IRELAND HOLISTIC Directory, Alternative Medicine, Colonics, Massage, Pilates, Dublin, Cork

Report of the National Working Group on the

Regulation of Complementary Therapists to the

Minister for Health and Children

Contents

Foreword 5
1. General Background 7
2. Definition, Categorisation and Scope of Practice 15
3. Education and Training 21
4. Curriculum for Complementary Therapy Courses 27
5. Professional Associations 31
6. The Consumer 33
7. The Regulation of Complementary Therapists 39
8. Recommendations 43

Conclusion 45

Appendices 47 3

Foreword Over the two years that the National Working Group on the Regulation of Complementary Therapistshas been in existence, I have become increasingly aware of the level of commitment that exists withinthe complementary therapy sector for the greater development of the sector and for the elimination ofareas of concern to them, such as variations in standards of education and training or codes of practice.It has been a source of great re-assurance and encouragement as regards these areas of concern to find,from the information submitted to the Working Group, that many professional associations are alreadyat a high level of development. What remains to be done is for all professional associations to reach these high standards through aprocess of unification and federation where necessary for different associations involved in the sametherapy. Every therapist practising a complementary therapy should be a competent, qualified andregistered member of a relevant professional association. This will ensure that the public will be able toaccess up-to-date sources of information and make an informed judgment as to what they can expectfrom a competent and registered practitioner. It is frequently the case that the term ``complementary therapist'' is inaccurately applied, usually by themedia, to an untrained and/or unregistered self-styled practitioner who has come to public noticethrough malpractice. A sham practitioner or rogue trader might be a more accurate description. Withgreater unification of the sector and availability of reliable, accessible sources of information for thepublic, it is hoped that such sad cases will become even more of a rarity. On a more positive note, such sources of advice will make information on the many benefits ofcomplementary therapies available to an even wider public. Appendix 3 of this report outlines examplesof research, particularly research in the interesting and expanding area of integrated healthcare, whereconventional medicine and complementary therapies interact and work in tandem and where the clientor patient can avail of the benefits of the best of both sectors. It has been my good fortune to have been involved in this process of development as Chairperson ofthe Working Group. I hope that recommendations 1 to 7 in Chapter 8 will be implemented withoutdelay and that the stage will be reached, which is the culmination of these recommendations, whererecommendation 8 can be attained. This is a stage where an overarching body, whether that is a Councilor a Congress, will oversee issues in a unified and harmonised complementary sector. The public willbe able to avail of the many benefits of complementary therapies in the knowledge that their therapistis qualified, competent and registered and that they, as a consumer, have full support, information andprotection from the wider complementary sector. There are many people to be acknowledged and thanked: the wider complementary sector who providedinformation and attended the consultative forum; the Department of Health and Children for their 5support, especially William Beausang and the Secretariat, Anne Tighe and Ruth Dunne; SuzanneCampbell, who undertook research on behalf of the Working Group; and the members of the WorkingGroup who have given generously of their knowledge, skills, expertise and, above all, time over the pasttwo years. To them, many thanks for their commitment and hard work. At this time we rememberparticularly the important contribution of Working Group member Sally Quinlan of the Irish Societyof Homeopaths who died in June 2005 and to whom this report is dedicated. Teri GarveyChairperson of the National Working Group November 2005 6

CHAPTER 1

General background to this report It is widely accepted that there has been a large increase in the number of people using complementarytherapies, here in Ireland and worldwide. This report will not cover in detail material already coveredby the O'Sullivan report of 2002 (The Regulation of Practitioners of Complementary and AlternativeMedicine in Ireland) regarding the use of complementary therapies and definitions of same. Peopleunfamiliar with this report are recommended to read it. The report can be found at the followingwebsite address: http://www.dohc.ie/publications/regulation of practitioners of complementary and alternative medicine.html.

Consumer Choice and Information The focus of this report is the regulation of complementary therapists and, as such, does not deal directlywith the efficacy of such therapies. It is for the consumer to make the choice of which therapy they intend to use. Whether they wish toconsult a qualified therapist such as a homeopath or an acupuncturist, a healer, the seventh son of aseventh son, a person reputed to have a cure for a particular ailment or a person with a special skill withbones; the choice is theirs. However, the public needs a reliable, current source of information regarding standards to be expectedin relation to good practice. The public also needs to know where they can find a competent andqualified therapist; how they can check that this therapist is currently registered with an association forthat therapy and what grievance procedures are available to them should difficulties arise. Some professional associations currently provide such sources of information through websites, leaflets,information days, contact numbers and help lines. Others are less organised and need to be supported indeveloping this area of communication.

Use of the term ``therapist'' Where the term ``therapist'' is used in this report, it is implicit in the term that the person is appropriatelyqualified and a currently registered member of a relevant professional association. Reputable professional associations have codes of practice, grievance structures, disciplinary proceduresand training standards. They have current registers of practitioners and continuing professional 7development structures. They insist on members having insurance cover for their members and supplysources of information on their therapy and their members to the public. Reputable therapists do not claim to cure, they do not impose conditions regarding conventionalmedicine, they abide by a code of ethics and good practice which they make available to a client on thefirst consultation, they do not seek to impose their personality or their personal judgment and they donot claim to be the sole authority. What the term ``therapist'' does not cover in this report are the rogue traders and sham practitionerswho may practise various mishmashes of therapies without any qualifications and without any on-goingeducation or monitoring. Such people exist in the complementary field, as in many other areas. Just as one would not entrust thedesign of an extension or the rewiring of a house to somebody sticking a leaflet through the letterboxwith only a mobile phone number on it, so it would also be expected that the public would exercise asmuch care and responsibility in taking sensible, informed decisions with regard to their own health care.

Use of the term ``Complementary'' The word ``complementary'' rather than ``alternative'' is used throughout the report. Use of the term``alternative'' sets up an either/or position whereas, for most therapists, the ideal position would be thebest use of both conventional and complementary systems. Reputable therapists would recommendconsulting conventional medical practitioners where they think that is advisable and if it has not alreadybeen done thereby availing in particular of the diagnostic expertise of conventional medicine. No reputable therapist would advise bypassing the use of modern diagnostic procedures such as scans,blood tests or x-rays where the need for these is evident. To quote one well-known proponent ofcomplementary therapies, Dr David Reilly of the Glasgow Homeopathic Hospital ``If you don't believedrugs and surgery are important, try operating an emergency ward for thirty minutes without them.''

Research on Complementary Therapies Research in the area of complementary therapies will be covered in Appendix 3 to this report but it isimportant to realise that research is increasing in this area. It is increasingly being supported by bodiessuch as the Foundation for Integrated Health in the United Kingdom with Government funding and inthe United States arising from the White House Commission. Given our small population size, it isunlikely that there will be major research projects of the RCT (randomised controlled trial) type herebut complementary therapy will benefit from the expansion of research available internationally. Moreresearch in Ireland needs to be encouraged, particularly quality of life and whole systems research.

Integrated Health Care Of increasing interest and of great hope to the complementary sector is the fast-growing area ofintegrated/integrative medicine or integrated healthcare, where complementary therapies are availablein a conventional healthcare setting and with conventional healthcare funding. Many hospitals, health-centres, GP practices and health areas in Ireland have an involvement in this area.For this development to expand more widely it is essential that the flow of information between the 8conventional and the complementary sectors is increased to educate more providers of conventionalhealthcare of the benefits, not least financial, of integrated medicine. Complementary therapies have been used for some considerable time in the area of palliative care andthere is considerable research from behavioural medicine studies in this area to show the benefits oftherapies such as yoga, meditation, visualisation and hypnotherapy. Such therapies have also been used in cardiac programmes for reduction of stress levels and reduction ofcholesterol levels. Names such as Benson, Selye, Simonton, Spiegel, Ornish, Kabat Zinn are familiar tomany from studies in psychoneuroimmunology or behavioural medicine. Increasingly, studies are beingconducted on less severe conditions, particularly common chronic conditions which can remainintractable to conventional medical treatment. The Glastonbury Health Centre and the St Margaret's Surgery studies (Russo 2000) 1 show how the use of complementary therapies in a conventional setting not only benefit the patients but can be self-fundinginitially and can cut future costs. The Glastonbury study was a project where over 600 patients werereferred to a complementary service for chronic conditions relating to muscles and joints. The therapiesused were acupuncture, herbal medicine, homeopathy, massage therapy and osteopathy. Eighty-five percent of persons reported an improvement in their condition. Of even more interest ifyou are a fund manager or an economist, the figures showed that the project was self-funding. Theimprovement in well-being came at no extra cost. When the figures were compared for reduced referralsto secondary care, the team estimated the corresponding savings to be over £18,000. To quote Russo``This analysis demonstrates the potential for improving patient care and producing longer term costsavings at no extra cost to the health service.'' The St Margaret's Surgery general practice project used homeopathy for certain chronic conditions;childhood eczema, sinusitis and chronic nasal catarrh. Ninety-five per cent of respondents were satisfiedtheir condition improved. The number of GP consultations for a sample of the participants was comparedfor the year before treatment and for the year after treatment. The findings indicated a significant savingin consultation time. The most common outcome was where no consultations were needed with theGP in the year after treatment. A conservative estimate of the total cost savings for the group selected, only 65% of the total group, wasapproximately £12,000. This was the cost of running the entire homeopathy service. The conclusion here, as at Glastonbury, was that the use of complementary therapies can not only beself-funding but can cut future costs through a reduction in secondary referrals, drug use and GPconsultations. This again has the benefit of reduced waiting lists and freeing up services for those in needof conventional treatment. Whether it was the effects of massage on mother-baby interaction, the use of tai chi in preventing fallsin elderly nursing home residents, the benefits of massage on recruitment and retention of staff in theoncology units in Hammersmith and Charing Cross Hospitals, or the benefits to staff morale in GlasgowHomeopathic Hospital allowing them to work more efficiently, reducing staff sickness and avoidingburnout; all these projects in integrated medicine or integrated health are good news for patients, staffand hospital and practice administrators. 1 Integrated Healthcare: A Guide to Good Practice, Hazel Russo, The Foundation for Integrated Medicine 2000. 9The outcome of a second research project at Christie NHS Trust Hospital in Manchester on the useand efficacy of a combination of three essential oils in counteracting the MRSA bug is eagerly awaitedby health care officials who might never previously have considered the potential of complementarytherapies. In December 2004, the hospital announced that initial research showed that essential oils maykill the MRSA bacteria. Researchers tested 40 essential oils against ten of the most dangerous bacteriaand fungi. Two of the essential oils were found to kill the MRSA bug and E-coli instantly while one-third of the oils showed positive results over a longer period of time. New trials are underway involvingaround 100 patients.

Foundation for Integrated Health Award Scheme The provision of a Foundation for Integrated Health award scheme for such projects in the UnitedKingdom has no doubt made some conventional healthcare providers more aware of the potentialbenefits to all concerned. On-going research on the benefits of complementary therapies for patients,carers, staff and administrators make it clear that the further development of complementary therapiesand the better regulation of complementary therapists is something that cannot be overlooked by anyhealth system. The initiation of such an award system for integrated projects here in Ireland is something that wouldcontribute enormously to bridging gaps between the complementary and conventional medical sectorsand would help strengthen and expand projects that are currently underway here and could help toinitiate further projects.

Primary Health Care Conferences on health issues frequently refer to the importance of primary care, usually referring to theGPs as the ``gate-keepers''. However, it could be said that the essence of primary care starts with thepatient or person themselves being pro-active and dealing with health promotion. This fits with thecentral tenets of complementary therapies. They are person-centred and they have a holistic approachto managing health and promoting well-being. The focus is on staying well, on taking steps to maintainone's immune system to minimise one's chances of becoming ill and then to support the healingmechanisms of the body when illness strikes. In this paradigm, primary care starts with the person themself at home. It focuses on protecting theimmune system, dissipating stress and practising good health habits in diet and exercise. At work,increasingly, employers are offering in-house complementary therapies to their staff for the same reasons. In an integrated system the complementary therapist might be included in the primary care team. Suchcomplementary care needs to be well organised by reputable therapy bodies and reputable, competent,well-qualified and monitored therapists. This leads us to the work of the National Working Group onthe Regulation of Complementary Therapists.

Origins of the National Working Group on the Regulation ofComplementary Therapists In November 2002, the Minister for Health and Children announced the establishment of a NationalWorking Group on the Regulation of Complementary Therapists to advise on future measures forstrengthening the regulatory environment for complementary therapists. The establishment of this grouphad its origins in the concerns of the complementary therapy sector for the greater development and 10harmonisation of the sector. Professional associations have developed for some therapies. Through theusually voluntary, hard work of many committed therapists, many of these associations have developedstandards of qualification and continuing professional development; codes of ethics and good practice;systems of registration, monitoring and regulation; sources of information for consumers; and links withinternational bodies for the individual therapies. However there are issues, which we shall return to throughout this report, of disparity in standards ofeducational qualifications and of confusion in the mind of the consumer as regards registration oftherapists. Such disparity and confusion allows rogue practitioners to operate. The situation may not be as bad as that described by Stone and Matthews (1996) 2 . While acknowledging the creditable success of some well established therapy areas or therapies in Britain in organisingthemselves and their willingness to set their own houses in order, they go on to say ``Beyond these well-established therapies the situation is too often a messy and dis-organised array of fragmentary legitimisingbodies which must be a cause of considerable bewilderment to even the most determined andconscientious of consumers''. However, there are many areas here in Ireland which need harmonisation and development and thecomplementary therapy sector was anxious to enlist the support of the Department of Health andChildren for this reason. From their contacts with the Department of Health and Children, a consultativeforum was organised in June 2001. To build on the discussions of that forum and a subsequent survey,the O'Sullivan Report was commissioned. This report recommended that a National Working Groupon the Regulation of Complementary Therapists be set up to further progress the work done to date,to examine the practical steps involved in the better regulation of complementary therapists and tocontinue to develop the consultative process for stakeholders in the sector.

Composition of the National Working Group The Working Group had its first meeting on May 28 th , 2003 and comprised representatives of the main therapy groups as selected by the various groups for those therapies, a consumer representative, theDepartment of Health and Children, the Department of Education and Science and Ministerialnominees. A list of members of the Working Group can be found in Appendix 1. In the composition of the group, a balance had to be struck between the need to facilitate focused andeffective working, which constrained the size of the group, and the need to ensure appropriaterepresentation with the required skills, knowledge and expertise. Initially, therapists from the complementary sector expressed the fear that if a therapy did not have arepresentative on the Working Group it could be overlooked. It was made clear that, while a person'sown therapy background would inform their contributions to the work of the group, once functioningas a group each person was working for the benefit and development of the entire complementary sector.

Work of the Group In its work, the group first considered the state of play of the different and differing associations forvarious therapies. It looked at background information on the number of associations for differenttherapies, the number of schools from which therapists are qualifying and the number of therapists in 2 Complementary Medicine and The Law, Julie Stone and Joan Matthews, Oxford University Press 1996 reprinted 2003 11practice. It also considered the level of communication and contact between the different organisationsrepresenting the same therapy. What emerged was a spectrum of situations. At one end of the spectrum was a position where thetherapy in question was represented by a single professional association with highly developed levels ofinitial qualification, with a code of ethics and good practice, with registration and on-going continuingprofessional development. At the other end of the spectrum was the example of a therapy representedby many associations with no common agreement on standards of qualification or practice. Regardingcommunication between the organisations, one source was quoted as saying ``the situation is complexwith much in-fighting''. The professional associations for most therapies had a commitment to the best development of thecomplementary sector and had a strong focus on continually improving and harmonising their standards.The impetus for regulation of the sector and for the development of better standards, with resultantgreater protection for the public, was coming from themselves. The lack of unity and confusion aboutstandards and qualifications in some therapies were causes of concern to them. The variation in coursesbeing offered and the lack of coherent, current sources of information for the public also caused concern. These concerns were addressed by the Working Group and are reflected in the recommendations to theTa´naiste and Minister for Health and Children regarding facilitated work days and the provision of acomprehensive information booklet for the consumer.

Quality and Accountability Two of the key principles in the 2001 Health Strategy 3 were identified as quality and accountability. These fundamental principles are just as relevant to complementary therapy practitioners as they are toconventional health practitioners. Action 106 of the Health Strategy on Quality and Fairness signalled the intention to enhance theregulation of complementary therapists as part of the comprehensive programme of reform envisaged forthe regulation of health and social care professionals generally. Quality healthcare services need to beunderpinned by the excellence of the skills, knowledge, expertise and high standards of professionalconduct maintained by all those who offer healthcare services to the public. Protection of the publicmust be at the heart of effective regulation of any activity. People's trust in the standard of all care being provided must be copper-fastened by a guarantee of qualityand accountability. They need to be properly informed so they can be confident that a practitionerproviding a service is competent to do so. Therefore, they need the provision of reliable and up-to-dateinformation which is crucial for them in making an informed choice about a therapist and a therapy. Because the principles of quality and accountability relating to the education and training of therapists isso central to any development of common standards, the Working Group focused its attention on thatarea from early-2004. This was followed by the question of definition and categorisation of therapiesand the question of professional associations. 3 Quality and Fairness -- A Health System for You, Health Strategy, Department of Health and Children 2001 12

Consultation with the wider sector As part of the on-going consultative process, the Working Group held a forum for the complementarysector and interested bodies in September 2004 to consult with them on outstanding issues of concern,to introduce the Working Group and to inform them of the work of the Group to date. At this forum, the various therapy bodies were encouraged to begin the process of unifying and federatingthe different and differing therapy bodies for the same therapy. It was highlighted that differing bodiescan unite and promote inclusivity while still preserving diversity. A federation of bodies for the sametherapy is essential for cohesive strength in the sector and for greater success in developing the aims andgoals for the therapy in question. Speakers from the Yoga Federation of Ireland discussed how the variousyoga bodies had come together to federate as an umbrella organisation for the further development andpromotion of yoga.

Importance of federating Since then, and arising out of the efforts of the Working Group, most of the acupuncture groups havecome together to form the Acupuncture Council of Ireland and the herbalism groups have done likewiseas the National Herbal Council. Groups in the massage and aromatherapy areas are also in the processof federating. Not every professional association may agree to join a federation of associations for that therapy.However, for greater harmonisation of standards, for clearer information and for greater protection ofthe public it is essential that such a process continues for all therapies. This should ultimately lead to anoverarching, overseeing body for all federated therapies such as a Council for Complementary Therapies. Greater unity among professional associations representing the same therapy is, as has been stated,essential. With competing rivalries, egos and political infighting among some professional associations, itmay not always be an easy process. However, without such federation and harmonisation, progress inthe development of common standards and sources of information will be delayed. One member of the Working Group described the process which has already happened for their therapy.``It did not happen easily and it did not happen overnight. Everybody came together and agreed to stepdown from the platform and elect a new body for the therapy.'' If egos and interests can be put aside inthe interests of the bigger picture, if differing bodies can agree to ``step down from the platform'' andelect a representative body for that therapy then greater progress will be made.

Summary The use of complementary therapies is increasing in Ireland and worldwide as is the area of integratedmedicine where conventional medicine and complementary therapies form an integrated healthcaresystem in many conventional medical settings. The Irish professional associations for complementary therapies are seeking to promote and develop theirsector, particularly in the area of harmonisation of standards of practice and qualifications. Through their interaction with the Department of Health and Children over a number of years, theNational Working Group on the Regulation of Complementary Therapists was set up in 2003 toprogress practical areas of regulation. 13The Working Group addressed the areas of definition and categorisation, education and training,professional associations, unification of the sector and differing professional associations for the sametherapy. Over the life of the Working Group, associations for several therapies have come together to unite asone overall group for the therapy in question. 14

CHAPTER 2

Definition, Categorisation and Scope of

Practice

Definition In his report of 2002, Tim O'Sullivan stated ``Complementary therapies are extremely varied andcomplex and are practised by a very wide range of practitioners so it would be very difficult to find atotally satisfactory and all-encompassing definition''. The situation hasn't changed since as regards a succinct definition covering all therapies. However,Zollman and Vickers (1999) and the Cochrane Collaboration offer two perspectives on definition whichare worth considering. They both use the older term ``complementary medicine'' rather than ``therapies''.The use of the word ``therapies'' includes the therapeutic aspect inherent in the word medicine but alsoallows for the promotion of well-being inherent in the philosophy of most, if not all, complementarytherapies. ``Complementary Medicine refers to a group of therapeutic and diagnostic disciplines that existlargely outside the institutions where conventional health care is taught and provided.'' (Zollman and Vickers (editors), ABC of Complementary Medicine, Complementary Medicine inconventional practice, Bmj publishing group, 1999) ``Complementary and Alternative Medicine (CAM) is a broad domain of healing resources thatencompasses all health systems, modalities and practices and their accompanying theories andbeliefs, other than those intrinsic to the politically dominant health system of a particular societyor culture in a given historical period. CAM includes all such practices and ideas self-defined bytheir users as preventing or treating illness or promoting health and well-being. Boundarieswithin CAM and between the CAM domain and that of the dominant system are not alwayssharp or fixed.'' (Cochrane Collaboration) The range of therapies which may be considered complementary is vast. The task of this Working Groupis to advise the Minister for Health and Children on the regulation of complementary therapists. Therewas no prior definition of what constitutes a complementary therapy or of which therapists, if any,would be excluded from consideration on the grounds of the therapy they practise. The focus was onthe initial education and training of the therapists, their continuing professional development and alsothe area of professional associations for individual therapies. This orientation arose from the focus onprotection of the public and on the quality and accountability of complementary therapists as describedin the O'Sullivan report (2002). 15The Working Group uses the term ``complementary'' rather than ``alternative''. The client is the personwho decides whether they will consult a conventional medical practitioner or a complementarypractitioner. It is their choice to consult a complementary practitioner perhaps following, or alongside,a conventional medical treatment for some condition or to use a complementary therapy in the firstplace, i.e. as an alternative to conventional treatment. The decision as to which approach to take lieswith the client. The decision to treat, however, lies with the complementary therapist and will beinfluenced by factors such as code of ethics and scope of practice which will be dealt with later inthe report. The focus of the Working Group's concerns was the area of the professional standards of personspractising complementary therapies and not the question of the efficacy of one therapy over another.The group did consider the question of the definition of a complementary therapy and what follows isbased on that consideration. A complementary therapist is a practitioner of a healing philosophy or tradition that offers health-relatedadvice and treatment that is considered to be of a different use, acceptance, study and understanding tomainstream western, conventionally practised medicine. A complementary therapist could be describedas one who is trained in a coherent but non-conventional system of therapeutic intervention. Complementary therapies comprise a vast range of practices. There are those which aim to achievetherapeutic benefit based primarily on the physiology of western medicine e.g. sports and therapeuticmassage and western medical herbalists. There are also therapies which primarily rely on a modernwestern understanding of the mind-body connection and its influence on healing, e.g. hypnotherapy,re-birthing, neuro-linguistic programming. Other therapies originate from the medical systems ofdifferent cultures, based on what can be called vitalistic systems of medicine. Such therapies as Chinesemedicine, shiatsu, ayurvedic and Tibetan medicine have physiologies, diagnoses and treatment parametersbased on theories of the vital or life-force of the individual. Some therapies span two or more of thesecategories, e.g. re-birthing, amatsu, cranio-sacral therapy and kinesiology. Complementary therapy theories generally use the word ``holistic''. A central defining tenet of the theoryand practice of a complementary therapy is that it works with the whole person; body, mind, emotions,spirit and energy within their socio-economic context. It sees the client as the integration of all theseaspects. In treatment, the whole person is considered not just the presenting issue. Implicit in this is thetheory that, with appropriate help, clients are capable of increasing well-being and, in many cases, freeingthemselves from illness. By utilising such traditional systems and other energy-based systems of healingin this holistic, mind-body way the immune system is protected and well-being is promoted. The defining aspects of a complementary therapy may be seen as the holistic approach to well-beingwhich underpins all therapies and working with the client's own energy and life force to promoteself-healing.

