Psychotherapy: Playing the Three Monkeys in Mental Health Service Provision?

Abstract

Introduction

The purpose of the present study was to investigate the effect of sociodemographic variables on the knowledge of, demand for, and reception of psychotherapy as a treatment modality among psychiatric outpatients.

Methods

Participants of the study were 240 psychiatric outpatients (170 females and 70 males). Data for mental health services were collected from a subgroup of 103 “experienced” patients (42.9%) having had received psychiatric help previously. All participants were administered a questionnaire containing questions about various forms of psychiatric services.

Results

Of all participants, 40.83% reported having heard of psychotherapy a few of times before, mostly (44.58%) from the media and only 3.33% from a mental health professional. Most participants with previous applications to psychiatric outpatient clinic had first received mental health service from a psychiatrist (93.2%) and at a state hospital (72.8%), and a small minority (17.4%) had subsequently received care from a psychologist. None had demanded to, but 5 patients (4.86%) had been recommended to receive psychotherapy by mental health professionals. Of these experienced patients, 20 (19.41%) have an idea that the interviews they had previously at the outpatient clinics were sort of psychotherapeutic interviews; yet, only 7 (6.79%) retained the same idea after reading the definition of appropriate psychotherapy written on the questionnaire. All of these patients declared that they have received both their medication and psychotherapy at the same time. Thus, only 2.91% of 240 participants received psychotherapy that corresponds to the given definition.

Conclusions

Findings from this study suggest that mental health care is mostly performed by psychiatrists alone, with a limited contribution by psychologists. Consequently, the choice of treatment is solely pharmacotherapy for most patients, while psychotherapy as a treatment modality is neither offered nor demanded in routine practice.

INTRODUCTION

Psychotherapy is the informed and intentional application of certain methods derived from established psychological principles and scientific knowledge for the purpose of assisting clients to modify their behaviours, cognitions, emotions, and/or other personal characteristics in a positive direction (1). Psychotherapeutic treatment may be offered to individuals, families, or groups. It may be conducted for relatively short periods or be open-ended. The format of treatment also differs in terms of the intensity (eg, five times a week compared to once a week or once a month), the setting (inpatient or community-based), and the extent to which nonpsychosocial treatments (such as medication) are offered adjunctively (2). Modern psychotherapy began with the leadership of Sigmund Freud in the first half of the twentieth century with the aim of improving an individual’s well-being and mental health. Toward the second half of the twentieth century various effective psychotherapy methods began to emerge, while psychopharmacologic developments were becoming evident. Eysenck’s article published in 1952 to address the effectiveness of mostly psychoanalytic psychotherapies by referring to the data from records of the insurance companies could be considered a prototype of modern quantitative research or meta-analyses (3). Seligman’s 1995 study investigating the effectiveness of psychotherapy in the context of the American mental health services on the basis of annual consumer reports of the United States constitutes another milestone in this trace of research (4). Recent systematic reviews of the Australian Psychological Association, American Psychological Association, and Canadian Psychological Association have demonstrated the positive effect of psychotherapy on almost entire psychopathological conditions, particularly on depressive and/or anxiety disorders (5,6,7). Likewise, recent reviews have supported the efficacy of cognitive behaviour therapy on depression, bipolar disorders, schizophrenia, and other psychotic disorders (8,9,10). Relevant literature contains several Turkish studies reporting the beneficial effects of psychotherapy on various conditions and populations, including psychodrama on alcohol and drug addiction; psycho-social training utilizing cognitive/behaviour techniques on schizophrenia; problem-solving therapy on depression and suicide rates of high school and university students; cognitive behaviour group therapy on adolescents with social anxiety; cognitive behaviour therapy on physical and emotional stress due to university entrance exams; group cognitive behaviour therapy added to the regular treatment on anxiety levels of patients with schizophrenia and schizoaffective disorders; group cognitive behaviour therapy on anger and aggressive behaviour of adolescents; school-based cognitive behaviour therapy on anxiety, depression and low self-esteem of the elementary students; and cognitive-behaviour group therapy on obsessive-compulsive disorder (11,12,13,14,15,16,17,18,19).

