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Ontario Coalition of Mental Health Professionals

Response to Bill 171, Schedule Q

Psychotherapy Act, 2006

March 28, 2007

Prepared by

Judith Ramirez

Consultant

Introduction

The Ontario Coalition of Mental Health Professionals welcomes the opportunity to comment on the government’s proposed Psychotherapy Act, 2006 or Schedule Q of Bill 171, Health System Improvements Act, 2006.

The Coalition has been actively promoting the statutory regulation of mental health professionals for many years. It represents well-established professional associations whose members provide a wide range of mental health services under a system of voluntary non-statutory self-regulation:

Canadian Association for Child and Play Therapists (Ontario)

Canadian Association for Pastoral Practice and Education (Ontario)

Canadian Counselling Association (Ontario)

Canadian Art Therapy Association (Ontario)

Music Therapy Association of Ontario

Ontario Art Therapy Association

Ontario Association of Consultants, Counsellors, Psychometrists and

Psychotherapists

Ontario Association for Marriage and Family Therapy

OntarioCollege Counsellors

Ontario Chaplain’s Association

Ontario Society of Psychotherapists

Professional Association of Canadian Christian Counsellors (Ontario)

The Coalition also has supporting members drawn from training institutes, certification bodies and agencies that employ mental health practitioners, includingthe Ontario Multifaith Council, Adler Professional Schools, Canadian Addiction Counsellors Certification Federation, Shepell.fgi, and others.

The Coalition represents approximately 4,300 highly qualified mental health professionals across the province. Of these, over 3000 (70%) have Masters-level degrees and some have doctoral degrees. The others have undergraduate degrees with extensive training and clinical experience in their respective fields of practice.

The Coalition was a stakeholder in the public consultation conducted by the Health Professions Regulatory Advisory Council (HPRAC) in 2005. Whenthe Council issued its report, Regulation of Health Professions in Ontario: New Directions, in April 2006, the Coalitionresponded with a comprehensive brief to The Honourable George Smitherman, Minister of Health and Long-Term Care.The Coalition’s comments below on the Psychotherapy Act, 2006reflect the views andconcerns expressed in earlier submissions.

Public Protection

The Coalition welcomes the government’s introduction of the Psychotherapy Act, 2006, as a critical step forward in providing much-neededprotection to the public as consumers of mental health services.We commend Minister Smitherman for referring the issue of how best to regulate psychotherapy to HPRACin 2005and for introducing draft legislation last December, only a few months after receiving the Council’s report last spring.

The Coalition had repeatedly called for statutory regulation to protect an unsuspecting public from unqualified or under qualified mental health practitioners who can “hang up a shingle” whenever they wish and are accountable to no one. This draft legislation, when passed, will finally provide the public with the protection they are afforded in other areas of health care and which many think they already have for mental health care!

Having argued that public protection must be the driving force behind the regulation of psychotherapy, the Coalition applauds the fact that the proposed new law wouldinclude not only registrants of the new College ofPsychotherapists of Ontario but also other professionals, such as physicians, nurses, occupational therapists and psychologists, who are already regulated under the Regulated Health Professions Act (RHPA).

The draft law clearly recognizes that psychotherapy is a distinct area of mental health care that requires not only the regulation of currently unregulated practitioners but also the psychotherapy-specific oversight of practitioners already regulated under the RHPA.

The Coalition supportsthe addition of social workers, who are regulated under their own statute rather than the RHPA, to the list of regulated professionsthat are recognized as providers of psychotherapy services in the Act.

Currently, mental health services are provided to the public by a wide range of practitioners, both regulated and unregulated,who operate in a variety of settings including hospitals, clinics, community agencies, schools, prisons, and many institutional and community-based programs funded by the government.