Categorisation of therapies A majority of the members of the Working Group favoured a two category system of categorisationbased on the element of risk involved for the client. Such risks could be physical and/or psychologicaland depend both on the level of intervention and the level of invasiveness of the therapy. Risks inCategory 1 would include such issues as puncturing of the skin, ingestion of products etc. Categorisationon the basis of risk arises out of practicality and is in keeping with the protection of the public remit of 16the Working Group. The categorisation does not concern efficacy of a therapy or the body of knowledgeand length of history of any particular therapy. Category 1 therapies include acupuncture, herbalism, Traditional Chinese Medicine (TCM),aromatic medicine and homeopathy. Category 2 includes all other therapies. It is also recognised that the level of risk involved in any therapy may vary depending on particularaspects inherent to the therapy involved. For instance, while the herbal and acupuncture aspects of TCMcause it to be seen as a Category 1 therapy, other TCM elements such as Tai Chi and Qi Qong do notcarry the same level of risk. The level of risk involved is also influenced by the condition of a client e.g.in aromatherapy, a pregnant client or one with a condition such as epilepsy would carry a greater levelof risk. Similarly, mind-based therapies such as hypnotherapy, re-birthing and neuro linguisticprogramming can be seen as having an element of psychological risk related to the stability or fragilityof the client's own psychological state. It is very important that, where relevant, levels of risk should be categorised within therapies irrespectiveof the placement of the therapy in Category 1 or 2. This concerns therapies such as aromatherapy andtherapeutic massage in particular. It should be covered in the therapist's initial education and trainingand maintained by continuing professional development. It is implicit throughout this report that anyreference to a therapist is based on the assumption that the therapist is fully qualified for the level oftreatment they are providing and that they are a member of a professional association relevant to thetherapy they are practising. It is imperative that the initial education and training of the therapist clearly distinguishes between thelevels of risk involved in a therapy; whether they are intrinsic to the therapy itself or arise from acondition relevant to the client. It is also imperative that through continuing professional developmentof the therapist and membership of a relevant professional association that this knowledge of risk ismaintained on an on-going basis. It is also taken as a given that any professional association willimplement a code of ethics and good practice which ensures that practitioners are competent to practisethe level of therapy offered by them. This competence should be monitored on an on-going basis bythe professional association. Professional associations should also provide public information on theirtherapies including a complaints procedure.

Scope of Practice Guidelines must be given to therapists (as mentioned already under the section on categorisation) whenundergoing their initial education and training and later through continuing professional developmentas to the scope of practice for their therapy. In particular, guidelines on the limits to the scope of practice,on contraindications to treatment and on questions of diagnosis must be given. As part of their code of ethics and good practice, all professional associations for complementary therapiesshould advise therapists to refer a client for conventional medical investigation if they have any doubtsas to the seriousness of a condition, the presenting symptoms or any new symptoms which arise in thecourse of treatment. When to treat, when to refuse to treat or to refuse to continue to treat, and whento refer on for conventional medical procedures or to advise a client to seek conventional medical advice;these are all extremely important matters for any complementary therapist and are as essential for themas they are for any conventional practitioner. 17As regards the question of diagnosis in complementary therapies, much hinges on what is meant by theuse of the term. Conventional medical diagnosis consists of history taking, clinical examination andinvestigations as appropriate. In many therapies (e.g. reflexology, aromatherapy, reiki, etc.), therapists arevery specifically advised not to diagnose medical conditions but therapists may carry out an assessmentof a client. Other therapies may diagnose as part of their therapy (e.g. TCM, acupuncture, medicalherbalism, etc.) but would have established diagnostic limits. Conventional diagnosis is a function of conventional medicine; it is not necessarily a function ofcomplementary therapies. Evaluation of a client is in accordance with the philosophy of healing of atherapy and in a manner appropriate to the treatment as, for instance, in homeopathy where finding thecombination of symptoms and characteristics indicates the appropriate remedy. In TCM, diagnosis isdone in terms of TCM diagnostic categories. Diagnostic tools include history taking, assessment of signsand symptoms as well as culturally particular diagnoses such as pulse and tongue diagnoses. Patients arereferred for conventional medical diagnosis when the symptoms are severe and/or indicate a potentiallyserious condition or where, in less acute cases, clients do not respond to the complementary therapy inquestion or where new symptoms arise in the course of treatment. Frequently clients approach a complementary therapist having previously obtained conventional medicaldiagnosis and treatment. Currently, and particularly where complementary therapists are not working indirect co-operation with conventional medical practitioners, there are no satisfactory routes ofcommunication between both conventional and complementary practitioners. Increasingly however, people are approaching complementary therapists with the knowledge, approvaland indeed sometimes the recommendation of their medical practitioner. With expanding emphasis,both nationally and internationally, on integrated medicine where conventional and complementarypractitioners work together and communicate with each other, the question of diagnosis will becomeless of an issue. A feature of diagnosis which complementary practitioners feel is particular to their approach is theattention paid to the total physiological and psychological aspects of the individual. Complementarydiagnostic systems are frequently concerned with ``patterns of imbalance'' in addition to a specific diseaseentity or a precise cause. This approach arises from the energistic or vitalistic aspects of manycomplementary therapies where patterns of disharmony provide the framework for treatment and wherethe treatment attempts to restore balance and harmony, vitality and the flow of energy to the client. It is important to distinguish between aspects of assessment and diagnosis. Assessments are made prior totreatment by a complementary therapist. Arising out of an evaluation of the assessment, the therapist willbe aware (because of their initial education and training, continuing professional development andtherapy body membership) whether treatment can proceed or whether this particular case/condition isbeyond the scope of practice of their therapy and level of qualification and needs to be referred to aconventional medical practitioner or a more qualified practitioner of their own therapy.

Summary There is no one definition for complementary therapies. A definition of a complementary therapist thatemerged from the Working Group is ``A practitioner of a healing philosophy or tradition that offershealth-related advice and treatment which is considered to be of a different use, acceptance, study andunderstanding to the mainstream western, conventionally practised medicine''. 18A central defining tenet of the theory and practice of a complementary therapy is that it is holistic, i.e.working with the whole person; body, mind, emotions, spirit and energy. Therapies were divided into two categories, based on the element of risk involved for the client. Category 1 includes herbalism, acupuncture, aromatic medicine, homeopathy and TraditionalChinese Medicine (TCM). Category 2 includes all other therapies. The level of risk involved in any therapy may vary depending on particular aspects inherent to thetherapy involved or the condition of the client. Codes of ethics and good practice, which involve direction as to the scope of practice allowed andknowledge of risks involved, must be implemented by a professional association for its members as partof their original training and maintained by continuing professional development. Complementary diagnosis, where it takes place, is based on the paradigm of the therapy in question andis not the same as conventional medical diagnosis. 19

CHAPTER 3

Education and Training

The Current state of play: Education and Training At present there is an array of courses in the area of the initial and on-going education and training ofcomplementary therapies. Courses vary widely and unacceptably in levels of quality even where a singletherapy is in question. The variations cover aspects of course content; course duration; theoretical and,where applicable, practical components of courses; assessment procedures; qualifications and practicalexperience of course providers, tutors and trainers. Course providers currently come from either professional associations or from commercial interests.Often there is little communication or agreement between both sectors. There is, at present, no onesource of independent, external assessment, validation and accreditation which would provide formonitoring of educational programmes and of providers, tutors and examiners. Concerns have been expressed by the professional associations and by members of the Working Groupabout:

· the number of therapists practising therapies on the basis of inadequate home study courses;

· courses not including practical aspects where these are integral elements to the proper practiceof the therapy;

· courses taught by therapists whose own practical experience of the therapy is inadequate ornon-existent. The continuation of such a situation is untenable both for the professional associations in thecomplementary therapy sector and for the Department of Health and Children.

Matters relating to professional practice As regards proper professional practice, concern has been expressed about people practising a therapywho are not members of any professional association relevant to that therapy. This gives rise to questionsof continuing professional development and, not least, insurance. As regards professional associations, in very many therapies there are differing associations at varyingstages of development and expertise. Communication between these associations ranges from good tofragmented to hostile. Although many therapies are at very different stages of development in relationto a regulatory framework, there does seem to be a general consensus that a credible system of regulationis a desirable goal for their therapy. 21The importance of a unified approach between professional associations, covering the same therapy inparticular and for all therapies in general, cannot be underestimated in relation to matters of properprofessional practice. These matters cover:

· initial education and training;

· registration with a professional association;

· on-going monitoring and clinical supervision, where relevant;

· ethical considerations, proper business practices, continuing professional development andgrievance and disciplinary procedures. Although this section deals in the main with education and training, it is not possible to separate entirelyfrom that the question of professional associations. Input, advice and provision of educationalprogrammes for instance will have to be informed by consultations with professional associations. Butwhich associations? What associations could be used as arbiters of best practice? A most urgent consideration for the professional associations is to seek a harmonisation and a unitybetween their varying associations, very particularly where those differing associations are dealing withthe same therapy. This harmonisation and unity is essential to the development of robust systems ofvoluntary self-regulation. Self-regulation is a process in which individual therapies develop their own education programmes,codes of ethics, statistics, research programmes and competency standards. This process will need thesupport of the Department of Health and Children to address areas of concern and to help existingregistering bodies improve communication between themselves. The support could be in the form offorums for the sector in general and small-group symposia for single therapies with multiple associations.In the long-term, on-going support and development could come from an over-arching group such asa Complementary Therapies Council which would represent all the stakeholders in the sector.

Possible routes to independent external validation of education andtraining programmes In October 2003, the National Qualifications Authority of Ireland (NQAI) launched a new frameworkof 10 levels of qualification which contains 15 award types. These range from basic literacy and educationto doctoral level and cover all award types in the state in the education and training sectors. The new framework is ``the single nationally and internationally accepted entity through which alllearning achievements may be measured and related to each other in a coherent way and which definesthe relationship between all education and training awards.'' The NQAI has also determined descriptorsfor these award types and has set out the overall standards of knowledge, skills and competences requiredfor an award at each level within the framework. A process of implementation is now underway which involves the Further and Higher Education andTraining Awards Councils (FETAC and HETAC) establishing arrangements in consultation withstakeholders governing quality assurance procedures, standards for awards across various disciplines in thenew framework, and procedures for validation of programmes leading to these awards. It is HETAC or FETAC who will be the primary contact point for industry and providers regardingthe content, standards and learning outcomes for particular awards. A flexible approach, rather than aprescriptive one, is to be adopted under which programme providers satisfy HETAC or FETAC that: 22

· their quality assurance procedures are satisfactory

· their programme is suitable for validation (staff, policies, processes, resources, and coursestructures are capable of achieving the learning outcomes and standards required within theframework for a particular award)

· their arrangements for assessment of learners are fair and consistent

· they implement the NQAIs policies for access, transfer and progression

· they have protection for learners. As a result of the development of an extensive framework of qualifications, and because of theopportunity for course providers and professional associations to collaborate with HETAC and FETACin the development and assessment of such courses, the way seems clear for the development ofindependently validated and accredited courses in complementary therapies. It is obvious that HETAC and FETAC would need to consult closely with the professional associationsfor each therapy to be considered and for programmes and providers to be evaluated for course validationand accreditation. But the question still arises. With which therapy body, which professional associationwould HETAC or FETAC consult as arbiters of best practice and information on the courserequirements for any therapy? If there are several associations for the same therapy how would one beselected for consultation on matters of course content? It is obvious that the multiple associations whichrepresent the same therapy would first need to come together in some form of federation or umbrellabody to facilitate effective consultation with HETAC or FETAC concerning that therapy and coursesspecific to it. In the interim period, HETAC and FETAC will consult the relevant sector as widelyas possible. A single, voluntary self-regulating body for each individual therapy would achieve a more focused andefficient approach to all matters related to that therapy and, in particular, to matters pertaining to externalvalidation of education and training. It ought to be possible for an umbrella body or federation ofassociations to be formed which would preserve the diversity of the separate associations and promoteinclusivity for the greater good of the therapy concerned. Given the number of separate therapies which are likely to be seeking validation and accreditation ofcourses, logistically it would be advisable for various therapies to come together to agree on standardcourse modules which would be common to all therapies. This could include best practice, elements ofrunning a business, codes of practice, professional ethics etc. at one level and common elements such asbasic clinical sciences e.g. anatomy, physiology, etc. at another level where associations could agree ona common approach to these areas. This would also avoid duplication of work. Accompanying thesecommon modules would be modules relevant to each specific therapy. Continuing professional development is another area which would need a degree of consultationbetween providers, HETAC and FETAC and the professional associations. HETAC and FETAC couldvalidate and accredit these areas, as they would with initial education and training courses, and theprofessional associations would deal with registration requirements, research, insurance, matters of ethicalpractice and disciplinary matters. The question of grand-parenting and of qualifications acquired outsidethe state is another area where consultation would be necessary between providers, HETAC and FETACand the various professional associations. 23Expertise and high standards are prevalent in many professional associations. This expertise ranges frominitial education and training provision to continuing professional development programmes, which is amandatory requirement in many associations for renewal of registration of members. Therefore, there isalready a base for development in many therapies which will greatly facilitate future negotiations withHETAC and FETAC as regards validation and accreditation. Providers in the statutory sector are obliged to have their programmes validated by FETAC or HETACor another relevant awards body, apart from programmes of a leisure or recreational nature which arenot intended to lead to an award under the Qualifications (Education and Training) Act 1999. Validationis optional in the private sector. Awards under the national framework of qualifications confer obviousadvantages in terms of the national status and portability of awards, particularly in the context of emergingproposals from the European Commission relating to the development of a European Framework ofQualifications. The National Qualifications Authority of Ireland provides a service, Qualifications Recognition --Ireland, which provides advice for individuals on the comparability of international awards made bybodies outside the State relative to the Irish system. Details are available at www.nqai.ie. Many therapies already have policy documents and guideline reports available which should furtherfacilitate the processes involved e.g. in homeopathy the European Council of Classical Homeopathyhave developed guidelines for the accreditation of courses, for code of ethics, for continuing professionaldevelopment, and for policy on research. Similarly WHO TCM have guidelines on training and examstandards for TCM. This position is replicated in other therapies and should facilitate the development of a template ofmodules common to all courses and those which are specific to a single therapy but which have to beaccepted and agreed on by differing associations within that single therapy. This would help with greaterharmonisation within the professions especially with regard to education and training. It would alsofacilitate the transfer of credits system in keeping with the Bologna agreement as part of the internationalprogramme for lifelong learning.

Conventional Healthcare Practitioners and Education and Training If conventional healthcare practitioners are practising complementary therapies it is essential that they arequalified to standards comparable to any practitioner in that therapy and comply with the requirements ofan appropriate registering body for that therapy. While there may be prior knowledge of, andqualification in, basic clinical sciences and principles of conventional diagnosis, which may be acceptedfor credits in any education and training programme in the complementary therapy they wish to practise,it would also be important that any area which might have specific requirements for that therapy becomplied with. For example, anatomy and physiology as it might relate to yoga rather than toconventional medicine etc.

Therapies not using independent external validation For therapies where there is not, at present, any body of knowledge which can be taught, examined andevaluated, it is clear that the question of independent, external validation does not arise. In the interests of safety and protection of the public, it is important that in such cases, an assessment ofthe level of risk involved in the practice of the therapy is considered with a view to providing the public 24with a checklist or kite-mark of reference as regards dangers, standards, proper practices, etc. The publicshould be provided with a reliable source of information or consumer guide as to what they mightexpect from such a therapist and as to the professional association guidelines for the proper practice ofthat therapy.

Summary Education and training courses for complementary therapists can vary widely and up to now there hasbeen no co-ordinated system of external, independent validation and accreditation available. The new ten level framework of qualifications from the NQAI now offers a route to independentvalidation of education and training courses for complementary therapies. To evaluate such courses the training awards councils -- HETAC and FETAC -- will need tocollaborate with the course providers and the professional associations or preferably an overall associationor federation of associations for each therapy. 25

CHAPTER 4

Curriculum for complementary therapy

courses Some therapies have long-established and well-developed curricula. Through affiliations to internationalassociations, these curricula are often linked into broader models, usually European. For other therapies,or indeed for other professional associations within the same therapy, levels of curricula may vary.With that in mind the Working Group considered what should form the essential elements in anytherapy curriculum.

Curriculum template for any complementary therapy The Working Group recommends that every course should include the following areas to an appropriatelevel related to the therapy being studied:

· Ethics and Code of Practice

· Scope of Practice including: I duty of care I contra indications

· Professional/practitioner development including: I professional conduct I communication skills I confidentiality I client relationships I psychological relationships I membership of related professional body national/international I awareness of reflective practice and CPD I business practices I record keeping

· Clinical practice including: I case history I questioning I assessment I diagnostic issues I contact 27I pharmacology I developing trust

· Clinical supervision

· Referral

· Anatomy, physiology and pathology

· Nutrition

· First aid and basic requirements of health and safety

· Legal obligations of service providers including: I health and safety I equality I child protection

· Personal development

· Study skills and research

· History, philosophy, theory and practice of the particular therapy being studied The aim of any training must be to establish basic competencies in the practitioner, competencies whichare developed into skills through clinical supervision in initial training and which are developed andconsolidated through continuing professional development. For those already practising, the concept ofsupportive grand-parenting and bridging can be used to facilitate those who may have extensive clinicaland empirical experience but whose training standards may be lacking in other aspects. Bridging trainingmay be required as part of grand-parenting, where it has been identified by the professional organisationthat there are gaps in the practitioner's knowledge that need to be filled before they can become fullyregistered. The professional association would inform the applicant of what areas need further trainingand where this can be obtained. Normally a time frame of 2-3 years is given for this to be achieved,depending on the amount of training that is needed. As with the initial training and accreditation of courses by HETAC or FETAC, under the newframework of qualifications there will be a process of accreditation of prior learning under whichindividuals may seek to have evidence of their learning assessed by reference to the requirements ofawards in the new framework. This could involve producing a portfolio of work as evidence or sittingassessments or doing further modules to address gaps. It could be a combination of all of these whichwould eventually result in the person being given an award under the new framework.

Admission Criteria for Students The question of admission criteria for students into any course providing a qualification to practise as atherapist, and the required background for course tutors, was also considered. Concern was expressed about proposals in the United Kingdom to allow 16 to 18 year old students ontocourses which would allow them to practise as therapists (as opposed to courses to gain knowledge of atherapy for their own interest such as an evening/weekend class or a longer PLC course aimed at thebeauty/leisure industry). It was agreed that age 18 should be the minimum age for entry to a course.Many professional associations prefer age 21 and age 23 was suggested for mind-therapy courses wherelife-experience is extremely important. 28Entry requirements for a professional training course should include the following:

· Leaving Certificate or equivalent as required by the professional association

· Proficiency in the English language

· A panel interview

· Two references and appropriate checks to gauge personal suitability. It was also considered essential that assessing the personal suitability of a student should be on-goingthroughout the course and into a probationary period of practice as a therapist.

Requirements for Course Tutors Some concern was expressed that tutors on courses are sometimes appointed as tutors on the basis oftheir having been a very good student on that course. They may not always have the desired degree ofpractical experience as a therapist. The Working Group considers it essential that course tutors or trainers should:

· have a qualification in the therapy concerned

· have at least three to five years full-time experience as a therapist, with clinical supervision,where relevant, before starting as a trainer on their own

· undertake a course in teacher training or adult education. The third component is seen as a necessary complement to their practical experience as a therapist andwould ensure the right balance of theoretical as well as practical training on a therapy course.

Length of training and continuing professional development Some therapy course providers have already applied to HETAC or FETAC for recognition andaccreditation of courses. The areas of content, tutor qualifications etc. will be overseen by HETAC orFETAC in collaboration with the course providers and the wider sector. For those therapies or professional associations not yet at this stage, the situation regarding courseprovision is very varied. The question of length of training, whether measured in years or hours, differsconsiderably between therapies and within therapies depending on the level to which the therapy isbeing studied. The Working Group agrees that all training needs to have a mix of practical skills and theoreticalknowledge and generally a minimum of two years training for any therapy, although very many therapieswould have a much longer training period. See Appendix 6 for some examples from different therapieson course duration. This is a matter which the professional associations need to address and it can onlybe properly addressed when the various related bodies or associations for the same therapy unite togetherto agree common standards and harmonisation of requirements. This highlights the need for the facilitated work-days for therapies as stated in the recommendations tothe Ta´naiste and Minister for Health and Children to progress these issues in collaboration, whererelevant, with providers and the Further and Higher Education and Training Awards Councils. 29

Continuing Professional Development (CPD) Skills based CPD is generally a requirement for professional associations. For some professionalassociations it is a requirement for annual entry on the register of therapists recognised by thoseassociations. It can involve attendance at seminars, training days or AGMs; work as a guest lecturer,writing books on the area or articles for professional journals; peer review and discussion groups; clinicaltraining; supervision or other approved activities. When initial training courses by course providers, validated and accredited by HETAC or FETAC incollaboration with professional associations, have been developed and are underway it should be possiblefor CPD courses to follow the same formula. All the activities mentioned above carry a score, assignedby the relevant professional association, which goes towards making up the total score required by thatassociation to fulfil CPD requirements for its members. Some associations have a passport-type documenton which the scores for activities recognised for CPD points are entered and verified and which are thenpresented, usually annually, to the professional association for continued registration.