In addition to empirical studies mostly addressing the efficacy and effectiveness of psychotherapy, the relevant literature also includes research findings investigating the required amount of therapy sessions for optimal response in each disorder (20,21,22,23). In countries where the cost of psychotherapies are financed by private insurance companies, knowledge about dose/effect relationship, that is, start and duration of the effect is of importance (24,25). Similarly, to compute the financial burden of mental health services on a country’s economy, one needs to know the costs pharmacotherapy and psychotherapy in comparison to one another.

The Turkish Mental Health Profile Research conducted in 1998 reported an overall prevalence rate of 17.2% for mental disorders across the country (26). Despite its importance, such a large scale epidemiological study screening all mental disorders has not been conducted since then. A recent review concluded that depressive and anxiety disorders might affect up to one-half of the female and student populations of the Turkey (27). These numbers demonstrate the severity of the social health problem due to mental illnesses and the importance of developing and applying effective treatment methods on a national scale. Over the past 50 years, Turkey has gone through a vast social and demographic changes, seemingly associated with an increased prevalence of psychiatric disturbances. However, to our knowledge the relevant literature contains no study assessing the impact of the social change on the manifestation of psychiatric disorders and related individual, societal, and economic costs in Turkey (27). Likewise, we are unaware of any empirical study addressing the extent of psychotherapy practise within the Turkish public mental health system. The first aim of this study was to investigate the rates of knowledge, demand, and reception of and having been recommended for psychotherapy in psychiatric outpatients together with the effects of sociodemographic variables on these issues. The second aim was to view the state of mental health services within the context of routine practices at outpatient psychiatry clinics. The findings obtained from this study could hopefully guide planning of rational and cost-effective national mental health services in the future.

METHODS

Participants

The study was conducted between December 2013 and March 2014 at the Nazilli State Hospital psychiatric outpatient clinic. A total of 240 randomly selected patients participated in the study. Eleven patients with psychotic disorders, dementia, manic attacks, or mental retardation; 2 patients older than 65 years, and 15 nonconsenting patients were excluded. The participants’ age ranged between 18 and 65 years (mean=31, standard deviation [SD]=11.48); 170 were females; (70.8%), and 70 were males (29.2%). The other demographics are presented in Table 1.

Table 1.

Demographic variables of the participants

Demographic variables	N	%
Sex
Women	170	70.8
Men	70	29.2
Age, years
18–25	103	42.9
26–35	59	24.6
36–49	59	24.6
50–64	19	7.9
Marital status
Married	111	46.3
Single	108	45.0
Widow+divorced+separate	21	8.8
Education
Uneducated+elementary+middle school	67	27.9
High school	68	28.3
University+masters, doctorate	105	43.8
Employment status
Steady employment	63	26.3
Irregular employment	21	8.8
Retiree	11	4.6
Housewife	55	22.9
Student	73	30.4
Unemployed	17	7.1
Income (monthly)
0–999 TL	49	20.4
1000–2999 TL	140	58.3
3000 TL+	51	21.3
Total	240	100

Instruments

Sociodemographic questionnaire

It was developed by the investigators to collect self-reported personal information with regard to sociodemographic characteristics of the participants, such as age, sex, marital status, education, employment status, and salary.

Mental health services questionnaire

It was developed by the researchers and is a 25-item self-report questionnaire constructed in two sections. Section one consisted of 17 questions inquiring about the content, quality, and modalities of the mental health care received so far by the participant. Section two included a description of psychotherapy (see below) followed by 8 questions querying whether the subject has ever received a psychotherapeutic treatment complying with the description, if yes, the extent to which the treatment was satisfying and if no, subjects level and sources of knowledge pertaining to psychotherapy.

“Psychotherapy is concerned with a person’s thoughts, emotions, and behavior and the problems may raise in their daily life and interactions with others. It is conducted by specially trained mental health professionals (psychiatrists, clinical psychologists etc.). It is a change and development process usually conducted one-on-one sessions, using scientific methods. Psychotherapy is conducted through sessions, each lasting at least 30–50 minutes, convened at least 5 times, with the same therapist(s), with regular intervals (maximum twice a week, minimum every other week). The goals, process, progress and results should be shared between the provider and the recipient; it must be open, cognized and measurable. Psychotherapy can be conducted in three forms: individual, group and couple or family therapy.”

