Ontario Coalition of Mental Health Professionals
Response to Bill 171, Schedule Q
Psychotherapy Act, 2006
March 28, 2007
Prepared by
Judith Ramirez
Consultant
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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
Ontario College 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, including the 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. When the Council issued
its report, Regulation of Health Professions in Ontario: New Directions, in April 2006,
the Coalition responded 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, 2006 reflect the views and concerns expressed in earlier
submissions.
Public Protection
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The Coalition welcomes the government’s introduction of the Psychotherapy Act, 2006,
as a critical step forward in providing much-needed protection to the public as consumers
of mental health services. We commend Minister Smitherman for referring the issue of
how best to regulate psychotherapy to HPRAC in 2005 and 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 would include
not only registrants of the new College of Psychotherapists 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 supports the addition of social workers, who are regulated under
their own statute rather than the RHPA, to the list of regulated professions that 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 the proposed
new law regulating psychotherapy to ensure 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:
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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:
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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
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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 College
would ensure that the public has access to the 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.
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This definition captures the full spectrum of activity along the continuum of what the
Coalition refers to as “clinical counselling” up to “psychotherapy” proper and is 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
memory that 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 review of 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.
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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 selfmutilation and suicide attempts, or harm to others.
Since the Psychotherapy Act, 2006 has not yet become law, Counsel reviewed Ontario
case 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.