Psychology and Psychotherapy
in Health Care
A Review of Legal Regulations in 17 European Countries
Nady Van Broeck1 and Germain Lietaer2
1Universite Catholique de Louvain, 2Katholieke Universiteit Leuven, both Belgium
Abstract. During the last 20 years, psychological interventions and psychotherapy have acquired a modest but significant place in health
care. The lack of a uniform legal definition of these professional activities in the domain of health care hampers quality control of training
programs and delivered services and complicates coordination of care. Training requirements are not always made explicit, and often
there are no mechanisms for quality control or for monitoring compliance with ethical codes of conduct. In this review, the legal regulation
of the professional activity of psychologists in health care and of psychotherapists in 17 European countries is examined. Eleven of these
have adopted a legal regulation the title and the professional activities of psychologists in health care. Seven have an additional law
regulating the title and the professional activities of psychotherapists. In five countries, professionals other than psychologists and medical
doctors can obtain a legally protected title and license to practice as a psychotherapist. Conclusions are drawn concerning the available
models of regulation of psychotherapy and their respective consequences.
Keywords: psychology, psychotherapy, legal regulations, Europe
Introduction
Around 1 person in 10 seeks the help of a psychologist or
psychotherapist at some time in his or her life (WHO, 2002,
2003, 2005). Studies have likewise shown that clients are
mostiy satisfied with the help they receive and they report a
range of positive changes that take place on emotional, cog­
nitive, behavioral, and relational levels (Howard, Moras,
Brill, Martinowich, & Lutz, 1996; Norcross, 2002; Lambert
& Ogles, 2004; Orlinsky, Ronnestadt, & Willutzki, 2004).
The image however is not entirely positive. Research
shows that for a certain number of patients, psychological
interventions and psychotherapy worsen their condition
(Jehu, 1994; Gabbard, 1995; Lamb & Catanzaro 1998; Par­
sons & Wincze, 1995; Fossy, From, & Safran, 2002). Neg­
ative outcomes are often associated with lack of compe­
tence of the professional and with bad practice or abuse of
the professional relationship (Special Task Force on the
Sexual Abuse of Patients, 2001).
Adequate training and control of the quality of the de­
livered services and of respect for ethical and deontological
principals can minimize the eventual iatrogenic effects of
psychological interventions and psychotherapy.To achieve
this goal some countries have developed legal regulations.
In many European countries, however, this regulation does
not exist. Especially with respect to psychotherapy, it is not
at all clear who does what, for which clients, and with what
results. Psychotherapy is practiced by an array of profes© 2008 Hogrefe & Huber Publishers
sionals whose training varies widely. Psychiatrists and psy­
chologists represent the most important group, but there are
also general practitioners, social workers, educators, and
nurses who include psychotherapeutic activities in their
work. Some practicing psychotherapists don’t have a basic
degree in either medical, human, or social sciences (Lie­
taer, Van Broeck, Dekeyser, & Stroobandts, 2005).
Psychological interventions and psychotherapy prac­
ticed by a medical doctor are regulated by law in all of the
European countries. In contrast, for the other professionals
the situation is far less clear. In what follows, we investi­
gate the legal regulations concerning psychological inter­
ventions and psychotherapy practiced by nonmedical doc­
tors in the European countries that surround us. Now that
the European Community is in a phase of enlargement, it
seems useful to assess the present state of affairs in order
to promote the development of comparable regulations and
to inspire those countries that have yet to begin the work
of regulation.
This review is based on the available written publica­
tions and oral communications of representatives of vari­
ous countries (EFPA, 2005; Lundt, 2001; Pulverich, 1997;
Pritz, 2002). Considerable differences on at least three lev­
els, namely the polity, the organization of the health care
and the organization of the educational system complicate
the construction of a unifying framework necessary for this
review. In addition, in many countries regulation initiatives
are in preparation and in various stages of discussion and
decision making, which can lead to rapid changes in time.
European Psychologist 2008; Vol. 13(l):53-63
DOI 10.1027/1016-9040.13.1.53
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N. Van B roeck & G. Lietaer: P sychology and Psychotherapy in H ealth Care
Nevertheless we tried to reflect the actual situation in the
different countries as accurately as possible.
The Countries
We explored the regulations concerning psychology and
psychotherapy in the countries of the European Communi­
ty from its inception until 2004, including Austria, Bel­
gium, Denmark, Finland, France, Germany, Greece, Ire­
land, Italy, Luxembourg, The Netherlands, Portugal, Spain,
Sweden, and the United Kingdom. Because Norway and
Switzerland are often integrated into networks of collabo­
ration, we have taken them into account, despite their being
nonmembers o f the EC.
Examined Parameters
Where psychological intervention is concerned1, we exam­
ined the legal regulations concerning the professional title
of psychologists, license to practice, and registry o f psy­
chologists in the health care system.
Forpsychotherapy, we examined, likewise, the laws on the
title and die license to practice in health care, and the registry.
In countries with a legal regulation o f psychotherapy, we
were especially interested in the option taken, namely psy­
chotherapy as a specialization of the professions o f psy­
chologists or psychiatrists, or psychotherapy as a multipro­
fessional activity. In the latter case, various basic profes­
sions have access to training as a psychotherapist.
In countries where there are legal regulations we exam­
ined the regulatory bodies. In addition, we were interested
in training requirements to obtain the title and the license
to practice. Especially what psychotherapy is concerned, it
is worthwhile to know which basic degree and what level
of clinical experience are the minimum requirements to be­
gin specialized training. The duration and structure o f spe­
cialized training and the existence of any systems of ac­
creditation for such training were considered as well.
