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Monday, 12 August 2019

Does my client need a medical referral?

I suspect I am opening a can of worms (hopefully metaphorical rather than medical) with this question, but thought it was worth looking at because there are so many conflicting bits of advice out there for hypnotherapists.

Do you need a doctor’s permission to work with a client or not? And if so, when?

Bear in mind I can only give my own view on this, but I’ll work my way through the advice available and try to come to some conclusions. But before you read on, it’s important to say that I’m in the UK and if you are practising elsewhere, I’m sure different rules will apply.

Ethics


Start by checking whatever Code of Ethics you work with, as each one words things slightly differently and in differing amounts of detail. If in doubt, drop a line to your professional body (or whoever wrote your Code of Ethics) and ask them what their policy is on getting medical referrals, so you have it from the ‘horse’s mouth’.


My primary professional body is the General Hypnotherapy Register so I’m going to look at their advice. If you are not a GHR member, read on so you can compare your professional body’s advice with theirs, or make a few notes about what your own Code has to say, and skip to the next section.

The GHR Code of Ethics has two things to say about this topic, which are

  • ensure that wherever a client is seeking assistance for the relief of physical symptoms, that unless already having done so, the client be advised to contact a registered medical practitioner. (Clause 8)
  • never knowingly offer advice to a client which either conflicts with or is contrary to that given by the client’s registered medical advisor/s. (Clause 9)

Firstly, you’ll notice that this clause only applies if the client is ‘seeking assistance for the relief of physical symptoms’ so your first job is to decide what that means. The client is presenting for pain relief or menopausal side effects? I’d say yes, definitely. But what about anxiety? It often has physical manifestations. What about a client who is very overweight or pregnant? Are these in themselves ‘physical symptoms’?

I tend to interpret this one on a case by case basis, using what I like to think of as common sense. So, for example, if my anxiety client has distinct physical symptoms (one reported pain in his chest and down his left arm as a symptom of panic attacks, for example, which was worrying) I ask them to get it checked out. After all, if they do have heart problems, my helping them with anxiety is not going to make the problem go away. If they are already being treated for anxiety by their doctor, especially if they are taking medication, I also advise them to let the doctor know they are working with me. That one is a bit of a stretch, perhaps, but seems like good manners.

The second thing you’ll notice about the GHR guidelines is that they don’t ask you to get a referral or permission from the GP, only to advise the client that their medical practitioner should be contacted. Nor do they say what form that contact should take, or what the client should say; it’s left up to you decide what’s appropriate for the client in front of you.

From this, simply asking the client to inform their GP they are seeing you should be fine. I recommend you either ask the client to sign something indicating they’ve been given this advice, or record it in your session notes. Follow up at the next session by checking if they have done so, and record that too. If they have chosen not to follow your advice you will need to ask why and review whether you feel it’s ethical to continue to work with them. If you’re not sure, that’s what your supervisor is for!

Most GPs, in my experience, when told a patient is seeing a hypnotherapist shrug and say something fairly neutral and non-committal (although some are gratifyingly supportive). They’re not being asked for an opinion, after all, just informed. But there is the possibility that the GP will say ‘No. Under no circumstances. Don’t do it!’ or words to that effect. If that happens, you would have to stop working with the client under clause 9, since to continue would be to contradict the advice given by the medical practitioner.  This has only happened to me once in 16 years, and under very unusual conditions, so I’d guess it’s rare.

The Training Standards/Voluntary Regs


If you choose to work within these guidelines, the latest (2019) version of the Training Standards states that if there are possible contra-indications therapists should
contact the client’s GP (always with the client’s permission) or other relevant healthcare professional (such as a psychiatrist) (para 9)

It says ‘possible contraindications'' I'd imagine this could arise if, for example, you suspect an undiagnosed condition which would be a contraindication if confirmed. In this case, you have to take action yourself and not simply advise the client to do so.

Get the client’s consent and then contact the relevant medical professional yourself. I’d say you will need this consent in writing, and it should include explicit instructions to the doctor concerned to release information to you. Otherwise, you can contact them, but they can’t respond because of GDPR and other confidentiality rules.

The paragraph doesn’t mention what it considers to be contraindications, of course. For that, the best guide is para 20, which says therapists should

 … work within [their] competence, understand their limitations and refer on to another hypnotherapist or healthcare professional if appropriate.

So, working outside of your training is contra-indicated, which seems quite reasonable. This doesn’t prevent you from working with an issue for the first time, just in areas where you have no knowledge or skills.

There are also some medical conditions widely (though not universally) considered to be contraindicated for hypnotherapy. The list you have will depend on who trained you. But we do have some indicators of what they might be in the next section.

ASA, CAP and the law

  
 According to its website, the Advertising Standards Authority (ASA) is ‘the UK’s independent regulator of advertising across all media’. The ASA ‘apply the Advertising Codes, which are written by the Committees of Advertising Practice (CAP)’. So their rules apply to you and your practice wither you work inside or outside of the voluntary regs and whichever professional body you belong to.

Both ASA and CAP have a bit to say about what issues hypnotherapists should and shouldn’t say we work with. Now admittedly this is about advertising, but if you can't legally advertise that you work with an issue I think there's a good argument to say you shouldn't be working with it. For example, the CAP website says

Claims to offer treatment on conditions for which medical supervision should be sought are likely to be considered to discourage essential treatment unless that treatment is carried out under the supervision of a suitably qualified health professional (12.2)...