Procedure

The ethical approval for the study was obtained from the Nazilli State Hospital Management and the Adnan Menderes University School of Medicine Ethical Committee. Participants of the study were randomly selected among the patients applying for treatment between December 2013 and March 2014 to the psychiatric outpatient clinic at the Nazilli State Hospital. The selection procedure was as follows: The first applicant and every following eleventh participant who consented was included in the study. When a selected patient declined to consent or was mentally unable to participate, s/he was passed on and the subsequent patient was invited. Each consenting patient was requested to fill in the Mental Health Services Questionnaire along with the Sociodemographic Questionnaire before being examined by a psychiatrist for his/her current complaints. Those who answered the first question negatively (‘Have you sought professional help previously for your psychological problems?’) skipped to the final section of the questionnaire to answer the questions about their general knowledge on psychotherapy. Therefore, certain items of the questionnaire were responded exclusively by those subjects who had previously sought care for mental problems (n=103) and the remaining items by the entire sample (n=240).

Statistical Analysis

All the descriptive and inferential statistics were conducted using the Statistical Package for the Social Sciences 17.0 software (SPSS Inc., Chicago, IL, USA). We employed the chi-square statistics to test our research hypothesis that demographic variables might exert an effect on the subjects’ level and source of information on psychotherapy. We interpreted the results associated with p<0.05 as significant, that is, implying the invalidity of the null hypothesis, thereby the validity of the research hypothesis.

RESULTS

Table 2 displays the findings pertaining to participants’ information on psychotherapy. Several demographic variables were found to exert significant effects on the extent and source of subjects’ information, namely participants’ education level, marital status, and professional status affected their responses to the question “Have you heard of the word ‘psychotherapy’ previously?” (χ²=63.4, p<0.05; χ²=11.4, p<0.05; χ²=14.7, p<0.05, respectively) and “To what extent your previous information on psychotherapy was in line with the written description provided?” (χ²=59.4, p<0.05; χ²=15.1, p<0.05; χ²=18.07, p<0.05, respectively). Hence, those participants with higher educational background, living in an enduring marriage bond, either pursuing an undergraduate degree, or having a steady job tended to have wider information on psychotherapy.

Table 2.

Knowledge of psychotherapy (n=240)

	N	%
Have you ever heard of the word ‘psychotherapy’?
None	75	31.25
A couple of times	98	40.83
A lot	47	19.58
Many times	20	8.33
Where did you hear of the word ‘psychotherapy’ from?
Press	106	44.58
Family-friend	35	15.0
Expert	8	3.33
Other (books and lessons)	16	7.08
Did you know the meaning of the word ‘psychotherapy’ as described above?
None	82	34.16
Partial	100	41.66
Sufficient	52	21.66
A Lot	6	2.5

Of the 240 participants, 103 (42.9%) had previously sought to use mental health care services among which 36 (34.9%) had been informed about their diagnosis. Of this subgroup, 15 (41.6%) had been diagnosed with depressive disorders; 6 (16.6%) with anxiety disorders; and 1 (2.7%) with bipolar disorder. Tables 3 and 4 summarize data pertaining to the knowledge about mental health services and psychotherapy by those participants having previously received mental health services.

Table 3.

Different variables regarding mental health services (n=103)

	N	%
How many times did you admit?
1–2	30	21.3
3–4	22	21.2
5 or more	51	49.5
At your first admission, how long did your interview last?
5–15 minutes	60	58.2
15–25 minutes	11	10.6
25–35 minutes	16	15.5
35–45 minutes	10	9.7
45 minutes or more	6	5.8
At your first interview was mental problem described as any ‘disorder’?
Yes	36	34.9
No	67	65.1
Were you given information regarding your ‘diagnosis’ at your first interview?
None	87	84.4
Partial	11	10.6
Sufficient/in detail	5	4.7
How would you describe the help you received at your first interview?
Only drugs	84	81.55
Only interview	4	3.88
Drugs and interview	15	14.56
Were you given information about the type and duration of treatment/getting help at your first interview?
None	65	63.10
Partial	32	31.06
Sufficient/in detail	6	5.82
When you look back at the help you received, whether it be therapy session or drugs, what was the total time frame? (continuing or stopping with the specialist/drugs included)
1–6 months	42	40.77
6 months-2 years	23	22.33
More than 2 years	38	36.89
Were you satisfied with the services and information you were given?
None	32	31.06
Partial	35	33.98
Sufficient/a lot	36	34.94

Table 4.