Related Questions
The parameters we examined are components o f basic reg­
ulations of the professional activities o f psychologists and
psychotherapists. In all the European countries, the diplo­
ma or university degrees of bachelor, master, and doctor in
psychology or psychological sciences are regulated by law
under the authority of the ministry of Education.
There are a series of related, but interesting, questions
that fall out of the scope of this review. For example, in the
countries where there are relevant laws, these regulations
have been relatively recently implemented. A systematic
investigation o f the consequences o f different models of
legislation upon the practice and the practitioners would be
veiy valuable but is beyond the scope o f this review.
We did not systematically investigate the reimbursement
for psychotherapeutic services by public or private insur­
ance. Needless to say, this issue is also of major importance
in the larger discussion and deserves systematic inquiry.
Another limitation of the present work concerns the pro­
fessional organizations that exist in the various countries.
In the majority of the countries where there are regulations,
the professional associations have played or still play an
important role in the regulation process. These associa­
tions, together with the other protagonists in the discussion,
constructed the profession and the description of the pro­
fessional practitioner. For the most part, they motivated the
governments to establish regulation, and they, together
with other professionals, hold seats on the relevant adviso­
ry and executive bodies. A lack of systematic discussion of
these associations does not, therefore, suggest a negation
of their significant role, but instead a wish to focus on the
results of their actions. In addition, accounting for all of the
professional associations at global, European, national, and
regional levels would have been very difficult2.
The Regulations
Austria
In July 1990, the law addressing psychologists and clinical
psychologists was passed at the same time as a law con­
cerning psychotherapy. This law describes the criteria that
professionals must fulfil if they want to carry the title of
psychologist, clinical psychologist, or psychotherapist and
the criteria for obtaining authorization or license to practice
these professions. Professionals with a license to practice
are registered in national registers of clinical or health psy­
chologists or psychotherapists. The Ministry o f Social Af­
fairs and Health is the regulatory body.
Psychologists who want to carry the title and practice in
the domain of health care have to complete 1,400 hours of
1 Psychological interventions arc defined as the applications of psychology as a science in different domains of human functioning. Health
care is the most important domain of application. For applications in health care the concepts of clinical cm- health psychology and clinical
or health psychologists are often used.
2 At the national level, they are sometimes large organizations with a significant representation, as in the United Kingdom where the majority
of psychotherapists in the UK are represented by the United Kingdom Council of Psychotherapy (UKCP) and the British Confederation of
Psychotherapists (BCP). However, in the majority of countries, there are a variety of associations that each represent a segment of die
psychotherapeutic community. Differences between the groups can relate to basic professions (physicians, psychologists, others), conceptual
frameworks (psychoanalytic, systemic, behavioral, experiential), or particular applications of conceptual frameworks (Jungian psychoanal­
ysis, Lacanian psychoanalysis, and so on).
European Psychologist 2008; Vol. I3(l):53—63
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N . Van B roeck & G. Lietaer: Psychology and Psychotherapy in H ealth Care
supervised practice after their m aster’s degree in psychol­
ogy, which takes approximately 5 years.
Psychotherapy is considered as multiprofessional activ­
ity. Within the Ministry, the Psychotherapy Council is com­
posed of psychotherapists with various basic professions
and different psychotherapeutic orientations. It is responsi­
ble for advising the minister with respect to recognition
(licensure and enrollment in the registry of psychothera­
pists) and compliance with professional ethics. In the event
o f an ethical transgression, psychotherapists can lose their
license and be barred from the register. Psychotherapy is
reimbursed by public insurance, sometimes with supple­
mentation by private insurance.
The law addressing psychotherapy also specifies training
requirements. Training is organized into two cycles. The ba­
sic training (or propaedeuse) requires 2 years. Its prerequisite
is a graduate or baccalaureate degree in education, psychol­
ogy, teaching, nursing, medicine, social work, or theology.
Other professionals can be admitted with special permission
from the Federal Ministry o f Health. The basic training re­
quires 1315 hours o f theoretical training and practice. Those
professionals who have completed only this basic training are
not allowed to carry the title o f psychotherapist or to practice
as an independent psychotherapist. To obtain authorization to
carry the title and practice as an independent psychotherapist,
basic training has to be complemented by specialized train­
ing. Private institutes accredited by the Psychotherapy Coun­
cil of the Federal Ministry of Health organize this specialized
training. The specialized training requires 1,900 hours spread
across 5 years of part-time training.
Belgium
Since 1993, there has been a law protecting the title of psy­
chologist, which is only linked to basic university training
criteria and is administered by the Ministry of the Inde­
pendent Professions. The practice o f psychologists in
health care is not regulated and there is no control with
respect to professional ethics.
The title and the practice o f psychotherapist are not regu­
lated by law (Fossy, From, & Szafran, 2002; Van Broeck,
2000). Because law does not define psychotherapeutic activ­
ities, there is not a system o f licensing that authorizes the
practice or an authority charged with regulating the practice.
Likewise, there is neither quality control nor ethical supervi­
sion of psychotherapy. In view o f the fact that the profession
is not regulated, there is no system of government accredita­
tion for psychotherapeutic training.
Denmark
In Denmark the tide o f psychologist and the authorization
to practice are regulated by law. Holders of a candidate’s
degree in psychology granted after 5 year of university
training (3 years bachelor’s and 2 years candidate’s degree)
© 2008 Hogrefe A Huber Publisher*
55
can obtain the right to carry the tide and practice their pro­
fession after recognition by the Danish Supervisory Board
of Psychological Practice, which is part of the Ministry of
Social Affairs. This recognition as a licensed and registered
psychologist (i.e., authorized psychologist) is only given
after 2 years of additional supervised practice in an institu­
tion accredited to accommodate interns. This authority
within the Ministry also deals with complaints and with
compliance with professional ethics.
