Can a psychotherapist practice holistic therapies?
February 1, 2015 4:05 PM   Subscribe

Dear AskMeFi, If I were to become a licensed psychotherapist (MFT, LMHC, LPCC; not a PsyD clinical psychologist), would it be within my legal scope of practice to help my patients using holistic traditional Eastern Asian therapies such as meditation, bodywork and body therapies, medicinal herbs, lifestyle guidance, etc? How about if I were to get a second credential or license? Rather... how *could* I make it legal, if there is a way to do so? Practice different modalities on different days? Lots of waivers?

I'm a Californian prospective graduate student doing research on possible future paths.

This would be in California, Oregon, Washington, or Hawaii - I am not sure yet where I'll go to school and live.

Thanks for the help!
s&s

ps. Please no "those are useless/quack/charlatan/pseudoscience practices with zero documentation of their efficacy" comments... I unchangeably believe in what I do, so this opinion doesn't matter to my present concern.
posted by anonymous to Law & Government (21 answers total) 2 users marked this as a favorite
 
I guess I'm not sure of your question. Do you want to know if you can recommend that your patients do things like meditate, take yoga classes, etc.? Or do you want to dispense medicinal herbs?

FWIW, I learned how to do mindfulness meditation from my therapist, so . . .
posted by chainsofreedom at 4:13 PM on February 1, 2015


Generally, no. Your license requires you to practice "within your scope of practice," and those scopes are reasonably well-defined not to include herbs or touching or (much) energy work. There are somatic-based therapy practices that would fit within the scope of practice, but are more about helping clients tap into what's going on in their bodies.

And part of the issue is regardless of any waivers, if you present yourself as a licensed masters-level therapist, you will be expected to adhere to the legal and ethical codes of your licensed profession, which means that if a client sues you, your malpractice insurance won't cover you if you're outside your scope of practice and legal protections may not apply if you're outside your scope of practice.

People who want to get around that usually become life coaches (which is fairly unregulated).
posted by jaguar at 4:14 PM on February 1, 2015 [15 favorites]


Since the therapies you mention don't require state licensing, and since there are probably myriad 'credentialing' options with different folks (ask me about my Reiki attunement) the credential won't matter at all to the state.

Chiropractors sell vitamins and chakra alignment. So you can combine to your hearts content. There is one thing, which is the ethical code of your licensing board or psychological 'school'.

This is much more an issue of ethics, than of state monitoring. The state doesn't care about medicinal herbs, at all. Hence you can buy Bath Salts in head shops. Is it right to discuss and to charge for other therapies with patients who seek help from you as a therapist? How do you feel about your Chiropractor selling you a diet program and a series of massages?
posted by Ruthless Bunny at 4:15 PM on February 1, 2015


This would be a huge problem for me if I were your client, to the point where our therapeutic relationship would be broken. (I would never be able to trust a therapist who believed in those things, except maybe the use of herbs--I've tried those too.) However, if you are obvious about it from the get-go, then there's no way I would choose you for a therapist in the first place, so perhaps that would be a positive? I would absolutely want to know from the start.
posted by Violet Hour at 4:31 PM on February 1, 2015 [6 favorites]


This is much more an issue of ethics, than of state monitoring. The state doesn't care about medicinal herbs, at all.

That is absolutely untrue. A psychotherapist who prescribes certain herbs can be charged with practicing medicine without a license.


Nutritional Advice: Healthy Reminders About Scope of Practice and Competence:
In this scenario, the advisement to “…take specific herbs to treat her insomnia” is not nutritional advice. It is not merely information as to the role of food and food ingredients like dietary supplements (i.e., herbs), but rather, it is a prescription of a dietary supplement (specific herbs) for the treatment of a particular disorder (insomnia).

Unlike nutritional advice, a specific advisement to take dietary supplements or prescribing certain dietary supplements to treat or cure an illness is outside an LMFT’s scope of practice. Because this communication is an LMFT’s specific assertion that certain herbs might, in effect, cure insomnia, it is arguably equivalent to the unlawful practice of medicine. Therefore, an LMFT who does not hold a license to practice medicine in California should not provide this type of advice to his or her patient.

