Tuesday, 30 July 2019

Other therapies practiced by Society of Homeopaths' members

A previous post discussed the accreditation of the Society of Homeopaths (SoH) by the Professional Standards Agency (PSA). One element of the Standards for Accredited Registers is to understand, monitor and control risks. This includes risks posed by members to the public that are the result of their practice.

This is not going to be a comprehensive risk analysis. It certainly doesn't capture all therapies offered.

What the PSA Standard 3 says
Standard 3: Risks The organisation:  
3a) Has a thorough understanding of the risks presented by their occupation(s) to service users and the public – and where appropriate, takes effective action to mitigate them. 
3b) Is vigilant in identifying, monitoring, reviewing and acting upon risks associated with the practice of its registrants and actively uses this information in carrying out its voluntary register functions. Evidence provided should demonstrate how the organisation seeks, gathers and handles information, and provide examples of having acted to prevent or mitigate risk. The Professional Standards Authority will decide whether this Standard is met with reference to guidance provided in the Accreditation Guide (2016).
What is meant by "occupation"? This is unclear. But "practice of registrants" suggests a more holistic view. The PSA don't accredit therapies, they accredit registers. Futher guidance on completing a risk matrix (which is worth reading) states that registers need to demonstrate that they 
are proactive in identifying risks to the public associated with their registrants’ practice, including their personal behaviour, technical competence and business practice, the places in which they carry out their profession and the products they typically use or supply
And that the the PSA will -
take into account the extent to which an organisation has engaged with stakeholders to identify risks, whether or not they have assured themselves as to the accuracy and reliability of the information used, and whether they have validated the information with external sources.
Stakeholders include service users, interest groups associated with service users, and employers (although less likely with some registers). External sources are important when a register or its members do not have the competence to properly evaluate risks. They may lack the specialist knowledge/experience to do so.

What the SoH say
Issues with the practice of therapies other homeopathy by SoH members were raised in the accreditation report.
12.14 The team asked if the Society had considered risks that may occur regarding such devices and set standards or provided guidance accordingly. The team had also asked if the Society would investigate and act on concerns raised around such practices. The Society responded that it did not review or regulate additional therapies offered by members and would refer to registration bodies covering a broader range of therapies.
This is relation to the use of the Asyra machine and similar devices. The SoH seems unconcerned by members offering other therapies. What they mean by referring to other registration bodies is unclear.

It is unknown whether the SoH (and by extension, the PSA) are aware of the prevalence of members using other therapies. A more detailed analysis is below but sampling suggests that more than half of members use other therapies in addition to homeopathy.

Models of use other therapies
These can be categorised as -
  • Separate - different therapies are used for different purposes. There is no overlap in the treatments given to a client.
  • Diagnostic - one therapy is used to determine a client's problem, another is used to treat it. This is common with applied kinesiology and bio-resonance machines.
  • Adjunctive - A core therapy is used but other therapies may be as a minor aid. 
  • Integrative - Routinely uses combinations of therapies.
Membership status
A practitioner who offers multiple therapies may be -
  • Registered with a body that covers a single therapy - but not other therapies.
  • Registered with multiple bodies that each cover the offered therapies.
  • Registered with a body that covers multiple therapies.
  • Combinations of the above.
It is entirely possible that a practitioner may practice a therapy that is not covered by any body. It is also important to consider the type of body. 
  • Registered with a statutory regulator
  • Registered with an accredited register
  • Registered with a non-accredited register that attempts to regulate. 
  • Registered with a non-accredited registers that makes no attempt at regulation.
  • Not registered with any other body.
A sample of 74 SoH members with websites was taken. A fairly cursory examination of the websites was made. Not attempt was made to look at directory list and other third party websites was made. Knowledge of certain members suggests that they do not always list every therapy that they offer on their websites.

Of those 74 members, only 34 appeared to practice purely homeopathy. Of the other 40, only 9 appeared to belong to another organisation. Some of the 31 others may belong to an organisation but have neglected to list it. Whilst they are under no obligation to do so, it would make it difficult to know where to turn in case of complaint, etc. Of the 9, one was registered with a statutory regulator, one was registered with two accredited registers.