Psychotherapy is not regulated by law as a title or as a
profession in its own right. In so far as psychotherapeutic
activities are carried out by psychologists and physicians,
the legal regulations of these two professions are in force
with respect to quality control and ethical obligations.
Finland
In Finland, the the practice of psychologists in health care
is regulated by law. Holders of a Master’s degree in psy­
chology can carry the title and practice the profession in
this field after recognition by The National Council of
Medico-Legal Affairs within the Ministry of Health. No
additional supervised practice after the 5.5 years of univer­
sity training is required. This council and in particular the
Centre for the Legal Protection of Patients in the Health
care system, handles ethical controls. This center functions
for all of the professions in the health domain.
The title of psychotherapist and the practice o f psycho­
therapy are also regulated by law. Psychotherapy is consid­
ered a multiprofessional activity. A psychotherapist can
practice only after recognition by the Ministry of Health.
For access to specialized psychotherapeutic training, the
basic minimum requirement is a bachelor's degree. Spe­
cialized psychotherapy training is spread across 5 years.
France
In France, the title o f psychologist is legally recognized and
is given after a minimum of 5 years of university training.
Registration in the Departmental official lists o f psycholo­
gists is needed to obtain a license to practice.
Since 2004, law regulates the tide of psychotherapist
(though the application rules still have to be made explicit
before the law can be applied). The recognition of the title
has no implications for the practice of the profession or for
ethical regulation. All psychiatrists and psychologists, and
also a number of psychoanalysts who are members o f spec­
ified psychoanalytical associations, can obtain the authori­
zation to use the title o f psychotherapist without further
specialized training. Other professionals can apply to the
Central Council o f Health within the Ministry of Health for
authorization to carry the title. Psychotherapy is, thus, seen
as a multiprofessional activity, with special training re­
quirements for basic professions other than psychologists
and psychiatrists. Recognized psychotherapists are enlisted
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N . Van B roeck & G. Lietaer: P sychology and Psychotherapy in H ealth Care
in a national register kept by the Central Council o f Health
within the Ministry of Health.
Germany
In Germany, the title o f psychologist is recognized on the
basis o f university training o f a minimum o f 5 years. There
is no regulation concerning the practice o f the profession
of psychologists in health care.
The 1999 law addressing psychotherapeutic psychol­
ogists and psychotherapists for children and young peo­
ple regulates the title and practice o f psychotherapy
(K rause-G irth, 2002). Psychotherapy is regarded as a
specialization o f the professions o f psychiatrist and psy­
chologist (diplom psychologen). People with M aster’s
degrees in education (Diplompadagogen) can apply for
the title of psychotherapists for children and young peo­
ple. The law addressing alternative medicine allows other
professionals to engage in psychotherapeutic activities,
but they cannot use the title o f psychotherapist.
The Regional Chambers of Psychotherapy within the
Ministry of Health advise the minister on matters o f train­
ing and the authorization to carry the title on the basis of
the Professional Law on Psychotherapy.
Authorization to practice or licensing for psychothera­
pists and handling of ethical matters is the concern o f the
Provincial Medical Associations (Kassenflrtzliche Bundesvereinigung, or KBV), according to the recommendations
of the Federal Medical Association and on the basis of the
Social Law on Psychotherapy, which also regulates the li­
cense to practice. The Provincial Medical Associations cal­
culate the number o f psychotherapists necessary for the
province and see that there is a baseline proportion of psychiatrists-psychotherapist on the one hand (40%) and of
psychologists-psychotherapist (40%) on the other.
The scientific committee o f the Federal Medical Associa­
tion, together with the social insurance institution, determine
which therapeutic orientations are recognized. Their criteria
are the empirically based effectiveness and efficiency of
methods. This authority also establishes recommendations
for treatment (i.e., treatment guidelines) and the diagnostic
categories for which psychotherapy is suitable.3
In 1992, a law was passed that regulated the postgradu­
ate training in psychotherapy o f general practitioners and
psychiatrists. In 1999, these regulations were extended to
psychologists and psychotherapists for children and young
people. The Federal Ministry of Health determined the
training criteria. For the psychologists - psychotherapists,
this training requires a minimum of 3 years at full time or
5 years at part time. This corresponds to 4,200 hours of
training, including 1,500 hours of theory, 2,400 hours of
outpatient and residential clinical practice, personal thera­
py for the trainee, and supervised work. The Ministry of
Health, on the advise o f the regional chambers of psycho­
therapy, grants accreditation to institutes and hospitals that
can accommodate psychologist-psychotherapists for prac­
tical training (i.e., internship) and to institutes responsible
for theoretical training, personal therapy, and supervision.
Greece
Law regulates the title and the practice o f psychologist in
Greece. Registration and licensing can be obtained after a
university study o f a minimum of 4 years. No additional
supervised practical training is required. The National Min­
istry o f Health is the regulatory body.
For psychotherapy, neither the title nor the practice is
regulated by law (Livas, 2002).
Ireland
University training to obtain a postgraduate degree in psy­
chology takes between 5 to 7 years, in which supervised
practice is included. Law does not protect the title of psy­
chologist and practice of this profession in health care is
not regulated. Legislation is being drafted at present and
should be passed by the government in 2006
Psychotherapy is not regulated by law. As in the United
Kingdom, an umbrella association of psychotherapists (the
Irish Council o f Psychotherapy) has put in place a system
of accreditation. Registry is voluntary and the association
has no legal power to sanction those who inappropriately
use the title or who practice the profession.
Italy
In Italy, the tide and practice of the profession of psychol­
ogy are regulated by law. Holders o f the bachelor’s degree
in psychology - obtained after 5 years of study, equivalent
to a master’s degree in other European countries - must
pass a state examination, complete a 1-year supervised in­
ternship, and register as a member of the Order of Psychol­
ogists (Ordine degli Psicologi) before they can carry the
title and obtain a license to practice the profession in dif­
ferent domains including health care (Parrini, 2002).
