Professional Practice and Jurisprudence for Registered Psychotherapists

In this document, a number of acts are referred to by their abbreviations, including the following:

AODA — Accessibility for Ontarians with Disabilities Act, 2005
CYFSA —  Child, Youth, and Family Services Act, 2017
HCCA —  Health Care Consent Act, 1996
MHA —  Mental Health Act, 1990
PHIPA —  Personal Health Information Protection Act, 2004
PIPEDA —  Personal Information Protection and Electronic Documents Act, 2000
RHPA —  Regulated Health Professions Act, 1991

Other abbreviations include the following:

CAS — Children’s Aid Society
CCB — Consent and Capacity Board
CRPO — College of Registered Psychotherapists of Ontario
CTO — Community Treatment Orders
HPARB — Health Professions Appeal and Review Board
ICRC — Inquiries, Complaints and Reports Committee
IPC — Information and Privacy Commissioner of Ontario
RHRA — Retirement Homes Regulatory Authority
RP — Registered Psychotherapist
SDM — Substitute Decision-Maker

RPs are regulated under the Regulated Health Professions Act, 1991 (RHPA) and the Psychotherapy Act, 2007. Together, these two Acts provide the regulatory framework for the practice of psychotherapy in Ontario.

The RHPA applies to all regulated health professions in Ontario. It helps protect the public from harm by requiring health professionals to be registered and to meet standards of practice and competence. The RHPA sets limits on the activities that non-regulated health professionals can do; e.g., only registrants of particular colleges, including CRPO, are authorized to perform 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.

The Psychotherapy Act establishes CRPO to regulate Registered Psychotherapists. CRPO is a regulatory body, not an educational institution or a professional association. CRPO’s mandate is to protect the public interest, not the interests of the profession (e.g., CRPO cannot advocate for RP services to be covered by insurance policies). Professional self-interest activities are the role of professional associations, not CRPO.

CRPO is not funded by government. Its revenue comes from fees charged to applicants and registrants. To ensure CRPO remains able to fulfill its mandate, it imposes a fee for late payment and may suspend a registrant’s certificate of registration for non-payment.

CRPO has several functions allowing it to regulate RPs in the public interest. These include

• registration requirements to ensure only qualified applicants are registered;
• a Quality Assurance Program to promote continuing competence;
• a Professional Conduct Department that investigates complaints and reports about registrants;
• holding discipline or fitness to practise hearings to consider allegations that a registrant has engaged in professional misconduct, incompetence, or is incapacitated; and
• a public register to provide transparent information about RPs, their registration status, and any conduct concerns.

Detailed information about these processes is available on CRPO’s website. Applicants and registrants are encouraged to review the site to become familiar with the work of CRPO.

There are a number of safeguards, set out in the RHPA, which ensure that all health regulatory colleges, including CRPO, serve the public interest in a fair and open manner. Examples of these safeguards are listed below:

• Council meetings and discipline hearings are open to the public. Anyone may watch the proceedings.
• CRPO must consult with the profession and the public before establishing any regulation and some by-laws.
• Decisions of CRPO committees may be reviewed by other bodies. For example, most decisions of the Registration Committee or the Inquiries, Complaints, and Reports Committee (ICRC) may be appealed to the Health Professions Appeal and Review Board (HPARB). Decisions of the Discipline Committee or the Fitness to Practise Committee may be appealed to the Divisional Court.
• The Office of the Fairness Commissioner makes sure that registration practices are transparent, objective, impartial, and fair.
• CRPO is accountable to the Minister of Health. CRPO must report annually to the Minister and provide additional information to the Minister if requested. The Minister may make recommendations or even issue directives to CRPO. If there are serious concerns, the Minster may audit the operations of the College and has the power to appoint a supervisor to take over its administration.

Regulatory colleges are encouraged to work with each other to develop standards relating to the performance of controlled acts common to several health professions. In the case of psychotherapy, five other regulated professions in Ontario are authorized to perform the controlled act of psychotherapy and to use the protected title “psychotherapist”. They are

• psychologists and psychological associates;
• physicians;
• nurses;
• occupational therapists; and
• social workers and social service workers.

CRPO has a Council, similar to the board of directors of a corporation, which governs the activities of the College. Council members have a duty of loyalty and good faith to the mandate of the organization, which is to protect the public interest. Council is comprised of registrants, as well as public members appointed by the government. Professional and public members work together to ensure that the views of clients and the public are represented in the regulatory process. Council’s activities include setting policy and strategy; approving by-laws, regulations, and budgets; and reviewing the performance of the Registrar (CEO), who is the senior staff-person of the College.

The RHPA requires all health regulatory colleges to have seven committees (sometimes referred to as “statutory committees”). Committees oversee specific areas of the College’s work and report to Council. As an example, the Registration Committee sets registration policy and reviews applications where CRPO staff are unsure if they meet the registration requirements. Another College committee is the ICRC, which screens complaints and reports about registrants. Colleges may establish other committees (sometimes referred to as “non-statutory committees”) or working groups as needed. For example, CRPO has an Examination Committee that considers appeals from candidates who have failed the registration exam. CRPO periodically recruits registrants to serve on various committees.

Which sentence best describes CRPO’s role versus that of a professional association?

i. CRPO serves the public interest and professional associations serve the interests of the profession.

ii. CRPO and professional associations both serve the public interest.

iii. CRPO and professional associations both serve the interests of the profession.

iv. The professional associations direct the operations of CRPO.

The best answer is i. CRPO’s mandate is to regulate the profession in order to serve and protect the public.

Answer ii is not the best answer because professional associations are designed to serve the interests of their members. While professional associations care about the public interest and often take actions that assist the public interest, they are under no statutory duty to do so and are accountable only to their members.

Answer iii is not the best answer because CRPO is not permitted to serve the interests of its registrants under its statute. While CRPO tries to ensure that it regulates its registrants fairly and justly, and consults with its registrants, CRPO’s mandate is to protect the public interest.

Answer iv is not correct. While CRPO may consult with professional associations and consider their views, it is not under the control of any professional association.

CRPO’s Code of Ethics sets out certain principles of professional practice — ideals that registrants should aspire to in their professional practice and community roles. These principles differ from practice standards. Practice standards can be thought of as the minimum standard of professional practice expected of all registrants, whereas the principles included in the Code of Ethics are ideals that registrants should strive to uphold.

As a registrant of the College of Registered Psychotherapists Ontario, I strive to practise safely, effectively, and ethically, and to uphold the following principles:

Autonomy & Dignity of All Persons

To respect the privacy, rights and diversity of all persons; to reject all forms of harassment and abuse; and to maintain appropriate therapeutic boundaries at all times.

Excellence in Professional Practice

To work in the best interests of clients; to work within my skills and competencies; to maintain awareness of best practices; and to pursue professional and personal growth throughout my career.

Integrity

To openly inform clients about options, limitations on professional services, potential risks and benefits; to recognize and strive to challenge my own professional and personal biases; and to consult on ethical dilemmas.

Justice

To strive to support justice and fairness in my professional and personal dealings, and stand against oppression and discrimination.

Responsible Citizenship

To participate in my community as a responsible citizen, always mindful of my role as a trusted professional; and to consult on potential conflicts-of-interest and other personal-professional challenges.

Responsible Research

To conduct only basic and applied research that potentially benefits society, and to do so safely, ethically and with the informed consent of all participants.

Support for Colleagues

To respect colleagues, co-workers, students, and members of other disciplines; to supervise responsibly; to work collaboratively; and to inspire others to excellence.

Professional practice standards explain the ways Registered Psychotherapists are expected to practise the profession. They may be written or unwritten. Written standards include those contained in legislation or College documents. Unwritten standards are requirements that are generally accepted within the profession. Falling below a standard is considered professional misconduct. This manual describes CRPO’s written standards in Section 2.

Professional misconduct is behaviour that falls below the minimum standards of the profession. Professional misconduct may lead to disciplinary proceedings potentially resulting in a reprimand, remediation, suspension, or in the most serious cases, revocation of a registrant’s certificate of registration.

The full definitions of professional misconduct are found in

• Section 51(1) of Schedule 2 of the RHPA; and
• CRPO’s Professional Misconduct Regulation.

The following are a few examples of professional misconduct:

• sexual abuse of a client, (e.g., engaging in sexual touching or remarks);
• failing to maintain professional boundaries (e.g., employing a client);
• failing to keep adequate records (e.g., not retaining emails in the client file; not securely storing files);
• breaching client confidentiality (e.g., identifying a client, even to their family member, without consent);
• fraudulent billing, (e.g., falsely claiming for insurance reimbursement that one’s services were supervised); and
• disregarding restrictions on one’s certificate of registration (e.g., a registrant who is required to practise with clinical supervision not doing so, or practising a type of therapy without adequate training).

Professional misconduct may also involve inappropriate conduct towards CRPO, including

• publicly challenging the integrity of CRPO (though registrants are encouraged to engage in constructive dialogue about CRPO policy, e.g., by making submissions during CRPO consultations, and by offering to join CRPO working groups, committees, and Council);
• breaching an undertaking (promise) given to CRPO;
• failing to participate in the Quality Assurance Program;
• failing to respond appropriately and promptly to correspondence from the CRPO; and
• failing to co-operate in an investigation by the CRPO or obstructing an investigation by the College.

Which of the following would be considered professional misconduct according to the Professional Misconduct Regulation?

i. Failing to maintain client confidentiality.

ii. Insulting a client by email because they wanted to stop seeing the registrant.

iii. Charging a higher rate because a third party is paying for the service.

iv. All of the above.

The best answer is iv. The Professional Misconduct Regulation describes many types of professional misconduct. All the situations described involve conduct that is specifically prohibited in the Professional Misconduct Regulation.

Answers i, ii, and iii are not the best answers because all the situations listed in the question are clear examples of professional misconduct.

