Information From the Practice Advice Service

NATURE OF INQUIRIES

COVID-19 INQUIRIES

The nature of inquiries received concerning the pandemic over the past seven months was very similar to those responded to since the beginning of the pandemic. Information provided in response to the most recent queries can be found in the October 2020 edition of HeadLines and on the section of the College website dedicated to COVID-19 Updates.

We appreciate that the current situation is difficult for everyone and can present unique ethical challenges. In situations where the government agencies have not provided specific guidelines, members are expected to make reasoned decisions based upon the ethical principles underlying the usual rules, the existing information about COVID-19 precautions, and the particular circumstances of their clients, practices and communities. It is also recommended that one consult with colleagues around these or other issues that arise. 

The pandemic is an increasingly active threat to community safety.  The College, therefore, continues to recommend that members provide services virtually when this can be done effectively. When clients require in-person services members should undertake all necessary and appropriate safeguards. In situations where there is ambiguity about the requirements, we urge members to take a conservative approach to minimize the risk of community spread as much as reasonably possible.

NON-PANDEMIC INQUIRIES

The top five areas of concern for those seeking advice from the College during the past seven months, in order of frequency, were:

1. Provision of Services Across Jurisdictions, Unrelated to the Pandemic was the subject of more questions than any others and were equally divided with respect to members of the College providing services in other jurisdictions and those registered in other jurisdictions seeking to provide services in Ontario;
   
2. Supervision, with most of these queries relating to the supervision of the controlled act of psychotherapy; supervision of non-regulated individuals; and supervision of members of other regulated professions;
   
3. Recordkeeping, with most questions relating to issues of file retention and destruction; the nature of information which must be contained in the records; planning for leaving or closing a practice; and the designation of a successor health information custodian;
   
4. Release of/and Access to Information, with most queries relating to a client’s right to access, or to authorize someone else to access, their record; release of test data; and substitute decision makers’ authority with respect to access to records, most often in the context of a dispute about parental rights; and  
   
5. Authorized Area of Practice, with queries relating to the specific services members with specified authorized areas of practice are permitted to provide.

While not making the “top 5” list, the following queries have been frequently asked and members may benefit from reviewing them, as the principles conveyed have wide application.

FEES AND BILLING – NAMES ON INVOICES AND RECEIPTS

Q:   When conducting parenting sessions, in the context of child and adolescent treatment, is it permissible to issue an invoice or receipt under the child’s name if the child has not participated in the session?

A:    The Professional Misconduct Regulation and Standards of Professional Conduct, 2017 do not specifically address the issue of whose name to put on an invoice.  Therefore, one must ensure adherence to the broader rules when deciding about how to proceed regarding what information to put on an invoice or receipt. The most important thing is to ensure is that any document, including an invoice or receipt, could not reasonably be seen as, 20. Making a record, or issuing or signing a certificate, report, or similar document that the member knows or ought to know is false, misleading or otherwise improper. [O.Reg 801/93 Professional Misconduct]

In cases where multiple members of a family are treated at different times and in different constellations,  it would be reasonable to make a principled decision and apply the same logic whenever similar situations arise, regardless of the wishes of the particular client or what their insurance coverage allows.

In this particular case, if an intervention is intended to impart parenting skills to the parent, it might be reasonable to assume that parenting work is intended to help the parents change their behaviour and consider that the services were provided to the parents. This would be different than meeting with the parents in order to provide them with therapy progress information or information to help them support the work being done individually with the child.

Most of the time this question comes up in the context of a family with per-person insurance coverage limits. In situations like this, a parent may ask to revise invoices or receipts once a family member reaches their insurance coverage limit.  One must be careful not to issue an invoice in a manner where it could be alleged that the person issuing the invoice was participating in something that could be seen as misleading.

Wherever possible, it might be helpful to ensure an invoice provides clear information about the nature of service and identifies those to whom the service was provided. If a person to whom the service was provided is different than the person who is the focus of the treatment, it may be appropriate to note on the invoice something like services were provided to Mr. and Mr. Smith re: the treatment of their child James Smith.  Clients may also be asked to consult with their benefits providers about how to best maximize their coverage and the insurer’s preferences with respect to billing.

