Area of Practice & Client Groups

Originally published in Volume: 1 Issue: 2 of HeadLines

The College doesn’t specify hard borders between age ranges for the different population groups but recognizes that there are not always clear demarcations with respect to population groups, particularly with respect to age. Members are expected to use their professional judgment to determine whether, in all the circumstances, the person’s status is consistent with the status of those for whom they are authorized to provide service. For example, when trying to determine whether a client, at a border age, is an “adult”, “adolescent”, or for that matter a “senior”, it would be important to consider whether the person’s abilities, life circumstances and challenges are consistent with those which would normally be expected within the population groups for which the member is authorized to work.

Originally published in Volume: 1 Issue: 2 of HeadLines

As members know, the College has defined Authorized Areas of Practice. The definitions for the authorized areas of practice focus on the nature of difficulties the services are intended to address, as opposed to the specific type of service offered. In order to answer questions like this it may be most helpful to keep this distinction in mind.

The Practical Application posted with Standard of Professional Conduct, 2017 5.1 states: In deciding whether one is authorized and competent to provide a service, the nature of the client’s presenting difficulties will generally determine whether the member has the appropriate and required authorization. For example, if a client who has suffered a traumatic brain injury has been referred because of a need to assess the nature of their neuropsychological deficits, it is expected that the member providing the assessment would have clinical neuropsychology as an authorized area of practice. If the person was referred because of difficulty performing activities of daily living or occupational requirements, it is expected that the member would be authorized to work in the area of rehabilitation psychology. If the person was referred because of suspected anxiety or depression, then it is expected that the member would be authorized to practice in clinical psychology…

It’s likely that most of what are often called “psychoeducational assessments” are meant to help identify the reason an individual has difficulty learning in an educational environment and to provide information for the purpose of planning for remediation of these difficulties.  If there is reason to believe that the nature of difficulties is neuropsychological in nature, then it would appear reasonable for someone with authorization in the area of Clinical Neuropsychology to assess the client.

At the same time, authorization in School Psychology requires certain knowledge not generally required for the practice of Clinical Neuropsychology, including knowledge of:

• academic, instructional and remedial techniques;
• interdisciplinary team approach for case management, program planning and crisis intervention;
• consulting, counselling, and primary, secondary and tertiary intervention programs and techniques;
• systems and group behaviours within, and related to, the school organization, including school climate and culture.

If making specific recommendations which require such knowledge, it’s expected that a member who has not acquired this knowledge would seek the professional guidance of another member who is authorized to practice School Psychology.

The College has not set out specific, concrete age boundaries between the various client populations:  children and adolescents; adolescents and adults; adults, and seniors.  One usually goes by conventional definitions.  That is, children to age 12 or 13; adolescents to age 19 or so; adults to 65 or 70.  While age is not an issue when considering providing service to a client who falls within these conventional age groups, problems can arise at the boundary ages, i.e., 12-13; 18-20; 65-70.  When determining whether it is within one’s area of competence to provide service to a “boundary age” individual, many things other than just chronological age come must be considered.

The concern that arises should a member, with demonstrated competence in working with adults, decide to provide service to an older, boundary age adolescent is that one may impart to the older adolescent some adult traits, characteristics, or difficulties based on one’s training and experience.  Conversely, a member may not recognize some adolescent trait, as one is approaching the client from an "adult" perspective.  Issues can also arise with the use of assessment measures and intervention techniques as one may be most familiar with both the objective and subjective norms related to working with adults.

The Registration Regulation (O. Reg. 193/23) requires that members practice the profession only within those areas of the member's competency that are authorized by the College [s. 10 (2) 1.]  There is some room at the boundary ages, however, for a member to provide service to a client who might fall, by convention, just outside of one’s authorized population group.  Whether a member is practicing within one’s area of competency, as required by the Regulation, is a determination a member must make on a case by case basis, based on the characteristics of the individual client.

A member whose area of competence is Clinical Psychology with adults may occasionally see a boundary age adolescent (18-20 age range), who many might consider a young adult, dependent upon the evaluation of his/her level of development and maturity.    It is important to stress however, that should such requests for service become a more regular occurrence, it would be prudent for the member to one consider expanding one’s authorized population groups.

While the above information relates to a boundary age adolescent and a member whose area of competency is with adults, the principles can be applied to a member considering providing psychological service to the other boundary age client groups.

Autonomous practice members wishing to add an area of practice or a client group must undertake training and supervision to achieve competency comparable to other members of the College who are recognized for similar practice.

Members are required to make a written request to the Registration Committee specifying the practice area or client group they wish to add and to provide detailed information about how they have or plan to acquire the knowledge and skills in this new area.

The College’s Guidelines for Change of Area of Practice, outline the process in more detail.

The Registration Committee meets approximately every other month, dates of upcoming meetings are posted on the College’s website.

There have been no changes to the Standards with respect to members limiting their services to their authorized client populations.  We have tried, in revising the Standards, to make more members aware of the advice we provide about both the limits to authorized client populations and authorized areas of practice.