In terms of separate/diagnostic/adjunctive/integrative use - this is much more difficult to quantify but it is noted that diagnostic and integrative use were explicitly mentioned by some members.

Generic Risks
Some of generic risks of homeopathy and other CAM therapies that don't involve obviously harmful substances or techniques are well understood. They revolve around delays in or a complete failure to seek appropriate medical treatment for serious conditions. Practitioner awareness of limits of their own competence and the efficacy of therapies that they practice can be a problem but it can also be consumer driven.

Some of therapies offered are difficult to categorise. Mostly because the language to describe them is so very odd. 

Applied Kinesiology
Kinesiology is a real thing but in the UK it tends to be part of other disciplines rather than being separate field of study. Applied kinesiology has no relationship to it. It doesn't help that UK practitioners tend not use the "applied" part. It is also known as muscle testing. It was invented by a chiropractor George Goodheart.

Applied kinesiology is primarily used for diagnosis. The kind of conditions that UK practitioners claim to diagnose are typically allergies, food intolerance and dietary deficiencies. There is no evidence that it can diagnose anything.

It is often linked to the practice of "nutritional therapy" sale of dietary supplements but some practitioners make a big deal out of allergy desensitisation. Allergen immunotherapy is a real thing, but the products used are often prescription only medicines and there are some risks associated with the treatments. It is more likely that homeopathic medicines are used. These may or may not be unlicensed medicines - there are a few registered homeopathic hayfever remedies.

This covers two types of device - skin conductance devices such as the Asyra machine (discussed in this post which also explains medical device regulation) but there are many others. Although none were encountered in research, radionic devices could also be included in this category.

Most of these devices seemed to be used for diagnosis. Obviously, they are incapable of diagnosing any condition.  Aside from imaginary things that the manufacturers claim the devices can diagnose (weasel words and disclaimers can't get around the fact that they do make claims), allergies, food intolerance and dietary deficiencies are frequently mentioned. Some "nutritional therapists" do use these devices. What is more concerning is that they may incorrectly diagnose a serious condition - causing considerable emotional distress. 

A few make radionic remedies (which often purport to be identical to conventionally made homeopathic medicines). Some are used to "program" plastic pendants with healing "vibrations". There is no evidence that SoH members are using them this way.

Energy Medicine
This is a very vague term. Some would class acupuncture, homeopathy, radionics as "energy medicine" but here it is used as a wastebasket for therapies that involve invisible/undetectable energies not categorised elsewhere.

Emotional Freedom Technique (EFT) belongs to a group of therapies that some categorise as "energy psychology". It posits that psychological problems can be treated by tapping on various parts of the body.

Healing carried out by SoH members is generally not faith healing in the sense of God(s) healing through the intermediary of the practitioner but rather the practitioner draws upon some varyingly described spiritual force or energy. Although none where found in the sample, it is known that some homeopaths who practice healing talk of "angels" and "spirits". There can be a tendency in some to see all disease as a manifestation of spiritual "imbalance" or something and that fixing this imbalance fixes the disease.

Reiki is less interesting for what it is but more interesting that it has been condemned by the Catholic Church. Many would find the Church's spiritual objections to Reiki laughable but there is a broader question about how harmful some ideas can be beyond the spiritual.

Morphogenetic Field Therapy is very odd. It seems to involve applied kinesiology and "digitised water" and was invented by a chiropractor. 

Hair Analysis
Hair analysis is a real thing and does have its uses. Chemical analysis can detect long term exposure to certain toxins such as heavy metals. More generally, the condition of hair can be indicative of an underlying condition. For example, brittle hair can be caused by malnutrition, hypothyroidism or biotin deficiency but it can be caused by use of certain hair products as well as heat treatment. Human hair is very variable and most of that variation is genetic.

