Pratique professionnelle

Introduction

The College has received many questions from members of the College and the public about the Controlled Act related to Psychotherapy since it was proclaimed on December 30, 2017.

Members of the College of Psychologists of Psychologists and Behaviour Analysts registered to practice psychology are permitted to perform the Controlled Act related to Psychotherapy, so members need not be concerned whether psychotherapy they provide falls within the definition of the Controlled Act.  As always, members are responsible to ensure that they are competent to provide any psychological service they offer.  The definition of when services fall within the Controlled Act becomes much more important when one is considering supervising someone in the performance of the Controlled Act.

Information currently available on the College website may address some of the member inquiries.  This can be found in the Practical Applications to the Standards of Professional Conduct, 2017 in the Standards of Professional Conduct.

Further information is available and in the Questions and Answers document accompanying the Standards

The following information is intended to address the most frequently asked Questions the College has received.  If there are other questions, you please email them to practiceadvice@cpbao.ca.

Definitions

The Controlled Act related to Psychotherapy is defined in section 27(2) of the Regulated Health Professions Act, 1991 (RHPA) as:

14. Treating, by means of psychotherapy technique, delivered through a therapeutic relationship, an individual’s serious disorder of thought, cognition, mood, emotional regulation, perception or memory that may seriously impair the individual’s judgement, insight, behaviour, communication or social functioning.

The legislation does not define the terms used in this definition particularly “psychotherapy” and what is meant by “serious”.  Within the Psychotherapy Act, 2007 however, the ‘practice of psychotherapy’ is defined as:

3. the assessment and treatment of cognitive, emotional or behavioural disturbances by psychotherapeutic means, delivered through a therapeutic relationship based primarily on verbal or non-verbal communication.

The legislation does not define “serious” with respect to what is a “serious disorder . . . that may seriously impair”.  This is left to the treatment provider to apply his/her own education, skill, and training to determine.  As noted above, this need not be of concern to members personally offering psychotherapeutic services as members of the College are authorized to perform this Controlled Act.  It is important, however, when one is considering providing supervision.  In the absence of any available jurisprudence defining these terms within the definition, especially as related to a “serious disorder . . . that may seriously impair” members of the College are expected to exercise their professional judgment in deciding whether the services which they contemplate supervising constitute the Controlled Act.

Whether an activity constitutes the Controlled Act requires consideration of the level of difficulty and potential impairment experienced by the client and is not dependent on a specific diagnosis or therapeutic modality.

Members who are not comfortable exercising their own professional judgment in deciding whether a service falls within the “serious disorder . . . that may seriously impair” definition of the Controlled Act should consult with another member, another regulated colleague authorized to perform this Controlled Act or seek legal advice.

Questions and Answers

1. Is the provision of all “psychotherapy service” now controlled by the new legislation?

No.  As noted in the definition, only psychotherapy delivered to a client with a “serious disorder . . . that may seriously impair” their functioning falls within the Controlled Act.

2. In general, under what circumstances may I supervise the performance of the Controlled Act?

Most of the concerns raised are related to supervision by College members of others who are performing the Controlled Act.  The RHPA specifically sets out that a person who is not yet authorized to perform the Controlled Act independently may do so under supervision but only if she/he is fulfilling the requirements to become a member of a health profession, the act is within the scope of practice of the profession and is done under the supervision or direction of a member of the profession [emphasis added].

It is important to note that College members may continue to supervise individuals they believe have the competence to provide psychotherapeutic services when those services fall outside of the Controlled Act.

3. With regards to performing the Controlled Act of psychotherapy, may I supervise:

a) Doctoral psychology students in practica or internship placements or individuals is in the process of obtaining their four years of supervised experience necessary to apply to become a psychological associate?

The legislation permits one to supervise individuals who are fulfilling the requirements of our College.  This includes supervised practice members, students in practica or internships as well as those gaining their required post-masters experience.

b) Autonomous practice members of the College who may require supervision to expand their authorized areas of practice or their authorized population groups or who require supervision pursuant to a decision of the Inquiries, Complaints and Reports Committee (ICRC) or Discipline Committee?