Summary The Working Group has devised a template of modules which should form the essential elements in atherapy course curriculum. The concept of grand-parenting and bridging can be used to facilitate therapists whose training standardsmay not be at the current level required by the professional association or who have not been formallyassessed. Admission criteria for acceptance of students into a course should include a minimum age of 18 andpreferably older, particularly for the mind-therapy courses. Assessment of personal suitability should beon-going throughout the course and into a probationary period of practice as a therapist. Course tutors should have a qualification in the therapy concerned, three to five years experience as atherapist in the therapy they are planning to teach and training in adult education or teacher training. Therapy courses should generally be a minimum of two years full-time. These recommendations are aimed at education and training for practice as therapists in thecomplementary health sector. Many, but not all of them, have relevance to programmes aimed atpreparing students for employment in the beauty and leisure industries. This issue is dealt with inChapter 6. 30

CHAPTER 5

Professional Associations Many therapies have several associations representing the one therapy. Some of these may originateoutside Ireland; others are affiliated to international associations. The communication and co-operationbetween these different associations can, as has been said previously, vary greatly. The problems posedby this fragmentation of the sector, and the question of what constitutes a professional association for atherapy, were considered at length by the Working Group. Over the two years of the life of the Working Group and with the encouragement of the group,particularly at the 2004 forum, several professional associations have come together, or are in the processof coming together, as a federation of associations for their therapy to promote and develop knowledgeof their therapy and excellence in practice. For greater unity within the complementary therapy sector and within each individual therapy it isessential that the different groups for each therapy come together to agree common basic standards ofpractice, education and training, for greater strength as a lobbying body and as a source of informationon their therapy. Without a common unified source of information on a therapy and the therapistspractising it, and on what one might reasonably expect from the therapy and the therapist, the generalpublic (the consumers) are at a loss as to how to make a judgment on what choice to make. For greater protection and information it is essential that associations come together to harmonise theirstandards of education and training and the conditions of regulation of their members. For this to happen,the various associations will need the support of the Department of Health and Children. This could bein the form of support for, and organisation of, work days for the different therapies or groups of similartherapies to come together, with facilitation, to undertake this process of harmonisation anddevelopment. This is a recommendation to the Ta´naiste and Minister for Health and Children from theWorking Group. As regards associations, it was pointed out that in many cases an association emerges initially from atraining school and may or may not become independent of that school in time. For greater objectivity,especially in the area of setting standards, a professional association needs to be independent of a trainingprovider and commercial interests. It is important that subtle commercial pressures do not enter intofactors affecting what is best for that therapy and the consumer. It is also important to avoid conflicts ofinterest, described sometimes as individual empire building, which might prevent or delay federationof associations. Crucial areas for associations to reach agreement on are questions of scope of practice, limits ofcompetence and referrals to another practitioner whether conventional or complementary. It is part of 31the code of ethics of almost all therapies that a therapist advise a client to seek conventional medicaladvice if they feel this is needed. In the majority of therapies, therapists would not continue to treat aclient who refused to follow this advice.

Template for a professional association The Working Group feels that a professional association for a therapy needs to have a written constitutionand open, democratic election procedures with limits to office holding. An association should:

· advise on standards and criteria for the education and training of therapists and for the practiceof the therapy

· maintain a current register of practitioners and provide for continuing professional development

· have a code of ethics and good practice and clear grievance procedures which allow for removalof a therapist from a register

· consider the interests of both the therapist and the consumer and provide sources of informationfor the public on their therapy

· represent the therapy at national and international level and consult with international bodiesregarding new developments and research Examples of codes of ethics and good practice, including grievance and disciplinary procedures, can befound at Appendices 7 and 8 in this report.

Summary Some therapies are represented by one overall body or a federation of associations for that therapyinvolving most, if not all, associations for that therapy. Over the life of the Working Group, and arising from the work of the group, several differing associationsfor the same therapy have come together to form one overall association to harmonise standards for thattherapy. This has happened in the case of two major therapies. Other therapies are represented by several different and differing associations. For greater developmentof these therapies, harmonisation of standards of education and training, codes of ethics and good practiceand continuing professional development, all such associations need to be supported by the Departmentof Health and Children. The Working Group recommends to the Ta´naiste and Minister for Health and Children that a series offacilitated work-days be held for these associations to progress the issues. In connection with this aspect,the Working Group devised a template of elements needed in a professional association. 32

CHAPTER 6

The Consumer An integral part of this report on the regulation of complementary therapists is the consumer or theclient. Arising from the central issue of duty of care to the public, any discussion on regulation has toconsider what might impinge on the consumer or the client. At present, as in many other countries,the area of complementary therapies, and in particular complementary therapists, is a confusing onefor consumers. Whether a therapist is properly trained or qualified, whether they are a member of a professionalassociation, whether they are currently registered with that association, whether they undertakecontinuing professional development, whether they have insurance cover, are all areas where informationcan be lacking. In some cases there is a unified body for a therapy which can be a source of informationon these areas but this situation does not exist for all therapies. If there was a grouping or federation of associations for a therapy working as one overall registeringbody, with agreed standards regarding length of training, level of qualifications, codes of ethics and goodpractice, this would be a greater safeguard for the consumer and would provide a checklist by whichclients could evaluate the suitability of a therapist. For this reason, the Working Group is recommending to the Ta´naiste and Minister for Health andChildren that the Department of Health and Children assist and facilitate the various therapy associationsfor any one therapy to come together to federate for the better development of their therapy, for greaterharmonisation of standards of education, training and good practice and as a source of information forthe public. It is also recommended that, following such a process for various therapies or therapy groupings such asmind therapies, body therapies and energy therapies, a comprehensive information booklet of currentinformation, regularly updated, on therapy associations be developed to provide a good source of reliableconsumer information. Such a booklet should be widely distributed. The absence of good information at present is shown in several areas of confusion for the consumer. Atthe most basic level, titles can be used by groups which can be confusing and misleading. For example,``the National Association of . . .'' or ``the National Centre for . . .'' implies some form of Governmentbacking and approval or implies a more widespread existence than might be the case. The use of the word ``medical'' in a description may cause consumers to think that there is conventionalmedical backing for, or involvement in, a therapy. 33The use of the term complementary therapies in the beauty industry or the leisure/spa industry can alsocause confusion and will be dealt with in a later paragraph. Well-produced glossy brochures on courses in complementary therapies with impressive titles may givethe impression of in-depth training courses. However, this can often be well-organised publicity materialfor courses which may be correspondence courses or courses which may not be of any great duration,may not have any depth of content or which do not involve practical experience or supervision. Suchcourses may not be recognised by professional associations. In the absence of a comprehensive information booklet covering most therapies, a unified overallassociation for a therapy will be able to give information through websites or other material as to thecourses which they accept as being of the required content and duration to meet their standards for thattherapy. The difficulty for the consumer is that at present such unified associations do not exist for themajority of therapies and this highlights again the need for unification of associations and reliableobjective information sources. Information on qualification standards is also important where a therapist might practise multipletherapies which may or may not be related. Provided the therapist is properly qualified in each therapythey are practising, there may not be a problem for the client. A point which should be consideredhowever is where something goes wrong in the practice of one of the therapies offered by the therapist.The client may wish to make a complaint against the therapist through the grievance procedures of theregistering body for that particular therapy. If the therapist is not registered with that particularprofessional association (although they may be registered with an association or associations for the othertherapies which they practise) the client may have no redress. If a practitioner is a member of a properly constituted professional association of any complementarytherapy, the insurance cover, code of ethics and practice and disciplinary/grievance procedures ofthat association should cover all the therapies that the practitioner has properly declared themselvesto be practising and shown evidence of adequate training in. It should be inherent in the ethics thatthey will only practise what they are properly qualified in and that they will practise within theproper scope of practice; i.e. it would be malpractice to practise a therapy in which they are notproperly qualified. As well as difficulties for the consumer in assessing general areas such as standards of qualification andgood practice, there are also areas specific to certain therapies which can be confusing or misleading.This is particularly important where there are different levels of the same therapy practised bytherapists or where variations on one therapy are included in the repertoire of therapists fromanother discipline. An example here would be homeopathy where fully qualified homeopaths generally practise classicalhomeopathy and where remedies are used in accordance with the original definitions of SamuelHahnemann, originator of homeopathy. Other therapists use combination formulae or products knownas complex homeopathy. These therapists may be qualified in a therapy other than homeopathy but mayuse homeopathic products. A consumer who has not got a source of information on homeopathy maynot appreciate the difference or be in a position to decide for themselves which therapy would be themost suitable one for them. 34A similar problem can arise in aromatherapy where there can be four different levels of practice:

· Holistic aromatherapy, the area most people would be familiar with;

· Aromatic medicine and psycho-aromatherapy, more widely practised in France and Germanythan here;

· Aesthetic aromatherapy, mainly practised as an adjunct therapy to beauty therapy using readyblended products; The qualification to practise aesthetic aromatherapy would not be accepted as sufficient to practise inhealthcare. Without an accurate and reliable source of information on the therapy in question theconsumer is not in a position to evaluate the qualifications or methods of the practitioner. As with any therapist, whether with an independent validation of educational qualifications or not, it isincumbent on the consumer to check matters such as current membership of a professional association,insurance cover, proper practice, etc. A possible checklist for any consumer thinking of consulting acomplementary therapist might include the following questions:

· Has research been done on this therapy?

· Are there books written on it and available to me?

· Is there at least strong suggestive evidence that it benefits the patient?

· Are there risks or side-effects?

· Could it interfere with my current treatment?

· Is there a national association of practitioners?

· Is the practitioner a member in good standing with a national association?

· Is the practitioner insured?

· What will the cost and duration of treatments be?

· Are there reputable international organisations for this therapy?

· Is there an available statement of the therapists' code of ethics and redress procedures?

Client/Therapist Charter As in all aspects of life, the consumer has an obligation to check out the qualifications, level of practicecovered and current registration of the therapist before commencing treatment. When therapy associations have federated and can be a source of information for the consumer andwhen a comprehensive information booklet on the sector has been published, it will be a simpler processfor the consumer to check out a therapist. Until that time, and also as a matter of good practice, it would be very important and would offer greaterprotection to the consumer if every therapist had a therapist/client charter prominently displayed in theirpremises. It should also be available in a form to be given to the client at the first meeting which theycan take away for further consultation. 35Some professional associations currently have such a client/therapist charter but it is recommended thatall associations and all therapists provide this. Such a charter should be a clear, concise, explicit andtangible statement defining good complementary practice as regards standards of qualification,membership of a professional association, code of ethics and good practice including grievanceprocedures, information on insurance cover, etc. It should involve a clear statement of the therapist'squalifications and current registration with a relevant therapy association with all required contact detailsfor that association including, where available, a client help-line number. Such a charter would delineate the importance of mutual trust between client and therapist, particularlyin the area of a client's medical history and any medication currently being taken or treatment beingfollowed. It would advise the client to consult with their GP if it is necessary to inform their GP of thetherapy they are undergoing and any product being used in relation to the therapy. From the therapist'spoint of view, if any product is being supplied, the client should be informed in writing of theformulation of the product and be told of any possible side-effects or interactions with any othermedicine. As would be set out in the therapist's code of ethics relating to scope of practice, the charter wouldadvise the client to avail of the appropriate care for their condition whether that is conventional medicalcare or another form of therapy for their condition if it is beyond the scope of practice for that therapist.It could also advise the client that if, in the opinion of the therapist, the client needs to be referred forconventional medical help, the therapist would not continue the therapy if the client refused to takethat advice. This is the position of the majority of professional associations. In the case of some therapies however, the therapist would continue to work with the client for a limitednumber of sessions, using those sessions to encourage the client to avail of conventional medicaltreatment. The therapist would then cease treatment if after those sessions the client continued to refuseto seek conventional medical advice. In the case of many homeopaths, while strongly urging the client to avail of conventional medical advice,they would continue to treat if the client made the decision not to avail of this. In the words of theIrish Society of Homeopaths ``The Society of Homeopaths supports the principle of the individual'sright to choose in personal health matters. In addition, having regard to a duty of care, homeopathicpractitioners will work within the bounds of their competence and within the law as it allows orotherwise attaches conditions to the freedom of the individual to make informed healthcare choices.This principle and understanding applies to appropriate referral for the diagnosis of disease as well as theprovision of any subsequent conventional, complementary or alternative medical assistance.''

Complementary therapies and the beauty industry There is no restriction of use and no reservation of title of the term complementary therapy orcomplementary therapist. In many cases, therapists describe themselves by the therapy they practice; aherbalist, a homeopath, a massage therapist, an acupuncturist etc. and the term complementary therapistis used by others about them in a generic way. However, there has been increasing use of the termscomplementary therapies and complementary therapist by the beauty industry along with the termholistic therapist. Generally, the therapies in question here are massage, aromatherapy and reflexology. These may beperceived to be therapies of low risk although this risk level can depend on the client's state of health, 36e.g. where a client has active cancer; or the risk level may be affected by the product involved, e.g.where undiluted essential oils are being used. Generally, the public are using these therapies through the beauty/hotel/leisure/day spa industry forrelaxation rather than to remedy a condition. However, there could be confusion regarding qualificationsand the scope of practice covered by the level of qualification of the therapist involved. Serious concernwould also arise where there is a level of invasiveness involved in the treatment such as cosmeticacupuncture or colonic hydrotherapy where the risk of injury or cross-infection may arise. Some beauticians may have additional qualifications as a therapist which are recognised as fullqualifications and may be registered by a professional association. Others may have done a module orseveral modules as part of an overall beautician training course but would not be recognised byprofessional associations to practise that therapy. The client may be paying full price for a service froma person without full qualifications. The beauty industry has expanded greatly in recent years into the spa therapy area, where beauty therapiesand complementary therapies are often combined. These can be located in hotel leisure centres, day spasor premises described as holistic centres. With this expansion and the increase in the range of therapiesbeing offered, it is important that the consumer is aware of the different levels of qualifications involved.Distinctions need to be drawn between both industries. With increasing integration between complementary practices and conventional medicine in GP practicesand hospitals, use of the term integrated practitioner could be used by those involved in this area.However, this term would not cover the complementary therapist who does not have any involvementwith the conventional medical sector. In the absence of such delineation by title, the existence and easy accessibility of a register of fullyqualified and currently registered therapists by a professional association for that therapy would be ofassistance to the public in distinguishing between fully qualified therapists and those who may have hada cursory introduction to a therapy as part of an overall beautician course. Consumers also need to be aware of the different levels of courses available which then might be usedas a qualification by a self-styled, unregistered and unmonitored practitioner. There are night/weekendclasses in many therapies which give a basic knowledge of a therapy sufficient perhaps for interest andself-use but not sufficient to practise as a therapist with the public. For their own protection, the public should seek a qualification at a level recognised by a professionalassociation as qualifying a therapist to offer treatment of pathological conditions needing remediation inline with the code of ethics and scope of practice of that professional association.

Summary The area of protection of the public is integral to any question of regulation of complementary therapists.The public needs to be well-informed and to take personal responsibility and due care in this area as inany other area of their lives. Where there are a number of professional associations for any one therapy, with differing standards ofqualification and practice, the consumer needs a reliable, up-to-date source of information to guide them 37towards the best choice of therapist for their needs. The Working Group recommends the publicationof such a consumer guide by the Department of Health and Children. Professional associations should provide a client/therapist charter for their members if it is not already inexistence. This would provide clear information for the consumer as to what they could expect fromthe therapist and the therapy and would provide them with contact information for the professionalassociation registering the therapist. While beauty therapists may be very well qualified within the parameters of their own industry, andsome may be fully qualified in a particular therapy, others may not have the full level of qualificationwhich would be accepted by a professional association to practise in healthcare. The public needs tocheck the qualifications and registration of any therapist. 38

CHAPTER 7

The Regulation of Complementary

Therapists There are two broad approaches to the area of regulation of professions. 1. Statutory regulation is a system whereby each individual member of a profession is recognised by a specified body as competent to practice within that profession under a formal mechanism that isprovided for by law. Unlike systems of voluntary regulation, it is a legally binding process: all personswishing to practise must be registered, and can be prosecuted for practising if not registered. 2. Voluntary self-regulation is a system where the profession itself self governs. Voluntary self- regulation, when administered by a single, professional body, is often thought to be enough toprotect the client and to organise practitioners. Provided a profession has all the self-regulatorymechanisms in place, it can prove as effective as statutory registration. The general thrust of public policy, here and in the EU, is towards minimising statutory regulation i.e.by law. The policy generally is only to regulate by statute when there is an overriding public interestfor an activity to be regulated. The trend internationally in the regulation of complementary therapists is away from statutory regulationand towards a robust system of voluntary self-regulation policed by one overall body for each therapy.For an overview of the regulatory position internationally please see Appendix 4. It is clear there is no one common position worldwide or even Europe-wide. In Britain, the movetowards statutory regulation of herbalists and acupuncturists is being delayed as government bodies awaitthe outcome of two major reviews of statutory regulation of health-care workers. This may be no bad thing as, according to Stone and Matthews 4 , statutory recognition to date has come at a high price, namely acceptance by the medical profession which they say ``almost certainly necessitatesa distancing from the more intuitive and esoteric underpinnings of holistic medicine''. Stone and Matthews say that ethics, as in codes of practice, have been seen as encouraging optimumstandards of behaviour whereas the law is usually concerned with enforcing minimum standards. Theygo on to say that ethics are central to statutory regulation and to voluntary self-regulation and that inorganisational terms there may be very little difference between statutory regulation and voluntary self-regulation. It concludes ``we must not rule out the fact that effective VSR may do a very good job offulfilling all the regulatory requirements we have identified'' and ``It is our central contention that 4 Complementary Medicine and The Law, Julie Stone and Joan Matthews, Oxford University Press 1996 reprinted 2003 39whether SSR or VSR is being pursued, a grounding in what it means to practise ethically is at the heartof either system of regulation. Ethics-led regulation provides the key to effective self-regulation.'' Regulation is sometimes proposed on the basis of perceived risk arising from a particular therapy. Thisposition has its defects because while certain therapies do carry more obvious risks e.g. acupunctureneedles or herbal medicines, less obvious risks also exist. Risks may arise from the therapy itself asmentioned above or they may arise from an inadequately trained practitioner or from lack of goodpractice on the part of the practitioner e.g. not referring on for a serious medical condition either at thecommencement of treatment or arising during the course of treatment. Risks may arise from the clientwhere there is a pre-existing condition or treatment has been undertaken which the client does notinform the therapist about. The solution to such difficulties is a two part process of greater voluntary self-regulation in thecomplementary sector and greater information for, and personal responsibility on the part of, the public. Protection of title, which is a feature of statutory registration, is sometimes referred to as a solution andthis can be useful if a protected title is being used unlawfully by someone posing as a reputable therapist.In this case there is redress. Where it is of no use and where it is a much more common occurrence iswhere operators make up their own title. In the United Kingdom, where the title ``osteopath'' isprotected by law, many operators use a similar sounding title e.g. ``practitioner of osteopathic technique''.In such cases, provision of reliable information for the public on titles and associations will enable themto check out the difference between similar sounding therapies. Having considered the area of regulation, the Working Group is recommending that statutory regulationshould be considered for herbalists, TCM practitioners and acupuncturists. For herbalists, this is becauseof the issues involved in the use of herbal medicinal products by herbalists. The Working Group's remitof the protection of the public is best served by statutory registration for herbalists. OTC, i.e. Over theCounter Herbal Products will be regulated by the Traditional Herbal Medicinal Products Directive.Herbalists using specialised herbal training, however, will be entitled to continue to use herbal medicinesin individualised, complex prescriptions for their patients. Given the necessity of high training standardsfor herbalists and the increasing use of herbal medicinal products whereby there is increasing potentialfor interaction between allopathic and herbal medicinal products, it is recommended that a process ofstatutory regulation be put in place for herbalists. In the case of acupuncture, the risks arising from theinvasive nature of treatment by needle demands a high degree of education and training and goodpractice. Because these therapies are often seen as stand-alone systems with their own methods of diagnosis, theymay be the primary point of call for a client, unlike other therapies where a client may have seen a GPfirst. As a primary point of call, it is essential that there is protection for the client in the form ofgreater regulation. The process of how precisely these therapies would be regulated by statute will take more time andneeds further examination by a single focus group to look solely at the issues involved. Such a groupwill benefit from the advanced work of the two UK bodies: the Acupuncture Regulatory WorkingGroup and the Herbal Medicine Regulatory Working Group. There is no need to re-invent the wheeland the years of work done by expert groups in Britain could help to greatly shorten the life of a similarIrish Working Group. 40For all other therapies, the Working Group is recommending the development of robust systems ofvoluntary self-regulation. This process is currently underway and has been for many years by manytherapies and by many professional associations. Their concern is that such development is neitheruniversal in the sector nor uniform even among associations for the same therapy. To bring about asituation where such voluntary self-regulation is both universal and uniform it is necessary that supportbe given to the sector to progress the level of development reached voluntarily by certain committedand hard working professional associations. The precise nature of that support is clearly delineated in the recommendation to the Ta´naiste andMinister for Health and Children that the Department of Health and Children offer facilitated workdays to groups of professional associations for the same therapy or for groups of similar therapies toprogress the issues which need to be harmonised. These could include issues of ethics and good practice,standards of externally validated education and training, the proper composition of a professionalassociation or any other related matters. In addition, the adoption of a patient's charter, used at the initialpoint of contact between patient and therapist, constitutes another useful initiative. Along with strong systems of voluntary self-regulation there needs to be a reliable and up-to-date sourceof information on therapies and professional associations for consumers. It is another recommendationof the Working Group that a booklet be published following the facilitated work days. Information oncomplementary therapies and complementary therapists tends frequently to come into the public domainvia the media, most usually involving a rogue practitioner who is subsequently found not to have hadappropriate qualifications and not to belong to the register of any professional association. With strongsystems of self-regulation, a well developed sector of unified professional associations and acomprehensive information source for the public it is hoped that such sad cases will diminish if notvanish totally.