This type of violation has serious consequences. In a recent case, the Board of Behavioral Sciences (“BBS”) placed an LMFT on probation for three years with mandatory enrollment in ethics courses and a hefty fine of more than $3,000. The BBS disciplined that LMFT for, among other acts, engaging in unprofessional conduct outside the scope of practice for advising a patient “…to take specific herbs for various illnesses.”
Practicing outside one's licensed scope of practice while providing services under that license can result in fines, license suspension, and license revocation. It is illegal, not just unethical.
posted by jaguar at 4:32 PM on February 1, 2015 [12 favorites]


What do you mean by "bodywork"? If you mean massage, then yes you do need a license to practice massage in almost all states at this point. Ditto acupuncture.

If you have two or more licenses, it becomes tricky to practice both at the same time, with the same client, for insurance reasons. Insurance won't cover anything other than what's within your scope of practice, and you'll need separate insurances for each modality. I have known people who actually have separate areas of their office so they can be super clear about what role they are acting in at any given time. If a client is interested in more than one service, they will receive, say, massage in one place and dietary counseling in another.
posted by mysterious_stranger at 4:34 PM on February 1, 2015


As someone who has been in therapy as a child and an adult, and now a social work practitioner in an agency, I can tell you that meditation techniques have been taught to me and I have taught them as part of my practice, and a few of the therapists I work with use yoga if their clients are open to it. Kids apparently can't get enough of yoga!

I think when thinking about this issue, you need to think about what your licensed psychotherapy practice would look like, and how you would want traditional Eastern therapies to supplement/integrate with that. You also need to think about which therapies make sense as part of a Western therapeutic practice--anything to do with the mind, or things to do with the body that can be safely tried by the client without special training (basic yoga poses, etc.) are fine. When you get into medicinal herbs, though, that starts sounding a lot like practicing medicine without a license to your licensing board.
posted by epj at 4:37 PM on February 1, 2015 [2 favorites]


If a client is interested in more than one service, they will receive, say, massage in one place and dietary counseling in another.

You could most likely provide non-psychotherapy services to certain clients and psychotherapy services to others, but not both types of services to the same client. Most psychotherapy ethics boards discourage "dual relationships" with clients (where you're functioning in more than one role in their lives), which means, again, if they sue, you're going to have an immense problem demonstrating that you somehow weren't that client's psychotherapist while providing them with a massage or whatever.
posted by jaguar at 4:41 PM on February 1, 2015


[folks, this isn't a debate on efficacy of alternative medicine, please answer towards the original question]
posted by mathowie (staff) at 4:51 PM on February 1, 2015


I've had such a visceral reponse to your question. I hope that if you did get training in psychotherapy you would come to a place where you would help clients develop tools to evaluate therapies like you've mentioned for themselves. I've had therapy and I came to try out yoga and do some mindfulness stuff so I'm not blankly hostile but...the purpose of the therapy was not to push me down a series of particular beliefs. Going to a yoga class or even trying certain poses or even Thinking my therapist wanted me to be present in my body would have been absolutely excruciating for years.

And sure, a summary over the phone of your beliefs would have sorted it out but wow, I would have been so bitter to find that someone claiming to be a psychotherapist really thought I should go to yoga or drink teas. Because there's no way that would occur to me right?

Also I can't think of anything that would have messed me up more in grappling with some stuff than trying some medicinal herbs.

I bring this up because if you are entering into a psychotherapy relationship, I really think it is your job to be present to your client's beliefs and needs, not to be sure yoga will help. So please do something else.
posted by warriorqueen at 4:55 PM on February 1, 2015 [3 favorites]


fwiw, I would *absolutely* be billing myself upfront as a psychotherapist whose tools are traditional Eastern mind/body therapies alongside psychotherapy.

Yeah, you pretty much can't do that. Mindfulness is obviously an Eastern practice that's been pulled into Western therapy, and so a lot of mindfulness practices or suggestions for those practices are fairly mainstream in a therapy office, but not as an ongoing part of the therapy sessions. I've had two therapists who provided meditation sessions, for example, but those sessions were free, never "prescribed" but instead presented as "This is another thing I do, feel free to come if it interests you," and kept as a very separate thing. (I would have been highly annoyed at paying psychotherapy rates to sit in a room meditating in silence for a half-hour.) But I think a good rule of thumb for it is that a psychotherapist generally cannot be touching someone's body (other than maybe a quick hug) or recommending they put certain substances in their body. That's certainly not a hard-and-fast rule, but it's a reasonable starting assumption.
posted by jaguar at 5:13 PM on February 1, 2015 [3 favorites]


I know a number of life coaches who got their master's in counseling psychology and then just didn't pursue the training and experience required for licensure. So they're able to bill themselves as life coaches with master's in counseling psychology, with the flexibility to basically not have a legal scope of practice.