Yes. Given that one is permitted to supervise a Supervised Practice member as noted above, it would seem inconsistent with the intention of the legislation for members not to be able to supervise another autonomous practice member to meet College requirements to practice in specific areas or with specific populations or fulfill a condition required by the ICRC or Discipline Committee.

c) Autonomous practice members of the College who may wish to increase their psychotherapy skills within their authorized areas of practice or their authorized population groups?

Generally, these members would become involved in a mentorship, consultation or training relationship, rather than a formal supervisory one.  Since they are already authorized in the area or with the population, the College does not require supervision when a member is learning new techniques or increasing the scope of their activities within their authorized areas.

d) Individuals who are in the process of becoming a member of the College of Registered Psychotherapists of Ontario (CRPO) or another College whose members are authorized to perform the Controlled Act, but are not yet members of that College?

On December 21, 2017, the Minister of Health and Long-Term Care announced that, “Individuals who provide these services [the controlled act] will have a two-year transition period, beginning December 31, 2017, to register with a regulatory college.”  Therefore, supervision of individuals in the process of becoming a member of the CRPO or another College whose members are authorized to perform the Controlled Act is permitted as follows:

Transition Period to December 31, 2019:
The transition period appears to permit individuals to perform the controlled act whether or not they are under supervision.  In keeping with the apparent intention of the transition period, that is to provide an opportunity for individuals to register with a relevant regulatory College; the College is of the view that it would be appropriate to permit members to supervise individuals who are preparing to become a member of the CRPO, during the transition period.

It is important to note that there is no restriction with regard to College members offering training, support, consultation and mentorship to other practitioners.  While the CRPO may use the term “supervision” in their requirements for candidates, their use of the term may connote a less formal arrangement than that outlined in Principle 4 of our Standards. Individuals seeking registration with the CRPO should inquire of their College if a mentorship, training or consultation relationship, rather than a formal supervisory one, as defined by our College, may satisfy the requirement. In agreeing to consult, the College would expect members to inform CRPO qualifying members that they should not indicate to clients that they are being ‘supervised’ as this could be misleading and suggest a degree of responsibility by the College member which is inaccurate. Rather it would be appropriate for them to explain that they are seeking consultation and training from a member of our College.

Post Transition Period:
The legislation only permits one to supervise individuals who are fulfilling the requirements of their own College, in our case, the College of Psychologists.  Therefore, after December 31, 2019 one cannot provide supervision, as it is defined by the College, to individuals who are becoming members of another College. Please see item e) below for information about the supervision of those registered with another College, but not authorized to practice autonomously.

As noted above, there is no restriction with regard to College members offering training, support, consultation and mentorship to other practitioners.  While the CRPO may use the term “supervision” in their requirements for candidates, their use of the term may connote a less formal arrangement than that outlined in Principle 4 of our Standards. Individuals seeking registration with the CRPO should inquire of their College if a mentorship, training or consultation relationship, rather than a formal supervisory one as defined by our College, may satisfy the requirement.

e) Members of another regulated health profession who themselves are authorized to perform the controlled act?

Yes. If these individuals are authorized by their own College to perform the controlled act, they can do so independently or under the supervision of a member of the College of Psychologists. As with members of the College of Psychologists who are authorized to perform the Controlled Act [as per 3.c) above], in most circumstances it may be appropriate to establish a non-supervisory relationship that would afford them training, support, consultation and mentorship. If, however, there is a reason that non-supervisory supports would be insufficient, and supervision is necessary, a member of the College may enter into a supervisory relationship as outlined Principle 4 of the Standards. 

4. Are there any circumstances when a member may supervise others in providing services, including performance of the Controlled Act, because a third-party payer will only cover services if they are supervised by a Psychologist or Psychological Associate?

Supervision of the controlled act of psychotherapy or any other psychological service may not be undertaken solely to facilitate third-party payment [Standards of Professional Conduct 4.1.1 (6)].

5. May I supervise a Registered Psychotherapist or Social Worker in services which fall outside of the definition of the Controlled Act?

Yes. You are permitted to supervise activities that fall outside of the definition of the Controlled Act by a Registered Psychotherapist or Social Worker or anyone else that you believe has the education, training and experience to provide those services under your supervision.