Incompetence refers to a lack of knowledge, skill, or judgment when assessing or treating a client. In serious cases, allegations of incompetence may result in a discipline hearing. If the Discipline Committee finds that an RP is incompetent, it could impose restrictions on the registrant’s practice, such as requiring intensive clinical supervision or upgrading courses. In the most serious cases of incompetence, the Discipline Committee could suspend or revoke the registrant’s registration.

In any investigation of incompetence, CRPO will usually look at the registrant’s records and speak with the registrant directly. CRPO will also interview the clients involved and ask other psychotherapists whether they think the conduct shows incompetence. The investigating committee and deliberating committee (i.e., the ICRC and the Discipline Committee) include RPs to assist in determining the difference between good and bad practice.

Incapacity occurs when a health condition prevents a registrant from practising safely. Usually, the health condition is one that interferes with the psychotherapist’s ability to think clearly. Often incapacity is related to substance abuse, addiction, or illness (mental and physical) that impairs the registrant’s professional judgment; e.g., a psychotherapist with a condition that includes delusions and lack of insight.

An RP who is incapacitated is not treated as if they have engaged in professional misconduct or incompetence. The investigation looks at the registrant’s health condition and the treatment they are receiving or may need. CRPO may require the RP to undergo a specialist examination. If the concern is justified, the registrant may be referred to the Fitness to Practise Committee for a hearing. The Committee may order the registrant to undergo treatment or receive medical monitoring in order to continue to practise, or it may restrict the psychotherapist’s practice. In an extreme case (e.g., where the registrant refuses treatment), the Fitness to Practise Committee may suspend or revoke the registrant’s registration, in order to protect the public.

Which of the following is not considered professional misconduct regarding a registrant’s conduct toward the College?

i. Failing to attend for a caution before the Inquiries, Complaints and Reports Committee.

ii. Failing to cooperate with the College investigating a matter that was brought by a client complaint.

iii. Failing to respond to a proposed regulation that has been put out to registrants for feedback.

iv. Not participating in the Quality Assurance Program because a registrant feels they know enough.

The best answer is iii. While it may be beneficial to the profession in general to contribute to the regulatory process by providing feedback to any proposed regulations, this is not a mandatory duty that would constitute professional misconduct if it wasn’t performed.

Answer i is not the best answer because failing to attend a caution directed by the Inquiries, Complaints and Reports Committee is professional misconduct. Cautions help make the complaints process work.

Answer ii is not the best answer because the College has the authority to regulate the profession, and registrants must cooperate with the College when it is investigating matters. Failing to cooperate is professional misconduct.

Answer iv is not the best answer because the Quality Assurance Program is a required part of being registered.

This mandatory report is required when regulated health professionals, including RPs, have reasonable grounds to believe that an Ontario regulated health professional has sexually abused a patient or client. The mandatory reporting duty applies to information obtained in the course of practising the profession. That is, it does not apply to information learned in the RP’s personal life. RPs should refer to the definition of sexual abuse (covered later in this manual), so they know what conduct is reportable.

The report must follow these requirements:

• The report must be made, in writing, within 30 days of receiving the information.
• If it appears that a client is continuing to be harmed and there is an urgent need for intervention, the report must be made right away.
• The report must be directed to the Registrar of the regulatory college to which the alleged sexual abuser belongs.
• The reporting RP’s name and the alleged grounds of the report must be included.
• To protect the privacy of potentially vulnerable clients, the report cannot include the client’s name unless the client consents in writing.

There is an additional mandatory reporting obligation where the registrant is providing psychotherapy to another regulated health professional. To illustrate, consider that “A” is an RP treating client “B”. B is a regulated health professional, (e.g., a chiropractor, dentist, nurse, etc.). A has reasonable grounds to believe that B has sexually abused one of their clients, “C”. In such cases, the registrant, A, must file a mandatory report with the Registrar of B’s college, even though this breaches client-therapist confidentiality. The mandatory report must also contain an opinion as to whether B is likely to sexually abuse clients in the future, if the registrant is able to form such an opinion. If B ceases psychotherapy with the registrant, the registrant must immediately file an additional report with B’s regulatory college. Again, the report must include an opinion as to whether B is likely to abuse again, if the registrant is able to form such an opinion.

Is a mandatory report required where a registrant overhears another RP tell two male clients a sexually explicit joke that causes the clients to laugh loudly?

i. No. Jokes are not sexual abuse.

ii. Yes. This is sexual harassment. The report should be made to the Human Rights Tribunal.

iii. No. The clients liked the joke and would not have been harmed by it.

iv. Yes. This constitutes sexual abuse.

The best answer is iv. Sexual abuse includes comments of a sexual nature to a client. Reporting sexual abuse is mandatory. While this situation does not involve sexual intercourse or touching, it is still important that RPs learn that this conduct can be harmful to clients. One never knows what experiences clients have had in their past that might make a joke harmful.

Answer i is incorrect because jokes can be considered sexual abuse as that term is defined in the RHPA.

Answer ii is not the best answer because there are no mandatory reporting requirements under the Human Rights Code. Also, the RHPA uses the term sexual abuse rather than sexual harassment and gives that term a unique meaning.

Answer iii is not the best answer because whether the client was a willing participant or not is irrelevant. The joke should not have been told. Also, one never knows what experiences clients have had in their past that might make a joke harmful. In addition, sexualizing the practice of the profession is inherently confusing to clients who assume that there is no sexual aspect to their relationship with RPs.

It is mandatory for a facility operator (e.g., clinic, hospital, agency) to file a report if they have reasonable grounds to believe that a CRPO registrant (or a registrant of any other college) has sexually abused a client, is incompetent, or is incapacitated. This report must be made whether or not the health professional is terminated from their position. A facility operator may or may not be a regulated health professional, but they have this duty nonetheless. Such a report must be filed in accordance with the requirements noted above.

Any person must file a report if they end a business relationship (e.g., a partnership, an employee/employer relationship, a corporate relationship, or a space-sharing arrangement) with a regulated health professional on the basis of incompetence, incapacity, or professional misconduct. The report must be made even if the regulated health professional quit or resigned before the business arrangement ended. This duty applies whether the employer or business partner is a regulated health professional or not.

The report must:

• be made in writing within 30 days of ending the business relationship; and
• be directed to the Registrar of the college to which the subject of the report belongs.

CRPO’s Professional Misconduct Regulation requires registrants to report to CRPO where they have reasonable grounds to believe another RP engaged in an incident of unsafe practice. Unsafe practice does not refer to any mistake or error. Rather, it involves conduct that poses a significant risk of serious harm. Registrants must not submit a client’s identity to CRPO in the report unless the client has given their written consent.

Registrants must inform CRPO when they have been found guilty of an offence by a court. All offences, including criminal offences; offences under federal drug or other legislation; and provincial offences (e.g., highway traffic offences) must be reported to CRPO. Speeding tickets and parking tickets do not need to be reported to CRPO.

Only courts can make offence findings. Thus, any findings by a body that is not a court, such as a tribunal, are not reportable under this provision. All findings are reportable regardless of whether or not they resulted in a conviction, e.g., an absolute discharge order for assault; a conditional discharge order for theft; or a conviction for public mischief.

Reports must be made to the CRPO Registrar as soon as possible after the finding and contain the following information:

• the name of the RP filing the report;
• the nature of, and a description of, the offence;
• the date the RP was found guilty of the offence;
• the name andlocationofthecourtthatfoundtheRPguiltyoftheoffence; and
• the status of any appeal initiated respecting the finding of

Once a report is filed, it will be reviewed by CRPO and may result in an investigation. If there is an appeal that alters the information reported, an updated report must be made. The RHPA requires criminal or drug offence findings to be posted on the public register.

Registrants are required to self-report any current outstanding offence charges and bail or other restrictions. The report must contain the following information:

• the name of the registrant filing the report;
• the nature of, and a description of, the charge;
• the date the charge was laid against the registrant;
• the name and location of the court in which the charge was laid or in which the bail condition or restriction was imposed on or agreed to by the registrant;
• every bail condition imposed on the registrant as a result of the charge;
• any other restriction imposed on or agreed to by the registrant relating to the charge; and
• the status of any proceedings with respect to the charge.

The self-report must not contain any information that violates a publication ban. If there is a change in the status of the charge or bail conditions, the registrant must file an additional report. The RHPA requires that outstanding criminal or drug charges, and bail or related conditions, must be posted on the public register.

RPs found by a court to have engaged in professional negligence or malpractice must report the finding to CRPO. Findings by a tribunal do not need to be reported. Settlements of claims for professional negligence need not be included if they did not result in a court finding.

Reports must be made to the CRPO Registrar as soon as possible after the finding and contain the following information:

• the name of the RP filing the report;
• the nature of, and a description of, the finding;
• the date of the finding;
• the name and location of the court that made the finding; and
• the status of any appeal initiated respecting the finding.

The report will be reviewed by CRPO and may result in an investigation. Information from the report is placed on the public register. If there is an appeal that alters the information reported, an updated report must be made.

In addition to those listed above, registrants are required to report the following events to CRPO:

• a finding of professional misconduct, incompetence or incapacity, or any similar finding, in relation to another regulated profession in Ontario or to any regulated profession in another jurisdiction;
• a current proceeding for professional misconduct, incompetence or incapacity, or any similar proceeding, in relation to another regulated profession in Ontario or to any regulated profession in another jurisdiction;
• a refusal by any body responsible for the regulation of a profession in any jurisdiction to register or license the registrant;
• resignation from another professional regulator, including whether the RP was in good standing at the time of resignation; and
• any other event that would provide reasonable grounds for the belief that the registrant will not practise psychotherapy in a safe and professional manner.

The last item is a ”catch-all” self-reporting obligation. It is intended to capture serious concerns not specifically listed. These concerns could include, but are not limited to, disciplinary action by an educational institution or a situation where a registrant recognizes they caused serious harm to a client.