Similar to psychology, the title and practice of psycho­
therapy is regulated by law. Psychotherapist is seen as a
specialized professional title for psychologists and psychi­
atrists. As semipublic institutions, the orders of psycholo­
gists (Ordine dei Psychologi) and psychiatrists have the au­
thority to recognize psychotherapeutic psychologists and
psychotherapeutic psychiatrists. The professional orders
J Experience since 1999 demonstrates that obtaining recognition of a new therapeutic orientation requires a well-documented dossier of
empirical research concerning the effectiveness and efficiency of the method. Recently, the humanistic client-centered therapeutic orientation
obtained this recognition.
European Psychologist 2008; Vol. 13(1):53—63
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N. Van B roeck & G. L ietaen P sychology and Psychotherapy in H ealth C ate
are also responsible for ethical controls and accreditation
of specialized training. This specialized training takes ap­
proximately 4 years part-time.
Luxemburg
There is no legislation with respect to the titles and profes­
sional practice o f psychologists and psychotherapists.
Because psychotherapy and psychotherapist have no le­
gal definition, there is neither a system of licensing to au­
thorize practice nor an authority to regulate the practice.
There is no quality control, nor are there ethical controls.
However, the Luxembourg Association o f Psychologists
has developed a code o f ethics that it imposes on its psy­
chotherapeutic psychologist members. This association has
also prepared a plan for legal regulation o f psychologistpsychotherapists.
57
In 2005, however, the Minister of Health reinstalled the
Register of Psychotherapists after a period of political pres­
sure from other professions who no longer had access to the
title. Health care professionals other than psychiatrists and
health care psychologists can again obtain the professional
title of psychotherapist after appropriate training. Psycho­
therapy can, thus, be a specialized service offered by a psy­
chiatrist or health care psychologist or it can be a multipro­
fessional activity as it was according to the law of 1993.
The actual situation is that The Ministry of Well-Being,
Public Health, and Culture recognizes the titles of health
care psychologists, clinical psychologists, and, among
these, the professionals authorized to practice psychother­
apy. Legal jurisdiction with respect to recognition, accred­
itation o f training, registration, management of complaints,
and decisions upon sanctions rest with the Medical Inspec­
tor General for Public Health.
Norway
The Netherlands
The “Law on the Professions o f Health,” or the BIG
(Beroepen in de Gezondheidszorg) law regulates all the
professions in the health domain in The Netherlands since
1993. The initial eight autonomous professions were phy­
sician, pharmacist, dentist, physical therapist, nurse, clini­
cal psychologist (the title o f “psychologist” is no longer
regulated by law since 1993), psychotherapist, and obste­
trician. For each profession, the law specifies the general
titles and specializations, the training requirements, the
fields of competence, the system o f registry, and the mech­
anisms of quality control4.
In the first version of the BIG law in 1993, psychother­
apy was considered multiprofessional activity with a legal­
ly protected title. Several basic professions had access to
the title, as long as a series o f training criteria were met.
Psychotherapists who met these criteria were added to the
Registry of Psychotherapists, held by the Ministry of Well­
being, Public Health, and Culture. Professional recognition
and accreditation o f training were carried out by the Med­
ical Inspection for Public Health. Evolutions in health care,
increases in the number o f registered psychotherapists, and
a growing insistence on “transparent, objective, and effec­
tive” psychotherapies brought a significant change in legal
regulation in 2001. In the new 2001 law initiated by the
Minister o f Health, the multiprofessional title of psycho­
therapist disappeared and the title o f psychotherapist be­
came a specialization o f the title o f psychiatrist and clinical
psychologist, itself a specialized title of health care psy­
chologist To be registered as a health care psychologist and
to gain access to training in clinical psychology and psy­
chotherapy, students must have earned their master’s de­
gree in psychology, pedagogy, or health care sciences.
In Norway, law regulates the title of psychologist and the
license to practice in health care. After 6 years of study
containing a 1 year period of supervised practice, the holder
o f a candidate’s diploma in psychology (equivalent in du­
ration to a m aster’s degree) can apply for recognition as a
psychologist and obtain a license to practice from the Nor­
wegian National Council of Health (i.e., Norwegian Board
o f Health) (van Baalen, 2002).
Psychotherapy is not regulated by law as a separate pro­
fession.
Portugal
Law regulates the title of psychologist and the practice of
psychologists in health care in Portugal. The Ministry of
Health is the regulatory body. The title and the practice of
psychotherapist are not regulated by law (Rodriguez, Cor­
reia, & Simoes, 2002).
Spain
In Spain, law protects the titles of psychologist and o f clin­
ical psychologist. A council in the Ministry of Health com­
posed o f members of The Official College of Psychologists
(Colegid Oficiale de Psicdlogos) and of representatives of
other health professions grants the title of psychologist and
clinical psychologist and gives authorization to practice
these professions. The official councils of psychologists
and physicians are responsible for the organization o f ac­
creditation exams for psychologists specializing in clinical
psychology and for the accreditation of training programs.
* The BIG law legislates titles without reserving acts for certain professions, except for certain exceptions referred to as “reserved acts.”
© 2008 Hogrefe & Huber Publishers
European Psychologist 2008; Vol. 13(1):53—63
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N. Van B roeck & G . L ietaen Psychology and Psychotherapy in H ealth C are
These colleges also deal with the recognition of hospitals
and centers that can accommodate trainees for supervised
clinical work.
The law does not regulate psychotherapy.