It is in the public interest to bring those who are currently unregulated under theproposed new lawregulating psychotherapy toensure that the full range of mental health practitioners meet high standards of training and are accountable for the services they provide. This would ensure that:

  • the pool of qualified and accountable mental health providers is increased
  • regulated mental health services are available in remote areas
  • regulated services are available in languages other than English and French
  • regulated services are available that are culturally competent and accessible to diverse communities

Greater public protection in the provision of mental health care is necessary because:

  • people receiving mental health care are vulnerable at the time of their lives when they seek assistance or treatment
  • the full range of mental health professionals, regardless of the setting in which they work, pose a risk of harm to the public due to the nature of their work
  • mental health care is an evolving area of health care with new approaches and treatment modalities that can pose a risk of harm if not developed within a regulatory framework

The Coalition has argued that some forms of mental health care that consist of information, advice and encouragement do not need to be regulated. Peer counselling with substance abusers, answering distress or kids lines, outreach work with the homeless, life skills counselling, credit counselling, assertiveness training and marriage preparation, all fit into this category. Organizations such as the Ontario Federation of Community Health and Addiction Programs have warned against too broad an approach to regulation.

The College of Psychotherapists

The Coalition strongly supports section 5 of the draft law which would create a new College of Psychotherapists of Ontario, as recommended by HPRAC. One of the strengths of the HPRAC consultation in 2005 was the recognition of the vital role played by currently unregulated practitioners in the delivery of mental health services.

At the time, the Coalition argued that none of the existing Colleges under the RHPA could be expected to serve as the regulatory body for thousands of additional practitioners with specific academic and clinical training in the field of psychotherapy. It strongly supported the creation of a new College that would capture the wide range of currently unregulated professionals who practice psychotherapy under a variety of titles such as “counsellor”, “counselling therapist” and “psychotherapist”.

When the law is enacted, the Coalition urges the government to appoint a transitional Council for the College of Psychotherapists of Ontario (section 12) that includes a critical mass of professionals from the currently unregulated sector.

The challenge of defining entry to practice standards and mechanisms for oversight and accountability will require the expertise of professionals who are actively involved in the currently unregulated sector as clinicians, academics and policy makers.

One of the first challenges will be to balance the need for public protection through “high minimum standards” and the need for public access to service through the acceptance of a wide range of practitioners in the new College.

Restricted Titles

The Coalition welcomes the provisions in section 8 that grant registrants of the new College the exclusive use of the titles “psychotherapist” and “registered mental health therapist”. It is essential for the public to be aware of who is accountable to the new regulatory body in order to exercise their rights as consumers of psychotherapy services. The protected titles would ensure that, through robust public education efforts, the public would have the information it requires to make accountability a meaningful proposition.

The Coalition also supports the fact that section 8 allows for two protected titles, “psychotherapist” and “registered mental health therapist”. This would give the new College greater flexibility in meeting other key public policy objectives in the regulation of mental health services, namely,access, inclusiveness and diversity.

There are scores of currently unregulated practitioners who do not practice as “psychotherapists” but who provide services typically described as “clinical counselling” or “counselling therapy”. Many of them consider “psychotherapy” as an advanced competency that is necessary for the treatment of more serious disorders. As well, many practitioners avoid using the title “psychotherapist” to help their clients deal with the shame or stigma attached to seeking help for emotional problems.

Allowing a broad spectrum of practitioners to become registrants in the new Collegewould ensure that the public has access tothe richness and diversity available in the mental health field.

To underscore the importance of diversity,the Coalition is on record as favouring the inclusion of “specialty” sub-titles under the proposed restricted titles to assist the public in choosing the most appropriate practitioner for their needs.

One example of a clearly-defined specialty area within psychotherapy is marriage and family therapy. Registered Marriage and Family Therapists are regulated in many jurisdictions in the United States and in Quebec as a distinct profession and credentialed through a series of rigorous academic and clinical requirements. Their specialized services could be more easily accessed by Ontarians if they were recognized by the new College’s regulations as specialists with their own professional sub-title.

As well, there are other professionals such as Registered Art Therapists, Pastoral Counsellors, Addiction Therapists, and others, who are credentialed by recognized bodies in many jurisdictions as specialized practitioners.