There is no general duty to report someone who has committed a crime. Clients are seeking help and trust registrants to safeguard their privacy to the greatest extent possible. Registrants may only disclose confidential information without the client’s consent if a specific legal exception applies. Exceptions include the mandatory reports listed in this section. Registrants may also disclose confidential information if doing so is necessary to prevent or reduce a significant risk or serious harm (e.g., if the client imminently plans to die by suicide, or threatens the registrant or others with violence).

Another exceptional situation is where the client draws the registrant into a criminal activity by association. For example, what if a client tells the registrant they plan to forge invoices in the registrant’s name, submit these to their insurance plan, keep part of the money, and offer to pay the registrant a cut? If the registrant did nothing, they would be seen as participating in the crime. In such a situation, the registrant should refuse to participate and attempt to gain the client’s assurance they will not move forward with the fraud. They should also seek legal advice regarding other potential steps such as terminating therapy and warning others, such as insurance companies, of potential fraud.

A registrant who has reasonable grounds to suspect that any child is in need of protection must report this to a Children’s Aid Society (CAS). This duty overrides all privacy and confidentiality duties and laws, including the Personal Health Information Protection Act, 2004 (PHIPA). No legal action may be taken against a registrant for making a report, unless the report is made maliciously or without reasonable grounds. CRPO cannot discipline a registrant for making such a report in good faith and with reasonable grounds.

As a result of a report, a CAS worker may investigate further, and where action is needed, in many cases, CAS will offer family services such as counselling and parental support.

A psychotherapist has a duty to report with respect to any child under the age of 16. Reports regarding children who are 16 or 17 years old and in need of protection may be made at the discretion of the registrant.

This duty applies to all children, including the child of a client, or a child who is a client, or any other child. However, a registrant has a special responsibility to report information about a client if the information was obtained in the course of their professional duties (as opposed to their personal life). A registrant may be fined up to $5000 for failing to make a report in such a circumstance. The duty to report is ongoing (for new information) even if a previous report has been made respecting a child. The report must be made directly, without relying on anyone else to file the report on one’s behalf.

A registrant must make a report when they have reasonable grounds to suspect any of the following:

A child has been harmed or is at risk of harm

A report is required if a child is likely to have been, or is at risk of being, physically harmed by a person in charge of the child (e.g., a parent or guardian), either directly or as a result of neglect or a pattern of neglect. A report is also required if a child has been, or is at risk of being, sexually molested or sexually exploited by a person in charge of the child. A report is also required if the person in charge of the child knows or ought to know of these risks and fails to protect the child.

Failure to provide or consent to services or treatment

There are numerous circumstances where the person in charge of a child does not (or cannot) provide services or treatment to a child, or where the person in charge does not (or cannot) consent to services or treatment for a child. A report is required where a child is not receiving services or treatment, and

• the child requires medical treatment to cure, prevent, or alleviate physical harm or suffering;
• the child has suffered or is likely at risk of suffering emotional harm, demonstrated by serious anxiety, depression, withdrawal, self-destructive or aggressive behaviour, or delayed development believed to be caused by action or inaction of the person in charge of the child;
• the child has a mental, emotional, or developmental condition that, if not remedied, could seriously impair the child’s development; or
• the child is under the age of 12, has killed or seriously injured another person or has caused serious damage to another person’s property, and services or treatment are needed to prevent a recurrence.

Abandonment

A report is required if a child has been abandoned by a parent or guardian, or is otherwise left without a caregiver. This includes the death of the child’s parents.

Failure to supervise a child

A report is required if a child has injured another person or damaged another person’s property more than once because a person in charge of the child encouraged the child to do so. A report is also required if a child has injured another person or damaged another person’s property more than once because a person in charge of a child has not or is not able to supervise a child adequately.

In Ontario, the Long-Term Care Homes Act regulates long-term care homes, which are facilities that provide 24-hour nursing care and supervision for persons in need of this level of care.

The Long-Term Care Homes Act sets out a Residents’ Bill of Rights requiring long-term care homes to ensure residents are treated fairly and with dignity and respect. This includes the right to participate in decision-making about the resident’s care, the right to privacy in treatment and care, and the right to receive care and assistance aimed at maximizing the resident’s independence as much as possible.

A long-term care home must have a zero-tolerance policy with respect to abuse (physical, sexual, emotional, verbal, or financial) and neglect of residents.

Registrants have a duty to report abuse and neglect of residents and certain other types of conduct to the Ministry of Health. A report is required if a therapist (or any other person) suspects on reasonable grounds that any one or more of the following has occurred:

• improper or incompetent treatment or care of a resident that results in harm or a risk of harm to the resident;
• abuse of a resident by anyone;
• neglect of a resident by staff, including management, that results in harm or a risk of harm to the resident;
• unlawful conduct that results in harm or a risk of harm to a resident;
• misuse or misappropriation of a resident’s money; or
• misuse or misappropriation of funding provided to a long-term care

It is an offence for a registrant to fail to make a report in any of the above circumstances if the therapist provides care or services to long-term care home residents. A registrant may be fined up to $100,000 for failing to make such a report.

Complaints and reports about the care of a resident or the operation of a long-term care home must be investigated by the Ministry of Health if they involve certain matters, including abuse of a resident by anyone, and neglect of a resident by staff. Every person, including an RP, is protected from retaliation for making a report or for cooperating with an investigation. This includes protection from being fired, disciplined, or suspended.

A registrant is not required to report the following regarding a long-term care home resident:

i. A resident’s son frequently yells and swears at the resident.

ii. A staff member is borrowing money from a resident with memory difficulties.

iii. A nurse has not been monitoring a resident over the past several shifts.

iv. A resident’s daughter has stopped visiting the resident.

The best answer is iv. All of the above except iv must be reported. While a resident’s family member may neglect that person, this does not have to be investigated unless the neglect is to the point of emotional abuse.

Answer i is not the best answer because this may constitute verbal and emotional abuse, which must be reported.

Answer ii is not the best answer because this may be considered financial abuse, and any person who financially abuses a resident must be reported.

Answer iii is not the best answer because a nurse who has not been monitoring a resident may be neglecting that client. Neglect of a client by a staff member must be reported.

A retirement home is a residence primarily for persons who are 65 years or older, where the operator of the home provides at least two care services (e.g., assistance with feeding, bathing, dressing, personal hygiene). Retirement homes are overseen by the Retirement Home Regulatory Authority (RHRA). Under the Retirement Homes Act, 2010, a person is required to report to the Registrar of the RHRA if they have reasonable grounds to suspect any one or more of the following:

• improper or incompetent treatment or care of a resident that results in harm or a risk of harm to the resident;
• abuse of a resident by anyone;
• neglect of a resident by the licensee or the staff of the retirement home if it results in harm or a risk of harm to the resident;
• unlawful conduct that results in harm or a risk of harm to a resident; or
• misuse or misappropriation of a resident’s money.

Under PHIPA, a health information custodian is required to notify an individual if their personal health information is lost, stolen, or used or disclosed without authority. This report must be made at the first reasonable opportunity and must include a statement that the individual is entitled to make a complaint to the Information and Privacy Commissioner of Ontario (IPC).

The custodian must also notify the IPC of the breach in a variety of circumstances, essentially where the breach is significant (e.g., negligent or intentional breaches, theft of personal health information, risk of additional privacy breaches, part of a pattern of breaches, where a mandatory report is also made to a college). The list of circumstances is set out in section 6.3 of the General Regulation made under PHIPA. To decide whether the breach needs to be reported to the IPC, custodians should consult the General Regulation, contact the IPC, or contact their legal advisor.

In addition to the above obligations, health information custodians are required to file annual reports with the IPC. These reports include general data about requests for access, correction, and other statistics as well as any privacy breaches from the previous year.

The controlled acts listed in the RHPA are as follows:

1. Communicating a diagnosis to the individual or a personal representative identifying a disease or disorder as the cause of symptoms of the individual in circumstances in which it is reasonably foreseeable that the individual or their personal representative will rely on the diagnosis.
2. Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth.
3. Setting or casting a fracture of a bone or a dislocation of a joint.
4. Moving the joints of the spine beyond the individual’s usual physiological range of motion using a fast, low amplitude thrust.
5. Administering a substance by injection or inhalation.
6. Putting an instrument, hand or finger, beyond the external ear canal, beyond the point in the nasal passages where they normally narrow, beyond the larynx, beyond the opening of the urethra, beyond the labia majora, beyond the anal verge, or into an artificial opening into the body.
7. Applying or ordering the application of a form of energy prescribed by the regulations under this Act.*
8. Prescribing, dispensing, selling or compounding a drug as defined in the Drug and Pharmacies Regulation Act, or supervising the part of a pharmacy where such drugs are kept.**
9. Prescribing or dispensing, for vision or eye problems, subnormal vision devices, contact lenses or eye glasses other than simple magnifiers.
10. Prescribing a hearing aid for a hearing impaired person.
11. Fitting or dispensing a dental prosthesis, orthodontic or periodontal appliance or a device used inside the mouth to protect teeth from abnormal functioning.
12. Managing labour or conducting the delivery of a baby.
13. Allergy challenge testing of a kind in which a positive result of the test is a significant allergic response.
14. 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.

*Examples of these forms of energy include the use of electricity for aversive conditioning, electromagnetism for magnetic resonance imaging, and soundwaves for diagnostic ultrasound.

**As a general rule, if a substance has a DIN (Drug Identification Number), it is usually considered to be a drug. Some non-drug substances have different kinds of drug numberings, such as a Natural Product Number (NPN) or Homeopathic Medicine Number (DIN-HM). These products are generally not considered to be drugs.

CRPO registrants are not authorized to communicate a diagnosis to clients; however, they are permitted to assess clients. It is important to keep the distinction in mind. A diagnosis is a conclusive statement that identifies a disease or disorder as the cause of a client’s symptoms. An assessment describes those symptoms and is aimed toward treatment planning.