While it may feel helpful to assist clients in maximizing their insurance coverage, insurers are becoming increasingly vigilant about such matters and this could result in denial of benefits to the client and a complaint to the College. It should be left to the client(s) and their insurers to work out issues about insurance coverage limits.

CONDFIDENTIALITY – INTRODUCING CLIENTS TO ONE ANOTHER

Q:   Is it permissible to introduce clients with similar concerns to each other, for the purpose of facilitating mutual support?   

A:    This scenario presents some potential challenges.   

Consent may be more complicated than might initially meet the eye. The clients in such a situation could decide to enter the relationship because of a perceived expectation by the therapist that they will agree and not want to disappoint the therapist by declining the invitation. For this reason, if this were to occur, such an opportunity would have to be presented in an entirely neutral manner.

To be fully informed consent, each client would have to be made aware of all the potential benefits and risks. These benefits would obviously include mutual support. On the downside, entering a relationship in which the client could be taking on further emotional (and perhaps other) demands should be presented as a risk to their own therapeutic relationship with the therapist and consequently to their therapeutic progress.

Confidentiality could also become a challenge when clients are introduced and encouraged to communicate. While each client would know that the other was seeing the same therapist, the therapist would have to be vigilant not to share any information about the other client without authorization. This would become difficult if they wished to talk about the other client or about interventions being used with them and it could become difficult to avoid inadvertently providing information, even in refusing to actively answer certain questions that could be posed. Even if information about one client was never disclosed to the other, the therapist would have to be vigilant about avoiding the collection of information about one from the other without consent. Even with full consent, collection of such information could pose challenges to professional objectivity, if information arose about any conflict arising between these individuals or any adverse information about them. This would become a dual relationship in the same way as working with clients who are relatives or friends of one another would, and it’s best to avoid dual relationships.

 There are no specific prohibitions against introducing clients, but these are some of the challenges in managing such an intervention, without the safeguards of therapist mediated interaction between clients, as might occur in a therapist mediated mutual support group.

RETIREMENT – PERMITTED ACTIVITIES

Q:   After retiring may a retired or former member hold themselves out as an expert at a trial involving a current client?

A:    A member of the College with a Retired Certificate of Registration or a former member may not provide any psychological services of any kind. They would however, be able to provide information regarding services provided while holding a Certificate of Registration Authorizing Autonomous Practice.  If, for example, the court required the client to be reassessed or needed testimony about matters not addressed while the member held a Certificate of Registration Authorizing Autonomous Practice, this would appear to be a new service and not one that should be provided unless one is authorized to provide psychological services.

The College is not in a position to require, and assure the public, that members with a Retired Certificate of Registration are maintaining their professional competence through continuing professional development. They are also not required to maintain their professional liability insurance coverage, which protects clients who may have a legitimate claim for financial awards as a result of a member’s professional activities. This is obviously also the case for retired members as well.

PRACTICE ADVICE TO SUPERVISEES

Practice advice is available to all members of the College regardless of their membership status.  The College also is pleased to provide accurate general information about professional standards when it is sought by members of the community.

Recently, many of those seeking practice advice are supervised providers of psychological services, although this is not always immediately evident.  While the College is interested in providing the best information possible to anyone offering a psychological service, we believe it is important that supervisors be the first resource for supervisees to approach. 

There is no expectation that members of the College “have all the answers” and there are many reasons for any member, including one who supervises, to use the College’s resources.  Supervisors should be aware of the gaps in knowledge and the challenges that their supervisees experience, so they can adequately plan for their training and determine the level of supervision necessary.  It is recommended that supervisors be part of the “practice advice” conversation with the College so that they have the same information as the supervisee and receive the message first-hand. 

Supervisors should ask their supervisees to discuss their needs with them before contacting the College and, when supervisees do contact the College, they copy their supervisor on emailed queries or participate in teleconference consultations. On occasion, a supervisee may wish to contact the College about concerns regarding a supervisor, without the supervisor’s knowledge. In such cases, it would be hoped that, when appropriate, the area of concern already has been brought to the attention of the supervisor.