Sweden
In Sweden, law protects the title o f psychologist Recogni­
tion as a psychologist by the Swedish National Board of
Health and Welfare is necessary to practice as an authorized
psychologist in the fields of health and medicine. This au­
thorization can be obtained after a 5-year university train­
ing (M aster’s degree) in psychology, complemented by a
1-year supervised practical training. There is no additional
legislation with respect to clinical psychology.
The profession o f psychotherapy is regulated by the laws
of 1978 and 1992 on the authorization to practice a profes­
sion within the health and medical services (Grebo & Elmquist, 2002). Psychotherapy is considered a multiprofes­
sional activity. Directives on the authorization to carry the
title and practice are given by the Swedish National Board
of Health and Welfare. Regulation of professional ethics is
the concern of a common authority for all the professions
in the field of health, specifically the Board o f Responsi­
bility of the Health Care System (or HSAN). This council
is a governmental authority composed o f eight members
representing the professions, the parliament, and profes­
sional unions.
Psychotherapy training is organized in three stages. The
first is a basic program of around 3 years, which is acces­
sible after secondary studies and which leads to a baccalaureate-level degree. With this degree the professional can
practice psychotherapeutic interventions under supervi­
sion. The majority of persons who complete this training
work in hospitals or institutions with specific populations.
The second stage is training in psychotherapy. Psychiatrists
and psychologists have direct access to this specialized
training. Other basic professions, such as social workers,
dentists, general physicians, nurses, priests, etc., must have
completed the first stage of training. The specialized train­
ing extends for a minimum o f 3 years, but it takes an aver­
age of 5 years and is composed of courses, supervised clin­
ical work, a thesis, and personal therapy. A possible third
stage o f training prepares psychotherapists to function as
supervisors.
The Swedish National Board o f Health and Welfare
grants accreditation to training institutions that offer the
specialized training and to centers that can accommodate
trainees for supervised practice (including public centers,
hospitals, and private practices).
Switzerland
Until now, Switzerland has not had a federal law regulating
the professions o f psychologist clinical psychologist and
psychotherapist but instead has had regional (i.e., cantonal)
laws (Faeh, 2002).
Currently, a law proposal concerning the titles of psy­
chologist and the established specializations (e.g., clinical
psychologist, psychotherapy specialist psychologist) and
the practice o f these professions is in the process of legis­
lation. This proposal envisages recognition o f the title of
psychologist and autonomous professional practice for
psychologists in general and allows for different special­
izations (clinical psychologist, psychotherapy specialist
psychologist traffic psychologist etc.).
In this law proposal psychotherapy is seen as a special­
ization of the professions o f psychology and medicine. Ex­
ecution of the law with respect to recognition and ethical
controls will be the concern of the Ministry of Health.
United Kingdom
There is no law protecting the titles of psychologist, clinical
psychologist and psychotherapist and as a consequence
there is no system o f legal regulation of practice (Loewenthal & Casement, 2002). By a Royal Decree, the profes­
sional association of psychologists (British Psychological
Society) has obtained authorization to grant the title of
Chartered Psychologist and the title of Chartered Clinical
Psychologist. For practice in the public health care system,
recognition and registry as a Chartered Psychologist or
Chartered Clinical Psychologist are required. To obtain the
title o f Chartered Psychologist and Chartered Clinical Psy­
chologist university training of a minimum of 6 years, in­
cluding a 1-year supervised practical training, is required.
There is no legal regulation for independent practice o f the
professions of psychologists and clinical psychologist.
The title o f psychotherapist and the practice o f psycho­
therapy are not regulated by law3.
Synthesis
Legal Regulations
A table synthesizing the regulations concerning the titles
and professional activities of psychologists and psycho­
therapists is not easy to draw. This is because there are
different models of regulation, each with their own charac­
teristic criteria o f recognition and their own particular reg­
ulatory authorities. In addition, different levels of regula-
5 Two professional associations attempt to regulate the profession. The first is the United Kingdom Council of Psychotherapy (UKCP) and
the second is the British Confederation of Psychotherapists (BCP). They are councils composed of representatives from the various profes­
sions who practice psychotherapy. They maintain the national registries of psychotherapists. They deal with registration of psychotherapists,
accreditation of training, and ethical regulation. The councils have no legal power and registration is voluntary.
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N . Van Broeck & G . Lietaer: Psychology and Psychotherapy in H ealth Care
Table 1. Legal regulations concerning the title and the prac­
tice o f psychologists in health care and the title
and practice o f psychotherapists in 17 European
countries
Country
Law on the practice Law on the title and
of psychologists (li­ the practice of psy­
censing and regis­ chotherapist
try) in health care
59
Table 2. Legal Agulation of psychotherapy as a specializa­
tion o r the professions o f psychiatrists and clinical
psychologist or as a multiprofessional activity in
the seven countries with a legal regulation o f this
professional activity
Country
Psychotherapy as a specialization Psychotherapy as
of the professions of psychiatrist a multiprofessionand clinical psychologist
al activity
1 Austria
X
X (M)
Austria
/
X
2 Belgium
3 Denmark
/
/
I
X
X
/
Finland
France
4 Finland
X
X(M)
Germany
/
X
/
5 France
6 Germany
X
X(M)
Italy
X
/
/
X(S)
Netherlands1 X
7 Greece
X
/
/
/
X
/
Total
3
5
In the Netherlands, both solutions exist: psychotherapy as a special­
ized professional title of psychologists and psychiatrists and psycho­
therapy as a multiprofessional activity.