Summary There are two broad approaches to the regulation of professions:

· Regulation by law or statutory regulation

· Voluntary self-regulation The general thrust is towards minimising statutory regulation. The trend internationally incomplementary therapies is towards a robust system of voluntary self-regulation by one overall body foreach therapy. The Working Group recommends setting up a single-focus group to consider the issues involved in thestatutory regulation of TCM, herbalism and acupuncture. The development of robust systems of voluntary self-regulation is recommended for all other therapies.This will need the active support of the Department of Health and Children. 41

CHAPTER 8

Recommendations of the National

Working Group The following are the recommendations of the group to the Minister for Health and Children: 1. Statutory regulation for herbalists/acupuncturists/Traditional Chinese Medicine practitioners. Toachieve this, it is recommended that a small, single-focus working group be established withoutdelay to consider the complex issues and various models involved in statutory regulation. 2. For all other groups, the development of a robust system of voluntary self-regulation isrecommended. 3. Facilitated work-days for various therapy organisations to progress areas of development with a viewto encouraging federation into one representative organisation for that therapy. This is a necessaryfirst step before harmonisation of advice on education standards in collaboration, as appropriate,with providers and HETAC/FETAC. 4. A report on the state of the sector following these facilitated work days. 5. Publication of a comprehensive, up-to-date information booklet incorporating a client/therapistcharter for the public following the publication of the report on the state of the sector. 6. Immediate setting up of a forum for dialogue between the complementary and conventionalmedical sectors. 7. The establishment of a National Annual Forum for the sector to continue the momentum arisingfrom the work of the Working Group. 8. Following the facilitated work days and the report on the sector, the establishment of a workinggroup on the single issue of the development of a Complementary Therapies Council which wouldoversee issues in the complementary therapies area. 43

Conclusion Having looked at the areas of the complementary therapy sector which need remediation anddevelopment, the National Working Group has very specific reasons for making the eight particularrecommendations to the Ta´naiste and Minister for Health and Children. Recommendation 1 arises from the importance of regulation for therapists practising therapies of a high risk category. Recommendation 2 arises from the need to develop robust systems of voluntary self-regulation for therapists practising complementary therapies not covered by recommendation 1. Recommendations 3, 4 and 5 arise from the need to support and assist therapy organisations to harmonise standards and to provide the public with reliable and current sources of information onproperly qualified and registered complementary therapists. Recommendation 6 arises both from the increasing expansion of integrated healthcare and from the importance of providing factual and accurate information on complementary therapies and therapists tothe conventional medical sector. This needs to be at the initial level of undergraduate education, forGPs, consultants and hospital administrators and on a continuing basis. This report is a stage in the process of development of the sector, not the end of the process.Recommendations 7 and 8 arise from the need to continue that process, to maintain and build on the momentum of the collaboration and interaction of the Department of Health and Children with thecomplementary therapy sector over the last few years and to progress the work done by the WorkingGroup over the last two years. Some recommendations are concurrent, some consecutive. They are necessary, realistic, focused, phasedand achievable in a reasonable time-frame. The implementation of all these recommendations willadvance the development of the complementary sector and the knowledge of the general public. Itshould lead to a point where the sad cases which make the headlines -- of rogue practitioners incorrectlydescribed as complementary therapists -- will be a welcome rarity and the consumer will no more goto an un-qualified, un-registered and un-monitored practitioner than they would to a barber to gettheir teeth pulled. The National Working Group looks forward to the speedy implementation of allthese recommendations. 45

APPENDIX I

Working Group on the Regulation of

Complementary Therapists

Membership Chairperson Department of Health and Children Ms Teri Garvey Ms Maeve O'BrienReplaced byMs Caroline Kelly (April 2005) Federation of Irish Complementary Federation of Irish Complementary Therapy Associations Therapy Associations Ms Catherine Dowling Ms Josephine Lynch Acupuncture Bodies Irish Society of Homeopaths Ms Noeleen Slattery, Lic.Ac.Dip Tuina. Ms Sally Quinlan C.Ac.Nanjing Replaced byMs Ursula Lynch (July 2005) Irish Herbal Practitioners Association Consumers Association of Ireland Dr Celine Leonard Ph.D. Ms Dorothy Gallagher General Practitioner & Homeopathic Practitioners from therapies with a Physician psychological base Dr Brian Kennedy Dr Sean Collins, Psychotherapist Education Representative Ministerial Nominee Ms Margaret Kelly Ms Phil O'Flynn, MA H.Dip Diploma in Department of Education and Science aromatherapy and reflexology Ministerial Nominee Ministerial Nominee Ms Frances Daly Ms Nicola Darrell, BSc(Hons), MIFA,MNIMH, MIMHO, MIMTA 47

APPENDIX II

National Working Group on the

Regulation of Complementary Therapists

Terms of Reference 1. To examine and consider regulatory issues in Ireland and to present its findings andrecommendations to the Minister for Health and Children. 2. To advise the Minister on the way forward in relation to regulation in Ireland, taking into accountrecent policy developments, the publication of the Health Strategy and the publication of a reporton the regulation of practitioners of complementary and alternative medicine in Ireland. Any registration scheme or schemes should take into account:--

· the categories of therapists to be covered;

· the evidence base for each therapy;

· the educational qualifications, training and experience of therapists;

· the scope of practice involved;

· the protection of the public and promotion of a quality service, including the efficacy of thetherapies offered;

· regulations governing alternative therapists in other countries; and

· the current proposals for statutory registration of health and social care professionals in Ireland. 3. To coordinate further consultation and organise a further forum on a national or regional basisas appropriate. 4. To assist and support individual therapies in developing or strengthening their systems of self-regulation. 5. To coordinate the gathering and collation of statistics on complementary and alternative therapiesin Ireland including the nature, number and scope of practice of such therapies and information ontheir representative/regulatory bodies. 6. To gather, in cooperation with the individual therapies, information on the educational programmescurrently being provided in educational institutions for complementary and alternative therapists,incorporating an assessment of such programmes by a body such as HETAC or FETAC inconjunction with the relevant professional bodies represented through the National Working Group. 497. To develop an agreed approach to continuing professional development (CPD) with the bodiesrepresenting the individual therapies. 8. To assist the proposed Health and Social Care Professionals Council in developing, for the benefitof complementary and alternative therapies that are considering applying for registration, someguidelines on the criteria governing such applications and on the requirements that they would haveto meet. 9. To develop, in consultation with the Department of Health and Children, the Health ResearchBoard and representative bodies, research on the efficacy/outcomes of CAM therapies and on theevidence base for each therapy. 50

APPENDIX III

Research on Complementary and

Alternative Therapies The rise in consumer use of complementary and alternative therapies has led to the need for furtherunderstanding of the effects of these therapies. We also need to know more about their application inpublic healthcare, their cost effectiveness, and to increase our knowledge of the basic mechanismsunderlying them. The large increase in their popularity has also stimulated health services internationally,academics and the biomedical community's interest in researching their safety and efficacy. The UK andUSA have established funded research bodies (the Foundation for Integrated Health and NCCAM) toaward research grants and establish centres of learning. These agencies also act to co-ordinate trials, shareinformation and improve the quality and rigour of the research being conducted. In recent years, thishas produced a rise in the quality and quantity of research and has led to a wider evidence base for theefficacy of a number of CAM approaches and treatments.

Issues surrounding research This evidence base of treatment effectiveness has become integral to effective clinical care across alltraditions of medicine. Over the past twenty years practitioners of conventional medicine have made amarked shift from a reliance on experience (directly observed or as recorded by others) to a reliance ona more rigorous research to evaluate the effectiveness of treatments. This development has also shaped research practices on how they are applied to complementary andalternative therapies. However, many people in the complementary community have pointed out thatthere are obvious differences between complementary and orthodox medicine and the way in whichthey work. Not only that, there are differences between researchers and research characteristics oftraditional Western-centred ideas of medical research and scientific practice from other cultures and typesof medicine. The former is more likely to think in terms of linear cause and effect and to identify thesimplest possible causal models. The latter is more likely to think of an overall ``system'' which is complexand has multiple levels of relationship rather than a linear pattern. [1] This difference in approach and understanding of the two medical traditions has influenced the idea thatWestern concepts of levels of evidence and use of Randomised Controlled Trials as the basic standardof evidence of effectiveness of complementary and alternative therapies may not be suitable as a researchmodel. Though, it may be that this methodology is better suited to some alternative and complementarytherapies than others. This is further complicated by evidence from the USA where studies have highlighted that manytherapies are not used to prevent a specific problem or disease but are used to prevent illness or topromote a more general sense of health and wellbeing. Randomised Controlled Trials may still be used 51to assess the effects of complementary and alternative therapies on general health and well-being butthey are even more difficult to conduct as it may require long periods of study (10 to 20 years) and verylarge sample sizes. Even then the outcome may be very hard to define as additional lifestyle changeswhich often accompany adoption of a complementary therapy also come into force, e.g. giving upsmoking, eating a healthier diet, etc. These can have a profound effect on a patient's well-being and soconfuse which variables have promoted the change in well-being. [2] Another complication in applying conventional research models is taking into account the particularfeatures of the healer-patient relationship which is central to some complementary therapies. This is notnew to orthodox medicine either; the relationship between a psychotherapist and their patient, the skillor surgical procedure of a particular surgeon have been taken into account in assessing the success of anoutcome. However, in some of the energy or touch therapies the effectiveness of the treatment isespecially bound up with the relationship between healer and patient and the healer's ``gift'' is somethingthat is not easily measurable. All of the agencies involved in research point out that there is a need for more innovative designs inresearch and new ways of thinking to accommodate these issues. In future years it is clear that we willsee changes in the way research is conducted on complementary and alternative therapies, using modelsand methodologies which can cater for the differences between often divergent approaches.

Randomised Controlled Trials Taking into account the more orthodox medical approach, many randomised trials have been conductedon complementary and alternative therapies. The Cochrane Collaboration lists more than 4000 examplesin its electronic library. Furthermore, a number of Cochrane Collaboration systematic reviews ofworldwide research literature have identified the benefits of complementary therapies, related approachesand products for a small number of chronic conditions including:

-- Low fat or modified fats for preventing heart disease

-- Acupuncture for the management of lower back pain and chronic headache

-- St John's Wort for treating mild to moderate depression

-- Herbal and glucosamine therapy for treating osteoarthritis

-- Nutritional supplements for several neurological conditions [3] In addition to these Cochrane systematic reviews, an American National Institute of Health scientificreview panel concluded that acupuncture is a plausible option for treating several conditions, includingnausea associated with chemotherapy and anesthesia, acute dental pain, headaches, temperomandibularjoint dysfunction, fibromyalgia, and depression. [4] All of the literature reviews point to the need for larger more rigorous studies and the need forcomprehensive research to be carried out particularly in those areas of complementary therapy that arebecoming more integrated and popular in mainstream medical care. There is an acknowledgement inthe sector that as it moves towards a more integrated model, (particularly in the UK and the USA) thatclear evidence of efficacy in practice in hospitals has both led to further integration of complementarytherapies but also more opportunities for the evaluation of how they are working alongside orthodoxmedicine. 52

Studies of Use In the UK, responses to the House of Lords Select Committee's recommendations on research have ledto increased awareness of promoting high quality evaluations of how complementary and alternativepractices are performing in integrated settings. In 2003, the Department of Health provided funding forresearch (£1.3 million for the first round of a research capacity building scheme, and £324,000 for threequalitative research projects on complementary and alternative therapies in the care of patients withcancer). [5] These projects aim to contribute to a better understanding of the demand for therapies and their effects on patient-centred outcomes among patients with cancer. They are focussed upon thosetherapies as an adjunct to conventional forms of treatment and in palliative/supportive care. Researching this use of complementary therapies in practice has also contributed to a rise in researchfunding; as the sector grows and patients express satisfaction with the therapies that they are using. Itadds more impetus to examine how these therapies are creating successful outcomes. Cancer sufferersare some of the biggest users of complementary and alternative therapies. In February of this year, animportant study conducted by the University of Manchester found that a third of cancer patients acrossEurope use complementary and alternative therapies. [6] This marks a significant increase since the last review of 29 studies was undertaken in 1998. The study found that usage rates varied from just under 15% of patients in Greece to a high of nearlythree quarters in Italy. Following the publication of its findings, the lead researcher Dr Alex Molassiotis,a Reader in Cancer and Supportive Care at Manchester University's School of Nursing, Midwifery andSocial Work said that: `Irrespective of what health professionals believe, our findings show that patients are using andwill continue to use CAM. This will necessitate a re-thinking of medical and healthcareeducation, and work towards integrating CAM therapies for which there is evidence ofeffectiveness into mainstream healthcare services.' Nearly 1000 patients aged 17 to 91 were surveyed in 14 countries for the survey, which was carried outin conjunction with member countries of the European Oncology Nursing Society. Patients are usingthe therapies for an average of 27 months, with only 3% feeling that they have received no benefit fromthis. Most patients reported using CAM to increase their body's ability to fight the disease (50%),although only 22% reported subsequent benefits. However, although only 35% initially used CAM toimprove their emotional well-being, 42% reported benefits in this area. Forty percent said they usedCAM to improve their physical well-being. This broad pattern of satisfaction with complementary therapies tracked outside controlled trial situationsis common and also with many studies conducted in the U.K. In a study by the Royal LondonHomeopathic Hospital NHS Trust, patients were surveyed about the complementary and alternativetherapies they received at the hospital. Of the 262 patients that said they were using conventionalmedication at the start of the survey, 29% stopped all conventional medication after receiving treatmentat the hospital and 32% decreased their medication [7] . Similarly, in the Glasgow Homeopathic Hospital, 46% of patients using complementary therapies reported a decrease in the use of conventional medicationand 72% reported significant improvement to their state of overall well-being three months afterdischarge. [8] 53

Cost Effectiveness For health services, one of the attractions of research into integrative models is examining cost savingsthat complementary and alternative interventions can yield for health providers. Increasingly, this hasbecome an important benchmark in evaluating health care projects and particularly integrated models ofcare. When complementary and alternative therapies work effectively in this environment, they producesavings in terms of reductions in visits to doctors, reductions in medication, reductions in referrals forfurther treatment in hospital (x-ray, ECG etc.) and/or the take up of beds in a hospital ward. Toconclude, patients who experience benefits in health from complementary therapies tend to have lessrecourse to the more expensive health services such as GP visits, consultant referrals and medicines. In a British/American study published in the British Medical Journal, acupuncture was assessed underradomised control trial conditions with an economic analysis of the outcome. Compared with controls,patients randomised to acupuncture used 15% less medication, made 25% fewer visits to GPs and took15% fewer days off sick. The report concluded that ``acupuncture leads to persisting, clinically relevantbenefits for primary care patients with chronic headache, particularly migraine. It is relatively cost-effective compared with a number of other interventions provided by the NHS.'' [9] The Glastonbury Health Centre Study is a good example of evaluation of complementary therapies ingeneral practice with a focus on their cost effectiveness. The centre offered various complementarytherapies to a range of patients visiting doctors at the facility. Taking into account the costs of providingthe service, it was possible to establish that a group of 41 patients from the practice which had cost theNHS around £4,000 each for NHS treatment, when in the year after their treatment withcomplementary and alternative therapies their costs went down to just over £1,500, giving a saving ofaround £2,500 per patient. The overall saving in secondary referrals in the year of the treatments wasover £18,000. [10] A Danish study which evaluated patients receiving acupuncture and other complementary treatments foracute angina pectoris outlined significant cost savings of US$36,000 and US$22,000 for surgical andnon-surgical patients, respectively. These savings were mainly achieved by the reduction in the use ofinvasive treatment and a 95% reduction in in-hospital days. [11] The report concluded that ``Integrated rehabilitation was found to be cost effective, and added years to the lives of patients with severe anginapectoris''. Acupuncture was also the focus of a study conducted by the University of Washington. Together withmassage therapy and spinal manipulation its aim was to examine the best available evidence about theeffectiveness, safety, and costs of the most popular complementary and alternative medical therapies usedto treat back pain. They found massage to be the most cost effective for persistent back pain. [12] In a wide ranging study, the University of Arizona examined 56 economic evaluations of complementaryand alternative therapies applied to a variety of conditions. [13] The studies that met their particular conditions of quality methodology indicated several therapies that may be considered cost-effectivecompared to the usual clinical care for various conditions: acupuncture for migraine, manual therapy forneck pain, spa therapy for Parkinson's, self-administered stress management for cancer patientsundergoing chemotherapy, pre- and post-operative oral nutritional supplementation for lowergastrointestinal tract surgery, biofeedback for patients with ``functional'' disorders (e.g. irritable bowelsyndrome), and guided imagery, relaxation therapy, and potassium-rich diet for cardiac patients. It is clear that there are proven cost savings to be made for health service providers by allowing patientsto avail of complementary therapies. Not all evaluations of complementary and alternative therapy 54programmes denote this to be the case outright, but there is widespread acknowledgement of a need forfurther in depth understanding of how and why these positive outcomes are taking place.

Award winning projects In the U.K., the use of complementary therapies in the field of community health care and preventivemedicine has provided successful and award-winning models of projects which offer visible benefits tothose who take part in them and to their health service providers. The Foundation for Integrated Healthon a bi-annual basis awards the most effective or innovative programmes offering therapies to varioustypes of patients and healthcare consumers. In a joint project, the Royal Berkshire Hospital and the Chinese Internal Arts Association established aprogramme of Tai Chi exercises for the patients and staff at the elderly care unit resulting in patientsreporting improved balance and muscle strength. A U.S. study conducted by the University of Atlantaalso found the practice of Tai Chi by the elderly to have a favourable impact on the occurrence of falls. [14] Infant Massage taught to neo-natal mothers in a programme run by the Imperial School of Medicine inLondon was another award winning project of this kind. Research has shown that mothers with postnatal depression who are taught infant massage suffer a reduction in depression and also have improvedinteractions with their infants [15] . In another audit of a maternity aromatherapy service in a small Midlands maternity unit, offering aromatherapy services to expectant mothers showed to be effective in normalisingchildbirth and increasing satisfaction of mothers in respect of their labour experiences. [16] Another award winning project is the work carried out at the Derriford Hospital in Plymouth, whereacupuncture is offered for pain relief in pregnancy and labour. They have treated over 5,000 women inPlymouth with antenatal problems -- mostly morning sickness and backache but also a wide range ofother conditions such as constipation, varicose veins, headaches and migraines, and pelvic pain needingadmission to hospital. Complementary therapies have found a particular place with pregnant women asthey are restricted in what pharmaceutical products they can take for health complications. These interventions of complementary and alternative therapies at community level are becoming morecommon in the U.K. and research tracking their success in economic terms will increase as time goeson. While projects that demonstrate cost benefits of complementary and alternative therapies are easierto track in terms of how and where they benefit a health service, Peter Mackereth, lecturer incomplementary therapies at the University of Salford points out that the outcome of patient well-beingis still at the top of the list in terms of the desired effect of complementary therapies offered to patientsat their cancer hospital. At Christies NHS Hospital Trust in Manchester the use of complementarymedicines and therapies can have a profound effect in helping patients ``comply with theirchemotherapy'' and ``improve their experience'' of care in the hospital. Currently, Christies is involved in a potentially ground breaking project which is using essential oils inorder to kill off the MRSA bug. While the research is at an early stage, lab trials have proved that essentialoils are acting in the desired way on the MRSA. The trial is continuing in a laboratory environment andwill proceed onto research with patients at a later stage. Suzanne CampbellResearcher to the National Working Group on the Regulation of Complementary Therapists August 2005 55

References 1. The Geography of Thought, How Asians and Westerners think differently and Why, New York,Free Press 2003, Nesbitt 2. Complementary Medicine in the United States, The Committee on the Use of Complementaryand Alternative Medicine by the American Public, The National Academies Press, 2004), 3. White House Commission on Complementary and Alternative Medicine Policy Report 2002 4. National Institute of Health, Office of the Director. NIH Consensus Statement: AcupunctureVolume 15 (5): November 3-5, 1997. 5. www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ComplementaryAndAlternativeMedicine 6. Annals of Oncology, publication date 3/01/2005www.annonc.oupjournals.org <http://www.annonc.oupjournals.org/> 7. A review of inpatient care integrating complementary and orthodox medicine at GlasgowHomeopathic Hospital. The Academic Departments, Glasgow Homeopathic Hospital 1998 8. Patients' perspectives on using a complementary medicine approach to their health; A survey atthe Royal London Homeopathic Hospital NHS Trust. F Sharples and R Van Haselen 1997 9. Acupuncture of chronic headache disorders in primary care: randomised controlled trial aneconomic analysis, AJ Vickers,1* RW Rees,2 CE Zollman,3 R McCarney,4 CM Smith,5 N Ellis,6P Fisher,7 R Van Haselen,7 D Wonderling8 and R Grieve8. Health Technology Assessment 2004;Vol 8: number 48 10. Complementary Therapy in General Practice; An Evaluation of the Glastonbury Health CentreComplementary Medicine Service. Dione Hills, Dr. Roy Welford 11. Long-Term Effects of Integrated Rehabilitation in Patients with Advanced Angina Pectoris: ANonrandomized Comparative Study (Denmark). Ballengaard, Borg, Karpatschof, Nyboe,Johannessen. Journal of Alternative and Complementary Medicine Oct 2004, Vol. 10, No. 5:777-1783. 12. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy,and spinal manipulation for back pain. Cherkin, Sherman, Deyo, Shekelle Group HealthCooperative and University of Washington, Seattle, Washington 98101, USA. 13. Is complementary and alternative medicine (CAM) cost-effective? a systematic review. Herman,Craig and Caspi.Program in Integrative Medicine, University of Arizona, Tucson, Arizona, USA.pherman@email.arizona.edu. 14. Reducing frailty and falls in older persons: an investigation of tai chi and computerized balancetraining. Wolf, Barnhart, Kutner, McNeely, Coogler, Xu, Atlanta FICSIT Group, Emory Schoolof Medicine, Atlanta, Georgia. (American GeriAtric Society 2003) 15 Infant massage improves mother-infant interation for mothers with post-natal depression. Onozawa,Glover, Adams, Modi, Kumar, Journal of Affective Disorders 2001 16. Audit of an aromatherapy service in a maternity unit in Warwickshire. S Mousely CommunityMidwives Office, George Eliot Hospital, 1st Floor Maternity Unit, Heath End Rd, Nuneaton,Warks, CV10 7DJ, UK. 56

APPENDIX IV

International Regulation The information below is supplementary to the 2002 O'Sullivan report which describes in detail howcomplementary and alternative therapies are regulated in each country. Detailed below is an update tothe 2002 report and a description of recent legislative changes internationally.

