Therapy regulation

A recent op-ed piece in the UK's Guardian suggested that counselling and psychotherapy should be state-regulated. The argument presented in the article asserted that one of the major needs for external regulation was to prevent misconduct and abuse. These are both legitimate concerns and need to be addressed, but my thoughts on more stringently regulating therapy* are related to using the most effective methods possible.

Finding a good therapist is a total shot in the dark. The leading ED "expert" in my metro area when I was first diagnosed was old-school psychotherapy. Yes, there was a couch, and yes, there was the "tell me about your mother." Not that I don't have issues with my mom (my current therapist can tell you that our relationship is very good though definitely not perfect), but discussing them didn't help my ED recovery.

Even in my last ride on the therapist merry-go-round, after I moved to DC, was frustrating. Although she said she used CBT, we didn't really address anything related to eating, which was why I had gone to see her in the first place. The clincher was when she asked, "So did you always feel a need for control or did it start later?" I realize I could have educated her, true, but I was also sick and tired of educating my medical providers. If I knew as much as them, how were they going to help? I don't resent being honest about what I need to work on, but I do resent having to educate "experts" about ED basics (it's a brain disease, it's not "about control," here are some good evidence-based treatments).

Therapy can be a powerful tool that changes the brain, just as do SSRIs and other psychotropic medications. Though I remain skeptical of the FDA's ability to weed out every last one of the bad eggs, the regulation is there. To be certified as a therapist in the US, you need to work under a licenced psychologist for a certain number of hours after graduating from your degree program. You also need to pass the board certification exams. All of which is well and good, but there is still no guarantee that a therapist will be up on the latest tools and research, the latest tests and diagnoses, the newest evidence-based treatments. With MDs, the expectation is much more omnipresent.

Medicine contains aspects of art along with science- I don't deny that. But working with people's brains and lives is a tremendous privilege that should be accompanied by certain responsibilities. I don't want to just feel better after therapy, I want to be better. After so many of my early therapy sessions, I "felt better" because I managed to avoid the hospital and avoid changing my behaviors. I could vent about my horrible, controlling parents, and I could discuss other things as well. But sometimes now when I leave therapy, I don't always "feel better" because I know I'll need to eat more food or start being accountable to myself or any number of things that just plain suck.** The difference is that I'm getting better, which makes me feel better.

Maybe this is less about regulating the actual therapists and more about regulating the types of therapies provided. I'm not looking to create a horde of Mr. Robato therapists- professional judgement is a powerful thing. But just because riding ponies is fun and enjoyable doesn't necessarily mean its effective (no, "research" from Remuda Ranch on equine therapy saying it's effective doesn't count). Nor does reliving your childhood trying to find out what first grade playground event "caused" your eating disorder. Discerning where I got some of my less-than-helpful ideas is useful, true, but the work doesn't stop there. Insight ain't action. I want someone to tell me what approach they're going to use, the reasons that it works, the evidence supporting it, and how the think it will help me.

I would love to hear everyone's thoughts on this, especially therapists (sending flares in your direction, Dr. Ravin!). What are the advantages to better regulation of psychotherapy and mental health providers? What are the disadvantages?

*The article focused on the UK's system, about which I know very little. Nonetheless, I do realize that in the US, anyone can call themselves a "therapist," though there are certifications and boards and internships, etc, to be formally licensed.

**For the record, I do feel better much of the time because I feel I have actual tools to begin combating ED.

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chylo said...

I'm all for making people aware & able to make their own choices. Maybe even government regulated labeling.

I don't like the idea of not being able to have access to the therapy that would be most effective for me.

It's trial an error, for sure. It's also a lot about being an informed consumer.

I really cringe at the idea of anyone other than me being in control of what therapy is available to me.

No, strike that-- I cringe at the idea of anyone *else* being added to this equation. My insurance has always paid for my treatment without any problems, but I know that for many people insurance already limits their options already.