8 Ireland
X
X(S)
/
11 Netherlands'
/
X
12 Norway
X
/
13 Portugal
X
/
14 Spain
15 Sweden
X
/
X
X (M)
16 Switzerland
/
/
9 Italy
10 Luxemburg
X(M + S)
/
17 United Kingdom
I*
7
Total number of
11
countries
M: psychotherapy is seen as a multiprofessionnal activity, S: psycho­
therapy is seen as a specialized professional title of psychologists and
psychiatrists. *no laws but Royal Decrees: titles of Chartered psychol­
ogist and Chartered clinical psychologist
In the Netherlands, both solutions exist: psychotherapy as a special­
ized professional title of psychologists and psychiatrists and psycho­
therapy as a multiprofessional activity.
tion can be adopted. Regulation can be at the level o f a
national law (Germany, Italy, The Netherlands, and Spain),
a regional law (Switzerland), or at the level o f a regulation
administered by professional associations (United King­
dom). Despite this diversity, we now attempt to identify the
recurrent themes.
As shown in Table 1, in 11 of die 17 European countries
taken into account, national legislation concerning the title
of psychologist and die practice o f this profession in the
field of health care is in effect (If we include the United
Kingdom with a regulation by Royal decree, this is the case
in 12 out of 17 countries.) The authorization to practice
implies control o f compliance with ethical regulations.
In seven of the 17 European countries taken into account
additional legislation concerning die title and the practice of
psychotherapy is in effect (Austria, Germany, Finland,
France, Italy. The Netherlands, and Sweden) (see Table 2).
Among the countries where there is legal regulation of
psychotherapy, two models can be distinguished. In the
first model, psychotherapy is considered to be a specializao 2008 Hogrefe & Huber Publishers
X
X
Sweden
tion of the professions of psychologist and psychiatrist.
This is the case in three out of the seven countries with legal
regulation of psychotherapy, namely Germany, Italy, and
The Netherlands.
In the second model, psychotherapy is considered a mul­
tiprofessional activity with a specific training curriculum
accessible to various professions. This is the case in 5 coun­
tries, namely Austria, Finland, France, The Netherlands,
and Sweden. In France, where psychotherapy is primarily
a specialized activity of medical doctors and psychologists,
the situation is mixed because psychoanalysts with various
basic training also have the right to use the title. O ther pro­
fessionals will also be admitted to specialized training. In
The Netherlands, both models coexist according to the
training program that has been followed.
Access to and Duration of Specialized
Training in Clinical Psychology and
Psychotherapy
In all the European countries where the law regulates the
title and practice of psychology in health care, a university
master's degree is required. The mean duration of the basic
university training is 5 years. In all these countries a period
o f supervised practice or internship is required to fulfill the
criteria for legal recognition. In die seven countries w ith a
law this training is included in the basic training, The other
4 countries impose a period of approximately 1-year of su­
pervised practice in an accredited institution after the mas­
ter’s degree in psychological sciences (see Table 3).
Access to training differs considerably in the seven
countries where psychotherapy is regulated by law. In those
countries where psychotherapy is considered a specializa­
tion o f the professions of psychiatrist and psychologist ac­
European Psychologist 2008; Vol. 13(1)^3-63
N. Van B roeck & G. Lietaer: Psychology and Psychotherapy in H ealth C are
60
Table 3. Training curriculum of psychologists in the 11 countries with a legal regulation of the title and the practice of
psychology in the field of health care
University training
Country
Supervised practical training
(Internship)
Title
Total duration
Degree/Nr. years Degree, Nr. years Included in uni­ Additional to university
versity training training and duration in
years if required
Austria
Bachelor (3)
Masters (2)
Clinical and health
psychologist
X (2)
Authorized psychologist
5+2
X (0:06)
Psychologist
5;05
Masters (2)
X
Psychologist
Masters (2)
X
Psychologist
5
4
Psychologist
6
Masters (3)
X (l)
Health care psychologist,
clinical psychologist
6
Denmark
Bachelor (3)
Candidate (2)
Finland
Bachelor (3)
Masters (2;06)
France
Bachelor (3)
Greece
Bachelor (2)
Italy
Bachelor (5)
The Nether­ Bachelor (3)
lands
X, (1480 h)
X (1)
Norway
Bachelor (3)
Candidate (3)
X
Authorized psychologist
6
Portugal
Bachelor (2)
Master (3)
X
Psychologist
5
Spain
Bachelor (2)
Masters (2)
X
Psychologist
5
Sweden
Bachelor
Masters
Psychologist
5+ 1
Number of countries
7
cess is limited to these professions and the duration of the
specialization training is approximately 3 years part-time6.
In the countries where psychotherapy is a multiprofession­
al activity, access and duration vary considerably. In Finland
people who have a completed a baccalaureate have access to
specialization training, which takes approximately 5 years
part-time. In Austria and Sweden access is broader and the
level of basic training is lower (secondary studies), but this is
balanced by a specialized training with a longer duration of
7 years. In France, for the time being, no additional training
is required. In The Netherlands a variety of programs for
specialization training are accredited with a mean duration of
3 years part-time after a master’s degree.
Regulatory Authorities
In all the countries where there is recognition o f the titles
and practices o f the professional activities of psychologists
in health care and psychotherapists, the decisional power
rests with the Ministries o f Public Health.
The ministers make decisions based on advice given by
the national councils. The national councils o f the profes­
sion are composed o f representatives o f the various health
care professions, with a majority o f the representatives
drawn from the profession in question7. These national
councils operate within the ministries, and they offer advice
on decisions related to criteria for accreditation of training,
X (l)
4
professional recognition, procedures for handling com­
plaints and sanctions, etc. The regional authorities respon­
sible for organization and coordination of health care are
charged with carrying out these decisions and hold the reg­
istries of licenses to practice (Germany and The Nether­
lands).
In Italy and Spain, power is delegated to the professional
associations, who become semipublic institutions. The ad­
vantage o f this solution is that the conceptual framework
of the profession is well represented. The disadvantage
may be that the government loses some o f its control and
that this creates a possibility that the institution’s objectives
may drift (e.g., toward corporatism, increasing financial
obligations for the professionals obligated to join, decreas­
ing transparency, etc.).