Issues surrounding regulation In the past few years, the rise in the use of complementary therapies, the improved quality of researchon efficacy and successful models of integrated healthcare have prompted much analysis of the best wayto regulate therapists in the sector. This has led to many countries conducting systematic reviews of theirregulatory systems, with several publishing reports arising from the findings of advisory committees andworking groups commissioned by governments. It has been a useful process internationally in helpingcountries gather facts on the issue and to set their regulation agenda. In terms of regulation, there are unique challenges affecting complementary and alternative practitionerswhich have been noted by many of the advisory documents and government reports arising from thisexamination. Some of these challenges of regulating practitioners were identified in the 2002 report ofthe United States White House Commission on Complementary and Alternative Medicine Policy [1] . They found the chief challenges to be:

-- Disagreement surrounding the nature and scope of some professions

-- Confusion and potential legal consequences arising from the overlap of approaches andtechniques used by practitioners

-- The variation in the views of practitioners about how much training is needed to attainregulation status in a given field There are also those points recognised by the New Zealand Commission on Complementary andAlternative Health in terms of regulation of practitioners by statutory regulation. [2]

-- Statutory regulation can be seen as a means to gain legitimacy with consumers and biomedicalpractitioners, facilitate integration and access public health funds

-- The costs of statutory regulation are not warranted for low risk modalities

Trends in Regulation Many countries, including New Zealand, favour strong self-regulation with statutory regulation of thosetherapies that are understood to have potential risk to the consumer. The model of self-regulation is also 57preferred in Canada, where the advantages of using the therapists themselves to self-govern have beenexamined by their health services. [3]

-- The therapists act as ``gate-keepers'' to the therapy, typically by establishing and enforcingentrance standards for the therapy.

-- They establish standards of practice for the therapy providing guidance to their members onthe performance of their duties.

-- They establish continuing education or continuing competence requirements which membersmust follow to maintain their competence throughout their career.

-- They administer a professional disciplinary process designed to protect the public fromincompetent or unethical professionals. Members of the profession found to have engaged inunprofessional conduct or unskilled practise can face a range of sanctions from a directive totake remedial training to the expulsion from the profession in extremely serious cases. Self-regulation through professional bodies seems to be a desirable option in many countries. This isparticularly the case where the level of perceived risk to the consumer as one of the main forces drivingthe need to statutorily regulate some professions while leaving others to police themselves. Increasingly,organisations and professional associations of complementary therapists are formulating frameworks forself-regulatory possibilities. A 2005 report by the European Council for Classical Homeopathy (an NGOwith participatory status with the Council of Europe) [4] gives an example of agreed minimum criteria for voluntary self-regulation. 1. A single national professional body, where appropriate, established according to common highstandards of education, registration and practice agreed across Europe. 2. Patient representation on all standard committees -- particularly for complaints and professionalconduct procedures. 3. An accreditation process for institutions providing education. 4. Continuing professional development required for all practitioners. 5. Professional indemnity insurance for all practitioners. 6. Code of ethics and practice. 7. Complaints and disciplinary procedures. The reports published by Canada, New Zealand and the House of Lords recommendations in the UKall favour a degree of self-regulation combined with statutory regulation for certain therapies as a possibleregulatory framework. In both the UK and New Zealand, recent legislation (The 2003 HealthPractitioners Competence Assurance Act and the Health Act 1999) allow for the possibility of the therapyto become statutorily regulated without separate lengthy legislation having to be formed. All GovernmentAdvisory Groups reporting in the last seven years point out that statutory regulation is not suitable ornecessary for all modalities. In most cases, solid self-regulation, preceded by a strong degree of uniformityin the sector, is seen as a useful way forward. 58

Europe Following the 1997 Lannoye report, the Collins resolution [5] was passed by the European Parliament in 1997 which called on the Commission to ``launch a process of recognising non-conventional medicine''and to carry out a study of its effectiveness, areas of application, and legal models to which it was subject. Two years later the 1999 COST report [6] (Cooperation in Science and Technology) was published. It identified two legal issues in relation to licensing therapies; licensing a therapist to practise complementarymedicine and the reimbursement by social security systems of the costs for the client. In relation to licensing, COST developed three categories of models of regulatory frameworks; the

-- monopolistic systems where only the practice of modern, scientific medicine is recognised aslawful, with the exclusion of, and sanctions against, all other forms of healing and practitioners.

-- tolerant systems where only the system based on modern, scientific medicine is recognised,although the practitioners of various forms of complementary medicines are tolerated, at leastto some extent, by law.

-- mixed systems where there are some monopolistic and some tolerant characteristics. Ireland, Germany and Britain fell into the ``tolerant'' category while countries like France and Spainwere seen as monopolistic and Denmark, Finland and Sweden were examples of mixed systems. Sincethe COST report and the Collins resolution, there have been no legislative procedures made concerningcomplementary and alternative medicine by the EU. Nuala Ahern, former MEP, led a working groupon the sector in the last parliamentary session. Since the new term began in June 2004, the positionregarding the basis on which the sector is regulated remains unchanged. To this end, a Brussels based NGO, the European Forum for Complementary and Alternative Medicine(EFCAM) was formed in 2004 in response to the EU Commission's call for single umbrella bodies torepresent the various stakeholders sharing broad areas of interest and concern in the EU. Its aim is torepresent the collective views and promote the interests of professional practitioners, patients and usersof complementary and alternative medicine in Europe. Together with lobbying groups such as theEuropean Public Health Alliance (EPHA), EFCAM hopes to keep the issue on the agenda. The EPHA represents over 100 non-governmental and other not-for-profit organisations working insupport of health in Europe. The platform was founded in 1994 in Brussels. Their aim is to create apermanent forum for exhange of views and information and to act as a point of reference for the EUinstitutions on policy and regulatory issues for CAM.

Updated status on regulation internationally

Denmark The Danish parliament has passed a resolution to establish a register effective from June 2004 for CAMpractitioners. The register is voluntary and practitioners will be self-regulated through their memberassociations. It includes practitioners who have well defined criteria for education and are members ofan organisation for practitioners that will take on the necessary tasks for registration and maintaining theregister. Politicians hope that the resolution will result in bridge building between alternative practitionersand healthcare practitioners. The register is voluntary and practitioners are self-regulated through theirmember associations [8] . 59

Italy The Government of Northern Italy (Piedmont region) issued a new regional law in 2002 which legallyrecognises the practice of Complementary and Alternative Medicine [9] . There is no national policy on CAM other than that in the Piedmont region.

Holland Holland has regulated CAM therapies since 1993. The Individual Health Care Professions Act came intoforce in 1997. In relation to alternative practitioners, the focus has been on voluntary self-regulation andon the development of systems to ensure quality. A quality framework has been established for alternativepractitioners. It includes 36 criteria developed in agreement with patient organisations, health insurersand the health inspectorate. The areas covered include education, vocational training and continuing education; the register ofqualified members; the application of alternative treatments; guidelines on practice organisation; codesof conduct; relationships with other health care providers; disciplinary rules and complaints procedures;and quality assurance. An independent research organisation is monitoring the progress whichorganisations are making in the implementation of this quality policy.

Norway A new law for alternative therapies was enacted from 1 January 2004. The law lays out regulation forthe legal practice of therapies by someone who is not a medical doctor. The law states that the practitioner:

-- must follow the same regulations for confidentiality as health care personnel.

-- may not treat dangerous contagious diseases or serious diseases, but may treat when the purposeof the treatment exclusively is to palliate or reduce symptoms of, or consequences of, the diseaseor side-effects of treatment given, or when the purpose is to enhance the body's immune systemor ability to heal itself.

-- may treat serious diseases in co-operation or understanding with the patient's doctor and whenthe patient is over 18 years of age and has the ability to give consent.

-- may treat serious diseases when the health care service can not offer the patient healing and canonly offer palliative treatment. In June 2004 a register for practitioners was also established by the Norwegian Government and is opento practitioners to join voluntarily. To qualify for registration they must be a member of a professionalorganisation that has been approved in accordance with the nine recommended points that the registerrequires for approving professional organisations. The register is run by the Bronnoysund Register inconjunction with the Directorate for Health and Social Affairs. The register is voluntary and theprofessions are self-regulated.

Belgium In Belgium, before 29 August 1999, anyone who practised medicine -- complementary or orthodox --without being enrolled with the Belgian General Medical Council was committing a criminal offence.Registered doctors have had clinical and diagnostic freedom to carry out whatever treatments theythink fit. However, those who chose complementary medicine found themselves in conflict with theirprofessional organisation, which requires them to treat patients `taking all reasonable care given the 60current state of scientific knowledge'. This discrimination led to Colla's Law, named after Minister Colla(29 April 1999). Colla foresees the installation of four `commissions' (homeopathy, acupuncture, osteopathy andchiropractic) and for the first time in Belgium, regulation concerning complementary and alternativetherapies. Work is now in progress to establish committees and procedures under the new legislation that willestablish the legal right to practise under a new national register.

Portugal In July 2003, the Portuguese Parliament voted in a new law that recognises the practice of acupuncture,homeopathy, osteopathy, naturopathy, pytotherapy and chiropractic. Under this law, the practice of thesetherapies will be controlled and accredited by the Health Ministry while the education and certification ofqualifications will be controlled by the Ministry of Education.

Sweden The Government has proposed the establishment of a register of complementary and alternativepractitioners. Funding for the process was included in the budget of 2004.

UK regulation since 2000 In the United Kingdom, the House of Lords Science and Technology Committee report oncomplementary and alternative medicine, published in 2000, is the chief blueprint for regulatory policy.The inquiry was mounted because of the increased use of complementary and alternative therapies notonly in the United Kingdom but across the developed world. This rise in its popularity and use raisedseveral questions of substantial significance in relation to public health policy. The inquiry lasted for 15months. It received more than 180 written submissions and took evidence from 46 different bodies. Tounderstand its recommendations on regulation we must first look at the report's subdivision of therapiesinto three groups.

· The first group embraces what may be called the principal disciplines, two of which, osteopathyand chiropractic, are already regulated in their professional activity and education by Acts ofParliament. The others are acupuncture, herbal medicine and homeopathy. Each of thesetherapies claims to have an individual diagnostic approach and are seen as the `Big 5'.

· The second group contains therapies, which are most often used to complement conventionalmedicine and do not purport to embrace diagnostic skills. It includes aromatherapy; theAlexander Technique; body work therapies (including massage); counselling; stress therapy;hypnotherapy; reflexology and probably shiatsu, meditation and healing.

· The third group embraces those other disciplines which purport to offer diagnostic informationas well as treatment and which, in general, favour a philosophical approach and are indifferentto the scientific principles of conventional medicine, and through which various and disparateframeworks of disease causation and its management are proposed. These therapies can be splitinto two sub-groups: Group 3a includes long-established and traditional systems of healthcaresuch as Ayurvedic medicine and Traditional Chinese medicine. Group 3b covers otheralternative disciplines which lack any credible evidence base such as crystal therapy, iridology,radionics, dowsing and kinesiology. 61Group 1 includes the most organised professions and Group 2 contains those therapies that most clearlycomplement conventional medicine. While the question of efficacy was not included in their initialterms of reference, in the absence of a credible evidence base it was seen that Group 3 cannot besupported unless and until convincing research evidence of efficacy, based upon the results of welldesigned trials, can be produced. Their chief recommendations were:

-- In order to protect the public, professions with more than one regulatory body should make aconcerted effort to bring their various bodies together and to develop a clear professionalstructure (para 5.12).

-- Each of the therapies in Group 2 should organise themselves under a single professional bodyfor each therapy. These bodies should be well promoted so that the public who access thesetherapies are aware of them. Each should comply with core professional principles, and relevantinformation about each body should be made known to medical practitioners and otherhealthcare professionals. Patients could then have a single, reliable point of reference forstandards, and would be protected against the risk of poorly-trained practitioners and haveredress for poor service (para 5.23).

-- Acupuncture and herbal medicine are the two therapies which are at a stage where it wouldbe of benefit to them and their patients if the practitioners strive for statutory regulation underthe Health Act 1999, and it was recommended that they should do so. Statutory regulationmay also be appropriate eventually for the non-medical homeopaths. Other professions muststrive to come together under one voluntary self-regulating body with the appropriate featuresoutlined in Box 5, and some may wish ultimately to aim to move towards regulation underthe Health Act once they are unified with a single voice (paras 5.53 and 5.55).

-- Each existing regulatory body in the healthcare professions should develop clear guidelines oncompetency and training for their members on the position they take in relation to theirmembers' activities in well organised CAM disciplines; as well as guidelines on appropriatetraining courses and other relevant issues. In drawing up such guidelines, the conventionalregulatory bodies should communicate with the relevant complementary regulatory bodies andthe Foundation for Integrated Medicine to obtain advice on training and best practice and toencourage integrated practice (para 5.79).

-- The report encourages the bodies representing medical and non-medical CAM therapists,particularly those in Groups 1 and 2, to collaborate more closely, especially on developingreliable public information sources. They recommended that if CAM is to be practised by anyconventional healthcare practitioners, they should be trained to standards comparable to thoseset out for that particular therapy by the appropriate (single) CAM regulatory body (para 5.83). Following on from these recommendations, between March and June 2004 the Department of Healthbegan a period of consultation on proposals to proceed with the regulation of herbal medicine andacupuncture practitioners. Over 1000 copies of the consultation were distributed to interested individualsand organisations and a total 698 responses were received to the consultation. The majority of theresponses indicated strong support for the introduction of statutory regulation, in order to ensure patientand public protection. Key areas of debate included the type and name of the proposed regulatorycouncil, protected titles, collaborative regulation and the composition of the council. 62The Department analysed the responses received and in February 2005 launched a report on theconsultation titled ``Statutory regulation of herbal medicine and acupuncture: Report on theconsultation''. The Department of Health planned to publish draft legislation for further consultation inAutumn 2005. However, pace on the statutory regulation of herbal medicine and acupuncture has slowed as a result ofthe UK Government's current scrutiny of the entire area of statutory regulation. Since the enquiry intothe deaths caused by Dr. Harold Shipman, two major reviews of statutory regulation of healthcareworkers are now taking place as part of the Government's response to the Shipman enquiry. At presentthere are nine different regulators in what is regarded by some as an unwieldy and time consumingprocess. This has resulted in the regulation of herbal medicine and acupuncture being put on hold untilthe Government reacts to the findings of these enquiries. Many people who are expert in the field of complementary therapies in the UK and their regulationfeel that voluntary regulation through a federal structure could be the way forward for most groups.This would mean the establishment of agreed umbrella organisations with bodies structured beneaththem through each (or related) therapies, a route which is in line with the recommendations of theHouse of Lords report. Also, further regulatory change is about to occur in the UK; regulation of health care workers such associal workers, domiciliary workers etc. allows for further registration and tracking of those who workwith potentially vulnerable adults and children. This process has raised questions for the alternative andcomplementary sector in terms of registration. Could registration and a rigorous framework of voluntaryregulation act just as effectively as statutory regulation? It is felt that for some groups, the economics ofstatutory regulation (and perhaps factors based on lack of perceived risk) could result in voluntaryregulation being a more effective choice. The Foundation for Integrated Health is currently examining these issues and looking at the variouspossibilities for non-statutory regulated therapies. It is felt that there are many issues to be examined suchas incentive for practitioners to belong to a federated structure and quality assurance criteria but thatvoluntary self-regulation could be the most suitable way forward for many groups. The Foundation receives Government funding to support the setting up of effective voluntary self-regulation schemes for therapies such as homeopathy, aromatherapy and reflexology. The Foundation'sfocus is to help establish a single regulatory body for each of the main complementary health therapiesand then to facilitate the development of robust forms of voluntary or statutory self-regulation.

United States In the U.S.A., every state has its own licensing scheme, with different laws and regulations and courtsand judicial documents that interpret these rules. The primary means by which states regulate health carepractitioners are: (1) mandatory licensure, the most common; (2) title licensure, where a licence is neededto use a particular professional title; (3) registration, with the designated state agency; and (4) exemptionfrom licensure requirements. In general, state regulatory boards establish educational and licensurerequirements such as requiring the passing of a specific exam and minimum number of training hours. Regulation for certain therapies is also moving faster than for others. For example, South Dakota passeda law in February of this year to regulate the state's massage therapy profession. According to theAmerican Massage Therapy Association (AMTA), South Dakota is now the 34th state to regulate massage 63therapy. The first state to regulate massage therapy was Arkansas, which passed its law in 1951. Fifty-four years later, there are still 16 states with no specific regulation and in many states, massage is stillregulated by individual town ordinances. This situation is one familiar to many complementary andalternative therapies in the U.S.A. Minnesota is a state where there is almost unlimited freedom to practise a therapy. Unlicensedpractitioners must inform clients of their education, experience and intended treatments, as well aspossible side effects or known risks of the treatment. Clients must sign an informed consent formacknowledging the practitioner is unlicensed, that complaints may be filed with the MinnesotaDepartment of Health if the treatment is unsatisfactory, and that they have the right to seek licensedcare at any time. Requirements for practice are minimal, but practitioners are not exempted from liabilityfor untoward outcomes. In a contrasting example, Washington provides licensure, registration, or exemption for various categoriesof therapists, based on their education and the extent to which their profession prepares practitioners toassume responsibility for the total health care of clients. Regulations delineate standards of practice, thescope of practice allowable, education and training requirements for licensure, registration or exemptionand required professional oversight. Four therapy groups (naturopaths, acupuncturists, massage therapistsand chiropractors) are licensed and regulated. While accepting the view that the U.S. has a multiplicity of regulatory and educational requirements fortherapists, in order to facilitate future uniformity the Federation of State Medical Boards SpecialCommittee for the Study of Unconventional Health Care Practises has begun to develop guidelines forthe use of complementary therapies. These guidelines address training and education with a focus on thescientific basis of treatment methods. The American Board of Holistic Medicine has administered aboard certification examination covering 13 areas of holistic medicine including nutritional medicine,environmental medicine, bio-molecular medicine, homeopathic medicine, manual medicine, ethno-medicine including acupuncture and conventional medicine. Chiropractic is the most developed in terms of national standards for education and training in theU.S.A. of any complementary profession. Traditional Chinese acupuncture, therapeutic massage andnaturopathic medicine have moved closer than other CAM professions to having national education andtraining standards. Because of this progression, these professions are appropriate candidates forconferences convened by the Department of Health and Human Services and other agencies where theleaders of the sector, conventional medicine, health professional groups, the public and otherorganisations will meet to facilitate the establishment of education and training guidelines. Establishingagreed levels of training, education and standards of continuing education and scope of practice isnecessary if legal authority to practise a therapy is to be recognised in a wider context across the states. As the U.S. regulatory framework is framed by its federal nature, one of the recommendations of thereport of the White House Commission on Complementary and Alternative Medicine Policy is toestablish a centralised office for the sector in order to facilitate policy formulation and implementation. It was also a recommendation of the White House Commission on Complementary and AlternativeMedicine Policy that the Department of Health and Human Services should assist the states in evaluatingthe impact of legislation inacted in various states in terms of regulation of practitioners and ensureaccountability to the public, with periodic review. It was also recommended that the Secretary of Health 64and Human Services, in collaboration with states, should assist CAM organisations that wish to developconsensus within the field of practice regarding standards of practice including education and training. [1] These conclusions could then be considered by states in terms of regulatory options such as registrationlicensure or exemption. In conclusion, it is evident that the United States is endeavoring to establish amore cohesive framework for regulation across the country and facilitate better communication,evaluation, and review of regulations between states, regulatory bodies and practitioners.

Canada Canada, along with many other nations, is examining policy issues relating to the safety, efficacy, cost-effectiveness and regulation of complementary and alternative health care. In the next few years, thepolicy choices that will be made with respect to the recognition and regulation of complementary andalternative health care practitioners will have a great impact on the continuing development ofcomplementary and alternative health care in Canada. [13] The predominant mode of regulation for health professions in Canada is self-regulation. Historically, thishas been achieved after certain acceptance or recognition by the political and economic players andinstitutions in the health sector. Regulatory precursors to such self-regulation include direct governmentregulation through mechanisms such as the Acupuncture Committee in Alberta. Legislation in Canadahas established three primary regulatory structures for the self-regulation of health professions. The provinces and the territories have the constitutional jurisdiction to regulate health care professionals,including complementary and alternative practitioners. While the national health service (Health Canada)does not have a direct role in regulating health professionals, the significant impact of complementaryand alternative health practices on the health system has necessitated policy analysis in this area. The 2001 report commissioned by Health Canada recommended four primary themes for furtherregulation of the sector. [14]

-- The importance of government to remain cognisant of the consumer driven nature ofcomplementary and alternative health care. The potential lack of an ``evidence-based'' approachshould not necessarily be a barrier to regulation.

-- Consideration of potential regulatory mechanisms should focus primarily on the identificationof risk and the meaningful reduction of risk.

-- Consider carefully the implications of championing complementary over alternative health care,or over-emphasising the concept of integration of Complementary and Alternative HealthCare with conventional health care. Many practitioners worry that complete integration ofComplementary and Alternative Health Care with conventional health care would lead to anundermining of the holistic nature of complementary therapies which is perceived by consumersto be of great value.