As an example, the following statement made by an RP to a client would be an inappropriate communication of a diagnosis: “It appears you are experiencing mild or moderate depression.” Depression is a mental health diagnosis, and the way the statement is phrased could lead a client to rely on it.

In contrast, the following statement by an RP to a client would be appropriate as a form of assessment, planning, and referral: “You have reported sadness and low energy. I am proposing we engage in CBT, and I suggest you follow up with your family physician to consider depression or other issues.” This statement does not apply a diagnostic label but summarizes what the client reported and makes a recommendation about treatment. It also suggests contacting a regulated health professional who is authorized to communicate a diagnosis. In situations that could confuse a client as to whether they are being diagnosed, registrants should make clear they are not authorized to communicate a diagnosis.

Confusion can arise when an RP works with another professional authorized to communicate a diagnosis. Registrants are permitted to refer to and treat a previously diagnosed condition but may not take on the role of the diagnosing professional.

Standard 1.4 describes the following three ways a health care provider can receive the legal authority to perform a controlled act:

1. if authorized to do so as a regulated health professional;
2. as an exception or exemption; or
3. if a controlled act is delegated by another regulated health professional who is authorized to perform the controlled act.

Except in very limited circumstances, RPs are not permitted to delegate the controlled act of psychotherapy to another person. Psychotherapy is a relational process rather than a technique. Providing psychotherapy requires extensive training and accountability. For these reasons, unlike other controlled acts, it generally cannot be delegated.

In exceptional circumstances, with prior approval of the CRPO Council, an RP may delegate the controlled act of psychotherapy. Alternately, an RP may delegate the controlled act of psychotherapy if circumstances exist where time does not allow the RP to obtain prior approval of CRPO Council, and the registrant notifies CRPO of the delegation as soon as reasonably possible.* These exceptional circumstances could conceivably involve an individual or public health emergency. To date, CRPO has not provided approval nor received notification of delegation of the controlled act of psychotherapy.

*O. Reg. 317/12: PROFESSIONAL MISCONDUCT, s. 1, para 12.

Which of the following is a controlled act?

i. Removing broken glass that has been deeply embedded in a child’s leg.

ii. Cleaning a scrape on a child’s elbow with soap and water.

iii. Applying alcohol to that scrape on a child’s elbow.

iv. Wrapping the child’s wounds.

The best answer is i. Deeply embedded glass has almost certainly gone beyond the dermis and is sitting in deeper tissue. There may be an issue as to whether this is an emergency (likely not as in most cases it would be possible to take the child to a hospital or physician’s clinic for treatment), but that does not change the fact that removing the glass is a controlled act. Similarly, the household exemption does not apply to these sorts of procedures.

Answer ii is not the best answer because a scrape on the skin implies that it has not gone beneath the dermis.

Answer iii is not the best answer because applying a substance to the skin is not administering a substance by inhalation or injection.

Answer iv is not the best answer because the procedure is above the skin and does not fall within any of the other controlled acts.

Some conflicts of interest can be resolved through a process of disclosure. The steps would be as follows, applied to the above example of recommending an addiction facility:

• disclosing the nature of the relationship in question (e.g., “My friend owns the facility I’m recommending”);
• providing alternative options (e.g., “Here are two other places you could get these kinds of services”); and
• reassuring the client that choosing another option will not affect the client’s care (e.g., “You’re free to choose any of the places to get treatment; you will still be welcome here as my client”).

By being transparent, giving options, and maintaining the same level of care, the registrant ensures their client’s best interests are being upheld.

Some conflicts are better avoided altogether as disclosure may not remove the risk of harm to the client. Suppose in the above example that the addiction treatment facility agreed to pay the RP a commission for every successful client referral. Even if the RP were to disclose the nature of the financial arrangement and provide the client with other options, a reasonable person could still conclude that the RP’s recommendation is being made with their own financial interest in mind, rather than in the best interest of the client. Standard 1.6 considers accepting or paying referral fees to be a conflict of interest.

In other cases, disclosing the conflict may be difficult or impossible. For example, an RP may discover that two separate clients are personally close to each other. The RP will not be able to share that fact, as each client’s information is confidential.

In addition to those listed in Standard 1.6, the following are examples of conflicts of interest:

• treating individual* clients who know each other well;
• having a dual personal relationship with a client or a conflicting professional role with a client (e.g., supervisor, teacher, parenting coordinator, mediator);
• having a personal relationship with a supervisee, e.g., supervising one’s family member. In such a case the supervisor’s personal relationship with the supervisee could be perceived as interfering with the supervisor’s duty to safeguard the well-being of the supervisee’s clients;
• selling a product to a client for a profit; and
• taking payment in kind (bartering) for psychotherapy. The therapist may be perceived as having an interest in undervaluing the consideration offered by the client.

*Different considerations apply in couple, family, or group therapy contexts.

See also Standard 6.1 Fees.

Which of the following is a conflict of interest?

i. Charging a client for a missed appointment.

ii. Suggesting that a client could buy lavender cream (for relaxation purposes) from your cousin’s store after making full disclosure and providing the necessary assurances.

iii. Agreeing to give a brand influencer $100 for every client referred to you.

iv. Giving a clinic owner an inexpensive bottle of wine every new year.

The best answer is iii. It is a conflict of interest to confer a benefit to someone who refers clients to a registrant. Such referrals should be based on the honest opinion of the referral source and not result from any benefit they might have received.

Answer i is not the best answer because one can charge for a missed appointment so long as this fee has been established in advance.

Answer ii is not the best answer as one can make a referral to a family business if one makes full disclosure, indicates that the client can purchase the product elsewhere, and indicates that not following the recommendation will not alter the relationship.

Answer iv is not the best answer because a token gesture given once a year would not reasonably be understood as conferring a benefit that would alter behaviour. All conflict-of-interest provisions are governed by reasonableness.

Therapists must be cautious when disclosing personal information about themselves to clients. Revealing personal details must be of therapeutic benefit and shared with rapport and sensitivity. When a registrant discloses information about their private life in a non-therapeutic manner, it may confuse or upset the client. Non-therapeutic self-disclosure suggests that the professional relationship is serving the needs of the therapist rather than the client’s best interests.

Self-disclosure can also involve sharing personal views, reactions, or opinions. Everyone has personal opinions and RPs are no exception. However, therapists should not use their position to promote personal opinions or causes with clients (e.g., religion, politics, lifestyle choices).

Giving and receiving gifts is potentially dangerous to the professional relationship. A small token of appreciation by the client purchased while on a vacation, around a holiday, or given at the end of therapy may be acceptable. However, anything beyond small gifts may indicate that the relationship is becoming personal.

In addition, the therapist must be sensitive to the client’s culture. In some cultures, refusing a gift is considered a serious insult. However, if a gift is large, the client may be developing an inappropriate attachment to the therapist. The client may even expect something in return. The therapist must use discretion in accepting gifts.

As well, gift-giving by a therapist, even if the gift is small, may confuse a client. While many clients would find a holiday season card from an RP to be a nice gesture, some clients might feel obliged to send one in return, and others with different cultural backgrounds may not be familiar with the custom or may not know how to respond to the gesture.

Ignoring a custom or normal business practice may confuse the nature of the professional relationship. For example, therapy sessions are usually held during regular business hours at a clinic. If a therapist were to ignore this custom by holding a session at a restaurant, confusion could result. The client might think that the meeting is a social visit or could feel that they have to pay for the meal. Treating a client as special, or different from other clients, may be easily misinterpreted.

Some modalities of psychotherapy, e.g., somatic therapies, may include touch as part of the clinical work. However, personal touching, e.g., comforting contact such as a hand on the client’s hand or shoulder, may be easily misinterpreted. A client may view an act of encouragement or consolation by an RP as a crossing of client-therapist boundaries or even a sexual gesture. When it comes to touch between a therapist and client, even if that touch is initiated by the client (e.g., asking for a hug), registrants are encouraged to act cautiously and document any instances. CRPO has a zero-tolerance policy for sexual touching of a client by a registrant, as this constitutes sexual abuse (see Standard 1.8, below).

Registrants must be cautious not to unintentionally cross from a personal relationship into a therapist-client relationship. This means not behaving toward a personal contact in a way that makes them believe they are a psychotherapy client. For example, accepting gifts from a neighbour in exchange for providing regular sessions of personal advice could be interpreted as providing psychotherapy. This kind of boundary crossing is especially risky because once a person is considered a client, the registrant will be expected to uphold all CRPO standards such as consent, confidentiality, and record-keeping. Since the relationship started off as personal, it is unlikely there will have been a consent process, guarantee of confidentiality, or creation of a record. This exposes the registrant to significant liability for failing to uphold numerous practice standards.

Sexual abuse is an extreme boundary violation. Clients have a right to receive care from a psychotherapist in a manner that respects the professional boundary between the client and the health professional, and ensures the client is free from harm. Given the inherent power imbalance between a psychotherapist and their client, any sexual contact by the therapist can cause serious harm to the client.

The RHPA considers any form of sexual conduct by a regulated health professional toward their clients a serious form of professional misconduct. The term sexual abuse is defined broadly and includes the following conduct by RPs:

• sexual intercourse or other forms of physical sexual relations between a registrant and a client;
• touching, of a sexual nature, of the client by the registrant; and
• behaviour or remarks of a sexual nature by the registrant towards a client.

Under the RHPA, “client” includes a former client within one year of termination of the therapist-client relationship. College policy states that sexual conduct by a registrant toward a former client must be strictly prohibited within five years of termination, and longer if a power imbalance persists.

Even if a client appears to initiate sexual contact, such contact is prohibited. Due to the power differential between an RP over a client, a client cannot give valid consent to sexual contact. The foundation of the therapeutic alliance is a safe and trusting relationship, and any form of sexual contact is a breach of the therapeutic relationship.