With respect to the titles of psychologist and clinical
psychologist, a solution along the same lines exists in the
United Kingdom. By Royal Decree the professional asso­
ciation has obtained the right to grant the titles of Chartered
Psychologist and Chartered Clinical Psychologist. These
are not legal titles, but by making these titles a prerequisite
for practice in the public health network, they acquire con­
siderable importance in the regulation o f the profession.
In a majority (11 of 17) of the European countries taken
into account, a legal regulation of the title and the practice
o f psychologists in health care is constituted. In some cases
a specific professional title of clinical psychologist or
health care psychologist is granted to psychologists work-
‘ If we include the United Kingdom with a regulation by Royal decree, this is the case in 12 out of 17.
7 It is necessary to ensure that these councils are carefully organized, so that one profession does not have a much greater influence on the
council’s decisions than does another. The psychotherapists in Germany complain about the significant influence of physicians on the
councils that make recommendations about decisions concerning psychotherapy.
European Psychologist 2008; Vol. 13(l):53-63
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N . Van B roeck & G. Lietaer: P sychology and Psychotherapy in H ealth Care
61
Table 4. Training o f psychotherapists in the seven countries with a legal regulation of the title and the practice o f psycho­
therapists
Minimal level of academic training
Country
Sweden
Secondary education
Austria
Bachelor
Clinical Specialized training in psychotherapy
experi­
ence*___ _______
____
____________
Bachelor
Masters
2_____ 3
1
2
Specialization (3 to 5 years)
Propaed
ease
Specialization (5 years)
Finland
Bachelor
Specialization (5 years)
Germany
Masters psychology, medicine
Specialization: 3 full time or 5 years
parttime
Italy
Masters Psychology/medicine
4 years part time
The Neth­ Masters medicine/clinical psy­
erlands
chology or other master
3 years
France
Masters in medicine, psychol­
ogy or psychoanalyst
* in many countries a period of clinical practice is required before having access to specialized psychotherapy training
Dark grey: minimal level of academic training required to have access to the specialized training in psychotherapy
Light grey: number of years of training in psychotherapy
ing in this field. This regulation implies control of compli­
ance with professional ethics.
The training curriculum required to obtain the title and
the license to practice is in most countries a university de­
gree (masters or equivalent) o f a minimum of 5 years of
formal training8 and supervised clinical practice. In seven
countries this supervised practice is included in the curric­
ulum, in 4 countries one or more years of additional super­
vised training in accredited training institutes is required
after graduation from the university.
Seven countries have an additional legal regulation of
psychotherapy. Three adopted the model of psychotherapy
as a specialization o f the professions of psychologist and
psychiatrist. In five out of these seven, psychotherapy is
considered a multiprofessionnal activity.
Discussion
Apparently most countries considered the regulation of
psychology in health care the most important issue.
When an additional legal regulation of psychotherapy
exists, both models o f regulation can be observed. With
respect to the choice among models, it seems to us that
there are advantages and disadvantages o f each system.
Recognition of psychotherapy mainly as a specialization of
the professions o f psychiatry and psychology (Germany,
The Netherlands, and Italy) has the advantage that there is
a guaranteed minimum level of training, namely a master’s
•
9
degree in the social or medical sciences. A disadvantage of
the specialization model is that a range of professionals
who engage in psychotherapeutic activities remain unrec­
ognized and uncontrolled. One could remedy this by cre­
ating a specific professional title, such as the title o f “coun­
sellor,” as it is used in the United Kingdom.
Recognition o f psychotherapy as a multiprofessionnal
activity in its own right9 has the advantage that there is
recognition and a degree of control over all the profession­
als who practice psychotherapy. The disadvantages are that
it is necessary to put in place an elaborate and expensive
system of accreditation of parallel training programs. The
number o f psychotherapists has a tendency to increase rap­
idly. The public is often unaware of the basic training of
these various psychotherapists. The only solution for this
is including the name of the practitioner’s basic profession
such as psychiatrist, psychologists, priest, nurse, or social
worker in front o f the title o f psychotherapist.
It is also possible to draw a few conclusions about train­
ing for psychotherapy. In most of the countries where theres
is recognition o f the titles and the practice, this recognition
depends, in part, upon obtaining a basic diploma (second­
ary studies, baccalaureate, master’s), followed by special­
ized training including supervised professional practice in
accredited institutions. Accreditation o f basic diplomas is
the concern of the Ministries of Education. Accreditation
o f the institutions that can accommodate psychotherapy
trainees (i.e., internships) is the concern of the Ministries
of Health (e.g., the national councils of the profession).
For psychotherapy practiced by nonmedical doctors,
Except in Greece and Portugal, where the master’s degree can be obtained after 4 years of university training.
With broad access where specialized training is accessible to holders of a secondary diploma, as in Austria and Sweden, or with limited
access after a bachelor’s degree, as in Finland.
© 2008 Hogrefe & Huber Publishers
European Psychologist 2008; Vol. 13(l):53-63
62
N. Van B roeck & G. L ietaen Psychology and Psychotherapy in H ealth Care
specialized training after the basic training is generally re­
quired. If the basic training is a master’s or a doctoral de­
gree, the specialized training takes, in the mean, 3 years (on
a part-time basis) and consists o f theoretical and technical
training, supervised clinical practice, and personal therapy.
In Austria and Sweden, where a secondary studies diploma
is sufficient, the training consists o f several steps and is
spread over 7 years. It is composed o f an introductory cycle
that gives no access to the title, followed by 5 years of
training that gives access to the title and to autonomous
practice. The lower the basic prerequisites, the longer the
complementary and specialized training. On average, train­
ing is completed 7 or 8 years after secondary studies.