-- Consider the pace and extent to which governments consider regulating CAM practitioners,given the dearth of evidence about harm done to the public because of the level of currentprofessional regulation. Government should advocate for appropriate regulation, rather than over-regulation or under-regulation. In some cases, no regulation of practitioners of certain CAMmodalities may be appropriate. Where some form of regulation is necessary, it cannot beassumed that the same type of regulation is necessary for all CAM modalities. 65

Australia Regulation of practitioners in Australia is the responsibility of the various state governments. Currently,Victoria is the only Australian jurisdiction to formally regulate therapists, requiring practitioners who usethe title ``Acupuncturist'', ``Chinese Herbal Medicine Practitioner'', and ``Chinese MedicinePractitioner'' to register with the Chinese Medicine Registration Board. However, all state jurisdictionshave legislation (with varying requirements) for the registration of chiropractors and osteopaths. Mosttherapists are therefore subject only to varying forms of professional self-regulation. However, the federal Government is getting involved in funding some groups of practitioners to exploreavenues for self-regulation. Under A New Tax System (Goods and Services Tax) Act 1999,complementary and alternative practitioners had to satisfy the definition of being a recognised professionalin order to continue to supply their services GST-free beyond 30 June 2003. To this end, the AustralianGovernment has provided AUS$500,000 to help professional associations form national professionalregistration systems for acupuncture, naturopathy and herbal medicine practitioners. The funding wasspread between the following groups: National Herbalists Association of Australia; Australian TraditionalMedicine Society Ltd; Australian Natural Therapists Association Ltd; Federation of Natural andTraditional Therapists; and Australian Acupuncture and Chinese Medicine Association Ltd. [15]

New Zealand New Zealand has taken a risk-based approach to the statutory regulation of health practitioners and todate has provided for the statutory regulation of two therapies; chiropractic and osteopathy. Othertherapies are at various stages of self-regulation through a range of therapy-based professional bodiesand/or through the multi-therapy body, the New Zealand Charter of Health Practitioners. The 2003 Health Practitioners Competence Assurance Act stresses the importance of the health andsafety of the public and an accountability regime for practitioners. Most importantly for the professionsunder discussion, it also provides an opportunity for additional complementary modalities to be coveredunder the act. Again, the risk-based approach is primary here and chiropractic and osteopathy wereregulated under this Act as they were felt to have appropriate level of risk for consumers. In 2004, the Ministerial Advisory Committee on Complementary and Alternative Health (MACCAH)published its report into the sector with advice to the Minister for Health on policy. [2] The MACCAH report examined the issue of statutory regulation for therapies while favouring the risk-based approach.The report also notes that other countries are at a similar stage of considering statutory regulation butthat no country has yet provided a best practice model for New Zealand. For future policy, the report concludes that an increased level of regulation of practitioners is needed toeffectively protect New Zealand consumers from the risks involved with complementary and alternativehealthcare. On the basis of the information available to them, the report recommends that strong self-regulation through professional bodies is the best way to protect consumers and that a strong regulatoryframework, including such elements as those set out in the House of Lords Report, is the most desirablebasis for regulation. Suzanne CampbellResearcher to the National Working Group on the Regulation of Complementary Therapists August 2005 66

References 1. United States White House Commission on Complementary and Alternative Medicine Policy 2002 2. The Ministerial Advisory Committee on Complementary and Alternative Healthcare (MACCAH)Report 2004www.newhealth.govt.nz/maccah 3. The Regulation of Complementary and Alternative Health Care Practitioners: PolicyConsiderations, a report commissioned by Health Canada Health Human Resource StrategiesDivision, 2001 4. European Council for Classical Homeopathy Recognition and Regulation of Homeopathy inEurope. March 2005 -- draft 5. European Parliament, Report on Non-Conventional Medicine (Collins Resolution: Doc-En/PR/289/289543 PE216.066/fin) Strasbourg, European Parliament 6. COST Action B4 Unconventional Medicine. Final report of management committee 1993-1998(EUR 18420 EN) Luxembourg, office for the publication of the European Communities 7. www.ft.dk/Samling/20021/beslutningsforslagoversigtsformat /B47.htm 8. Legge Regioinale 24 Ottobre 2002, n.25. Regalomentazione delle practiche terapeutiche e deelediscip line non convenzionali 9. Lov am alternativ behandling av sykdom mv 10. www.eatcm.net European Association of Traditional Chinese Medicine 11. Project of law No.263/IX (for framing the base of Non-Conventional Medicines) and Project oflaw No.27/ IX Legal procedures of the Non Conventional Therapies 12. Regeringen proposition 2003/04:1. Budgetpropositionen for 2004. Forslag till statsbudget for 2004,finansplan, skattefragor och tillaggsbudget m.m 13. de Bruyn, T. 2000. Taking stock: Policy issues associated with complementary and alternative health care.A commissioned report for the Health Systems Division, Health Promotion and Programs Branch,Health Canada, March, 2000. 14. The Regulation of Complementary and Alternative Health Care Practitioners: PolicyConsiderations, a report commissioned by Health Canada Health Human Resource StrategiesDivision, 2001 15. Ethical and legal issues at the interface of complementary and conventional medicine. IanMcKerridge and John R McPhee Medical Journal of Australia 2004 67

APPENDIX V

Associations In Ireland, the complementary and alternative therapy community is a very disparate one with a broadrange of levels of expertise, training and level of association with other practitioners and/or internationalorganisations. In comparison to some countries, Ireland is at a slightly earlier stage of forming solidframeworks of associations and federations with which to link, and in some cases govern, the sector. In Ireland (as with many countries) it is frequently the case that alternative and complementary therapistspractise on a part-time basis, are not registered with any association or group and work in a non-businessorientated way. The basis of some therapies is the relationship between the therapist and the patientbeing healed; the economics of this transaction are not always as important. At the other end of the scale are groupings of therapists in clinics or with large numbers of clients orreferrals, therapists who practise on their own but on a full-time basis and who are active members of asingle association which governs or lobbies for their particular discipline. This variance is to be expected where the level of practice that individuals have is influenced by theamount of time they are prepared to dedicate to training, their commitment to continuing professionaldevelopment and/or earning from their expertise. Some associations point out that most of theirtherapists only use their therapy on family or friends and don't charge for their therapy. Others, at themuch more professionally organised end of the scale, have total reliance for income on their therapy anda high degree of involvement in one single therapy association. Many therapists concentrate on one single therapy while others practise as many as 18 different therapies(the most identified in this study) and offer a very diverse range of treatments. With this broad range ofdifferences in practice, one of the challenges for the complementary and alternative therapy communityis providing organisational or regulating frameworks that are inclusive for everyone.

Methodology For the purposes of this project, 63 groups were contacted by post or e-mail and more than 80 additionalindividuals and groups who had attended Department of Health and Children forums were also contactedby post. Each was asked for the following details:

-- Background on their association, why and when it was established, its purpose and goals

-- The number (and if possible) names of therapists that are members of the association

-- A note on training; what are the qualifications acceptable for membership of your associationand where these qualifications can be gained

-- What other associations or groups of members are active in your therapy in Ireland? 69

-- In terms of individuals we would like to hear from people who are practising single or multipletherapies, details of your qualifications, professional practice and membership of professionalbodies (if any)

-- We would also like to know the rates charged for treatments (if possible) [The full query letter is included at the end of this appendix along with the survey results.] The response to the questionnaire was mixed. Some groups did not make contact, despite follow upphone calls on three or more occasions. Some original contact details were inaccurate and so effortswere made to find someone in a group or association who would respond. Following this, the newcontact often failed to reply. Some organisations' contact people were abroad and others did not receivethe query letter in time from the former contact person. Most organisations were reluctant to forward names to the study and nearly all omitted the costs oftreatment. Some organisations responded with substantial information about their group but werereluctant to give membership numbers. When pushed, most submitted membership figures. It appearsthat the smaller groups were more reluctant to give membership figures as they felt that their membershipsize could result in them being left outside of future decision making processes. Some organisations gavegreat responses with a comprehensive breakdown of everything that was requested in the query letter. In Ireland, level of association falls into the following groups: 1. Associations representing one therapy only who are part of two or more associations representingtheir therapy e.g. Kinesiology Association of Ireland representing the Association of SystematicKinesiology in Ireland and Brain Gym Educational Kinesiology 2. Associations or registers established by a school and representing only those trained in a therapy attheir particular school, e.g. The Irish Reflexology Institute 3. Associations that are pan-therapy and represent therapists who may also be a member of anassociation for their own therapy, e.g. Complementary Therapy Association of Ireland 4. Federations i.e. groups representing single therapy associations e.g. Yoga Federation of Ireland orthe National Herbal Council, or groups representing associations encompassing many therapiese.g. FICTA. In Ireland the associations in Group 1 are the most common. Single representative bodies for a therapyare unknown. There are four associations in Group 3 representing many therapies namely -- IrishAssociation of Holistic Therapies, Association of Registered Complementary Health Therapists ofIreland, Complementary Therapy Association of Ireland and Association of Holistic Therapies. In Group4 there are three federations representing associations for a particular therapy i.e. -- Yoga Federation ofIreland, National Herbal Council and Federation of Irish Reflexology Professional Bodies. From the research it follows that there are many factors affecting why therapists join particular bodies.Many therapists want to remain in contact with those in the same field as they often work on their ownand in some cases are geographically isolated. The idea of community is fostered by therapy associationswhose aims tend to fall into the same general terms:

-- To promote communication and exchange of expertise between members 70

-- To have an established code of ethics and training guidelines

-- To promote the benefits of the therapy and to offer continuing professional development

-- To offer newsletters and/or email communications of events and research to members

-- To provide a directory or website of accredited practitioners to facilitate the public Some practitioners become registered with the register or organisation that is based around their collegeor training association. Some therapists leave their initial association because of personal differences withthose in charge of their original association. One common situation that was mentioned frequently is the predicament of therapists who practisemore than one therapy. Some of them are members of several associations while others have joined thepan-therapy associations which are The Association of Registered Complementary Health Therapists ofIreland (ARCHII), established in 1999 and the Complementary Therapy Association of Ireland (CTA),established in 2004. The cost of joining and paying yearly membership to several associations is a factor in the establishmentof these pan-therapy groups. To some therapists it is more attractive to pay one single membership feeeach year and to have an involvement with one single association rather then pay for membership andhave to attend meetings etc. of several associations. At present, these pan-therapy groups are at an earlystage of development and are not affiliated to each other or to FICTA. However, both have plans tolobby on the part of their members for better recognition and influence on the process of regulation oftherapists in Ireland. The price of insurance premiums is also a driver for therapists seeking membership of organisations. Oneof the pan-therapy groups indicated that since they began to offer an insurance policy on their website,75% of its membership queries are from people who are interested in joining the association to take upthe insurance offer. Another therapist said that the reason he left an Irish association to go to an Englishpan-therapy group was because the insurance premium with the English group (Embody) was lowerthan his professional association here.

Amalgamation/Federation There are quite large differences in the degree or openness to federation or amalgamation from groupsacross the complementary and alternative therapy community. Most associations tend to operate on their own but have an awareness of others working in their sector.Many have a positive attitude to integration, amalgamation or federation of groups within their therapy.In opposition to this, some associations were formed by a group of therapists that has left anotherorganisation and formed their own association. These groups tend to have negative attitudes to joiningwith the former association in any capacity. In terms of associations which represent a single therapy, there were many reasons stated for reluctanceto join several groups in their sector into one single association. The main differences arise over accepted standards of training and education. This is a common difficultyin that some associations don't recognise the standards accepted by other groups in their field. Some feltthat their association could not join with another as it was affiliated to a European body with a sharedstandard that was above those standards accepted by other associations in its field. For example, one 71association's governing European body insists that all practitioners hold a primary degree which was notdemanded by other associations representing the same field. Therefore this association felt that it wasdifficult to join with other Irish associations as it would lower the standard of their practitioners. Likewise, some groups were subject to a U.K. standard and had difficulties accepting practitioners trainedin Ireland under what they felt were lower standards. However, there is an awareness generally that a more cohesive structure is desirable and more beneficialto therapists in the long term. Many felt that a federated structure of one umbrella association in eachtherapy with others affiliated to it is more attractive than a complete amalgamation of the presentassociations in their field. Many groups who discussed this issue wish to stay autonomous; they felt that in a federated system thebigger groups can dictate to the smaller groups and drive policy their way. One therapy group reportedthat when trying to get a federation structure off the ground there were basic logistical issues such as thefact that representatives of other groups didn't always turn up to meetings to move the process along,and not all groups in their therapy were interested in a federated body. In short, in some cases there isan openness to a federated structure within their field, it is often simply a matter of needing the incentiveto do so. Some associations are open to amalgamation but feel that sometimes this is driven by a larger group orfederation who is more dominant in their field. They are reluctant to become ``swallowed'' by a largergroup already in existence, whose structure and membership would become the dominant frameworkof the new group. Broadly they would be amenable to amalgamation provided it was conducted on abasis of equality and that one single group (or more than one) would not take charge at the expenseof others. There is also overlap between associations and registers offered by schools; for example, the NationalRegister of Reflexologists has twelve accredited schools on its register. One of these schools, The NaturalHealing Centre in Cork, runs its own register of therapists (The National Healing Institute) which coversa range of therapies including reflexology. In some ways, it is understandable why therapists might beconfused about the benefits of joining an association, or which one is the best choice to represent theirinterests. Many simply practise on their own and are happy to remain outside a group where they seeno benefit to joining it. This idea of incentive is an important point to remember as a factor in futureregistration or regulation of therapists. The following are the therapy associations in Ireland who have moved or are moving towards a degreeof amalgamation/federation:

-- Bio-energy Therapists Association is a member of FICTA and formed from two separate groupsin 2003

-- The IMTA have made attempts at bringing the other physical therapy groups together. In2004, the Irish and International Aromatherapy Association joined with them and the IMTAis in talks with the Natural Healing Institute for possible joining up in the near future

-- The Federation of Irish Reflexology Bodies comprises three groups [The Association of IrishReflexologists, The Irish Reflexology Institute and the National Register of Reflexologists]

-- Five of the herbal groups are working to form a herbal council, with a herbal register. Atpresent, it is more of a steering group who are in the process of agreeing common standards,and a lobbying position. These groups are 72

-- The Irish Medical Herbalists Association

-- The Irish Association of Master and Medical Herbalists

-- The Irish Register of Chinese and Herbal Medicine

-- The Association of Chinese Herbalists in Ireland

-- The Irish Herbal Association There are two Herbal Associations who exist outside this process.

-- The Yoga Federation of Ireland is an umbrella group with:

-- Yoga Therapy Ireland

-- Contemporary Yoga (Cork)

-- Yoga Fellowship of Northern Ireland

-- Galway Yoga Centre

-- Aurolab Project (Offaly)

-- ViniYoga Ireland is an Associate Member Three other yoga associations operate outside of the Federation In conclusion, while the community of therapists involved in complementary and alternative therapiesis a disparate one, there are some moves to provide uniformity in terms of establishing single professionalbodies. This process is going to be quicker in some therapy associations than in others, but this studyfound an increasing awareness of the benefits of working towards more cohesiveness within therapygroups. Suzanne CampbellResearcher to the National Working Group on the Regulation of Complementary TherapistsAugust 2005 73

Letter sent to associations and individuals in the complementary andalternative therapy community On behalf of the National Working Group on the Regulation of Complementary Therapists, I amcompiling statistics on the complementary and alternative therapy sector in Ireland. To enable the group to carry out this function, we would like to hear from therapists and/or associationsactive in this field. The information we are seeking regarding associations is:

-- Background on the association, why and when it was established, purpose etc.

-- The number (and if possible) names of therapists that are members of the association -- A noteon training; what are the qualifications acceptable for membership of your association andwhere these qualifications can be gained.

-- What other associations or groups of members are active in your therapy in Ireland? In termsof individuals we would like to hear from people who are practising single or multiple therapies,details of your qualifications, professional practice and membership of professional bodies (ifany). We would also like to know the rates charged for treatments. This information will remain confidentialand the names, qualifications or rates for treatment will not be published in the report. The purpose ofgathering these statistics is to collate an accurate picture of the complementary and alternative therapysector in Ireland, and most importantly, to find how many individuals and associations are active in it.Relevant research on the efficacy of your therapy which you feel might be useful for the report can besent my way, or any pointers which you feel are relevant to a description of what is happening in termsof new developments or projects in your area. I would appreciate it if you could send this informationto me as soon as possible. The gathering of statistics for the report is to be completed in five weeks timeso it is vital that people contact us soon. Thanking you in advance. Sincerely Suzanne CampbellProject Manager, National Working Group for the Regulation of Complementary Therapists. 74

List of Associations with notes on membership and educationalstandards

Federations The Federation of Irish FICTA -- 25 Complementary Therapy associations, 3 Associations affiliated members

Pan-Therapy Groups Irish Association of Offers diploma awards 300 members Holistic Therapies in various therapies practising various using City and Guilds therapy groups qualifications and IrishYoga Groupqualifications. Association of Registered www.Complementary Complementary Health therapists.org Therapists of Ireland(ARCHII) Complementary Therapy The CTA aims to Members are qualified 12 members Association of Ireland affiliate with the in various therapies. (CTA) (est. 2004) BritishComplementaryMedicine Association(BCMA) Association of Holistic founded in 1986 to www.taht.ie 60 members Therapies represent graduatesfrom the College ofHolistic Therapieswhich givesqualifications inseveral therapies. Ithas recently becomeITEC registered andplans to offer ITECcourses

Associations

Acupuncture The Acupuncture and 170 members Chinese MedicineAssociation* The Association of Irish Members must have 115 members Acupuncturists* completed a 3yrcourse with not lessthan 1250 trainingcontact hours Acupuncture FoundationProfessional Association* The Professional Register 36 members of Traditional ChineseMedicine (PRTCM) *[all three moving to amalgamation by end 2005, early 2006] 75

Amatsu Amatsu Association ofIreland

Ayurvedic Medicine Mary Daly

Bio-Energy Bio-Energy Therapists Therapists must have 16 members Association; BETA a diploma in Bio-Energy therapy

Bio Testing and Therapy Bio Testing and Therapy Offers basic course of 89 members, 20 International 5 days and an associate members advanced course of 5days.

Bowen Therapy Accredited Bowen www.bowenireland.com 32 members across Therapists of Ireland 32 counties

Cranio Sacral Therapy Irish Association of Training is provided www.upledgerireland.com They have 500 Cranio Sacral Therapy by the Upledger therapists practising Institute which is an in Ireland international body.

Endorphin Release Endorphin Release The only centre Clinics Ltd. offering this therapyand training oftherapists 76

Herbal Groups The associations marked with an asterisk are affiliated to the National Herbal Council. Professional Register of 8 members on its Traditional Chinese register of herbal Herbal Medicine medicinepractitioners Irish Register of ChineseHerbal Medicine* Irish Association of Masterand Medical Herbalists* Association of ChineseHerbalists of Ireland* Irish Herbal Register* Irish Medical Herbalists Must be graduates of 12 members Association* colleges accredited bythe National Instituteof Medical Herbalistswith a minimum ofthree years training

Homeopaths The Irish Society of 3 schools in Ireland 390 members Homeopaths teaching over a fouryear period,application made toHETAC for degreestatus Institute of ComplexHomeopathy

Healing (multi-discipline) The National Healing Based at the National Member training 113 members Institute (NHII) Healing Clinic and school of the British Training School in Complementary Cork. Medicine Association.Graduates can jointhe Institute'sAssociation, NationalRegister ofReflexologists orIMTA 77

Indian Head Massage Ayurvedic bodyworkconsortium

Kinesiology Kinesiology Association of Does not provide Professional Ireland training, members members 86, others must have 120 hours 30 training fromaccredited courses Association of Systematic Affiliate to ASK in Professional Kinesiology in Ireland the UK, offer a two members 32, year part time student members diploma course 18, associate 14 Brain Gym Educational 13 practising Kinesiology members withqualificationsgained over 360hours Professional Register ofthe Kinesiology Collegeof Ireland PRKCI

Manual Lymph Drainage MLD Ireland Registered therapists 16 full members must have completedtraining in nursing,physiotherapy,physical therapy ormassage therapy.Following this theymust complete a basiccourse in MLD of 40hours, followed byTherapy 1 (48 hours)and Therapy 2 and 3(80 hours). Studentsare then certified asMLD therapists

Massage Irish Massage Therapists 750 members, also Association includesaromatherapists 78

Neuromuscular Therapy Association of The association offers 892 members Neuromuscular Therapists membership to (ANMT) graduates of theNational TrainingCentre inNeuromuscularTherapy

Mind Therapies Irish Institute of Members undergo a 70 members Counseling and three year part time Hypnotherapy diploma with externalassessment from Cityand Guilds in the UK Institute of Clinical Offers training courses www. hypnosiseire.com 284 members Hypnotherapy & up to higher diploma Psychotherapy level Association for Neuro 20 members. Lingustic Programming Neuro-Developmental Neuro- Circa 20 therapists Therapy Ireland Developmental Delay are in part time or Therapy clinic was full time practice. opened in the early Circa 400 1990's professionals aretrained to use thework within theirown profession. Association of Neuro-Developmental Therapy

Naturopathy The Association of Colleges in Cork, Over 100 members Naturopathic Practitioners Limerick, Galway andDublin. The Collegeof NaturopathicMedicine has appliedto HETAC forapplying the award ofBachelors Degree totheir Naturopathicprogramme Naturopathic Society of 50 members Ireland 79

Nutritional Therapy Professional Body -- the Diploma and Degree Contact -Director of Irish British Association for courses available in Institute of Nutrition and Nutritional Therapy the UK, Irish Institute Health. (IINH,is a recognised www.iinh.net) teaching body forNT; awards a diplomain NutritionalTherapy in a 3 yearpart time course

Physical Therapy The Irish Association of 120 members Physical Therapy Irish Institute of PhysicalTherapies

Reiki Reiki Association of Some members do Members must have www. 100 members Ireland not have public completed Reiki 1 to reikiassociationireland. practise and just join. com practise for the benefitof family and friends. Reiki Federation Ireland. ???(163) (F)????

Re-birthing Psychotherapy Re-birthing No training courses www.rebirthing.ie 8 members Psychotherapy currently in Ireland Association. which are of asufficient length toqualify people for thisassociation 80

Reflexology Federation of IrishReflexology ProfessionalBodies* The Association of Irish Members must have 40 members Reflexologists* completed a course ofat least 100 hrsteaching time spreadover a 12 monthperiod. Irish Reflexologists Members must have www.reflexology.ie 1300 members Institute* completed a course of with 20 accredited at least 120 hours reflexology schools National Register of 412 members, has Reflexologists 12 accreditedschools Association of ClinicalReflexologists * Those marked with an asterix have federated

Scenar Scenar Practioners Society www.scenrtherapyireland. of Ireland com

Seichem (now disbanded) Irish Seichem Association

Shen SHEN Association Ireland 12 members

Shiatsu Shiatsu Society of Ireland Affiliated to the Three schools in 33 professional European Shiatsu Republic and one in members Society Belfast. Three yearspart time professionalcourse

Tai-Chi Tai-Chi Association. Affiliated to the IrishMartial ArtsAssociation 81

Tibetan Medicine Tara Institute of TibetanMedicine

Yoga Irish Yoga Association. Members of the Runs teacher training www.iya.ie 214 members European Union of courses; 621 hours Yoga (EUY) over four years. Yoga Society Ireland. (F) trains teachers and 250 members most membershipcomes from studentsthey have trained. Yoga Therapy Ireland & Umbrella group for Standard training www. yogatherapyireland. Over 600 members Yoga Federation of five Yoga training course is a minumum com Ireland (F) organisations of two years with throughout Ireland compulsory COPDCurrently putting aproposal together forHETAC Harmony Yoga Ireland* 82

APPENDIX VI

Training Standards

1.

