquo;s mental health workforce.\u003c/p\u003e","manuscriptTitle":"State of Allied Mental Health Services in Pakistan: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-27 12:15:20","doi":"10.21203/rs.3.rs-9036338/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-23T09:02:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121890845270608501701369355729563432898","date":"2026-04-20T06:17:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4485704544822911031474000240789099381","date":"2026-04-18T00:29:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-17T17:50:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-06T05:47:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-06T05:43:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Mental Health Systems","date":"2026-03-05T05:43:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-mental-health-systems","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jmhs","sideBox":"Learn more about [International Journal of Mental Health Systems](http://ijmhs.biomedcentral.com/)","snPcode":"13033","submissionUrl":"https://submission.nature.com/new-submission/13033/3","title":"International Journal of Mental Health Systems","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e292cd11-220c-4fc1-b739-a577d8b93770","owner":[],"postedDate":"April 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T12:15:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-27 12:15:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9036338","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9036338","identity":"rs-9036338","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}