6. Can exceptions to the restrictions on performance or supervision of the Controlled Act be made for clients who require services in remote communities or who would be affected because a therapist is no longer eligible for supervision?

The legislation does not provide for any exceptions and the College cannot recommend or condone any activity that would not be permitted by legislation. In assuming responsibility for the supervision of a psychological service, the supervisor has taken on responsibility for the client’s care. Where a supervisee is no longer able to provide the supervised service, the supervisor may provide client care him or herself, or help the individual to find another competent practitioner from whom they can receive services. 

You’ve asked about situations in which you are being required to act in contravention of the Standards. The Standard requiring best efforts to affect change in the workplace relates to situations in which others in the workplace are doing things that contravene the Standards.

When attempting to address the conduct of others in the workplace, Standard 3.1.2 does require you to make the best efforts to ensure that your work setting adheres to the Standards.

If your efforts to change the behaviour of others at work meet resistance, best efforts could include presenting additional information that supports a compelling argument for the changes,   writing a formal memo to those in a position to modify policies, or escalating the issue to a higher level in the organization. You would not be expected to take steps like resigning from your position and losing your livelihood, as this would be considered undue hardship.

It is different if you, as opposed to others in the organization, are required to contravene the Standards, as a failure to comply with the Standards, yourself, would constitute Professional Misconduct. For example, if an employer were to ask you to provide services outside of your authorized areas of practice and/or competence, without the opportunity for supervision, you would not be permitted to so under any circumstances.

Fortunately, it is in the best interests of most employers to support ethical practice and most of the time it is possible to affect change. If you are unable to resolve this problem with your employer on your own, it may be necessary to seek independent legal advice to discuss your range of options.

Please don’t hesitate to contact the College’s Practice Advisory service if you’d like to discuss any specific situations like the ones described above.

The Supervision standards apply to the supervision of all psychological services and psychological research is deemed to be a psychological service. In the public interest, it is important to ensure that research is conducted ethically and that it produces reliable and valid information.

Some activities which non-members perform in the course of assisting with research may not require supervision if one would not need professional education, training, and/or experience in order to perform them. For example, tasks like administratively providing and collecting self-administered questionnaires may be performed without the supervision of the nature required by the Standards. Tasks which do require professional education, training, and/or experience, like interactive administration of tests and/or interpretation of subjects’ responses, would require supervision in the manner set out in the Standards.

Providing training does not necessarily make a relationship supervisory.  A relationship in which you have been specifically asked to provide training, or a consulting relationship which may have a training component, only becomes a supervisory relationship if it becomes evaluative and hierarchical and when the person receiving information from you is required to do as you instruct. In the kind of consultation situation, you have described it is particularly important to ensure that an agreement makes it clear that you are not taking on responsibility for client care and that that responsibility is exclusively the consultee’s.

If you do not wish to take on the responsibilities of a supervisor, you would need to ensure that he would be satisfied with your acting as a consultant and/or trainer, but not as a supervisor as defined within the Standards of Professional Conduct for members of the College of Psychologists of Ontario. You’d have to have an agreement with him that makes it clear that you are not clinically responsible for the casework, that it’s his responsibility to evaluate any information you are providing to him and that he would need to make his own independent decisions about whether to heed any advice you give. In the event that he requires someone to assume clinical responsibility for his services, you must make it clear to him that by consulting and/or training you would not be assuming responsibility for client care.

If you are supervising psychological services, the public is entitled to rely on an expectation that the services delivered will meet the standards of the profession.

There are unregulated professionals providing many services in Ontario, including behavioural intervention, counselling, and rehabilitation therapy.  These professionals may be providing competent and ethical work but they are not subject to rigorous entry to practice requirements, standards of conduct to comply with, mandatory quality assurance requirements or a complaints mechanism to address concerns that may arise about the services. When a College member is supervising the provision of any psychological services, the College and its members have an obligation to the public to ensure that the services meet the same standards as they would if delivered directly by the member.

Your question suggests that you would be supervising another professional’s “practice”. It is important to remember that clients seen under your supervision are actually considered to be your own clients and, as such, you should consider them as clients of your practice and not the supervisee’s.