Training standards agreed by the Herbal Council, now comprising 5discrete registers and therefore the majority of trained herbalists inthe State:

Accreditation & Training The minimum requirements for membership in respect of the National Herbal Council are as follows: The training curriculum for all traditions of Herbal Medicine must include the following:--

Human Sciences 250 Hours of lectures and study time in those aspects of normal Anatomy, Physiology and biochemistrythat are essential to understanding the causes, mechanisms, diagnosis and clinical features of disease asunderstood by biomedicine.

Nutrition 80 hours of lectures and study time to comprehensively understand the foundations of nutrition and dietas a means for the maintenance of good health and treating disease. Included in this would be anunderstanding of the effects of food and diet on specific body systems and disease processes whilstunderscoring the holistic aspects of this type of approach. To provide a perspective on the possible interactions between foods, herb supplements and drugs, withan emphasis being placed on the safe limitations of their usage including nutrient/drug/herb and foodinteractions. To allow the herbalist and related practitioners to use an understanding of nutrition as an essential partof their existing discipline.

Clinical Sciences 350 hours of lectures and study aimed at outlining the common diseases, their causes, mechanisms,clinical features and diagnosis. Training and experience in case-history taking and physical examination. Training to enable students to develop an understanding of the limits of their own medical capabilitiesand thereby enhance the skills of appropriate referral. 83To provide practitioners with a foundation from which to compare and contrast this knowledge withtheir own approach to medicine and to communicate effectively with practitioners of conventionalmedicine.

Plant Chemistry and Pharmacology 80 hours of lectures and study time to ensure that herbal medicine practitioners are familiar with themain chemical constituents of the most common herbs, the effects they have on the human body, andtheir reactions with orthodox drugs.

Pharmacognosy and Dispensing 80 hours of lectures, study time to ensure the safety of herbal practice by enabling herbalists to evaluatequality control and quality-assurance processes for herbal medicines. To ensure a good understanding of the processes by which herbal medicines are grown, harvested, storedand processed. To enable herbalists to read and evaluate technical material published on herbal medicines inpharmacopoeias, monographs etc. To teach the legal requirements relating to herbal practice. To teach the necessary skills for the running of a herbal dispensary.

Practitioner Development and Ethics 40 hours of lectures, study time to enable practitioner self-development leading to effectivecommunication (including listening and counselling skills, and empathy) within the therapeuticrelationship, and within their professional lives as a whole, e.g. in liaising with GPs, etc. To support the development of reflective practice -- the practitioner as a life-long learner; and anunderstanding of how personal and psychological factors influence the therapeutic relationship. To provide practitioners with the ethical, legal and professional foundations of good practice, enablingthem to apply these principles appropriately.

Practitioner Research 80 hours of lectures and study time to enable practitioners of herbal medicine to develop an orientationtowards continuous professional development, recognising that learning is a life-long process, and thatpart of this process is concerned with the ability to frame enquiry within the context of personal practice,reflecting and analysing in a systematic and critical way. To introduce the principles and practice of research as a system and critical process of enquiry in thecontext of health care in general and herbal medicine in particular.

Tradition Specific Training 1,000 hours of lectures, study time and clinical training within the theoretical and practice frameworkof the specific herbal tradition such as Ayurvedic, Chinese, Tibetan and Western Herbal medicine.

Clinical Practice 450 hours under the supervision of an experienced herbal practitioner(s), including developing a herbal-medicine treatment strategy, dispensing herbal medicines, dispensary management, health and safetyaspects and practitioner development issues. 84

2.

Reiki Practitioner Module Please note that the following recommendations presented by Reiki Federation Ireland are currently awork in progress and not the finalised recommendations. The Practitioner Module will be presented to RFI members at the next AGM -- 25 th March 2006 for approval.

Reiki Practitioner Module

Reiki Reiki is an ancient non-intrusive complementary therapy. As hands on healing energy technique, Reikienhances the body's own innate natural ability to heal itself on all levels. Reiki complements conventionalmedicine. It has no major side effects or contraindications. Recommended Supervised Minimum Training Hours: 100 The complete module for Reiki Practitioner would include:

-- Reiki Level One

-- Reiki Level Two

-- Duty of Client Care

-- Professional Conduct

-- Clinical Practice

-- Membership of Professional Body

-- Anatomy & Physiology

-- First Aid

-- Business Awareness

-- Continual Personal Development

-- Review of Case Studies Non Supervised -- Student Hours

-- Reiki Level One -- 10 12 hours

-- Reiki Level Two -- 10 12 hours

-- Case Studies -- 20 Hours minimum 85

FIRST LEVEL REIKI TRAINING

· Definition of Reiki

· How Reiki actually works

· The benefits of Reiki

· History of Reiki

· The Reiki Principles

· Receiving First Level Reiki

· Meditation/visualization

· Teaching and practice of Reiki hand positions for self-healing, chair treatment, and lying ona plinth

· With regard to hand positions it must be emphasised to students that the genital and breastareas are not physically touched and that clients remain clothed while receiving Reiki

· Each student to practice giving and receiving Reiki

· Explanation of the energetic systems of the body including the aura, chakras and endocrinesystems

· Teacher emphasize importance of using Reiki self healing every day

· Opportunities for students to share workshop experience

· Teachers must make students fully aware of the possible effects during and after a Reikitreatment

· The ethical use of Reiki in the student's life is emphasized

· Course manual to be given

· Certification of First Level Reiki to be given

· Brief introduction to the various levels of Reiki

· Suggested reading list

· Overview of RFI and information on joining RFI

· Teaching on the integration of Reiki energy and possible experiences following the ReikiOne workshop

· Teaching of the importance of personal energy management, self care and well being whilegiving Reiki 86

SECOND LEVEL REIKI TRAINING

· Revision of all aspects of Level One in detail

· Receiving of Second Level Reiki

· Meditation/visualization

· Sharing of experiences

· Teaching and practice of Reiki hand position for self-healing, chair treatment, and lying ona plinth

· With regard to hand positions it must be emphasised to students that the genital and breastarea is not physically touched and that clients remain clothed while receiving Reiki

· Each student to practice giving and receiving Reiki

· Sharing of feedback since first level workshop and the experience of using Reiki on self andfamily and friends

· Introduction to the Reiki Symbols

· Teaching the Reiki symbols and practice of them physically

· Explanation and practice of distant Reiki Healing and distant treatments

· Teacher emphasize importance of using Reiki self healing every day

· Opportunities for students to share workshop experience

· Teachers must make students fully aware of the possible effects during and after a Reikitreatment

· Course Manual to be given

· Second Level Certificate to be given

· Suggested reading list

· Teaching on the integration of Reiki energy following Reiki Two workshop

· If student is new to the Reiki Master/Teacher they must ensure that the First level ReikiCertificate is presented

· The ethical use of Reiki in the student's life is emphasised 87

Duty of Client Care

· Consultation Methods

· Boundaries

· Creating Client Consultation Forms

· Assessing Client Consultation Forms

· Greeting and briefing the client

· Client Record Keeping

· Consent to treatment -- (to include gaining consent from legal guardian)

· Explaining the Treatment To Client

· Helping onto and off the Plinth

· Ensuring client's comfort -- need to use supports, chest, head, knees etc.

· After Treatment Feedback and assessment

· Home Care Advise

· Referral Procedure -- GP, Counsellor etc.

· Understanding the Holistic Approach

· Knowledge and understanding of other complementary therapies.

· Client confidentiality

· Developing trust

Professional Conduct

· Code of Ethics and Conduct

· Boundaries for the Practitioner

· Communication Skills -- listening, feed back

· Confidentiality

· Working in Harmony/Respect and Professional Behaviour with other ComplementaryTherapists

· Working in Harmony/Respect and Professional Behaviour with Conventional MedicalPractitioners

· Hygiene -- personal, premises, plinth and equipment

· Professional appearance and conduct

· Never using `hands on' technique over the genital and breast area

· Reiki is a fully clothed treatment

· Client relationships

· Diagnosis -- The Reiki Practitioner must never diagnose 88

Clinical Practice

· Treatment Procedure

· Length of Treatment

· Course of Treatments

· Treatment procedure for babies, young children and elderly

· Knowledge of other holistic therapies and how they work

· Referral Procedure

· Full Treatments given by each student; observed, supervised and discussed

· Introduction to Case Studies

· Clinical Supervision -- to avail of ongoing supervision as required

· Respect

· Non discrimination

· Non judgement

· Therapy Room preparation to include: Heating, Lighting, Atmosphere, Security, Outsideinterference, Appropriate Music

· Possible Reactions: people may experience an emotional release, detoxification symptoms,increased need for sleep, relaxation.

· Contraindications -- Do not perform a Reiki Healing if the client or Reiki Practitioner isunder the influence of alcohol or mind altering substances.

· Special Recommendations -- To assess and make decisions as to the suitability of treating aclient suffering with an Acute Mental Psychotic Episode at the specific treatment time withspecial regard for the safety of the client and Reiki Practitioner.

· While Reiki is not contra-indicated to any medication we advise that clients' medicationmay need to be reassessed by their GP as Reiki can enhance the clients' rate of recovery.

Anatomy & Physiology Understanding of the structures being worked over and their function:

· The Cellular System

· The Skeletal System

· The Muscular System

· The Skin

· The Circulatory, Cardiovascular & Lymphatic Systems

· The Neurological System

· The Endocrine System

· The Respiratory System

· The Digestive System

· The Urinary System

· The Reproductive System

· The Nervous System 89

First Aid We recommend a recognised First Aid Certificate

· Contents of First Aid Box

· Teaching on how to deal with First Aid emergencies in professional practice

· Necessity for an accident book and its contents

· Correct first aid procedures for the following:

· Fainting

· Burns/scalds

· Epileptic fit

· Bleeding

· Hysteria

· Heart attack

· Unconsciousness

· Twisted ankle

· Asthma attack

· Diabetic coma

· Nose bleed

· Insect sting

· Hyperventilation

· Migraine

· Dizziness

· Recovery position

· Knowing how to call for medical assistance

· Types of fire fighting equipment required in the workplace

· CPR 90

Business Awareness

· Data Protection Act

· Child Protection Act

· Health & Safety

· Fire Prevention & Fire Regulations

· Insurance

· Appropriate Legislation applicable to Reiki (e.g. local authority)

· Registering and establishing a Business

· Types of Business -- Sole Trader, Partnership, Limited Company

· Home Visiting

· Tax Returns

· Legality of Keeping Accounts

· Bank Accounts

· VAT

· Marketing -- Leaflets, Flyers, Health Shows, Interviews

· Advertising -- Newspapers, Radio, Talks, Leaflets, Mail Shots, Word of Mouth

· Contract of Employment

· Presentation Skills

· Planning a talk,

· Costing & Pricing

· Room Preparation , atmosphere, temperature, lighting,

· Suitable Equipment

· Keeping Accounts- Including income, expenditure and VAT

· Scheduling appointments, telephone manner, Customer Service, Taking money andlogging payments

· Communication Skills

· Security -- Premises, confidential client records, equipment, stock, people 91

Membership of Professional Body

· Benefits

· Choosing a Professional Body

· Constitution

· Code of Ethics

· Grievance Procedure

Continual Personal Development Further training in personal development as a Holistic Therapist This may include:

· Further Holistic Training

· Personal study skills

· Knowledge and awareness of research in the complementary field

· Reiki share groups or workshops

· AGM's or events of Professional Bodies

· Workshops, Talks, Health Fairs

· Reading, Books, Videos, Audiotapes

· Selected events

· Further related educational training (computer skills, business skills, etc.)

· Avail of supervision made available by Reiki Master Teacher

Case Studies

· Consultation including thorough medical history and general lifestyle

· Client Consultation Form Review

· Client profile

· Evaluating and reviewing the Reiki treatment programme

· Recording client's feedback and experience as appropriate

· Effectiveness of treatment

· Details of how the therapist conducted the treatment

· Details of how the client felt during and after the treatment

· Details of home care advice given to client

· Overall conclusion of each case should be recorded

· Reflective Practice -- students should reflect on their own professional practice and learningoutcomes of the case study. 92

3.

Craniosacral Therapy

PROFESSIONAL TRAINING PROGRAMME (OCTOBER, 2005)

TRAINING PROGRAMME All course material is written by Dr John Upledger DO., O.M.M., founder of CranioSacralTherapy (CST) and SomatoEmotional Release (SER) and is subject to constant review. Current teaching formats are the result of development over a 20-year period. All Workshops are conductedby Upledger Institute Certified Instructors who are all practicing Healthcare Professionals and havecompleted intensive training programmes with the Institute. To meet the standards and objectives of the Irish Government Legislation, practitioners' work mustbe verifiable. As part of the training programme there will be study groups for the practitioners. Thepractitioners will share their written case histories with the study group leader. This will help witheach practitioner's understanding of the work and will show areas for further study. There will be adocumentary system that requires signatures to show that the work has been completed.

CONTINUED PROFESSIONAL DEVELOPMENT (CPD) Therapists are given many opportunities for on-going professional development.

· Become a Teaching Assistant at Upledger Institute Ireland Workshops

· Become a Certified Presenter of one-day Seminars

· Become a Certified Instructor for the Upledger Institute

· Attend official study groups, and become a leader of study groups

· Organise and participate in supervised intensive clinic treatment programmes

THE IRISH ASSOCIATION FOR CRANIOSACRAL THERAPY (IACST) IACST exists to promote Cranio Sacral Therapy, for YOU. It obtains preferential insurance rates.IACST works with the Federation of Irish Complementary Therapists Association (FICTA). FICTAworks with the government and represents the Practitioner professional body. IACST represents YOUR professional interests. www.iacst.com (Web) E-mail: michael.j.ward@usermail.com (Secretary)

NEW SYLLABUS -- HOURS CRANIOSACRAL THERAPY 1 28 Home Study CST 1 84 Practice Hours 70 Study Groups 28 Personal Therapy 20 Anatomy & Physiology & Pathology 50 A & P & P Module Home Study 100 93Anatomy & Physiology can be taken with a school of your choice but it MUST be approved by theUPLEDGER INSTITUTE IRELAND. We can recommend the name of an Instructor nearest towhere you live. CRANIOSACRAL THERAPY 11 28 Home Study 84 Case Studies 32 Study Groups/Preceptorship 28 Personal Therapy 10 Professional Standards/Procedures 50 Professional Standards/Procedures Module Home Study 100 Before carrying out your practice of CST it is necessary to be covered by insurance. This can be donethrough the IACST which offers a discount rate for group insurance. For your own protection it isimportant to know that it is a LEGAL requirement, when working with a child under the age of 16years, that a PARENT or GUARDIAN, MUST be present at ALL times.

TECHNIQUES EXAMINATION At this point you are eligible to take the Upledger Techniques Examination. For information on thisplease contact the Upledger Institute Ireland. After successful completion of the TechniquesCertification Programme, a practitioner is CST-T. Cranio Sacral Therapist, TechniquesCertified. SOMATOEMOTIONAL RELEASE 1 28 Home Study 84 Case Studies 16 Study Groups/Preceptorship 16 Personal Therapy 10 SER 1 is open to non-Upledger trained students who have studied CST with other organisations thatwish to skip CS1 and CS11. Proof of substantial CST training in CS1 and CS11 is required, youwould then be eligible to attend a special 4 day course that combines CS1 and CS11 review. PAEDIATRICS 32 Home Study 96 Case Studies 10 Study Groups/Preceptorship 20 Clinical Supervision 20 To enable you to work with babies from birth to 4 years, it is a requirement to attend this coursewhich can be taken after SER1. 94SOMATOEMOTIONAL RELEASE 11 32 Home Study 96 Case Studies 16 Study Groups/Preceptorship 16 Personal Therapy 10 ADVANCED (ADV) 1 60 Home Study 120 Personal Intensives 10 Total hours (Excluding Paediatrics) 1226

DIPLOMATE CERTIFICATION A second level of certification is available after attending SomatoEmotional Release , SomatoEmotional Release 11 and Advanced. For information on the Advanced seminar and Diplomate Certification, please contact the Upledger Institute Ireland.After successful completion of the Diplomate Certification Programme, a practitioner is CST-D.CranioSacral Therapist, Diplomate Certified. Note: The workshops involve continual assessment of the participants by the instructor and teachingassistants. For a participant's benefit, he/she may be asked to repeat a workshop (at a reduced rate) ifit is felt that extra help is needed to fully grasp the concepts and techniques in the seminar.

GRANDPARENTING CLAUSE From August 1 st 2005, the `new' syllabus applies for all training students. Those in active practice as CST/SER for 5 years and more, have reached Advanced 1 level, certifiable, will not be required toretake any Upledger course training already completed. Those mentioned practitioners will berequired, in certain cases, to complete approved bridging courses e.g. a relevant module such asAnatomy, Physiology; module on professional practice and procedures. There is a period of 2 years from August 1st 2005 when upgrading as appropriate will be completed(refer to IACST). Ongoing continued professional development (CPD is a requirement for allpractitioners. CPD is built in to the Upledger training programme e.g. Training Assistant (T/A) orCST 1, CST11 etc. (refer to UI Ireland). Approved external CPD training is also accessible (referto IACST). 95

APPENDIX VII

Codes of Ethics

1.

Irish Institute of Counselling and Hypnotherapy

Introduction The purpose of this document is to define the general code of ethics and practice for IICH members.This code is based upon a set of philosophical principles which are detailed later in this paper and whichare drawn from the European charter defining documents. Organisational and individual members are bound to adhere to the code of ethics and practice detailedin Appendix A. The IICH code of ethics and practice is a controlled document bound to the articles ofassociation of the IICH.

Definitions Therapist: a person offering a therapeutic service to a client within the IICH definition of counsellingand hypnotherapy, who has the levels of skill and training specified by standards laid down by the IICH. Client: a person, couple, family, group or organisation seeking help through a therapeutic relationship. Therapeutic Relationship: an explicit agreed and formally contracted professional relationship betweenthe therapist and client/s.

Philosophical Principles The core values of the therapist are based upon respect for human rights, individual and culturaldifferences. These values underpin a set of attitudes and skills which have regard for the integrity,authority and autonomy of the client. Respect is the unconditional acceptance of clients but not necessarily acceptance of all of the client'sbehaviour. Therapists have the responsibility to make themselves aware of individual and culturaldifferences. Integrity means the right of the client to maintain their physical and emotional boundaries and the rightto not be exploited in any way. Authority recognises that the responsibility for entering into and out off the therapeutic relationship isvested in the client. Autonomy realises the freedom of the client to express themself, as they see fit, within their own modelof actualization, with an unbiased attitude towards the client's beliefs and culture. 97Privacy means that there must be no un-contracted observation of the therapeutic relationship, nor mustthere be allowed any inappropriate observation, interference or intrusion by a third party. Confidentiality respects that any personal information shared between client and therapist during thetherapeutic process remain undisclosed and that the therapist, further undertakes to maintain any writtenrecords pertaining to the therapeutic process in such a way as to prevent inappropriate disclosure tothird parties. Responsibility requires that the therapist ensure strict adherence to the philosophical principles outlinedabove and conduct themselves in a professional manner consistent with the IICH Code of Ethics andPractice as detailed in Appendix A. Competence is the requirement of the therapist to ensure, at all times, that they maintain the highestquality of standards in their practice. Therapists should only provide services and use only thosetechniques for which they are qualified by dint of education, training or experience. The IICH is determined that its members shall be aware of, and conduct themselves at all times, to thestandards of the Code of Ethics and Practice. Deviations from the Code of Ethics and Practice notifiedto the IICH will be investigated as defined by the Disciplinary Procedure of the IICH. In cases wherethere exists an ethical conflict the therapist is bound to take a position that reflects the greatest good andleast harm to the client and other third parties, with due respect to the common law of the State. Members of the IICH are required to present any ethical conflicts they may encounter to their clinicalsupervisor and the sitting standards committee. In these presentations the privacy and confidential natureof the therapeutic relationship is required to be maintained and may only be discussed in the third party. 98

Appendix A

The Code of Ethics and Practice of the Irish Institute of Counselling

and Hypnotherapy 1. To establish and maintain standards of competence and integrity among members. 2. To respect the client's model of the world and to avoid imposing the therapist's values on the client. 3. To maintain the confidentiality of the client at all times, except where doing so would endangerthe life or health of the client. 4. To accept that clients possess within themselves the resources needed for change. 5. To take responsibility for maintaining a high standard of competence, pursuing on-going trainingand courses of study and to maintain regular contact with colleagues and supervisors forconsultation. 6. To be aware of the limits of their own competence and skills and, where necessary, refer clientsto more suitably qualified persons. 7. To take care not to misrepresent their qualifications or level of competence 8. To refrain from practice if their judgement is impaired due to drugs, illness, stress. 9. To establish a boundary between a therapeutic or working relationship and a personal relationshipand, where necessary, to make this boundary clear to the client. 10. To use hypnosis for therapeutic and/or training purposes only, and disassociate themselves fromthe use of hypnosis for entertainment. 99

2.

Irish Massage Therapist Association

CODE OF ETHICS AND PRACTICEIRISH MASSAGE THERPAIST ASSOCATION

Code of Ethics and Practice

· This code applies to registered members of the I.M.T. A. Its purpose is to establish and maintainstandards for the practice of massage therapy, and to inform and protect members of the publicseeking massage therapy treatment.

1

THE DUTIES These are the general principles that therapists need to observe in order to responsibly fulfil their calling.To ignore these would imply a lack of regard for the needs of the patient and the reputation of massagetherapy and the Irish Massage Therapy Association. 1.1 In general, members should endeavour to act in such a manner as to: Inspire public trust andconfidence, uphold and enhance the good standing and reputation of the massage therapy professionand above all safeguard the interests of the client. 1.2 Members' professional conduct towards their client is respectful of the dignity and integrity of theindividual, as a whole person, their beliefs and values must be taken into account; empathy, care,trust and confidentiality are characteristics of a professional massage therapist. 1.3 A therapist should practice their profession with integrity and dignity. 1.4 The highest standards must be maintained in conduct, the care of the client and professionalexpertise. 1.5 The therapist owes loyalty to their client and should have regard for their wishes. 1001.6 The therapist should not exploit their clients emotionally, physically, sexually or financially. 1.7 The therapist should neither claim nor guarantee to cure, nor should they prescribe medication. 1.8 Essential oils should not be introduced or prescribed by the therapies unless qualified to do so. 1.9 Members' certificates and fee scale should be clearly displayed. 1.10 If a client is currently receiving medical treatment for a specific condition liaison between practitioner and the clients medical professional is advised.