A wide range of actions constitute sexual abuse. For example, telling a client a sexual joke or hanging a sexually explicit calendar on a wall where it would be seen by clients are examples of sexual abuse. Non-clinical comments about a client’s physical appearance, such as, “You look sexy today,” also constitute sexual abuse. Dating or asking a client on a date is also sexual abuse.

Remarks of a clinical nature are not sexual abuse. For example, if information about the client’s sexual history is required for a therapeutic purpose, the RP may ask about the history. However, asking about a client’s sex life to satisfy the personal interests of the therapist is considered sexual abuse.

It is always the responsibility of the registrant to prevent sexual abuse. Psychotherapists should consider ways of preventing the perception of sexual abuse. For example, if a client begins to tell a sexual joke, or makes comments about the appearance or romantic life of the psychotherapist, the psychotherapist must act to stop it. If the client asks for a date or initiates sexual touching, the RP must say “no,” explain why such behaviour between a client and therapist is inappropriate, discourage future incidents, and set appropriate boundaries. If the client does not adhere to the boundaries set by the registrant, or if the client’s behaviour has interfered with treatment, the registrant should transfer care of the client to another practitioner.

The following are suggestions for preventing even the perception of sexual abuse:

• Maintain established customs (e.g., do not change office hours to accommodate a specific client).
• If a client initiates sexual behaviour, put a stop to it — be sensitive, but firm when doing so.
• Do not socialize with clients, and avoid non-therapeutic self-disclosure.
• Avoid comments that might be misinterpreted, such as, “You’re looking good today.”
• Be cautious in touching a client.
• Do not make gratuitous or inappropriate comments about a client’s body or romantic life.
• Thoroughly document any discussion of relevant sexual matters or any incidents of a sexual nature.
• Avoid being in contact with clients through any social media (e.g., Facebook, Twitter, Instagram, etc.).

It is normal for clients and therapists to have sexual thoughts or feelings toward each other. Responding appropriately to such transference or countertransference can assist in the therapy process. The key is for the registrant to seek clinical supervision, personal therapy, or consultation, and not to allow those thoughts or feelings to develop into any sexual touching, behaviour, or remarks by the registrant toward the client.

When a client develops feelings for the therapist, the RP must take action to stop inappropriate contact from proceeding. Registrants are reminded that in the context of the therapeutic relationship, the client is never a mutual participant due to an imbalance of power. By definition, clients come to an RP because they are seeking care from that professional. Clients share sensitive, personal information and rely on their therapist, who has knowledge and skill, for help. Given this reliance and the inherent power imbalance, “consent” is not valid or legitimate.

Where a registrant has developed sexual feelings for a client, they should either

1. seek supervision, consultation, or personal therapy to resolve the feelings; or
2. transfer the care of the client to another RP

Treating a spouse or partner is also considered sexual abuse. A number of court decisions have established that a regulated health professional cannot treat their spouse, except in very limited circumstances, such as an emergency. RPs must not provide assessments or therapy to a spouse or partner and need to direct them to another practitioner.

Under the law, it does not matter that the spousal relationship came first. For example, the Court of Appeal in Ontario held that a chiropractor who became sexually involved with a person, and some months later began to treat them, had committed sexual abuse. The Court said that even though the personal relationship had come first, it was still inappropriate for the chiropractor to treat their partner, even occasionally. In this case, the treatment was not simply providing household advice or temporary physical comfort to a family member in physical pain, rather it was a formal assessment and treatment plan of the patient.

The College takes all complaints regarding sexual abuse very seriously. There are a number of special provisions that address the handling of sexual abuse matters throughout the complaints and discipline process.

At a discipline hearing, the identity of the client is protected. The client may have a role at the hearing; e.g., if a finding is made, the client might make a statement on the impact of the sexual abuse. Where the sexual abuse involves sexual intercourse or particular kinds of sexual touching, and a finding is made, there is a mandatory minimum penalty: the therapist’s registration will be revoked for a period of at least five years. In all cases where a finding of sexual abuse has been made, the registrant will be reprimanded, their registration will be suspended for a period of time, and they may be ordered to pay for the costs of any counselling and therapy needed by the client. The College also has a fund for counselling or therapy needed by clients alleging sexual abuse by a registrant.

If a registrant has reasonable grounds to believe that a regulated health professional (whether a registrant of this College or another college) has engaged in sexual abuse, the registrant is required by law to make a report. In this case, the report is made to the Registrar of the college where the health professional is a registrant. This reporting obligation is discussed in detail in the section on Standard 1.3.

Because sexual abuse is such an important issue, colleges take it very seriously. Each college must take steps to prevent sexual abuse by its registrants; e.g., CRPO’s Client Relations Committee is required to develop a sexual abuse prevention plan that will educate RPs, the public, and College personnel in this regard.

Which of the following is clearly sexual abuse?

i. Taking a sexual history when it is clinically appropriate to do so.

ii. Using glamour shots of scantily dressed Hollywood stars as an interior design theme in order to attract younger clients.

iii. Telling an employee a sexual joke when there are no clients around.

iv. Dating a child client’s parent.

The best answer is ii. Such pictures, which could be seen by clients, sexualize the atmosphere at the clinic which is inappropriate in a health care setting.

Answer i is not the best answer because taking a sexual history is appropriate when it is needed to assess the client and it is done professionally.

Answer iii is not the best answer because the sexual abuse rules only apply to clients. However, sexual behaviour with employees may constitute sexual harassment under the Human Rights Code and could otherwise be unprofessional.

Answer iv invites consideration but is not the best answer because the parent may not be the registrant’s client. However, it would still be sexual misconduct to date a child client’s parent due to the power imbalance between the therapist and the parent as the child’s close family member or substitute decision-maker.

In the RHPA, the term “sexual abuse” is defined to include conduct by registrants toward clients. Inappropriate sexual behaviour toward non-clients may be referred to as “sexual misconduct.” Sexual misconduct may involve a client’s representative, family, or partner. It would also include sexual conduct toward an RP’s supervisees and students, given the RP’s position of authority over these individuals. Sexual misconduct would also include non-consensual sexual activity by an RP in their personal life. As with sexual abuse of clients, CRPO does not tolerate these other forms of sexual misconduct.

A key concept in defining professional limits is scope of practice. A regulated health profession’s scope of practice is a general description of what that profession does. Under the Psychotherapy Act, the scope of practice statement reads as follows:

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.

In Ontario, no health profession has an exclusive scope of practice. Members of other professions have overlapping scopes of practice and can do some of the same work that RPs do.

It is acceptable for RPs to incorporate some non-psychotherapy activities as an adjunct to their main psychotherapy practice. For example, an appropriately trained RP might guide clients in yoga poses or breathing exercises to promote grounding and relaxation, before engaging in psychotherapy.

When working outside the scope of practice of psychotherapy, registrants need to be vigilant to avoid treating or advising clients in ways that pose a risk of harm.

No RP has the knowledge, skill, and judgment to practise every aspect of psychotherapy. Rather, each RP has their own area of competence and is required to practise within that area. Standard 2.1 discusses the obligation to provide services only if a registrant is competent to do so. Standard 2.1 also explains the steps to take if a situation falls outside a registrant’s scope of competence. These situations include, but are not limited to, times when

• a client presents with a complex condition or one the registrant does not have experience working with;
• a registrant plans to learn a new modality of therapy; or
• a registrant plans to serve a new client population, e.g., seeing couples or families instead of only individual clients; beginning work with clients from an Indigenous community without prior experience.

Personal health information refers to almost anything that would be in an RP’s client files or discussed between an RP and the client. Information is covered by PHIPA if it

• relates to the person’s physical or mental health, including the person’s family health history;
• relates to the provision of health care to the person, including the identification of a person as someone who provided health care to the person;
• is a plan of service within the meaning of the Home Care and Community Services Act, 1994 for the person;
• relates to the person’s payments or eligibility for health care, or eligibility for coverage for health care;
• relates to the donation by the individual of any body part or bodily substance of the person or is derived from the testing or examination of any such body part or bodily substance;
• is the person’s provincial health insurance number; or
• identifies a person’s substitute decision-maker.

The health information custodian (“custodian”) is a person or organization responsible for health records. If an RP is working independently or in sole practice, they are the custodian of any health information collected during the course of practice. If an RP works for a health organization such as a community health centre or a mental health agency, the organization is usually the custodian of health records. The custodian develops privacy policies for their organization, which must meet PHIPA requirements and explain how health information will be protected. Privacy policies should clearly explain how and when personal health information will be collected, used, and disclosed.

Two or more psychotherapists who work together could decide to act as a single organization for the purposes of PHIPA and could create a single privacy policy. This would allow for consistent record-keeping practices, and the therapists would have shared responsibility for complying with PHIPA. Alternately, they could decide to be separate custodians. Under this approach, each therapist would be responsible for creating their own privacy policies.

PHIPA requires every custodian to appoint a contact person (often called a privacy officer) who ensures compliance with the privacy policy and requirements of PHIPA. The privacy officer’s duties include reviewing the organization’s privacy practices, providing training, and monitoring compliance. The privacy officer is also the contact person for requests for information from the public. An RP working independently or in sole practice usually acts as the privacy officer. A health organization may appoint a person within the organization, or hire a person outside the organization, to be its privacy officer.

An RP or organization may collect, use, or disclose a person’s personal health information only if the person consents or if the collection, use, or disclosure is otherwise permitted or required by law. A registrant should collect, use, or disclose no more information than is reasonably required in the circumstances.

Under PHIPA, collection, use, and disclosure of personal health information is permitted without consent in the following limited circumstances:

1. Disclosure to Other Healthcare Providers

Under PHIPA, RPs may assume that they have a client’s implied consent to disclose personal health information to the client’s other health providers unless the client instructs otherwise.* For example, in circumstances where it is necessary to provide care to an individual, but not reasonably possible to obtain consent in a timely manner, the client’s health information may be shared with other providers. However, to avoid misunderstandings, many practitioners do not disclose information to other providers without the client’s explicit consent, except in emergencies. Caution is particularly important where the information is sensitive.