Also, I feel that there's often a timeline attached to this kind of standardization. I really don't think there will ever be funding to evaluate the efficacy of therapy long term therapy-- I've been in therapy with the same psychologist for five years. Over the years we've addressed various ED/other things using different techniques. I can't imagine how that would be classified or typed.

[NB: I feel like some people will cringe at the length of time I've been in therapy, hold it up as proof of principle that therapy *needs* to be standardized etc. I'm not floundering in therapy, I'm doing quite well, and I've dealt with a number of issues aside from the eating disorder. Still, I can't imagine how I could receive the quality therapy I receive now under a 'standardized' plan.]

Anonymous said...

I'm not sure what to think about regulation, but the idea of certification in specific therapies has a lot of merit IMO. I'm especially glad to see that therapists interested in FBT can seek certification which requires review and supervision of cases post-training to insure treatment fidelity and addition advances training. I think this not only helps therapists put treatment into practice but will be helpful information for families looking for care.

cbtish said...

Our system here in the UK will regulate use of the word "psychotherapist" but not the actual practice of therapy. So anyone who has the right kind of academic qualifications, and who pays money to the right agencies, will be able to call themselves "psychotherapists". Anyone else will be committing a criminal offence if they do that.

But other words will not be regulated. For example, anyone at all will still be able to call themselves an "eating disorders specialist".

There's no evidence that this regulation will prevent misconduct and abuse. It hasn't prevented misconduct and abuse in other fields of medical practice. But a government department will get to increase its power and its revenues, and that's surely what counts. Perhaps one day they'll regulate the entire dictionary.

I agree with Jane, that skills-based certification in specific therapies would be a much better idea. In my field, CBT, much of the malpractice happens because people who are qualified in something else entirely (nursing or psychology, for example) think they can do CBT without full training in it.

Unknown said...

I know that Lawyers need to earn so many Continuing Legal Education credits every year in order to keep their license. Is it the same with Doctors and Therapists? If not, I think it should be. And I think that some many of the CME credits should be in your area of practice.

Amy said...

Regulation/information/education aside, some people just don't click. Some people are just (really smart) jackasses. So even if the government tidies things up, there will still be trial and error for the patient.

Eating With Others said...

The thought of Goverment getting involved terifies me. Let's face it they are just not qualified to make those kinds of choices. They are all, ok mostly, lawers. Choosing the right therapist is hard and if you don't fit with the right one, the expert, you might get a lot of benifits from one that is not an expert in that field but you feel comfortable talking to.

Dr. Ravin said...

While I'm not opposed to government regulation of therapy per se, I really don't think it would do any good in terms of ensuring that patients get quality, evidence-based care. The field of psychology is already highly regulated. To become a clinical psychologist, you have to have a doctoral-level degree in psychology (Ph.D. or Psy.D.) which takes an average of 7 years to complete, including years of clinical training, a pre-doctoral internship, and passing comprehensive exams. You also need to pass a national examination which tests basic knowledge of psychology and a state exam which tests knowledge of the laws and rules in your state. After completing your doctorate, you need to complete 2,000 post-doctoral hours under the supervision of a licensed psychologist. We also have to complete 40 hours of continuing education every two years after getting licensed. NONE OF THESE THINGS guarantee that that the psychologist will use effective, evidence-based treatment. I know many experienced, licensed psychologists whom I would never consider referring to because their methods are simply ineffective. Some doctoral programs emphasize evidence-based practices and others don't. Psychologists trained in evidence-based practices don't necessarily always provide evidence-based treatment. For all intents and purposes, a psychologist can use whatever methods he/she wants. So tighter regulation will not necessarily lead to more effective therapy, because each psychologist is free to use his/her clinical judgment in any given case.
I think a good solution to this dilemma is to require that all therapists (including psychologists, social workers, licensed professional counselors, and psychiatrists) provide full disclosure in informed consent at the start of any therapeutic relationship. The process of informed consent should include the therapist's training and qualifications, the types of treatment methods available for the patient's condition (whether or not the therapist practices them), what method(s) the therapist plans to use and why, explanation of the evidence base (or lack thereof) behind the methods the therapist is using, explaination of other types of treatment available and the pros and cons of these other treatments, and referrals to other types of treatment if the patient or her parents request it.
I recently blogged about this issue:

Carrie Arnold said...