[ASA and CAP] do not consider that hypnotherapists who do not hold a general medical qualification are likely to be suitably qualified to treat serious medical conditions...

Claims to treat depression, addiction, eating disorders and other serious mental or psychological conditions are likely to be considered claims to treat serious medical conditions… 

Just as an ‘aside’, the word addictions here doesn’t seem to include working with smokers, as there are separate and specific rules about advertising to them.

Getting back to the paragraph, it seems they are worried that if someone sees you for a serious condition, that client will be less likely to seek out conventional medical advice. Whatever your view on that one, the rules apply anyway. Unless you have medical qualifications or other specific training in working with the relevant issue and a health professional overseeing your work, you should consider any ‘serious medical condition’ contra-indicated.

The question then becomes what do they mean by being ‘supervised’ by a medical professional? It’s possible that requesting a formal referral from a doctor might tick this box, but I couldn’t find any test cases to confirm that. If this situation comes up in your practice, I strongly suggest contacting CAP, your insurance and/or your supervisor and asking for advice before proceeding.

While we are speaking about legal stuff, we also have to bear in mind the Cancer Act 1939. Under Section 4 of this Act, it is a criminal offence to advertise services which claim to 'treat any person for cancer'. Use of wording that breaches this legislation can lead to enforcement action by Trading Standards, which could result in a fine or up to three months in prison. It would also lead to the advertiser having a criminal record, which might well have an impact on your ability to get insurance to practice and your professional memberships.

Overview


So where does this leave us regarding doctor’s referrals? There is some flexibility in how you interpret some of these guidelines, especially when they are all taken together, but here are my thoughts.

  • Generally speaking, you don’t need a doctor’s referral to work with a client.
      
  •  If the client reports physical symptoms, but you are confident you can work with them safely and ethically, you should advise them to contact their doctor. There is no requirement to give this advice in writing, but I would keep a record of some sort as proof you have done so.
        
  • You do not need permission or a referral from the doctor in this situation, but if the client’s doctor, when contacted, advises against undertaking hypnotherapy, you should respect that.
      
  • If you suspect the client might be contraindicated, it is your responsibility to obtain suitable permission and contact the doctor yourself. If there are definite contraindications presumably you wouldn’t be working with the client at all, so this wouldn't be needed.
        
  • Both the Code of Ethics and the Training Standards say you should only work within your training and competence.
        
  • ASA and CAP say that they do not consider hypnotherapists qualified to work with ‘depression, addiction, eating disorders and other serious mental or psychological conditions’ unless they hold medical qualifications and/or are supervised by a medical professional.
      
  • The Cancer Act says you cannot claim to 'treat' cancer. This doesn't stop you working with people who have it if you are helping with other issues like stress, anxiety and the like. If you work with pain control it would come under the 'physical symptoms' provisions above.
      
  • These guidelines combine to provide a kind of minimum standard, but you can always have stricter rules for your practice if you wish.
FREEBIE!
Do you want this guide as a flow chart? Just email Debbie and ask.

I hope this will help you in your practice. Feel free to post comments, thoughts or questions below.

WARNING! Please remember that this is written from my personal experience and is only intended as a guide. I am not an expert in this area, and every client is different. So is every professional body, so you'll have to check out what yours says on this topic. If you are unsure how to proceed, err on the side of caution. Get a medical referral or contact your supervisor, professional body, insurance or CAP for advice.


References:
https://www.cap.org.uk/Advice-Training-on-the-rules/Advice-Online-Database/Therapies-Hypnotherapy.aspx#.WKW_tK-mmCg CAP Guidelines for hypnotherapy, 2016.


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Author: is an experienced hypnotherapist and hypnotherapy trainer. She is the author of Their Worlds, Your Words and has co-written the Hypnotherapy Handbook, both of which are available from Amazon.
Find out more about Debbie's services on
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2 comments:

  1. Hi Everyone, Bruni here from the Australian Hypnotherapists' Association. These are my thoughts and not to be taken as the thoughts of the current AHA National Executive. I have a 'Client Intake Form' on my website that I ask any person who has made an appointment to fill in and send to me. I print this and have it waiting for them to sign when they come for their first appointment. I like to do that because it gives the client time to think about the answers, rather than miss out details because they feel rushed. Just recently a prospective client told me that she suffered with epilepsy and I said that I needed to speak with her treating health practitioner to get the okay. Permission was granted and I spoke with the client's Psychiatrist about her condition. And fortunately we were both on the same wave length about the possibilities on the client's condition and I gained permission to work with the client. I sent a short letter thanking the psychiatrist for their time and advice and that I would keep him advised of my session with his patient. Sending the letter to the health practitioner is covering me for having asked permission to deal with the client. For interest sake, I don't know if you are aware of this recent research from UK: A recent study, published in Psychiatry Research, has concluded that psychiatric diagnoses are scientifically worthless as tools to identify discrete mental health disorders - https://www.sciencedaily.com/releases/2019/07/190708131152.htm No doubt we will hear more about this research. All the best from 'Down Under'

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  2. Thanks for this Bruni, much appreciated. And a great link to follow through.

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