CAM claims for hair analysis do include heavy metal poisoning and various "detox" treatments may be "prescribed" as a result but there are also claims that mineral deficiencies can be diagnosed. This often drives the sale of expensive (and unnecessary) dietary supplements.

Herbal therapies
This is a complex area. There are several different "traditions" that involve the use of herbs (and potentially other substances) - Western herbalism, Ayurveda and "Traditional" Chinese Medicine (TCM) are the most familiar but, for example, even what of thought of as the Western tradition is very diverse.

Both Ayurveda and TCM can involve the use of toxic substances. TCM can involve the use of substances from endangered species. Some are illegally imported in the UK and can end up in the retail supply chain. The products are not manufactured to international standards. Contamination and adulteration are not unknown.

There were moves towards statutory regulation of herbal practitioners but nothing has happened in years. It is surprising that herbal practitioner groups have not applied for PSA accreditation. There is the National Institute of Medical Herbalists (NIMH) but most of the degree courses that would gain admittance are closed. There is also the Association of Master Herbalists and the Unified Register of Herbal Practitioners.

Not that many SoH who offer herbal therapies will have completed a degree course, if any course at all. Statutory regulation would put a big dent in SoH members offering herbal therapies.

The most shocking things found in this analysis was a member offering Gerson therapy.

Manipulative therapies
Osteopathy and chiropractic are regulated in the UK but there are a number of therapies invented by osteopaths and chiropractors that are not. 

Bowen technique 
Cranio-sacral therapy

There are also a huge range of massage therapies. The evidence base varies considerably. Massage is contra-indicated for some conditions. Any form of physical manipulation carries risk and the more vigorous the manipulation, the greater the risks. 

Massage is sometimes used in physiotherapy.

There's also the oddity of Neuro Emotional Technique (NET) which seems like EFT with the tapping replaced by manipulation (or even acupuncture) and without explicit mention of "energy". 

Nutritional therapy
This is a very broad category and in depth treatment is beyond the scope of this post. There is some cross over with herbal therapies in terms of products used. 

"Nutritional therapy" is meant as something other than what dietitians and nutritionists do. Dietitians are statutorily regulated in the UK by the Health and Care Professions Council. Dietitian is a protected title. Nutritionist is not - anyone call call themselves a nutritionist but to work as a nutritionist for the NHS (and likely other employers in the healthcare sector), it is necessary to be registered with the Association for Nutrition (AfN). The AfN would like nutritionists to be statutorily regulated and the title protected but there are obstacles to this discussed here. In an NHS context, dietitians' role is to assess, diagnose and treat dietary and nutritional problems, as well as provide information to the public, patients and clinicians. They are seen as Allied Health Professionals - clinicians. The role of nutritionist is purely informational. They are seen as Clinical Support Staff - not clinicians. What some dietitians and registered nutritionists get up in private practice is another matter.

The British Association for Nutrition and Lifestyle Medicine (BANT - it used to the British Association for Nutritional Therapy) describes nutritional therapy as -
Nutritional Therapy is the application of nutrition science in the promotion of health, peak performance and individual care. Registered Nutritional Therapists use a wide range of tools to assess and identify potential nutritional imbalances and understand how these may contribute to an individual’s symptoms and health concerns. This approach allows them to work with individuals to address nutritional balance and help support the body towards maintaining health. Nutritional Therapy is recognised as a complementary medicine and is relevant for individuals with chronic conditions, as well as those looking for support to enhance their health and wellbeing. 
Practitioners consider each individual to be unique and recommend personalised nutrition and lifestyle programmes rather than a ‘one size fits all’ approach. Practitioners never recommend nutritional therapy as a replacement for medical advice and always refer any client with ‘red flag’ signs or symptoms to their medical professional. They will also frequently work alongside a medical professional and will communicate with other healthcare professionals involved in the client’s care to explain any nutritional therapy programme that has been provided.
This statement seems to suggest that nutritional therapists are like dietitians. The statement contains weasel words as well as a number of falsehoods. There are BANT members who are anti-medicine and do recommend nutritional therapy over medical treatment. The ability to recognise "red flags" is questionable. This story is a few years old but evidence suggests nothing has changed.