I have no idea what the market and income for life coaches vs. naturopaths/chiropractors/herbalists/nutritionists/etc. is, but I do think it would be worthwhile for you, given your goals, to look into life coaching. Like I said, it's currently unregulated but there are certification programs and some organizations (I think) trying to put together codes of ethics. It might be a really good fit for you.
posted by jaguar at 5:44 PM on February 1, 2015


In agreement with Jaguar above, there are also restrictions to who/what licensure/degrees can call themselves a 'psychotherapist'; this also varies by state. It sounds like you want more of a counselling modality, not purely psychotherapy.
posted by cobaltnine at 5:45 PM on February 1, 2015


So it's looking like psychotherapy is a no-go, unless I were willing to commit more fully and purely to the psychotherapy profession, and delegate the rest of the stuff by giving patients referrals, but very strictly only if they independently initiate this.

And again, that's not really true, you just likely couldn't legally do the psychotherapy with the same clients to whom you're doing the rest of the stuff. I also know a number of therapists who have both therapy and coaching practices.
posted by jaguar at 5:51 PM on February 1, 2015


(Though, again, you'd need to be very clear that you were not providing psychotherapy to your coaching clients.)
posted by jaguar at 5:53 PM on February 1, 2015


Can I ask why you're bothering with psychotherapy at all? It seems like it would be a waste of your money and time. Why not just (am I saying this, really) study naturopathy, which is apparently a regulated profession in some US states?

Or, how about choosing a standard profession more closely aligned with what seem to be your actual interests? I think massage therapy or acupuncture might let you do a lot of the things you're wanting to do. Or, you could formally and seriously study yoga; I understand that some branches have their own approach to mental health. I think, honestly, it's better to be really, really good at one core skillset, and so do most licensing boards. Your clients would appreciate that too, I'm sure. Some of these interests, you could do on your own time (or for fun).

Also, most complementary approaches to healthcare involve some kind of informal "counselling", if you mean just talking to people about their problems. So do a lot of standard approaches - I talk to my physiotherapist, for example. (So does hairdressing.) That isn't the same thing as e.g. doing CBT with a depressed person every week for 2 months. If you don't want to do that, don't.
posted by cotton dress sock at 6:31 PM on February 1, 2015 [2 favorites]


FWIW, a former LCSW therapist absolutely did meditation as part of her practice. She also "prescribed" specific yoga poses, though as far as I know she was not a yoga teacher, and never demonstrated the poses. (She recommended I go to yoga as part of mental health/stress management.) She also did EMDR, which I think is pretty standard therapy stuff, and visualization exercises. I was a little grumpy about the meditation, because I can go to a meditation class for free at a nearby UU church, or $20 at a yoga studio, and paying $90 for it when I'd rather be talking through issues made me cranky. On the other hand, I think her slightly woo approach to mental health was probably good for me in the long run, and hey, I'm all about the meditation and yoga these days.

You might be interested in researching yoga therapy if you decide against psychotherapy.
posted by instamatic at 7:20 PM on February 1, 2015


Dissenting here. From the client's side, I've had therapists who do everything from making getting a tattoo part of the therapeutic process (I didn't partake in that part), sand tray therapy / play, roleplaying and psychodrama and, yes, nutritional therapy (and those were the least wack ones). This woman, for instance, is covered by my insurance plan for mental health visits. As you can see, she offers a lot of the things you're talking about.

It might be good to refer to the Good Therapy list of kinds of therapy. YMMV a whole lot depending on your locality whether you need to call yourself a coach/counselor/what degree you'd want, whether you could get insurance reimbursement, etc. None of my therapists called themselves anything else. Most I paid in cash, but that is more and more common with mental health professionals in general.
posted by sweltering at 8:54 PM on February 1, 2015 [2 favorites]


Sand tray and roleplaying/psychodrama are established psychotherapy techniques that are taught in grad schools for counseling psychology and are well within a normal scope of practice for psychotherapists. There is a huge variety of well-established psychotherapy interventions and modalities, even those that people might consider "woo," that have a long history and are still considered bog-standard for therapy. Prescribing herbs and massage are not generally considered within the normal range of professional activities for a therapist.