There is no specific prohibition against supervising another professional with respect to the care of some individuals, without supervising the care of all of the individuals they work with. It can, however, be challenging to ensure that all of those concerned are aware of which activities you are supervising and which ones you are not. In addition to complying with the Standards relevant to supervision, you would have to be mindful of adhering to all of the other relevant Standards, including:

6.4 Public Announcements
Public announcements of psychological services and fees must be offered in the name of an
autonomous practice member of the College.

This means that you may not permit a supervisee to advertise the services which you supervise under his or her own name, and must instead advertise the supervised services as part of your own practice.

9.1.2 Members Responsible for Supervising Supervised Practice Members and Non Members
Members supervising Supervised Practice members and non-members are responsible for the security, accessibility, maintenance and retention of records.

This means that you must ensure that you have full control over the records of those clients whose services you supervise, and take possession of those files when the supervision (and your authority) ends.

11.1 Fees and Billing Arrangements
A member must reach an agreement with an individual, group, or organization concerning the psychological services to be provided, the fees to be charged, and the billing arrangements prior to providing psychological services. Any changes in the services to be provided must be agreed to by the client before the service is delivered or fees are changed. Fees must be based on the amount of time spent and complexity of the services rendered.

This means that you must be directly involved in all agreements for services, as well as fees and billing arrangements, prior to the supervisee beginning to provide service or before arrangements are changed.

All of the information above applies, regardless of whether the supervisee is a member of another health regulated profession if you are supervising them in the provision of psychological services.

The Standards relevant to supervision are only applicable to the supervision of psychological services. If your supervisory role is strictly administrative and you only do such things as approve vacation time, arrange scheduling or perform other human resources-related activities, then you would not be subject to the requirements for supervisors of psychological services. If you do supervise activities that would fall within the scope of practice of psychology, then you are required to adhere to the Standards regarding the supervision of psychological services.

Section 3 of the Psychology Act, 1991 defines the practice of psychology as:

… the assessment of behavioral and mental conditions, the diagnosis of neuropsychological disorders and dysfunctions and psychotic, neurotic and personality disorders and dysfunctions and the prevention and treatment of behavioral and mental disorders and dysfunctions and the maintenance and enhancement of physical, intellectual, emotional, social and interpersonal functioning. 1991, c. 38, s. 3.

The Standard is intended to ensure that there is clear agreement between the supervisor and supervisee with respect to all of the minimum elements listed in the Standards. It may be onerous to individuals make agreements that are redundant. So long as it can be demonstrated that each individual supervisor and supervisee has agreed to all of the following elements, whether directly or through a third party, you could consider that there is an agreement which meets the Standards:

a) the date upon which the agreement is effective and the expected date upon which it will expire; b) the specific duties and obligations of the supervisee; c) any limitations imposed upon the activities of the supervisee; d) the specific duties and obligations of the supervisor; e) the expected frequency and length of supervision meetings; f) the manner in which the supervisor will be directly involved in the planning, monitoring and evaluation of the services provided to clients; g) contact information and emergency contact information for both the supervisor and supervisee; h) confirmation that the supervisee will comply with all requirements under the legislation and regulations relevant to the service and the Standards of Professional Conduct (2017); and i)  identification of a plan for appropriate support for the supervisee in the event of the supervisor’s unavailability.

To the extent that any of the minimum elements of an agreement listed above are not addressed, an additional agreement covering the missing elements would be required.

Many of the elements of a supervision agreement listed within the Standards apply broadly to any situation in which supervisors take responsibility for the work done by their supervisees. Some elements of Standard 4.1.1 (5) which may be applicable to the supervision of research and other non-clinical activities include:

a) the date upon which the agreement is effective and the expected date upon which it will expire;
b) the specific duties and obligations of the supervisee;
c) any limitations imposed upon the activities of the supervisee;
d) the specific duties and obligations of the supervisor;
e) the expected frequency and length of supervision meetings;
g) contact information and emergency contact information for both the supervisor and supervisee;
h) confirmation that the supervisee will comply with all requirements under the legislation and regulations relevant to the service and the Standards of Professional Conduct (2017); and
i) identification of a plan for appropriate support for the supervisee in the event of the supervisor’s unavailability.