I guess to me, this is less about bureaucrats telling me what kind of therapy I need, and how many sessions it will take until I'm "cured". To me, it's about who can call themselves an "expert" in treating a particular illness or using a specific type of therapy. There doesn't quite seem to be the patient pressure to insist about this, combined with other limitations in terms of geography and insurance.

I think many people in the US are science-phobic or science-illiterate, which I think is a huge problem. There is a fundamental lack of understanding about what "evidence-based" even means.

I guess I'm just frustrated with many of the so-called experts I've met and having no real way to judge on what basis they are calling themselves experts. Even membership in IADEP and NEDA is no guarantee. I love the idea of Lock and Legrange's training sessions.

Dr. Ravin, you are truly a diamond in the rough. I wish more therapists had your outlook.

Anonymous said...

I also agree with the approach recommnded by Dr. Ravin. I think there is a role for the government in drafting informed consent guidelines that, in the case of eating disorders, would discuss various treatment models, evidence of effectiveness, and other important information. After all, the FDA requires that drugs be labeled with specified information about effectiveness, risks, alternatives, and use guidelines. I'd like to see the National Institute of Mental Health require the same type of comprehensive information be given to eating disorder patients and parents of minors.

Fiona Marcella said...

I think that what the Guardian is talking about is regulation against bad individuals (for example those who abuse the therapeutic relationship for sexual or financial gain) rather than bad (or indeed good, or indifferent) therapy.

There is a big drive for "talking therapies" and, as CBTish has pointed out, a danger of all sorts of partly trained people calling themselves or even being set up by cash-strapped health providers as specialists when they are not. Regulation against the "bad eggs" wont stop that, but it hopefully WILL call to account people who bring the professionalism of the word therapy (which we psych-phobic Brits tend to have problems with anyway) into disrepute.

In the more narrow world of eating disorders there is debate about what specialist treatment is and should be which I have already discussed with CBTish. We have the NICE guidelines against which most NHS (ie free at the point of use and technically available to all) provision should be measured (not that it measures up that well in terms of provision on the ground). These advocate evidence based treatment and are at least somewhere to start from - or at least I think so but I know not everyone agrees.

Anonymous said...

Well, I'm both a therapist in training and in treatment for an e.d., so here goes! :-)

I agree with your point that we expect M.D.s to be up to date with research treatment methods (though many obviously are lacking), etc., but we don't regulate therapists in the same way, and perhaps we should. I think that it is crucial for therapists to be aware of new and changing methods of treatment, etc.

That said, I also think that it's necessary for them to draw their strokes broadly. What works for one client - be it Maudsley, be it Equine therapy, be it finding the root causes (which, honestly, has been incredibly helpful for me and spurred me to action), dbt, cbt, etc. - may not work for others. Treatments are not necessarily transferable. For example, I actually think that equine therapy would be incredibly useful to me. Having therapy dogs at my current treatment center has been very healing. More "directional," or "concrete" therapies (I think this would include Maudsley, in my case) have actually been harmful to me. I think that the client should have a strong say in the kind of treatment approach that is used.

I also think that different therapies can be useful to clients at different times, and though eating disorders are, in part, a "brain disease," I firmly believe that that is only a piece of the puzzle, and therefore only one aspect of many that treatment should address.

Tom said...

As someone who creates performance indicators for psychologists; most of the metrics for mental health are qualitative. Most (if not all) come from patient surveys. The sorts of negative things mentioned in the article would be caught on patient surveys.

Sure, you'll have some patients who give their therapist lots of negative scores here and there on something or another. And some patients will show less or slower progress towards reaching whatever goals they might have, but averages are likely to present themselves eventually and I'd assume outliers would get some sort of scrutiny. I don't know how they intend to design this structure, but it can be done in a way that protects patients, not to say it will.

Carrie Arnold said...

Very interesting thoughts, everyone. Thank you so much for sharing!

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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