Despite the circumstances in which sharing a client’s personal health information is permitted, when a client or client’s substitute decision-maker says that they do not want information to be shared, the information cannot be disclosed unless another provision in PHIPA permits it, e.g., to prevent a significant risk of serious harm.**

2. Disclosure to Members of the Client’s Family

Generally speaking, RPs must obtain consent before disclosing personal health information to members of a client’s family. However, personal health information may be disclosed in emergencies. It may also be disclosed for the purpose of contacting family members, friends, or other persons who may be potential substitute decision-makers, if the individual is injured, incapacitated, or ill, and not able to provide consent. This may be particularly relevant for registrants working in acute care settings.

3. Disclosure Related to Risk

An RP may disclose a client’s personal health information if the RP believes on reasonable grounds that disclosure is necessary to eliminate or reduce a significant risk of serious bodily harm to the person or anyone else.***

4. Missing Persons Act

Ontario’s Missing Persons Act, 2018 allows a police officer to require anyone to produce records for the purpose of locating a missing person. This power does not involve criminal investigations but is meant to ensure the safety of missing persons. The Act has several safeguards, including the following:

• • An officer must have reasonable grounds before making an urgent demand for records, and they must use a specific form.
  • If the officer agrees, the person with the relevant information may provide it orally instead of providing written records.
  • Police officers must report their use of urgent demands for records within their police department.
  • Police departments must report annually on their use of urgent demands for information to locate missing persons.
  • The Minister of Community Safety and Correctional Services must review the Act within five years.

5. Disclosure under Other Laws or for Legal Proceedings

PHIPA allows disclosure of personal health information under other laws or for the purpose of a legal proceeding. For example, PHIPA permits disclosure of personal health information to CRPO if this information is required in a College process such as a complaint investigation or the Quality Assurance Program.

Disclosure of personal health information is permitted or required by many other Acts, including the following:

• • The Healthcare Consent Act, 1996 (HCCA) or Substitute Decisions Act allow disclosure for the purposes of determining, assessing, or confirming capacity.
  • Various Acts deal with compensation or benefits for injury or disability, e.g., workplace injury, social benefits, or motor vehicle accidents. If a client needs to prove the nature or extent of their disability, injury, or recovery, registrants may be requested or required to provide health information about the client.
  • Disclosure to an investigator or inspector is permitted when authorized by a warrant, or by any provincial or federal law, for the purpose of complying with the warrant or facilitating the investigation or inspection.

Additionally, as discussed under Standard 1.3: Mandatory Reports, there are some circumstances in which disclosure of personal health information is required.

*Section 20(2). The IPC refers to this as the “circle of care”. See Information and Privacy Commissioner of Ontario, Circle of Care: Sharing Personal Health Information for Health-Care Purposes (2015): online: https://www.ipc.on.ca/wp-content/uploads/resources/circle-of-care.pdf.

**The IPC refers to this as a ‘lock-box’. See Information and Privacy Commissioner of Ontario, Lock-box Fact Sheet (2005), online: https://www.ipc.on.ca/wp-content/uploads/resources/fact-08-e.pdf.

***For additional guidance about this limit to confidentiality, see CRPO’s guideline, Disclosing Information to Prevent Harm.

Jessica and Alyia are getting divorced and advocating custody arrangements for their children. Jessica is alleging Alyia suffers from depression and should not be given custody. Jessica’s lawyers contact Alyia’s psychotherapist, Kamala, and request disclosure of Alyia’s client record. What should Kamala do?

i. Disclose Alyia’s record to Jessica’s lawyer.

ii. Disclose Alyia’s record to the judge directly.

iii. Acknowledge the request, then make Alyia aware and ask whether she consents to the disclosure.

iv. Call Jessica’s lawyer and refuse to provide the record because Alyia does not have depression.

Answer iii is the best answer. Unless an exception applies, clients must consent to disclosure of their record to a third party. One exception is if the registrant receives a summons, subpoena, or court order. If a registrant is unsure about how to respond to legal requests, they should contact their clinical supervisor and legal counsel.

Answers i and ii are not the best answers because there is no indication that Alyia has consented to the disclosure, or that a legal exception applies allowing for disclosure without consent.

Answer iv is not the best answer because even disclosing the identity of a client to a third party is a disclosure of confidential information.

Every client has a right to access their own personal health information. One important exception is when granting access would likely result in a risk of serious harm to the client’s treatment or recovery, or a risk of serious harm to the client or another person. An RP or other custodian who receives a written request must respond by either granting or refusing the request within 30 days. It is also a good idea to respond to verbal requests as soon as possible. If the request cannot be fulfilled within 30 days, the person should be advised of this in writing.

If a person makes a request to access their personal health information, the custodian must do one of the following:

• permit the person to see the record and provide a copy at the person’s request;
• determine, after a reasonable search, that the record is unavailable, and notify the person of this in writing, as well as their right to complain to the IPC; or
• determine that the person does not have a right of access because of the risk of serious harm and notify the person of this as well as their right to complain to the IPC.

The Information and Privacy Commissioner may review the custodian’s refusal to provide a record and may overrule the custodian’s decision. If the law does not permit disclosure for any reason, the RP must black out (on a copy, not the original) those parts that cannot be disclosed, if it is reasonable to do so, so that the client can access the rest of the record.

Individuals generally have a right to request corrections to their own personal health information.[1] The timelines noted above regarding access to personal health information apply similarly to correction requests.

Corrections to records must always be made in a way that allows the original record to be traced. The original record should never be destroyed, deleted, or blacked out. If the record cannot be corrected on its face, it should be possible for another person accessing the record to be informed of the correction and where to find the correct information. The person should also be notified of how the correction was made.

At the person’s request, the RP should notify anyone to whom the RP has disclosed the incorrect information, of the correction. The exception to this is if the correction will not impact the person’s health care or otherwise benefit the person.

The RP (or custodian) may refuse the request if they believe the request to be frivolous or vexatious; if they did not create the record and do not have the knowledge, expertise, and authority to correct it; or if the information consists of a professional opinion made in good faith. In other words, corrections are limited to factual information, not professional opinions.

An RP who refuses to make a correction must notify the person in writing, with reasons, and advise the person that they may

• prepare a concise statement of disagreement that sets out the correction that the RP refused to make;
• require the registrant to attach the statement of disagreement to their clinical records and disclose the statement of disagreement whenever the RP discloses related information;
• require the RP to make all reasonable efforts to disclose the statement of disagreement to anyone to whom the registrant has previously disclosed the record; and
• make a complaint about the refusal to the Information and Privacy

[1] For more information about record-keeping, refer to section 5 of the Standards.

Every health information custodian must have a system in place to deal with complaints regarding personal health information. Clients should also be aware of their right to complain to CRPO and the IPC.

Which of the following best describes a client’s right to look at their personal health information contained in an RP’s records?

i. Clients have an unrestricted right to access their personal health information.

ii. Clients generally have a right to access their health information and have a right to complain to the Information and Privacy Commissioner if access is refused for any reason.

iii. Clients have a right to access their health information unless the RP believes it is not in a client’s best interests to see the information.

iv. Clients may request a copy of a record containing their personal health information, but an RP does not have to provide it.

The best answer is answer ii. Clients’ rights to access their health information is broad but has some legal limits. However, even if access is refused for an appropriate reason, the client is entitled to bring a complaint to the Information and Privacy Commissioner.

Answer i is not the best answer because the right to access personal health information may be restricted in some circumstances (e.g., where there is a serious risk of significant bodily harm).

Answer iii is not the best answer because an RP’s opinion about whether it is good for the client to see the record is irrelevant. Only if the RP believes on reasonable grounds that viewing the information would seriously harm the client’s treatment, may access be refused.

Answer iv is not the best answer because an RP does not have a general right to refuse a person access to personal health information.

Another privacy law that registrants should be aware of is the Personal Information Protection and Electronic Documents Act (PIPEDA). PIPEDA is a federal law that governs the collection, use, and disclosure of personal information in relation to commercial activity, such as the sale of products and the offering of educational sessions. PHIPA and PIPEDA are based on the same principles. PHIPA simply provides more detail about how to achieve those principles in the health care context.

The following ten privacy principles apply to a registrant’s commercial activities:

Accountability

An organization must have a privacy officer who is accountable for the collection, use, and disclosure of personal information; develops privacy policies and procedures; and ensures that staff receive privacy training.

Identifying purposes

An organization must identify the purposes for which personal information will be used at the time the information is collected.

Consent

Informed consent is required to collect, use, and disclose personal information except in limited circumstances.

Limiting collection

An organization must collect only information needed for identified purposes.

Limiting use, disclosure, and retention

An organization must use, disclose, and retain only personal information that is necessary for the identified purposes, and is obtained with consent. It should be retained no longer than necessary.

Accuracy

Personal information must be as accurate, complete, and up-to-date as is necessary for the purposes for which it is to be used.

Safeguards

An organization must protect personal information with appropriate safeguards in order to protect against loss, theft, unauthorized access, disclosure, copying, use, or modification.

Openness

An organization must make its privacy policies readily available.

Individual access

Upon request, an individual must be informed of the existence, use, and disclosure of their personal information, and be given access to it. An individual may request corrections to the information. Access may be prohibited in limited circumstances.

Challenging Compliance

An organization must have a complaints procedure relating to personal information and must investigate all complaints.

To be valid, a client’s consent must meet the following criteria.

Relate to the assessment or therapy

An RP cannot receive consent for one purpose (e.g., taking a history of the client’s health for personal therapy) and then use it for a different purpose (e.g., disclosing it in group therapy). The client’s consent must be for the purpose stated.

Be specific

An RP cannot ask for a general or a vague consent. One must explain the assessment or therapy that is being proposed. This means that the registrant may need to obtain the client’s consent again as changes in therapy become advisable. This also means that a registrant cannot seek blanket consent to cover every intervention when the client first comes in.