Scope of Practice

The Coalition supports the general definition of psychotherapy in section 3:

The practice of psychotherapy is 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.

This definition captures the full spectrum of activity along the continuum of what the Coalition refers to as “clinical counselling” up to “psychotherapy” proper andis thus inclusive of the many approaches and modalities that make up mental health care in Ontario. It is the Coalition’s understanding that all registrants of the new College, whether registered as “psychotherapists” or “registered mental health therapists” will come within the scope of practice of psychotherapy.

Authorized Act

The Coalition recognizes that an Authorized Act of psychotherapy was deemed necessary due to the seriousness of the harm that can result from the treatment of more serious mental health disorders. The Coalition supports the definition of the Authorized Act in section 5:

In the course of engaging in the practice of

psychotherapy, a member is authorized, subject to

the terms, conditions and limitations imposed on his

or her certificate of registration, to treat, by means of

psychotherapy technique delivered through a therapeutic

relationship, an individual’s serious disorder of thought,

cognition, mood, emotional regulation, perception or

memorythat may seriously impair the individual’s

judgement, insight, behaviour, communication or

social functioning.

The draft law does not state who in the proposed College of Psychotherapists of Ontario shall be granted the Authorized Act of psychotherapy. It is possible for the transitional Council to assign it to all registrants of the new College or to a select sub-set of registrants. Who will be granted the Authorized Act of psychotherapy and why is an important public policy question.

Review of Case Law

Because the draft law draws from the definition used in Alberta, Counsel for the Coalition, Beth Symes, has conducted a reviewof the case law in Alberta where the “restricted act” (“Authorized Act” in Ontario) is defined as follows:

To perform a psychosocial intervention with an

expectation of treating a substantial disorder of

thought, mood, perception, orientation or memory

that grossly impairs

i) judgement

ii) behaviour

iii) capacity to recognize reality, or

iv) ability to meet the ordinary demands of life.

The review of how the Alberta courts have interpreted the term “mental disorder” -defined the same way in both the “restricted act” and the Mental Health Act – shows that only the most severely mentally ill come under the “restricted act” and only specialists, or those with most expertise, can treat such persons.

The Alberta courts have set a narrow threshold for what is included under the “restricted act” of a “substantial disorder” that “grossly impairs”. What did not meet the test were cases involving: antisocial personality disorder, a history of substance abuse, serial hospitalizations, prostitution, and a violent lifestyle. What did meet the test were cases involving: serious mental illness such as paranoid schizophrenia, delusional thinking about people out to harm the patient, and a history of serious self-harm such as self-mutilation and suicide attempts,or harm to others.

Since the Psychotherapy Act, 2006 has not yet become law, Counsel reviewedOntariocase law where the Courts interpreted the word “serious” with respect to another statute, the Insurance Act.In defining what constitutes “serious impairment” in insurance claims to determine who can sue for damages after a motor vehicle accident, the Ontario Courts have set a significantly lower threshold than in Alberta.The test was met where the person is: unable to sleep through the night, perform household chores, socialize in a meaningful way, and perform pre-injury job (though fully employed again).

The Ontario case law pertaining to the Insurance Act is significant in light of the legal presumption of consistent expression across statutes. How the Courts have interpreted “serious impairment” in the context of the right to sue in insurance claims is relevant to how it may interpret “serious disorder” that “seriously impairs” in the context of the proposed Psychotherapy Act, 2006.

The case law review above would strongly suggest that there is an opportunity for the transitional Council of the new College of Psychotherapists of Ontario to take a broader, more expansive approach to the Authorized Act of psychotherapy than the narrow, restrictive approach taken in Alberta.

Conclusion

The Coalition thanks members of the government for the opportunity to comment on the Psychotherapy Act, 2006.On behalf of thousands of currently unregulated mental health practitioners,the Coalition calls on the government to pass this draft law without delay to provide the public with much-needed protection in the delivery of mental health services.