Members are still required to limit their services to their authorized populations and areas of practice. The College has never set age cutoffs, with the belief that members will use good judgment to determine whether a person is a child, adolescent, adult, or senior. Those distinctions should be based upon whether, in the member’s judgment, the client’s abilities, life situation, and challenges are consistent with those commonly associated with a particular group. We’ve provided some examples in the Practical Applications to Standard 5.1 contained within the Standards.

If you are not authorized to work with seniors, it would not be appropriate to take on a client facing age-related mental health challenges such as cognitive decline or social isolation.

If deciding whether to continue ongoing treatment with a client who has recently begun to experience the adverse effects of old age, it would be a good idea to refer him or her to someone authorized to work with seniors and, until this has occurred, seek consultation from someone with the specific training, skills and experience and who is authorized to work with seniors.

If an existing client is at a chronological age when age-related difficulties could reasonably be expected but are not yet occurring, it may be reasonable to still consider the client an “adult”. For example, if the client continues to work productively, live independently, has a vigorous fitness routine, is free from age-related health concerns, has meaningful and satisfying close relationships, etc., he or she need not be categorized as a “senior” for the purposes of the Standards, even if his or her age exceeds a commonly applied age marker such as 65.

The answer to this question depends upon the reason for involving family members in the treatment of an individual.

Individual therapists appropriately may involve a client’s family member(s) for the purpose of facilitating support for intervention with the individual. For example, a person’s family member(s) might be asked to become involved in making changes in the client’s environment to facilitate change or to be trained to provide reinforcement for desirable behaviours as part of a behavioural intervention program. A family member could also be asked to attend sessions with a person who, for some reason, may not be able to successfully participate in individual therapy without support. In such a scenario, the family member(s) attending would not be the object of the intervention themselves but would instead be there to help the client obtain optimal benefit from the individual therapy.

If the purpose of involving family members is to facilitate any changes in the family dynamics or the way in which family members interact with one another, this would be viewed as an family intervention. For example, this would be the case when it is the therapist’s intention to address an individual’s symptoms or behaviours of concern by addressing the patterns of interaction between family members which precipitate or maintain the difficulties. In order to provide such intervention to families, one must have specialized knowledge and training and the specific authorization of the College.

This is a situation that requires some definitional framing, before looking at the issue of feedback.

The Standards of Professional Conduct, 2017 define a “client” as:

 an entity receiving psychological services, regardless of who has arranged or paid for those services. A client can be a person, couple, family or other group of individuals with respect to whom the services are provided. A person who is a “client” is synonymous with a “patient” with respect to the administration of the Regulated Health Professions Act (1991). 

This means that the person who has been assessed is, from the perspective of the College, the client. Members are expected to be proactive in ensuring that clients are aware of their rights, including the right to access information about themselves, in accordance with the following Standard:

3.2 Clarification of Confidentiality and Professional Responsibility to Individual Clients and to Organizations

In situations in which more than one party has an interest in the psychological services rendered to a client or clients, members must, to the extent possible, clarify to all parties, prior to rendering the services, the dimensions of confidentiality and professional responsibility that must pertain in the rendering of services.  The provision of psychological services on behalf of an organizational client does not diminish the obligations and professional responsibilities to individual clients.

Practical Application: The need for clarification may arise, for example, in the provision of an assessment of a claimant in an insurance matter, where the insurer has retained the assessor. Regardless of the wishes of the insurer, members are under all of the obligations that pertain to a client within these Standards and the relevant privacy legislation.   This includes providing access to the individual or their authorized representative to their personal information and any reports or records which members have in their possession unless prohibited by law or they are otherwise permitted to refuse access.  

The requirement to provide feedback, upon request by the client, is addressed in Ontario Regulation 801/93 Professional Misconduct:

The following are acts of Professional Misconduct:

…
13. Failing to provide a truthful, understandable and appropriate explanation of the nature of an assessment, intervention, or other service following a client’s request for an explanation.

…
21. Failing, without reasonable cause, to provide a report or certificate relating to a service performed by the member, within a reasonable time, to the client or his or her authorized representative after a client or his or her authorized representative has requested such a report or certificate.

Similarly,  members are required to make information, including assessment results, available to all clients and authorized representatives, under the following Standard:

8.2 Access by Client or Client’s Authorized Representative

Members are responsible for ensuring that access to an individuals’ personal or personal health information is provided to the individual and/or their authorized representative unless prohibited by law or the member is otherwise permitted to refuse access.

While it may at first seem possible to find a technical “out” to providing feedback to someone who has not actually requested it, the Personal Health Information Protection Act, 2004 (PHIPA) specifies that consent to disclose information must be obtained from the person who has been assessed (or an authorized Substitute Decision Maker),  and only if they have knowledge of the purposes of the disclosure. The consent must also be related to the information to be disclosed. In other words, there is a positive responsibility on the part of the Health Information Custodian to ensure that the client has been provided with an opportunity to make a free and informed decision about the disclosure of the information that would be disclosed.

The College has not identified “parents” as a specific population to whom one needs particular authorization to consult to or otherwise work. The answer to your question then is:  It depends upon the specific focus of the consultation.