And it's worth remembering that just because someone is publicly doing something does not mean that their actions would withstand a legal challenge.
posted by jaguar at 9:32 PM on February 1, 2015 [1 favorite]


I was thinking about this overnight, so I apologize for the serial posting but I think this might help explain the reasoning for the potential issues:

Therapists have a weird, unique role in clients' lives. Clients come to us specifically in order to talk about their secrets, usually at extremely vulnerable times in their lives, while we reveal very little of ourselves; plus we have training in spotting and diagnosing clients' psychological vulnerabilities. That creates a very unequal relationship with an enormous potential for exploitation and manipulation. Because therapy doesn't work if clients can't trust their therapists, there are ethical and legal guidelines in place to make sure therapists are not exploiting or manipulating their clients. Manipulating clients is usually (though not always) an ethical issue, while exploiting clients is usually both an ethical and legal issue.

Exploitation most often (in all areas of life) is either financial or sexual, and so therapists generally have to avoid even the appearance that they are forcing clients into unwanted or exploitative financial transactions (whether the therapist is paying the client (e.g., giving them a job) or getting paid by the client (e.g., selling them something)) or physical relationships. Ethically, therapists are encouraged not to even go to the same community meetings, dance lessons, choir practices, etc., as their clients, because the weird inequality of the relationship can make the client uncomfortable, which undermines the therapeutic work. A therapist who seems to be putting pressure on clients to buy things not generally considered part of therapy (astrological charts, herbs) can be exploiting that client financially. (What happens if they say No? Are they bad with boundaries and the therapists knows that because they've been counseling them about boundaries? Is the therapist therefore using "inside information," so to speak, to manipulate this client into buying expensive products on which the therapist will make a profit? Etc.) A therapist who seems to be putting pressure on clients to do things physically (massage, especially if unclothed; probably certain yoga poses, especially if the therapist does physical adjustments on the client) can be exploiting that client sexually, even if no sex is involved, because the emotionally intimacy required of a good therapeutic relationship (especially if there are transference issues) can make things murky.

On top of that, the state granting the professional license has an interest in making sure that any professional activity conducted under that license falls within the definitions of that license. It's kind of like drivers' licenses -- you don't get one license and then can drive anything you want, there are specialized licenses for various types of vehicles and it's illegal to use a regular license to drive a motorcycle or a semi. The state has an interest in these definitions both because they want to protect consumers and because the creation of the professional definitions generally involves a lot of lobbying by professional organizations who want to be able to control the type of work that happens in their name. Doctors, and more importantly doctors' professional and lobbying organizations, do not want to see people without MD licenses from the state calling themselves "doctors" and doing potentially harmful things without training or experience, both because it can harm patients and because it makes doctors overall look bad. Ditto for Marriage & Family Therapists, Social Workers, Licensed Professional Clinical Counselors, Psychologists, and all the rest of them. There are laws about what you can call yourself (anyone can call themselves a "Therapist," only licensed MFTs can call ourselves "Marriage and Family Therapists") because these professions want, generally for very good reason, to preserve their image as people with experience, training, professionalism, and ethics.

A cashier at Whole Foods giving advice on supplements is not presenting herself as a medical doctor. A women sitting in an office with diplomas on the wall who's licensed to diagnose your mental-health conditions, for whom you signed informed consent and demographic forms like at the doctor, and who is giving you advice on supplements is creating a much different picture about her expertise. Bring in the questions about potential exploitation, and a therapist is setting up a situation in which a vulnerable client might easily be confused and manipulated into believing things that aren't necessarily said or paying money or exposing her body in ways she might not be totally comfortable with. The therapist, being in a position of power in the relationship, is going to be held legally accountable for those ethical lapses if the client claims those lapses harmed her, even if the therapist had nothing but good intentions.

Therapy is a weird profession, and practicing it ethically requires doing a lot of things, and avoiding doing a lot of things, that are not at all intuitive (like pretending you've never met someone if you run into them at a party, or not offering advice, or not initiating hugs or sometimes even handshakes) until you get the training about why they're necessary. If you do want to provide any sort of therapy to clients -- rather than only lifestyle coaching -- I do encourage you to do the master's program and learn about why what you're currently considering (or were considering at the start of this thread) is problematic. Because I think working through those ethical considerations, learning why they're important, will help you decide the actual best way for you to proceed.

If you only want to give advice and not provide therapy, however, the skip the master's in counseling. Advice-giving is fine in context, but my grad-school classmates who had that motivation going into school had a rough time of it, and I wouldn't recommend any of them as therapists.
posted by jaguar at 7:18 AM on February 2, 2015 [7 favorites]


I just saw this which deals with the ethics of selling complementary and alternative medicine for health professionals.
posted by Violet Hour at 7:47 PM on February 2, 2015


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