It is also worth reading about Patrick Holford.

Psychological therapies
It might be thought that these carry no risk of harm but this is not the case.

The place of psychotherapy in modern psychiatric practice article talks about the potential adverse effects of psychotherapy -

  • Malignant regression and suicide
  • Psychotic episodes
  • Increased depression and hopelessness
  • Rash or irresponsible behaviour
  • Increased risk of aggression of assault

  • Cost and inconvenience of weekly sessions (travel, time off work)
  • Dysphoric emotions and increased self-doubt
  • Disrupted interpersonal relationships

A quote from this article -
A therapist that prioritises his or her own needs (exploitative, narcissistic, voyeuristic) over the patient’s needs can do harm.
It is obvious that a therapist dealing with a case that is beyond their competence can do harm. It is also the case that certain therapies do not help certain types of patient and may even cause harm to them. There are some therapies that lack any evidence base and are seen as pseudo-scientific. It isn't clear if there are therapies that are harmful to the majority, if not all, of patients subjected to them.

The types of therapies offered by SoH include -

Hypnotherapy is often confused with stage hypnotism. Some may also associate it with recovered memory therapy and past life regression. The more mainstream strands of hypnotherapy tend to eschew those things. One of the most common applications of hypnotherapy is smoking cessation (although advertised success rates are often questionable) but some types of hypnotherapy look very like traditional psychotherapy with some adjunctive use of hypnosis. 

Hypnotherapy is interesting because of its attempts to achieve some sort of recognition and regulation. The UK Confederation of Hypnotherapy Organisations (UKCHO) make a big deal out of a statement from the defunct Prince's Foundation for Integrated Health.
Single voluntary self-regulatory bodies should be established for the Complementary and Alternative Medicine professions most widely practised in the United Kingdom and these bodies should have a single independent body funded by registration fees and a Governing Council made up of a balance between professional and lay members.
This would one of the steps that would be required on the road to statutory regulation but this is not the model of the Accredited Registers scheme. It allows multiple registers covering the same kind of therapy, possibly because competition is seen as healthy. It is also the case that some "professions" are highly fragmented and fractious. There are several Accredited registers that will accept hypnotherapists. The Wikipedia page on Hypnotherapy in the UK is useful in understanding some of the issues re regulation of hypnotherapy - that some hypnotherapists don't see the practice as CAM and that some think voluntary self-regulation is useless is telling. It was possible for cats to become hypnotherapists.

NLP is controversial to say the least, partly because of its history and those involved in it but it is widely regarded as pseudo-science and ineffective. It was very popular beyond the therapeutic context for several years. Practitioners would offer training especially to sales and marketing people. The premise that any skill can be acquired by "modelling" those with it is attractive to some, as are persuasion techniques. 

But homeopaths also offer to treat mental health conditions with homeopathy. This will be covered in a future post. 

Therapies covered by Accredited Registers
Most of the registers accredited by the PSA tend to cover only one type of therapy and the majority of their members will only practice one type of therapy (even if the definition of that therapy is quite broad).  Registers have educational/training standards for entry. They vary but many of them require a degree, actual training in the role and supervision.

There are a couple of "umbrella" registers, the Federation of Holistic Therapists (FHT) and the Complementary and Natural Healthcare Council which cover a wide range of therapies. What is interesting about both of those is that they have effectively outlawed members from offering certain therapies (CEASE and homeoprophylaxis in the case of FHT, GAPS and DAN! in the case of CNHC).