Be voluntary

The psychotherapist cannot pressure a client to consent to an intervention. This is particularly important when dealing with younger or older clients who may be overly influenced by family members or friends. This is also important where the assessment or therapy will have financial or legal consequences for the client (e.g., the client will lose their job or be penalized if the client refuses to consent). The registrant should inform the client that consent is the client’s choice.

No misrepresentation or fraud

An RP must not make claims about the assessment or therapy that are not true, e.g., telling the client that a particular therapy will result in improvement when in fact the results are uncertain. Clients must be given accurate, factual information and opinions based in truth and fact.

Be informed

It is necessary that the client understand what they are agreeing to. The registrant must provide information to the client before asking the client to give consent, and the registrant must respond appropriately to client requests for additional information. This issue is covered in more detail below.

In order for consent to be considered informed, clients must understand what they are agreeing to. Generally speaking, the following information should be provided to clients when seeking their consent:

Nature of the Assessment or Therapy

The client must have a reasonable understanding of what the RP is proposing to do. For example, before beginning therapy, therapists should explain why they are asking personal questions and why the client should be candid.

Who Will Be Doing the Assessment or Therapy

Will the psychotherapist be doing the intervention personally or will a supervisee, supervisor, or colleague do it? If it is another person, are they registered with CRPO, another college, or unregistered? Is the treating therapist receiving clinical supervision?

Material Risks and Side-effects

The RP must explain any material risks and side-effects. A risk or side-effect is material if a reasonable person would want to know about it. For example, if there is a high likelihood of a modest side-effect (e.g., emotional distress), the client should be told. Similarly, if there is even a low risk of a serious side effect (e.g., triggering traumatic memories), the client needs to be told.

Reasons for the Assessment or Therapy

Therapists must explain why they are proposing the intervention. What are the expected benefits? How does the intervention fit in with the overall treatment goals? How likely is it that the hoped-for benefits will occur?

Consequences of No Intervention

One option for a client is to do nothing. The therapist should explain to the client what could happen if the client chooses not to consent to the intervention. If it is not clear what will happen, the therapist should say so, providing outcome scenarios if possible.

Particular Client Concerns

If some aspect of the intervention would be of special interest or concern to the client, the client should be informed. This requires the therapist to be reasonably aware of and sensitive to particular client concerns or interests, such as strongly held values or beliefs, or even certain personal considerations. For example, clients ascribing to a particular religion would need to know if an aspect of the intervention would violate their beliefs.

Alternatives

If there are reasonable alternatives to the intervention, the client must be told. Even if the psychotherapist does not recommend the option (e.g., it is more aggressive or carries more risk), they should describe the option and tell the client why they are not recommending it. Also, even if the therapist does not offer the alternative intervention (e.g., it is provided by a member of a different profession, such as a physician), they must inform the client, if it is a reasonable option.

There are three different ways an RP is able to receive consent. Each has its advantages and disadvantages.

Verbal Consent

A client may give consent by a verbal statement. Verbal consent is the best way for the therapist and client to discuss the information and ensure the client really understands it. Making a detailed note of the discussion in the client record may provide useful evidence later on, if there is a complaint. A note is especially important when written consent is not obtained.

Written Consent

A client may give consent by signing a written document agreeing to the intervention. Written consent provides some evidence that the client gave consent. A disadvantage of written consent is that some registrants may confuse a signature with consent. For example, a client who signs a form without actually understanding the nature, risks, and possible alternatives to the intervention has not provided consent that could be considered informed. Written consent may actually inhibit full disclosure between the client and therapist about consent, thereby affecting the therapist’s ability to gauge whether the client understands the information and is providing informed consent.

Implied Consent

Clients may give consent by their actions. For example, the registrant may consider the client willingly attending and sharing information in therapy as implied consent to continue participating. Similarly, a client could simply nod their head to indicate consent. The main disadvantage of implied consent is that the RP has no opportunity to check with the client to make sure they truly understand what is being agreed to. Therefore, registrants should not rely on implied consent for significant or complex decisions and in these situations should obtain verbal or written consent.

A client is not capable of giving consent when they do not understand the information provided, or when they do not appreciate the reasonably foreseeable consequences of the decision.

An RP may assume a client is capable and does not need to conduct an incapacity assessment unless there is evidence that the client may be incapable. The psychotherapist can assess the capacity of the client by discussing the proposed intervention with them and determining whether the client understands the information and appreciates its consequences.

A client may be capable of giving consent for one intervention but not for another. For example, a 15-year-old client might be capable of consenting to group counselling about handling stresses at school, but not capable of consenting to therapy for a major eating disorder. There is no minimum age of consent for health care treatment. In each case, the registrant must look at the maturity of the minor.

In cases where the client is found to be incapable, a substitute decision-maker must be identified. Unless it is an emergency, the RP must obtain consent from the substitute decision-maker before commencing therapy. According to the HCCA, the substitute must meet all of the following requirements:

• The substitute must be at least 16 years of age. However, there is an exception where the substitute is the parent of the client, e.g., a 15-year-old mother can be the substitute decision-maker for the care of her child.
• The substitute must be capable. In other words, substitutes themselves must understand the information and appreciate the consequences of the decision.
• The substitute must be able to act (i.e., available) and willing to assume the responsibility of giving or refusing consent.
• The substitute must not be prohibited by a court order or separation agreement from acting as the client’s substitute decision-maker.
• There must be no higher-ranked substitute who wishes to make the decision. (See Rankings for the Substitute Decision-Maker, below.)

If an RP concludes that the client is not capable of providing consent for therapy or other intervention, the therapist should tell the client. The therapist should also discuss the selection of the substitute decision-maker with the client and should include the client in discussions about the therapy (e.g., plans or goals, options, and progress) as much as possible. Of course, there are circumstances where involving an incapable client in discussions will not be possible (e.g., if such discussions would be upsetting to the client, or if the client is unconscious).

The HCCA also lays out the following principles on which a substitute decision-maker must base their decisions:

• The substitute must act in accordance with the last known capable wishes of the client. For example, if a terminally ill client, while still thinking clearly, said: “Don’t send me to the hospital, I want to die at home,” the substitute needs to obey those wishes, in so far as it is possible to do
• If the substitute is not aware of the last known capable wishes of the client, or if the last known wishes are unattainable, the substitute must act in the client’s best For example, if a proposed therapy is simple and painless, would make the client more comfortable through a difficult illness, and has little risk of harm, the substitute decision-maker should, in general, consent to it.

Where it becomes clear that a substitute decision-maker is not following the principles above, the psychotherapist should speak with the substitute about it. If the substitute decision-maker is still not following the principles and is making decisions that, in the opinion of the therapist, will harm the client, the therapist should call the Office of the Public Guardian and Trustee. The contact information for the Public Guardian and Trustee of Ontario is available on the internet.

The ranking of the substitute decision-maker is as follows (from highest ranked to lowest ranked):

1. A court appointed guardian of the person.
2. A person who has been appointed attorney for personal care. The client would have signed a document appointing the substitute to act on the client’s behalf in health care matters if the client ever became incapable.
3. A person appointed by the Consent and Capacity Board to make a health decision in a specific matter.
4. The spouse or partner of the client. A partner is defined in the HCCA as “either of two persons who have lived together for at least one year and have a close personal relationship that is of primary importance in both persons’ lives.” This means a partner does not need to be a spouse or sexual partner of the client.
5. A child of the client, a parent of the client, or the Children’s Aid Society who has been given wardship of the client.
6. A parent of the client who does not have custody of the client.
7. A brother or sister of the client.
8. Any other relative.
9. The Public Guardian or Trustee if there is no one else.

If there are two equally ranked substitute decision-makers (e.g., two siblings of the client), and they cannot agree, the Public Guardian and Trustee may then make the decision.

Child and family therapy can present complex consent and capacity issues, including whether a child has the legal capacity to consent to their own therapy. While RPs sometimes base conclusions about capacity on a child’s age, the issue is more complex, and capacity needs to be determined on a case-by-case basis.

Many older children (e.g., 12 to 17 year olds) are capable of consenting to their own psychotherapy. They do not require a substitute decision-maker. In borderline cases, registrants should document their clinical opinions about the young person’s capacity, including how capacity was determined. Capacity is usually determined by discussing the proposed therapy with the child and asking questions about their understanding of the therapy itself and of the implications of participating or not participating. Even if a child has the capacity to consent to treatment, registrants should consider with the child whether the psychotherapy is in their best interests in their particular context, and whether some parental involvement in the therapy process is desirable.

In general, young children may not understand the nature and implications of deciding to receive therapy or not. While capacity needs to be determined on a case-by-case basis, many young children will require a substitute decision-maker, usually a parent. Unless a parenting agreement or order states otherwise, the presenting parent can make decisions about the child receiving therapy. In situations of two parent families, it is legally permissible to accept the consent of one parent on behalf of another unless the RP has reason to believe that the other parent does not agree. However, there are risks in not performing due diligence. For example, failing to involve both custodial parents in a child’s treatment can limit successful outcomes for the child, and is one of the most common complaint issues received by the College.

Registrants are advised to have policies and practices in place to manage issues related to obtaining consent to treat children and adolescents. For example, when treating a young child whose parent acts as a substitute decision-maker, it is advisable to inquire if the child has another custodial parent, obtain the other parent’s consent if applicable, and review any relevant parenting agreements or orders. Including both custodial parents, where applicable and possible, can reduce the perception of bias on the part of the therapist (i.e., that the therapist is more aligned with one parent than another). This perceived bias can ultimately interfere with the child’s care. In situations where the registrant cannot reach the other parent to obtain consent, the registrant will consider the best interests of the child in making all decisions about proceeding with psychotherapy and will document their attempts to reach the parent as well as the rationale for all clinical decisions made.