Various professional associations (psychiatrists, child psy­
chiatrists, psychologists, psychotherapists with another basic
profession, etc.) have outlined models for training in psycho­
therapy. In 1998, the European Federation o f Psychologists’
Associations (EFPA, 1998) published a standard of training
in psychotherapy for psychologists. This standard starts with
a basic training level of master’s or doctorate in psychology
or medicine. Accreditation o f a specific training program de­
pends upon multiple criteria related to the empirical basis
underlying the program’s conceptual framework, the dura­
tion, the subjects in which participants are trained, and the
qualifications of those who cany out the training. With re­
spect to the content, four elements must be addressed for a
specified minimum number o f hours, namely: theoretical and
technical training, supervised clinical practice, personal ther­
apy (training or learning therapy), and a thesis.
General Conclusions and
Recommendations
We have tried to give a description of the current state of
the legal regulation o f the practice o f psychology and psy­
chotherapy in Europe, based on a range o f sources. On the
basis of this study of the situation in various European
countries, a series of recommendations can be formulated.
These recommendations reflect our personal interpretation
of the available information.
If quality of psychological and psychotherapeutic inter­
ventions and compliance with professional ethics are taken
seriously, legal regulation of activities is necessary. Profes­
sional associations are often confronted with cases o f intense
personal suffering caused by the lack o f control over the qual­
ity o f psychological and psychotherapeutic interventions.
Currently Belgium is located with Luxemburg, Ireland, and
Switzerland in the bottom group with respect to regulating
the professions of psychology, clinical psychologists, and
psychotherapists. The United Kingdom has no law either, but
this country has a rigorous system o f certification in which
professional associations manage the entry into the profes­
sion and the minimal necessary controls.
Health care is a special and very important field of appli­
cation of the profession of psychologists. For protection of a
European Psychologist 2008; Vol. 13(I):53—63
European citizen’s rights its training requirements and its
practice clearly need to be controlled - preferably by govern­
ment health authorities. Legal regulation of the practice of
psychology in health care is a priority.
Some countries opt for additional regulation of psycho­
therapy. In this case we see psychotherapy as a specialization
of the professions of psychologists and psychiatrists in order
to guarantee quality and transparency o f training require­
ments. The basic training of these professions prepares them
adequately for the specialization training necessary to acquire
psychotherapeutic competencies.
Where the regulatory body is concerned, the decisional
power should be situated in the Ministries of Health, who
would base their opinions on advice from a national council
of representatives of the profession. The national council
should be composed, in the majority, of representatives of the
profession, academics in charge of the university training
programs in psychotherapy, and trainers from private training
institutes. Representatives of other professions (physicians,
ethicists, and lawyers, among others) would be added to
these.
If countries opt for the solution of psychotherapy as a mul­
tiprofessional activity, efforts will have to be made to guar­
antee sufficient basic and specialized training for all those
who want to practice. The baccalaureate level of training
should be supplemented by a master’s level university train­
ing program. This master’s would consist of courses in devel­
opmental psychology, clinical psychology, neurosciences,
psychodiagnostics, psychopathology and psychiatry, psychopharmacology, and psychotherapeutic interventions as
well as an internship of at least 6 months. The basic bacca­
laureate-level training followed by a master’s as described
above would allow access to specialized training in psycho­
therapy. To guarantee maximum clarity for the patient, the
title of psychotherapist should be preceded by the name of
the practitioner’s basic profession. In this way, the client/pa­
tient knows that he or she is speaking with a psychiatrist-psychotherapist, a psychologist-psychotherapist, a social worker-psychotherapist, or a nurse-psychotherapist, etc.
To conclude, a final remark. It is clear that psychothera­
pists occupy an important place in health care, but do we
really need them? Do we really want to be psychotherapists
and do we need the concept of psychotherapy to talk about
our work and ourselves? More and more health care profes­
sionals strive to administer specific, empirically based psy­
chological interventions emanating from psychology as a sci­
ence in the treatment of various health problems. Wouldn’t it
be clearer and more specific to talk about psychological in­
terventions or treatments? This is also the position David
Barlow defends in his article in the American Psychologist of
December 2004. Maybe w e should give tins serious thought
Acknowledgments
Thanks to the EC liaison, the chair, and the members of the
Standing Committee on Psychotherapy of the EFPA for re­
Q 2008 Hogrefe & Huber Publishers
N. Van B roeck & G. Lietaer: P sychology and Psychotherapy in H ealth Care
viewing the information on the respective countries, name­
ly Katharine Althaus (Switzerland), David Lane (United
Kingdom), Fransisco Labrador-Encinas (Spain), Philippe
Grosbois (France), Heinrich Bertram (Germany), Yvonne
Kronberg (Denmark), and D ecian Aheme (Ireland).
Thanks to Wim Trijsburg and Salvatore D’Amore for the
updating o f the information on the state of affairs in, re­
spectively, The Netherlands and Italy. Thanks to James M.
Day for his comments on an earlier draft of this paper.
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About the authors
Nady Van Broeck is Professor of Clinical Psychology and Psy­
chotherapy at the Catholic University of Louvain at Louvain-laNeuve, Belgium. Her main research interests are developmental
psychopathology and pediatric psychology.
Germain Lietaer is Emeritus Professor at the Catholic University
of Louvain at Louvain-la-Neuve, Belgium. His main research in­
terests are client-centered/experiential psychotherapy and process
research in psychotherapy
Nady Van Broeck
University Catholique de Louvain
Place Cardinal Mercier 10
B-1348 Louvain-la-Neuve
Belgium
TW. +32 10474511
F ax +32 10474834
E-mail [email protected]
European Psychologist 2008; Vol. 13(1>:53—63