Psychotherapy in mental health services (n=103)

	N	%
At any one of your admission did you directly requested or were recommended ‘psychotherapy’?
Recommended	5	4.85
Not recommended	98	95.14
For those who noted that they received ‘psychotherapy’ services	20	19.41
If you received service to be known as ‘psychotherapy’ how well does it relate to the above description?
None	13	65
Partial	2	10
Sufficient/a lot	5	25
If you received any mental health services, please think above description, and describe your treatment modality?
Drugs	93	93.0
Psychotherapy	-	-
Drugs and psychotherapy	7	7.0

With regard to facilities and professionals having provided mental health services previously to our participants, our data indicate that the state hospitals were the main providers, followed by private clinics, university hospitals, and private hospitals (72.8%, 16.5%, 6.7%, and 2.9%, respectively). Participants first sought mental health care through psychiatrists, child psychiatrists, or neurologists (93.2%, 4.8%, and 1.9%, respectively) and subsequently through psychologist, psychiatrists, or neurologists (17.4%, 5.8%, and 3.8%, respectively). A notable finding was that none of the patients in our sample had sought help through either a clinical psychologist, psychological counsellor, social worker, or psychiatric nurse.

Among 7 participants admitting to have received psychotherapy complying with the definition provided in the questionnaire, 5 had received psychotherapy at state hospitals (4.85%), 2 at university hospitals (1.94%), and 2 at private clinics (1.94%). Reportedly, the therapist involved had been a psychiatrist or a psychologist in 6 cases (85.7%) and a speech therapist in 1 case (14.3%). The therapy had been offered in an individual format to 6 cases (85.7%) and in a group format to 1 case (14.3%). In rating how satisfied they were with the psychotherapy they had received previously, none rated “dissatisfactory”, whereas 4 (57.14%) rated “somewhat satisfactory”, 1 (14.28%) “satisfactory”, and 2 (28.71%) “highly satisfactory”.

DISCUSSION

Mental health studies about psychotherapies in our country are scarce and with a focus on the efficacy. This study addresses knowledge and utilization of psychotherapy among individuals applying for mental health services, thereby providing a preliminary data concerning general condition of the services in Turkey.

Overall, 40.83% of the our participants admitted to having heard the word psychotherapy a few times, media being the most likely source of information (44.58%) and a physician specialized in psychiatry or neurology being the least likely source (3.33%). Of all the participants, 34.16% declined to have known of psychotherapy at all as described on the questionnaire sheet, while 41.66% admitted to having partial knowledge and 21.66% to sufficient knowledge of psychotherapy. These findings indicating that a considerable portion of our psychiatric patients were unaware of psychotherapy and the rest have become aware by means of media sources rather than professionals of this area strongly suggest that this treatment modality has been overlooked in daily routine of mental health services in our study. Apparently, low educational background and unemployment are demographic characteristics associated with inadequate knowledge of psychotherapy.

Approximately half of the participants (42.9%) have already applied for mental health services, and half of them (49.5%) have applied for 5 and above. This shows that psychiatry outpatient clinics of the state hospitals seem to be engaged with providing treatment to the same patients repeatedly. It is noteworthy that psychiatric evaluation of a novice patient is performed merely within 5–15 minutes at these clinics, and such a tight schedule is enforced by the administrations of the state hospitals rather than psychiatrists in charge. Depressive disorder was diagnosed in 41.6% of the 36 (34.9%) patients who reported that the psychological problems were diagnosed as a mental disorder at the first application. Unfortunately, of those who applied for mental health services, no information was available on the diagnosis of the 87 (84.4%), and on the 65 (63.10%) patients, no description of treatment or assistance were indicated. Such conspicuous ignorance of the patients’ need to be informed by their physicians could be due to short duration of psychiatric interviews enforced by appointment systems of the hospitals as well as to underdeveloped insensitivity to this matter on the part of the physicians.