The therapies covered by CNHC are -
  • Alexander Technique teaching
  • Aromatherapy
  • Bowen Therapy
  • Colon Hydrotherapy
  • Craniosacral Therapy
  • Healing
  • Hypnotherapy
  • Massage Therapy
  • Microsystems Acupuncture
  • Naturopathy
  • Nutritional Therapy
  • Reflexology
  • Reiki
  • Shiatsu
  • Sports Therapy
  • Yoga Therapy
Therapists are eligible to join if they have passed a course in any of the above that meets National Occupational Standards (NOS) - basically all of them bar homeopathy (the CNHC and the SoH have some history). There is an exception for Yoga Therapy in that a portfolio application route exists as well. The CNHC allow members to add members therapies to their register entry but only if the training meets NOS - not just a weekend course. They also say -
Please note, use of the CNHC quality mark is limited to publicity material specific to the therapies for which you are registered. If any of your promotional materials list more than one therapy, you must state clearly next to the quality mark on these materials, including any website(s), which discipline(s) you are registered for, unless you are registered for all of them.
Compliance is another matter though. Registering a therapy is relevant for the CNHC's search facility. The PSA's website doesn't have a search facility itself - it directs the public to individual register's website. Whilst both the CNHC and PSA would like the public to use the search facility, the extent to which they do vs, say, simple Google search is unknown. 

The situation with the FHT is more complicated and unusual. The FHT registers professions outside health and social care as well as those within. Effectively, only part of what it does is an Accredited Register. And the entry requirements for that are courses that meet NOS, as above with the CNHC with the addition of homeopathy. These members can be found by the Complementary Healthcare Therapist Register search facility. As with the CNHC, additional therapies can be added if training meets NOS strandards. They can also be found on the FHT Directory which includes all members.

Implications for the Society of Homeopaths
The SoH has a questionable record recognising, evaluating and mitigating the risks posed by members' practice. CEASE therapy, homeoprophylaxis and the promotion of anti-vaccination propaganda are evidence of this.

If the SoH genuinely takes the position that risks posed by therapies other than homeopathy practiced by their members is of no concern, this poses all sorts of problems.

To begin with, there is the question of advertising and the use of the Accreditation logo etc. The SoH could take a similiar position to the CNHC and instruct members to make it clear what therapies are covered by accreditation and which aren't. One alternative would be to suggest to members that they separate advertising of their homeopathic practice from other therapies. However, the utility of this where other therapies are used diagnostically, adjunctively or intregratively is moot.

If the SoH directs members to join another register as well, it must be pointed out that with some of these therapies there is nothing that could be considered a register for them. Even where a register of sorts exists, does that register have a Code of Ethics? Does it act to protect public safety? The argument for the Accredited Registers scheme is that these registers do. As can be seen above, there are a wide range of therapies that have NOS standards but these courses are time consuming and expensive. It isn't always clear what courses members have completed but some are purely online courses and others are very short. If the SoH wants members to join another Accredited Register, it may make more sense for them to leave the SoH and join the FHT (unless they practice CEASE therapy). Mark Taylor, CEO of the SoH has said that some SoH members struggle to make a living. FHT membership is a lot cheaper.

Imagine the scenario where an SoH member uses a Bio-resonance device. There are no registers for the use of these devices. A client has a bad experience. Perhaps they are given an incorrect "diagnosis" that causes them upset or they receive electric burns from it. Would the SoH deal with a complaint from the client? 

Prohibiting members from offering other therapies unless they belong to another register (of whatever kind) would be draconian and would likely lose them a lot of members. As would prohibiting members from practicing therapies where no register exists. It could have a huge impact on the SoH's financial viability. Requiring separation of practice and advertising would probably have a similar effect and with actual practice, be impossible to police.

This suggests that the default insurance package offered by the SoH does not cover therapies other than homeopathy unless they are specifically added to it. Of course, members do not have to sign up for the insurance that the SoH offers (although they do have to have insurance). There could be a number of SoH members whose practice is not fully covered by insurance. Which poses a real problem with PSA accreditation. It is a requirement of the Standards 8 that register members have indemnity insurance. It would be very odd if this did not mean for the whole of their practice, especially where other therapies are used in a diagnostic, adjunctive or integrative way. Even if practices of therapies are separated, not to be insured would place the member at financial risk. If nothing else, the SoH really should ensure that members are fully insured.

But given the prevalence of other therapies and the lack of registration, are the SoH doing enough to manage risk posed by its members? To the satisfaction of the PSA?