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The Therapeutic Relationship As the Cornerstone of the Controlled Act of Psychotherapy

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The Therapeutic Relationship As the Cornerstone of the Controlled Act of Psychotherapy -2- The Therapeutic Relationship as the Cornerstone of the Controlled Act of Psychotherapy Volume 1 Submitted to the Minister of Health and Long-Term Care November 1, 2017 The Controlled Act of Psychotherapy: Recommendations of the Health Professions Regulatory Advisory Council Volume 1 TABS Tab 1………………………………………………………...……Report Tab 2………………….…………….Alternative Clarification Document The Therapeutic Relationship as the Cornerstone of the Controlled Act of Psychotherapy Volume 1 Thomas Corcoran Thomas Corcoran Chair President 56 Wellesley St W., 56, rue Wellesley Ouest, 12th Floor 12e étage Toronto ON M5S 2S3 Toronto ON M5S 2S3 Tel (416) 326-1550 Tél (416) 326-1550 Fax (416) 326-1549 Téléc (416) 326-1549 Web site www.hprac.org Site web www.hprac.org E-mail Courriel [email protected] [email protected] November 1, 2017 The Honourable Eric Hoskins Minister of Health and Long-Term Care 10th Floor, Hepburn Block 80 Grosvenor Street Toronto ON M7A 2C4 Dear Minister, The Health Professions Regulatory Advisory Council (HPRAC) is pleased to present our report on the controlled act of psychotherapy. Our approach included completing literature, jurisdictional, and jurisprudence reviews. To meet the timeline outlined in your August 4, 2017, correspondence, HPRAC undertook a targeted stakeholder consultation with key informants who would be affected by the recommendations on the controlled act of psychotherapy. HPRAC relied on this information to formulate the following advice: 1. In relation to clarifying the controlled act of psychotherapy: HPRAC believes that the client’s perspective should guide the clarification of the controlled act. As such, the key element of the controlled act is the therapeutic relationship between the client and the provider. This relationship includes diagnosis or assessment, a structured treatment plan, education of the client, securing the client’s informed consent, and the use of psychotherapy techniques. HPRAC also noted that further clarification is required on the activities that are not considered the controlled act of psychotherapy, such as counselling and coaching. 2. In relation to exemptions: In an ideal situation, the controlled act of psychotherapy should be restricted to the six regulated colleges listed in the Regulated Health Professions Act, 1991 (RHPA). Exemptions to practise the controlled act of psychotherapy should not be given to anyone who is not a member of the six regulated colleges listed in the RHPA. …/2 -2- HPRAC felt that clarifying specific pre-conditions for the controlled act of psychotherapy and provider categories that are not practising the controlled act would avoid the need for exemptions. However, as certain unregulated providers are concerned that their activities may be misinterpreted as the controlled act of psychotherapy, the Minister may consider that specific activities and categories of providers be exempted from the controlled act of psychotherapy. In this case, HPRAC has suggested approaches that use some of the activities HPRAC has defined as not performing the controlled act. If the controlled act is proclaimed, a transition period should be enacted to allow providers who perform the controlled act to meet the entry-to-practice requirements and register with one of the six colleges listed in the RHPA, or to reposition their practice. Lastly, the government should consider creating a robust registry of individuals who provide psychotherapy outside of the controlled act. During the information-gathering process and consultations, HPRAC observed that further communication to the public, regulated providers, and unregulated providers is required to clarify what is, and is not, the controlled act of psychotherapy. To that effect, if the controlled act is proclaimed, it would be beneficial for the six regulatory colleges and the Ministry of Health and Long-Term Care to undertake a communication campaign. HPRAC also observed variation across the six regulatory colleges in relation to the minimum knowledge, skills, and judgement required for the colleges’ members to practise psychotherapy. We suggest that the Minister consider requesting that the six regulatory colleges work together to establish minimum requirements for their members to practise psychotherapy. We look forward to meeting with you to discuss the findings in this report and our recommendations. Sincerely, Thomas Corcoran, Chair _________________________________ ________________________________ Rex Roman, Vice Chair Bob Carman, Member _________________________________ ________________________________ Jeanette Dias D’Souza, Member Mary Gavel, Member _________________________________ ________________________________ Paul Macmillan, Member Said Tsouli, Member Executive Summary Background In 2007, the Regulated Health Professions Act, 1991 (RHPA) was amended to include the controlled act of psychotherapy, defined as “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 judgment, insight, behaviour, communication or social functioning.” As of the writing of this report, in October 2017, the controlled act of psychotherapy has not yet been proclaimed. On August 4, 2017, the Minister of Health and Long-Term Care requested that HPRAC provide advice on how to make the meaning of the controlled act of psychotherapy clear so that it is better understood by the public and providers. The Minister also asked HPRAC to recommend criteria for determining whether there are certain providers who are not members of a regulated health profession who may require an exemption from performing the controlled act. The Minister requested that HPRAC provide its advice no later than November 1, 2017. In responding to the Minister’s request, HPRAC acknowledges the efforts of the Working Group established by five of the six regulatory colleges whose members may be authorized to perform the controlled act (i.e., the College of Nurses of Ontario, the College of Occupational Therapists of Ontario, the College of Physicians and Surgeons of Ontario, the College of Psychologists of Ontario, the College of Registered Psychotherapists of Ontario, and the Ontario College of Social Workers and Social Service Workers). The Working Group developed a document entitled Understanding When Psychotherapy is a Controlled Act (the Clarification Document). Consultation Process HPRAC’s key decisions were informed by results from its targeted stakeholder consultations; these were based on in-person meetings, written submissions, and key informant interviews, as well as presentations from subject matter experts. Meetings were held with the six regulated colleges, multi-disciplinary provider groups, professional associations, and patient groups. Approximately 35 invitations to respond to questions on the controlled act of psychotherapy were sent to selected organizations and individuals. HPRAC received 25 submissions. Consultation Findings The findings from the stakeholder consultations revealed varied positions on the controlled act of psychotherapy and who should be allowed to practise it. For instance, regulated colleges did not support allowing non-regulated providers to practise the controlled act of psychotherapy. Other providers were concerned that the activities they carried out would be considered the controlled act and require them to withdraw their services. A key issue noted by stakeholders was the lack of standardization among the six colleges with regards to education and competencies to practise 3 the controlled act. Another highlight from the consultations was the importance of protecting the title “psychotherapist.” HPRAC also relied on information garnered from its literature, jurisdictional, and jurisprudence reviews. Key learnings from the reviews included the approaches taken in other jurisdictions in relation to regulating psychotherapy, and potential exemptions. HPRAC made every effort to capture all voices that have a stake in how the controlled act of psychotherapy is practised, including exemptions to the act, and to carefully assess the information when making its recommendations. As per the Minister’s request, HPRAC aimed to balance the dual values of protecting the public and ensuring continued access to psychotherapy services. Clarifying the Controlled Act of Psychotherapy In order to make clearer the meaning of the controlled act of psychotherapy, HPRAC concluded that the client perspective is the key to further clarification, because the client’s active role is the cornerstone of a strong therapeutic relationship. Although many regulated and unregulated providers use psychotherapy techniques, the following specified set of conditions that define a strong therapeutic relationship must exist for the controlled act to be practised: Determining that an individual has a mental health impairment that is affecting the individual’s judgement, perception, and actions Determining that psychotherapy could improve the client’s mental health impairment Establishing a therapeutic relationship between the client and the provider Receiving treatment by means of a psychotherapy technique The controlled act of psychotherapy occurs when a therapeutic relationship that includes psychotherapy is established between the client and the provider. This relationship is structured and includes a number of key elements: A structured assessment and/or
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