Given that a great majority (81.55%) of the participants had been offered medication alone and had been receiving treatment between 6 and 24 months or longer (59.22%), one might be inclined to consider our sample mostly consisting of patients diagnosed with chronic mental disorders and receiving pharmacotherapy as the primary mode of treatment. However, it is not unlikely that this group might have been offered no additional treatment option other than medication. This explanation is supported by our data revealing that nearly one-third of our subjects were completely unsatisfied and another one-third partially unsatisfied with the mental health care they had received so far. The researchers of the Mental Health Profile of Turkey drew attention to excessive and unnecessary drug use almost two decades ago on the basis of their findings that 5% of the nations adult population were taking psychotropic drugs, and one-half of whom were doing so despite having received no diagnosis within the past year, and one-third of whom were doing so for a period longer than 1 year (28). Moreover, Aydın et al. (29) data collected from several sources (such as Turkish Ministry of Health, Turkish Statistical Institute, Mental Health Profile of Turkey, and Intercontinental Marketing Services - Health) indicated a nationwide 162% increase in the use of antidepressant drugs between 2003 and 2012, and a 50% increase in prescriptions between 2007 and 2012. Considering that Turkey is a developing country capable to reserve restricted financial source for mental health care, these figures should alert the policy makers to investigate the reasons for increasing consumption of psychotropic drugs and to promote means to keep excessive and unnecessary prescriptions under control (29).

The participants of the present study admitted to having been treated for mental problems most frequently at state hospitals (72.8%) and by a psychiatrist (93.2%) initially and referred infrequently (17.4%) to a psychologist later on. Seligman (4), based on the annual consumer reports of the United States, presented a picture in contrast with that of our study. The data suggested that the gateway for professional help was a psychologist for 37% of the Americans, a psychiatrist for 22%, a social worker for 14%, marriage counsellors for 9%, and other mental health professionals for the remaining 18%. Another important finding of Seligman’s study was that no significant difference was observed among psychologists, psychiatrists, and social workers in terms of the effectiveness of psychotherapy as reported by their clients (4). In Turkey, mental health services are given at secondary health care facilities, which explains why individuals with any sort and severity of psychological difficulties are obliged to seek professional help through psychiatry clinics of state hospitals and to be evaluated and treated first by psychiatrists working at these hospitals.

Our data reveal that none of the participants treated at a psychiatry outpatient clinic demanded psychotherapy. Only a small portion (4.86%) were recommended to receive psychotherapy. Of these experienced patients, 20 (19.41%) had the idea that the interviews they had previously at the outpatient clinics were somewhat psychotherapeutic interviews, yet only 7 (6.79%) retained the same idea after reading the definition of appropriate psychotherapy written on the questionnaire. All of these patients declared that they have received both medication and psychotherapy at the same time. Hence, 2.91% of 240 participants received psychotherapy that is suitable for the given definition. These figures suggest that psychotherapy is a rarely utilized professional help modality in our country, given that 3% of the general population and not psychiatric population of the United States receive psychotherapy on a regular basis (30). The appointment system of the Turkish state hospitals enforcing insufficient time allocation for each visit, widespread tendency among individuals with psychology to depend on drugs, low number of psychotherapy experts, and lack of office space available for psychotherapy sessions are among the major obstacles before wider utilization of psychotherapy as a treatment and guidance modality in Turkey. Whereas no one in this study reported dissatisfaction with psychotherapy they received.

Overall, 59.22% of the patients have received and continue to receive treatment, except psychotherapy, for 6 months. This finding requires thinking on treatment cost and efficiency. In one study of the relationship between the number of psychotherapy sessions and psychiatric symptoms 8, 26, and 52 sessions resulted in 53%, 74%, and 83% decrease in psychiatric symptoms, respectively. In another study, psychotherapy led to a 74% decrease in symptoms of the clients for a period of 1 year (20,21). Shapiro et al. (22) recommended that a psychotherapeutic intervention should continue for at least 16 sessions on the basis of their observations that short-term therapy consisting of merely 8 sessions was associated with negative feedbacks from the clients and were transitory rather than persistent benefits. A meta-analytic study concluded that psychotherapy of depressive and dysthymic patients should be continued for nearly 18 sessions for optimal gains (23). Data from another study suggest that in patients with mood and/or anxiety symptoms, the gains of short-term psychotherapy tend to be shorter in duration than those of long-term psychotherapy in terms of psychosocial functioning and quality of life (31). Findings of the comparative cost-effect analyses of short- and long-term therapies for depression and anxiety suggest that long-term interventions are indeed relatively less costly (25). A meta-analytic study concluded that the combined treatment of depression is usually more effective, although results are confounded by severity and chronicity of the disorder (32). Compelling evidence from previous research and from the present study lead us to believe that psychotherapy offered to our patients mostly seeking treatment for depressive or anxiety symptoms by competent therapists through weekly 45-minute sessions for a period of nearly 4.5 months in combination with pharmacotherapy or alone will prove to be a cost-effective treatment modality. Unfortunately, the recently implemented performance system compelling physicians to work “as fast as possible” at the outpatient clinics renders psychotherapy an unfeasible treatment modality in the eyes of hospital administrations and of psychiatrists.