If the parenting work involves psychoeducation, that is, providing parents with information about child development and advice about how they can address childhood difficulties, then it would make sense that a practitioner has been deemed to have the requisite knowledge, training, and experience required to understand the developmental factors at play with children/adolescents being ‘parented’. In this situation, authorization to work with children and adolescents would be expected.

If the focus of the work is to help parents improve their relationship with their child, then specialized knowledge, skill, and experience in the area of family dynamics is important. For this reason, authorization to work with families would be necessary.

Similarly, if the focus of the work is helping the parents work together as a couple, then authorization to work with couples, would be appropriate. Likewise, if the work involves assisting an individual parent who for personal reasons experiences challenges in interacting with a child and this requires them to receive individual therapy to address their own difficulties, authorization to work with individuals within that parent’s own age group would be required.  Since you are authorized to work with adults, assuming that the parents are adults, then this would not be problematic.

Basically, one size can’t fit all, and the system of authorized populations allows for flexibility because of all of the possibilities with this kind of work.

Although there are no specific requirements identified with respect to formal notetaking in a consultation relationship, there are specific requirements with respect to services to Organizational Clients. The Standards of Professional Conduct, 2017 define an Organizational Client as:  an organization, such as a business, community or government that receives services that are directed primarily at the organization, rather than to the individuals associated with that organization.

If the social worker is thought of as operating a business, it is the business (as opposed to the social worker’s clients) to whom you are providing consultation. This would mean the records are Organizational Client Records. The Standards of Professional Conduct, 2017 set out the following requirements for Organizational Client records as follows:

9.3 Organizational Client Records

1. Members must keep a record related to the services provided to each organizational client.
2. The record must include the following:
3. the name and contact information of the organizational client;
4. the name(s) and title(s) of the person(s) who can release confidential information about the organizational client;
5. the date and nature of each material service provided to the organizational client;
6. a copy of all agreements and correspondence with the organizational client; and
7. a copy of each report that is prepared for the organizational client.

Although the “nature of each material service provided” is not described, it can be reasonably understood that this means information about the issues discussed and advice given should be recorded. This would apply to any consultation, including those involving members of other professions.

The Definition of Practice Areas are published as part of the Registration Guidelines.  Within the Guidelines, the definition of Counselling Psychology stresses fostering and improving human functioning by helping individuals solve problems, make decisions and cope with stresses of everyday life.  These can include work/career/education, family and social relationships, and mental health and physical health concerns.  In other words, these are the types of difficulties which may cause distress to an otherwise well-functioning or psychologically healthy individual. Some common examples of such problems are bereavement, unemployment, marital separation, or bankruptcy, etc. Generally, an individual presenting as having a disorder of behaviour, emotion or thought, should be assessed and treated by a member authorized in Clinical Psychology.

As described in the Definition of Practice Areas, members who practice Counselling Psychology, at a minimum, are expected to have "the ability to formulate and communicate a differential diagnosis in order to develop an appropriate counselling intervention and to identify clients who must be referred elsewhere”.

In contrast to that of Counselling Psychology, the definition of Clinical Psychology, as described in the Definition of Practice Areas, is "the application of knowledge about human behaviour to the assessment, diagnosis and/or treatment of individuals with disorders of behaviour, emotions and thought”.

It is sometimes unclear at the initial stages of involvement whether a client has a “disorder”, and this is an important reason that those authorized in Counselling Psychology be able to perform a differential diagnosis.  When a client presents with indicators of a disorder of behaviour, emotion or thought, a member who is not authorized in Clinical Psychology should refer them to a member authorized in this area.

If, at the time of referral, an individual presents with indicators that suggest they may have a diagnosable disorder, it would be most appropriate for an assessment to be conducted by someone qualified to work with those with clinical disorders. One should carefully consider the implications of beginning to work with someone that is likely to need to be transferred to someone else’s care. This could be quite disruptive to the client and the clinical relationship, and may even be damaging to their well-being and/or treatment.

At times, the extent of a client’s difficulties may not be apparent at the initiation of services, and it may later become evident that the client is suffering from a clinical disorder.  If a member, authorized in Clinical Psychology, is not available to accept a referral, it would be permissible to obtain supervision from someone so authorized.  This should be considered a “last resort” however, and not a “workaround” for appropriate authorization.

 In deciding whether one is authorized and competent to provide a service, the nature of the client’s presenting difficulties will generally determine whether the member has the appropriate and required authorization. In this case, the initial presenting problems did not include the difficulties associated with the traumatic brain injury. It may, however, be difficult to intervene effectively without the knowledge and experience necessary to understand the complexities of central nervous system dysfunction.

As long as the focus of your intervention is the challenges associated with a personality disorder, you may be able to continue to work within your established clinical relationship with the client, if you obtain consultation from a member authorized in clinical neuropsychology, who can help to tailor the interventions to take into account the client’s new challenges. If the task becomes one of helping the client address these new challenges as well,  then it may be appropriate to consider a referral for someone authorized in both clinical psychology and clinical neuropsychology.