In institutional settings, such as Universities and hospitals, employment contracts that address the terms of supervision referred to in these Standards may be considered to constitute a supervision agreement.

Many of the elements of supervision records listed within the Standards apply only to the care of clients. Some, however, apply more broadly to any situation in which supervisors take responsibility for the work done by their supervisees. Some elements of Standard 4.1.1 (3) which may be applicable to the supervision of research and other non-clinical activities include:

a)    the date and length of time of each supervision meeting;
d)    a summary of discussions regarding any relevant ethical, professional and jurisprudence issues discussed at each supervision meeting;
e)    a notation of any directives provided to the supervisee at each supervision meeting; and
f)     a notation of any of the supervisee’s strengths and needs for further development identified at each supervision meeting;

A supervisor would be expected to make a record of any relevant ethical, professional, and jurisprudence issues discussed, directives provided, and strengths and needs for development identified during a supervision meeting. If few or none of these things were discussed at a particular meeting, then only a very brief notation including only the date and length of the meeting would be required.

Because of the diversity of supervision and consultation arrangements members are involved in, the College could not possibly provide examples or templates of agreements that would cover every situation.

We encourage you to design agreements that make sense for your own particular practice that contain at least the minimum information specified in the Standards.  You are also free to add any additional elements you consider important in an agreement and may use any kind of language you wish to use.

If it would help to see how some similar agreements are structured, here is a link to a few sample supervision contracts online: https://www.cfalender.com/supervision-contracts.html. These may or not be relevant or appropriate for all kinds of relationships but may provide a sense of what others’ agreements look like.

Although the Standards require you to record information that will permit the identification of each client, there is no need to use full client names, as long as it is possible for you to associate these identifiers with the clients should you need to. The use of coded names would prevent the release of unnecessary personal health information about clients to those reviewing a file for purposes related only to the supervisee.

Examples of appropriate references to clients in a supervision file include: “Discussed Interpretation of Test Scores for A.L. and asked Supervisee to correct tabulations and reinterpret with new scores” or “Discussed Supervisee’s own reaction to N.Q.’s disclosure, Supervisee discussed own discomfort with this issue and we generated a list of other possible responses, including seeking more information or waiting for the client to reflect before problem-solving. Will discuss Supervisee’s reactions to client information again following N.Q’s next session.”

When a client makes a request for his or her record, or authorizes release of it to another person, subject to the specific exceptions in privacy legislation, you must comply with the request. All information about a client that is relevant to the services provided should, however, be contained within the client record. There should be no information relevant to client care in a supervision record that would not also be found in the client’s own file.

A supervision record should contain only information relevant to the member’s supervision of the supervisee’s performance, developmental goals, progress, and challenges. It should only include incidental reference to clients to relate the narrative to specific cases.

If for any reason, you are compelled to provide a supervision record because it contains information related to a client, it would be important to ensure that information about other clients recorded in the supervision record is not disclosed without their consent or unless you are legally compelled to release it. Similarly, you should not release personal information about the supervisee without the supervisee’s consent, unless you are legally compelled to release it.

If faced with a request which leads you to believe that supervision records are specifically being sought, you may indicate that the supervision records pertain to the supervisee’s own developmental goals, training, and growth, that all client-related information is incidental to these issues, and that all client-related information is contained in the client file. Again, unless required by a court of law, you must not release supervision records unless both the supervisee and client specifically authorize you to do so.

You may supervise anyone you believe has the competence to provide services under supervision, so long as they are not performing one of the Controlled Acts as listed and described in the Regulated Health Professions Act, 1991, which include: communication of a diagnosis; applying or ordering the application of a form of energy; and, once proclaimed in force, the Controlled Act of Psychotherapy. As counselling is not a controlled act, there is no requirement that they be registered, or seeking registration, in a College.

Making case specific recommendations to behavior therapists, advising with respect to the development of processes, and discussing general issues, are activities which are consistent with the role of a consultant, so long as it is understood that the recipients of the recommendations and advice are fully responsible for deciding whether to implement your recommendations.

If you are in a relationship with the behavior therapists that is educational, evaluative, and hierarchical, and they are required to comply with your direction, you would be considered to be supervising them.