According to the statistics given in the National Mental Health Action Plan (NMHAP) of Turkey (2011–2023), the number of psychiatrists, child psychiatrists, and psychologists actively practicing in 2011 is 2.2, 0.28, and 1.85 per 100 000 population, respectively. The corresponding figures in the United States for psychiatrists, psychologists (PhD clinical psychology, PsyD psychology), and social workers are 12.5, 26.5, and 69 per 100 000, respectively (30). Likewise, the number of practicing (adult and child) psychiatrists are estimated at 12.9 per 100 000 population across the 15 European Union countries (33). It appears that to reach the mental health service standards of the western countries, Turkey needs to increase its psychiatrist workforce by a factor of five and its psychologist workforce by a factor of twenty or more. Unfortunately, the NMHAP of Turkey fails to recognize the importance of psychotherapy within the realm of mental health care. Ignorance of the patients” needs for psychotherapy or psychological guidance at public health facilities might oblige some patients to attempt to receive psychological treatment at private offices from some “professionals” unqualified to offer psychotherapy at the internationally defined standards. These practices are often conducted by someone carrying self-defined titles, such as personal development expert, relationship consultant, and personal coach. Unfortunately, such practices have been encouraged and legitimized by recent jurisdiction addressing certification of family consultants.

In terms of psychotherapy practices, four basic problems can be identified as follows: education, employment, practice conditions and career issues. For all mental health professionals acquiring solid theoretical knowledge and practicing under supervision are imperative for psychotherapy training. Reaching a consensus on basic training criteria and transcending narrow professional perspectives might facilitate a collaboration among mental health professions for promoting psychotherapy practise nationwide at public facilities, which would be in the best interest of recipients of mental health services (34). The basic guiding references for such a collaborative initiative could be psychotherapy competencies defined by European Board of Psychiatry and partly adopted by the Psychiatric Association of Turkey, and psychotherapy competency standards defined by the European Federation of Psychologists’ Associations (EFPA) and observed by the Turkish Psychological Association in awarding practise licenses for psychotherapy (35,36). Even those psychiatrists with psychotherapy training however appear to work in conditions not allowing them to use their psychotherapeutic skills extensively in their practise. The second largest segment of the mental health workers in the country, the psychologists, mostly without a graduate degree, are supposed to perform psychotherapy to a variety of patients despite the fact that the undergraduate psychology programs do not aim to equip their students with psychotherapy skills. Therefore, some psychologists working at the psychiatry clinics of state hospitals opt to gain these skills by attending private courses offered by private psychotherapy societies; some choose to perform “improvised” psychotherapy complying with no standards; and some prefer to stay away with the rationalization that psychotherapy is not in demand. Moreover, psychologist with sufficient training in psychotherapy are seldom able to reserve enough time for psychotherapy because of their tight work schedule at the state hospitals. There exist only a few well-established clinical/applied psychology graduate programs in the country providing intensive training to their students to gain competency in several psychotherapy techniques. Due to a recent legal decree recognizing the title of clinical psychologist officially and defining the job within the mental health services for the first time in the nations history, the privately funded universities have rushed in to start graduate programs characterized with severely undersized faculty and oversized student mass hence questionable psychotherapy training. Besides, ever increasing number of clinical psychologists with necessary qualifications and competencies have a poor chance to work at public hospitals and use their psychotherapy skills in mental health services owing to the Ministry of Health’s hiring policy to give no priority to those with graduate training.

The fact that data for this study was collected at a relatively small state hospital restricts to some extent the generalizability of our findings across larger state hospitals, as well as private and university hospitals. Further studies encompassing all the relevant environments of the country’s mental health services are needed to have a more clear nationwide picture, which would hopefully guide the policy makers to use financial and human resources of the nation more efficiently and to work in collaboration with professional organizations toward a mental health care system associated with highest international standards, evidence-based, and ethical practices observing and protecting the patient rights.