2

THE OBLIGATIONS These are the restrictions and regulations, which the association must impose upon its members for legaland professional reasons.

THE THERAPIST IS REQUIRED 2.1 To comply with the law of the state or territory where the therapist practices. 2.2 To advise the Secretary of the Association immediately in the event of any police or governmental(including local government) inquiry into their practice. 2.3 To secure and maintain full indemnity insurance. 2.4 Not to treat or make a physical examination of a child under 16, except in the presence of a parentor guardian. 2.5 Not to disclose any information about a patient which comes to them through their professionalrelationship with the patient, except: (a) Where required to do so by rule of law; or (b) In an emergency or other dangerous situation where, in the opinion of the therapist, the information may assist in the prevention of possible injury to the client or to another person; or (b) Where the client has consented to the mature and the extent of the disclosure.

3

CONDUCT 3.1 A therapist shall keep full records of all treatments of clients, including the following details; (a) Name, address, telephone number and date of birth and contact no. (b) Essential details of medical history. 101(c) Dates of treatments. (d) Details of treatments 3.2 On deciding to retire or move practice, a therapist must inform all clients of their intentions to doso and of any arrangements being made for the transfer of the practice to another therapist. It isrecommended that records should be kept for a minimum of five years. 3.3 A therapist may not in public nor to a client disparage or speak disrespectfully of a fellow therapist. 3.4 Where a therapist has good reason to believe a fellow therapist has committed misconduct or hasany complaint whatsoever about them a confidential report should be made to the Irish MassageTherapist Association and the therapist concerned will be informed by the Secretary.

GENERAL 3.4 Dress should be clean and appropriate for the professional practice of a Massage Therapist 3.5 Premises should be of a professional standard and should be kept, along with all equipment, in aserviceable and hygienic condition.

4

ADJUDICATION The Executive Committee of the Association sitting as a professional purpose subcommittee shall adviseupon conduct and adjudicate upon matters concerning the skill, competence, qualification and conductof Massage Therapist on the register. 4.1 The executive committee shall make a ruling. 42. An appeal may be made to the committee, following which; the decision is final and binding. Breach of Code of Ethics shall invalidate membership of the Irish Massage TherapistAssociation. Amended August 2000. 102

3.

ACUPUNCTURE FOUNDATION PROFESSIONAL SOCIETY

AFPA Code of Ethics RULE ONE Members shall comply at all times with the The requirements of the Codes of Ethics and Practice. By accepting membership of the organisation, members agree to abide by all terms andconditions of membership, and agree to accept sanction in the event of a breach of the Codes. RULE TWO Members shall at all times conduct themselves in an honourable manner in their relations with their patients, the public, and with other members of the Organisation. RULE THREE No member may advertise or allow his or her name to be advertised in any way, except in the form laid down by the Organisation. See Advertising format. RULE FOUR Members shall not give formal courses of instruction in any TCM therapy without the approval of the Organisation. RULE FIVE It is required that members apply the foregoing Code to all their professional activities. RULE SIX Infringement of the Ethical Code renders members liable to disciplinary action with subsequent loss of privileges and benefits of the Organisation.

RULE ONE

Members shall comply at all times with the requirements of the Code of Practice They shall thoroughly familiarise themselves with the contents of the Codes of Ethics and of Practiceand any amendments made to the codes, and ensure that their premises meet the required standards.Any member who requires advice or help in meeting the requirements of the Code of Practice isencouraged to contact the Council of the Organisation which will offer every possible assistance. Local authority bye-laws in his or her area under Part V111 of the Local Government (MiscellaneousProvisions) Act; or any similar Local Authority Act; or

U.K. and N.I. Members Members are reminded that under Part V111 of the Local Government (Miscellaneous Provisions) Act1982 and the other Private Acts, Local Authorities in England and Wales are empowered to require theregistration of acupuncturists and their premises, and to introduce bye-laws and inspection proceduresto ensure the cleanliness of the practice and the sterility of instruments. Where such bye-laws areintroduced, they will apply to all practitioners in the area concerned, regardless of when they establishedthemselves in practice or what qualifications they possess.

RULE TWO Members shall at all times conduct themselves in a professional and ethical manner in their relations withtheir patients, the public, and with other members of the Organisation.

A. Member's obligations to their patients Member's obligations to their patients are governed by the contractual relationship between them.Members owe their patients a duty to act with reasonable care in accordance with the standards ofprofessional skill expected of an Acupuncturist and TCM Professional. 103

Professional and private life are indivisible The relationship between an acupuncturist and his patient is that of a professional with a client. Thepatient puts complete trust in a practitioner's integrity and it is the duty of the member not to abuse thistrust in any way. Proper moral conduct must always be paramount in member's relations with patients.Members must act with consideration concerning fees and justification for treatment. Members must take care when explaining the procedures and treatment which they propose toadminister, and should recognise the patient's right to refuse treatment or ignore advice. For the purposes of `medical treatment' the consent of a parent or guardian in the case of a minor isa requirement. The practitioner will only offer treatment to patients within the bounds of practitioner competence, andif a practitioner is in doubt as to whether their ability is sufficient to offer the best treatment to theclient, that he consults with, or refers to a more senior colleague, or to a practitioner within a differenthealth care profession if it is in the client's best interest to do so. Members as practitioners will maintain a suitable dress code while treating clients. It is the duty of the member if he or she is away from the practice for any length of time to ensureadequate arrangements are made to enable patients to receive treatment. Members have an implicit duty, within the law, to keep all information concerning, and views formedabout, patients entirely confidential between the member and the patient concerned. The same level of confidence must be maintained by any person employed in the practice. This extendsto all information concerning the client or patient. Practitioners will keep confidential documents relating to clients locked at all times, and only releasethem to other healthcare professionals upon the receipt of written consent by the client. Members are warned not to assume that details of a wife's or husband's case should be discussed withthe other. The above ruling applies to all parties including next of kin and members should never allowa third person to be present unless it is with the express consent of the patient. Disclosure of any confidential information to a third person is only in order when all the followingrequirements are met:

-- Disclosure is in the patient's interest

-- It is done with the patient's knowledge and consent except when the patient is not in acondition to give this and a third person is in a position to be responsible for the patient'sinterests.

-- There is a real need for such information to be imparted, such as when a member considers acase should be referred to a colleague. The only exceptions to this principle of confidentialityare:

-- When the law requires the information to be divulged (see below, members obligationsto the Public). 104

-- When for reasons relating to the condition or treatment of a patient it is inappropriate toseek his consent, but is in the patient's own interest that confidentiality should be broken.

-- When the member reasonably considers that his or her duty to society at large takeprecedence. Members must ensure that they keep clear and comprehensive records of the treatment they administerto patients (see also Code of Practice, Appendix C). The use by a member of an illegal substance e.g. narcotics, or the misuse of or improper use of legal butaddictive substance e.g. alcohol is considered to be a breach of the Code of Ethics.

B.

Members Obligations to the Public

B.1

Disclosure of Information If members receive requests for the disclosure of confidential information they should first refer thematter to the Organisation for advice. If a member is asked in a Court of Law to disclose informationwhich he or she considers to be confidential, the member should ask the Court to take into considerationhis or her reasons for not wishing to divulge the information requested, i.e. on the grounds ofprofessional secrecy. If the Court nevertheless overrules this contention and requires disclosure of the information, themember may be in contempt of Court by refusing to disclose it, but if he or she does refuse, the Councilwill not hold the member in breach of this Code of Ethics. In cases where sensitive information is given to a practitioner, especially regarding activities of a possiblycriminal nature, members are strongly advised to take legal action and to consult the Committee beforedeciding how best to proceed.

B.2

Use of the title `Doctor' No member may use the title `Doctor' either directly or indirectly in such a way to imply that he orshe is a medical practitioner, or holds a doctorate unless that is the case.

C.

Members Obligations to other practitioners Though this Code of Ethics is of course applicable to members of the Organisation, in this section theterm `practitioners' includes all Complementary and Alternative Practitioners. It is against the interestsof the Organisation to have distrust or disputes between practitioners. Members shall at all times conductthemselves in a professional manner in their relations with other practitioners.

C.1.

Transfer of a patient Action taken by a member to persuade the patient of another practitioner or of his principal (If he orshe is employed as an assistant), or of a clinic in which he or she may be working, to patronise him orher is in all circumstances unethical and contravenes this Code of Ethics. In consequence it is advisablethat members should apply a clear and proper procedure when exchanging or referring patients or dealingwith the patients of other practitioners. When a member treats a patient of another practitioner (referred by the other or not) due to holiday,illness, or any other reason, the member should consider himself or herself to be under an obligation toencourage the patient to return to the original practitioner as soon as the practitioner can accept themback for treatment, and to inform the original practitioner as to which patients have been treated andthe treatment that has been given. 105In the same way, when a patient attends a second practitioner because the original practitioner has forany reason neglected to refer them or give them advice on where to go, the obligation on the secondpractitioner still remains the same. An exception to this may be if the original practitioner indicates thathe or she wishes otherwise. Any such attempt would, in the view of the Organisation, amount to soliciting the patient to accepttreatment when he or she had not specifically requested it and would therefore be constructed asunethical conduct. Where a patient transfers to another practitioner for any reason, e.g. change of location; all possible helpshould be afforded to the second practitioner if requested. If a patient chooses for personal reasons to transfer to another practitioner without the knowledge orrecommendation of the original practitioner, it would be advisable as a matter of courtesy for the secondpractitioner to inform the original practitioner before making any further arrangements, so that anyrelevant information may be exchanged.

C.2

Denigration No matter how justified a practitioner may feel in holding critical views of a colleagues competence orbehaviour, it is unprofessional and would be considered unethical that he or she should communicatesuch an opinion to a third party. Not only might such criticisms be considered unjustified or slanderous, but also it is contrary to goodpractice that the confidence of the public should be undermined because of personally held views. A member, to whom criticisms of a colleague's competence are communicated, whether he or she be amember of the Organisation or not, should at all times act with discretion and should himself expressno opinion. An exception to this is when a member needs to refer a complaint to the Organisation.

RULE THREE No member may advertise or allow his or her name to be advertised in any way, except in the formlaid down by the Council of the Organisation. See advertising format.

RULE FOUR Members shall not give formal courses of instruction in a Chinese Medical Therapy without approval ofthe Committee of the Organisation. The Council of the Organisation has no wish to impede the free flow of information between fullyqualified practitioners of acupuncture. Nevertheless, at a time when the major professional organisationsare making great efforts to standardise and improve the teaching of acupuncture in this country, it isundesirable that there should be an uncontrolled proliferation of courses, `colleges', etc; the spread ofwhich can only further confuse the general public as to the qualifications of acupuncturists practicingin Ireland. Lecturing to medical and paramedical groups and the public, in order that they may better understandthe work of the qualified acupuncturist, the scope of his or her services and overall role is perfectlyacceptable. The permitted scope of such lecturing is largely a matter of common sense in interpretingthese guidelines. However, such lectures should be strictly informational and should not be promotedor constructed as being `training' in the theories or techniques of acupuncture, or any TCM therapy. 106The training of an individual or individuals by a member in the techniques of acupuncture, herbalismor tuina without the express consent of the Committee of the Organisation is strictly forbidden. Theonly exceptions to this rule are:

-- Where the training is done by a member under the auspices of a teaching establishmentapproved by the Organisation.

-- Where the member is training other qualified practitioners of acupuncture and

-- The contents of the course have been vetted and approved by the the Organisation and

-- Completion of the courses does not lead to any qualifications, degrees, certificates; etc;apart from certificates of attendance, except where these have been approved by theCouncil of the Organisation. In this section the word `training' includes any lectures, demonstrations or study material given toindividuals with the implication that the satisfactory completion of said work will enable them to referto themselves as `Acupuncturist's', or lead them to believe that they will be qualified to practiceacupuncture on the general public. The above rules do not preclude the participation of students of acupuncture teaching establishmentsapproved by the Organisation as observers, and in so far as they are qualified, as assistants in a member'spractice. Whenever acupuncture students are permitted to participate in the work of a member, themember must ensure that:

· The teaching establishment where the student studies has been consulted and permissionobtained.

· The student is never allowed to perform any function, which he or she is not fully trained tocarry out.

· Where case taking is observed or confidential information is discussed, the consent of the patientis always obtained before allowing the student access to this.

RULE FIVE It is required that members apply the Codes to all their professional activities. A. Membership of other Professional OrganisationsMembers of the Organisation may belong to other organisations whose ethical standards may differ fromthose of the organisation. Such members must accept that their dual membership does not give themany immunity from the consequences of contravening the regulations of the Organisation, whethercontained in it's Memorandum and Articles of Association, this Code of Ethics or any rules, memoranda,recommendations or advice issued by the Committee of the Organisation for the conduct of it'smembers.

RULE SIX Infringement of the Ethical Code renders members liable to disciplinary action with subsequent loss ofprivileges and benefits of the Organisation. 107

APPENDIX VIII

Disciplinary and Grievance Procedures

Irish Society of Homeopaths

ARBITRATION AND DISCIPLINARY PROCEDURES 31. Failure by a Full Member to observe the provisions of either these presents or the Code of Ethicsof the Society or any other standards or regulations made by the Society may render them subjectto arbitration and/or disciplinary procedures, upon receipt of a complaint against them. 64. The Committee shall appoint one of its members to be the Arbitrator who shall be responsible forthe maintenance of standards within the Society and to investigate all complaints against FullMembers. 65. Complaints received by the Society concerning Full Members shall be referred to the Arbitratorand the member concerned and the Registrar shall be notified without delay of the fact that acomplaint has been made against them. 66. Enquiries into complaints must be made impartially by those involved and they shall conciliate,where possible, by frank discussion and exchange of letters. The Arbitrator shall endeavour toresolve the complaint where necessary in consultation with one other Committee member and/orspecialist advisors. The results of investigations and mediations shall be made known in writing toboth the complainant and the member involved, and a report made to the Committee. 67. Where conciliation has proved unsatisfactory or unacceptable to any of the parties involved, or tothe Committee, the disciplinary procedure, referred to at Articles 68 to 77 shall be followed.

DISCIPLINARY PROCEDURES AND DUTIES OF THE CONVENOR 68. The Arbitrator shall appoint a Convenor who shall be a Registered Member to conduct thehearing. More than one Convenor may be appointed to hear different cases occurring at thesame time. 69. The Convenor shall appoint a mutually agreeable Registered Member to be supportive of thehomeopath who is subject to the disciplinary procedure and a Registered Member to represent thecomplainant, if so desired. 70. The Convenor shall notify all parties and invite them to appear at a hearing with or withoutrepresentation and any witnesses on their behalf. The Convenor shall also seek from each partywritten statements of all allegations, evidence, or other relevant material they wish to be available 109at the hearing. Copies of such documents shall be sent to each party at least twenty-one days beforethe hearing. 71. The Convenor shall arrange a time, date and place for the hearing, notify all parties at least twenty-one days beforehand and shall nominate and ensure the attendance of a panel of three RegisteredMembers, who are not Committee members, and one other person who is neither a member ofthe Society nor a homeopath, with full voting rights in this instance. 72. Where the homeopath under investigation is a member of the Committee, the panel may suspendthem on the basis of the written submissions, until a final decision is made. 73. The Convenor shall attend the hearing, as an observer, but may take no part in its decision. 74. The Convenor shall communicate in full confidentiality, within seven days, the decision of thehearing to the Committee members, for ratification at the next meeting. Upon ratification by theCommittee the Convenor shall notify, in writing, within seven days, the decision of the Committeeto the complainant and the member, giving the latter notice of their rights to appeal.

THE PANEL IN DISIPLINARY HEARINGS 75. The panel, as convened, shall consider all written and oral evidence presented to it by all partiesand witnesses attending the hearing. 76. The panel shall dismiss a case unless they consider beyond all reasonable doubt that the memberhas contravened or insufficiently observed any provisions of these presents or the Code of Ethicsof the Society or any other regulations of the Society. In this instance, the panel shall impose apenalty on the member from the following categories: a warning; a demand to give a writtenundertaking not to re-offend; a reprimand, a suspension; an expulsion from membership. The panelmay, in addition or as an alternative to the above penalties, recommend that a member shouldembark on a period of counselling or supervision or training which is relevant to the matter in hand. 77. The panel shall make its report to the Convenor within twenty-eight days of completion of thehearing. 78. The Committee shall have the discretion to reimburse any reasonable out of pocket expensesincurred for work undertaken in the course of a panel hearing.

APPEALS 79. A Full Member can, within twenty-eight days of the date of the notice of the decision of theCommittee, give written notice of their intention to appeal to the Society. Such notice shall statetherein the grounds for such an appeal. 80. An appeal may be made on the grounds that: (a) there is evidence which was not available at the panel hearing; or (b) there is evidence that procedures were not properly followed; or (c) the appellant considers that he/she has been unjustly or unfairly treated in the adjudication process generally. 11081. Within three calendar months of receipt by the Society of the notice of intention to appeal, anappeal hearing shall be convened by the Secretary of which at least twenty-one days notice inwriting shall be given to all Registered Members of the Society. 82. An appeal meeting shall be held in camera, consisting of twelve Registered Members, of whomeight shall be a quorum, who are neither members of the Committee nor the panel, the appellantwith or without representation and the Arbitrator with or without representation. 83. Both parties to the appeal may supply written evidence in advance to be sent with notice of themeeting and provide written and oral evidence to the appeal meeting and to call any witnesses ontheir behalf. 84. Upon completion of the evidence from both sides, the Registered Members to whom the case hasbeen presented shall make their decision. A decision of at least three-quarters of those membersshall be final. In the absence of such a majority, the appeal shall be upheld and the decision of thepanel set aside. 85. Within seven days of the appeal decision, the Secretary shall notify the complainant and themember concerned and any suspension or expulsion shall commence fifteen clear days from thedate of such notice. All outcomes of the arbitration and disciplinary procedure shall be made inwriting to the Registrar by the Arbitrator, who shall keep a confidential copy. 111Wt.--. 500. 4/06. Cahill. (M92296). G.Spl.
Original version available as pdf at www.dohc.ie/publications

Detox Dublin

Colonic info & prices in Dublin

detoxdublin.net

College of Naturopathic Medicine Ireland
Diploma Courses in Naturopathy, Nutrition, Acupuncture, Homeopathy, Herbal Medicine
www.Naturopathy.ie

Cork Natural Fertility Clinic

Specialist Fertility Programmes

www.corknaturalfertility.com

Bodyfirm Pilates
Ireland's best Pilates and Bowen Therapy Courses
pilates ireland.org

Institute of Complementary & Integrative Medicine
Courses in Nutrition and Health
www.icim-ireland.net

Local search

Acupuncture

Acupuncture Supplies

Alexander Technique

Allergy Testing

Amatsu

Angel Workshops

Angel Healing

Angel Shop

Animal Healing

Antenatal Yoga

Aromatherapy

Artist's Way

Art Therapy

Ayurveda

Astrology

Aura Photography

Aura Soma

Baby Massage

Baby Sign Language

Bach Remedies

Beauty Therapy

Bi-Aura

Biodynamic Massage

Biodynamic Psychotherapy

Bio-Energy/Healing

Bio-Energy

Biofeedback

Bio-frequency Therapy

Body Harmony

Bowen Technique

Breathwork

Brennan Healing

Brunelle Method

Buteyko for Asthma

Cellular Healing

Chakra

Chelation

Chi Kung

Chiropractic

Clairvoyant / Psychic Medium

Coaching

Cognitive Behavioural Therapy

Colonic Irrigation

Colon Hydrotherapy

Colour Therapy

Counselling

Courses

Cosmetic Acupuncture

Cranio-sacral

Crystals

Cupping Massage

Dance

Dietitian

Holistic Dental treatment

Deep Tissue Massage

Doula Services

Dorn Therapy

Dowsing

Dramatherapy

Dream Interpretation

Ear Candling

EFT (Emotional Freedom Techniques)

EMDR: Eye Movement Desensitization and Reprocessing

Equine

Family Constellations

Feldenkrais Method

Feng Shui

Fitness

Flotation Tank

Geopathic Stress

Gift Vouchers

Guided Self Healing

Healing Massage

Healthfoods

Health Spa

Herbalists

Holotropic Breathwork

Heavy Metal Detoxification

Home Birth

Homeopathy

Hopi Ear Candling

Hot Stone Massage

Hydrotherapy

Hypnobirthing

Hypnosis

Hypnotherapy

Indian Head Massage

Integral Transformative Practice (ITP)

Integrated Energy Therapy

Iridology

Ki Massage

Kinesiology

La Stone

Laser Therapy

Lomilomi Hawaiian Massage

Louise Hay

Macrobiotics

Magnetic Therapy

Magnified Healing

Massage

Medical Qigong

Meditation

Melchizedek method

Metamorphosis

Mineral Hair Analysis

Muscle Effect Therapy

Music and Singing

Naturopathy / Naturopathic medicine

Neuro-linguistic Programming / NLP

Neuro Muscular Therapy

Nutrition

Organic

Osteopathy

Oxygen Therapy

Ozone Therapy

Past Life Regression

Personal Development

Personal Training

Physical Therapy

Pilates

Pilates Instructor Training

Polarity Therapy

Pranic Healing

Primal Integration

Pregnancy Massage

Pregnancy

Psychics

Psychotherapy

Psychosynthesis

Quantum Touch

Rebirthing

Reconnective Healing

Reflexology

Reiki

Relaxation

Rolfing

Sacred Stones

Seaweed Baths

Seichem

Shamanism

Shen® Therapy

Shiatsu

Singing

Stop Smoking

Somatic Psychotherapy

Sound Healing

Spa

Spiritual Healing

Sports Massage

Steam Cabinets

Stone Massage

Stress Management

Swedish Massage

Sweatlodge

Tai Chi

Tapas Acupressure Technique

Tarot

Thai Massage

Thought Field Therapy

Time line Therapy

Traditional Chinese Medicine

Training

Transference Healing

Tui na

Vastu

Vega Testing

Vortex Healing®

Water Filters (Reverse Osmosis)

Weight Management

Workshops

Yoga

TERMS CAUTIONS & CONDITIONS

holisto.com

IRELAND'S HOLISTIC DIRECTORY

Report on the Regulation of Complementary Therapists