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Therapy regulation

Posted Aug 23 2009 10:04pm
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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