Therapy with children in high-conflict child custody and access cases, especially those coupled with intimate partner violence, is highly complex and requires significant training and experience supported by regular supervision and consultation. In these situations, registrants may be required to make complex decisions about psychotherapy with children based on the best interests and wishes of the child. All decisions must be made with appropriate supervision and clearly documented. In such cases, the onus will be on the registrant to provide support justifying their decisions.

Treatment cannot be provided if joint substitute decision-makers (e.g., two parents with custody) do not agree with each other about whether to consent. In such a situation, the Public Guardian and Trustee, the Consent and Capacity Board (discussed below), or a court, may become involved. In the interim, the child will not be able to receive the therapy disputed by the parents.

In an emergency, an exception to the requirement for informed consent can be made. There are two kinds of emergencies:

• The client is incapable and a delay in treatment would cause severe suffering or serious bodily harm to the client.
• There is a communication barrier (e.g., language, disability), and despite efforts to overcome this barrier, a delay in treatment would cause suffering or serious bodily harm to the client.

In either case, the therapist must attempt to obtain consent as soon as possible, even if it is after the fact, either by finding a substitute decision-maker (as in the first case) or by finding a means of communication with the client (as in the second case).

Obtaining a broad consent, often called a blanket consent, in writing from the client on their arrival at the office is usually a bad idea because

i. The client does not know if they will need a ride home afterwards.

ii. The client does not have confidence in the RP yet.

iii. The client does not know what they are agreeing to.

iv. The client does not know how long the visit will be.

The best answer is iii. Informed consent requires the client to understand the nature, risks, and side-effects of the specific intervention proposed by the psychotherapist. It is impossible for the client to know these things upon arrival at the office.

Answer i is not the best answer because it focuses on a side-issue and does not address the main issue.

Answer ii is not the best answer because having confidence in the psychotherapist does not constitute informed consent. A client may trust the psychotherapist, and this may motivate the giving of consent, but the client still needs to know what they are agreeing to.

Answer iv is not the best answer because it focuses on a side-issue and does not address the main issue.

Which of the following is the highest ranked substitute decision-maker (assuming that everyone is willing and able to act as a substitute)?

i. Someone appointed as attorney for personal care for the client.

ii. The client’s live-in boyfriend.

iii. The client’s mother.

iv. The client’s son.

The best answer is i. Only a court-appointed guardian is higher ranked than a power-of-attorney for personal care.

Answer ii is not the best answer because the client’s spouse or partner is a lower-ranked substitute decision-maker. In addition, it is not clear that the live-in boyfriend is a spouse or partner. Under the HCCA, the couple must have been living together for at least one year, have had a child together, or have a written cohabitation agreement to be spouses.

Answers iii and iv are not the best answers because they are lower ranked than both an attorney for personal care and a client’s spouse. In addition, the client’s mother and son are equally ranked so either they would have to give the same consent or would have to sort out which one would give consent.

Where there is a dispute about the care of an incapable client, the therapist, client, or substitute decision-maker may apply to the Consent and Capacity Board (CCB) to render a decision regarding the client’s consent or capacity. The CCB may agree with the therapist’s determination that a client is incapable or may find that the client is capable with respect to the treatment. If the CCB overrules the therapist, the therapist may not administer the treatment unless the client consents.

The CCB may provide direction to a substitute decision-maker with respect to an incapable person’s wishes (e.g., whether the wish applies to the circumstances, or whether the client’s wish was expressed when the person was capable). The CCB may also consider a request from a substitute decision-maker to depart from a person’s wish that was expressed while the person was capable.

The CCB may review decisions regarding a person’s capacity to consent to treatment, admission to a care facility, or use of a personal assistive service. The CCB may appoint a substitute decision-maker to

• make decisions for an incapable person with respect to treatment, admission to a care facility, or use of a personal assistance service;
• amend or terminate the appointment of a representative;
• review a decision to admit an incapable person to a hospital, psychiatric facility, nursing home, or home for the aged for the purpose of treatment; and
• review a substitute decision-maker’s compliance with the rules for substitute decision-making. A client may challenge a decision of the CCB by appealing to the courts.

Multidisciplinary settings are places where members of different professions work together and where clients may be seen by multiple health care providers. Unique issues can arise in these situations. Registrants can ask themselves the following reflection questions to help plan for, arrange, and navigate multi-disciplinary practice issues:

• Who is the health information custodian that owns the records?
• Will the setting have shared records, or will the RP have separate records?
• How does the setting deal with the wording used in the records? Will everyone use the same abbreviations?
• What happens if the RP leaves to practise elsewhere? Will the client be told where the therapist has gone? Will another therapist from the setting take over the client’s care? Will the client be given a choice? (The client should be given a choice, although some settings will only do so if the client asks.)
• Will there be one person who has overall responsibility for the care of the client? If so, who? If not, how will the client’s care be coordinated?
• How will disagreements in the approach to the care of the client be dealt with? If it is the RP who disagrees, when and how do they tell the client?
• How will the client be made aware of any of the above?

Which of the following is a benefit of interprofessional collaboration?

i. There is less record-keeping required.

ii. Client care can be better coordinated.

iii. Clients can be charged more fees.

iv. All of the above.

The best answer is ii. When healthcare providers treating the same client share information, treatment is better coordinated, and health care providers do not give inconsistent treatment.

Answer i is not the best answer because the amount of record keeping will usually be about the same. There may even be more record-keeping involved as healthcare providers record the discussions they have with each other.

Answer iii is not the best answer because charging more fees does not benefit the client. Hopefully, if care is well coordinated the client will require less treatment and the overall fee charged to the client will be less.

Answer iv is not the best answer because answers i and iii are not the best answers.

Tatianna, an RP (Qualifying), is considering expanding her practice to include electronic as well as in-person therapy. Which of the following actions does she not need to take?

i. Confirm that her professional liability insurance coverage applies to electronic services.

ii. Discuss with her clinical supervisor her readiness to offer this form of service.

iii. Familiarize herself with the video-calling features on Facebook.

iv. Prepare policies and templates to facilitate the informed consent process with clients.

The best answer is iii. Facebook is not designed for the private exchange of health information. Tatianna would need to research reputable platforms for offering electronic therapy.

Answer i is not the best answer because registrants are required to carry professional liability insurance. Standard 3.4 expects registrants who engage in electronic practice to have insurance that covers those services.

Answer ii is not the best answer because Qualifying registrants are required to practise with clinical supervision. Electronic practice raises a variety of clinical and ethical considerations requiring attention.

Answer iv is not the best answer because registrants need to provide information to clients about the risk and benefits of electronic practice and how to prepare for a session (e.g., find a private spot, if possible, test one’s internet connection and the communication platform).

Which of the following is inappropriate conduct by a clinical supervisor?

i. Reporting to CRPO about the supervisee’s refusal to follow instructions necessary to assure client safety.

ii. Refusing to approve the supervisee to see a client with a particularly complex presenting issue.

iii. Completing an evaluation saying the supervisee needs to further develop some competencies.

iv. Borrowing money from a supervisee.

Answer iv is the best answer. Due to the power a clinical supervisor holds over their supervisee, borrowing money is an example of an inappropriate boundary violation by the supervisor.

Answer i is not the best answer because clinical supervisors are obligated to file a mandatory report with CRPO if another RP, including a supervisee, engages in unsafe practice.

Answer ii is not the best answer. Clinical supervisors must intervene if they become aware a supervisee plans to take on a client the supervisee is not competent to treat.

Answer iii is not the best answer because evaluation and feedback are part of a normal supervisory relationship.

In sole private practice, it is usually clear that the RP themself is responsible for client records. In employment settings, it is also generally straightforward that the employer (e.g., hospital, agency), is the custodian of client records.

Complications can arise in group practice or contractor arrangements. For example, if an RP has an office in a private group clinic, is the RP, another provider, or the clinic itself ultimately responsible for health records? These situations can be further complicated if the RP has more than one practice setting. If an RP works remotely, they may administer both practices from the same physical location, making it even more relevant to separate and organize records appropriately.

It is important to agree in advance about who is ultimately responsible for the records. If working in more than one setting, it is important to separate records as needed so as not to confuse one group of clients with another. When a business relationship terminates, the health information custodian is responsible for retaining the original record, unless the record is transferred to another provider.

Aija, an RP, recently accepted a contractor position with an established practice that hires mental health professionals from all professional backgrounds. As her first day approaches where she will begin to see clients, Aija notes that it was never expressly stated whether the practice will maintain client records or whether it expects contractors to maintain their own records. What is the best course of action for Aija?

i. Decide to act as the health information custodian, as it allows her to ensure PHIPA compliance.

ii. Do nothing, assuming that the practice will be the health information custodian.

iii. Ask the practice owner on her first day of work to confirm whether Aija or the practice will have health information custodian duties.

iv. Ask the practice owner prior to her first day of work whether Aija or the practice will maintain the health records.

Answer iv is the best answer, as Aija quickly sought clarity on the matter and confirmed which party would be responsible for maintaining health records. Importantly, she also gave herself enough time to prepare in response. That is, she made sure she was able to act in a PHIPA-compliant manner from her first day of work should she be responsible.

Answers i and ii are not the best answers because it is important for all parties to be clear about who will have responsibility for health records. In these scenarios, Aija did not confirm with the practice owner, which may lead to confusion and disagreement over who is responsible for the records.

Answer iii is not the best answer because it does not give Aija adequate time to prepare a record-keeping system prior to seeing clients if the practice owner confirms she is expected to act as the health information custodian.

Registrants can expect to receive a variety of requests for access to or disclosure of client records. Some requests are relatively straightforward (e.g., an individual client requesting a copy of their own health record). Clients have a right of access to their own health records, subject to limited exceptions listed in section 52 of PHIPA.

Some requests may not be straightforward, for example if the request comes from a third party, relates to a legal proceeding, or involves a joint therapy record, e.g., couple or family therapy. Registrants may need legal advice tailored to their specific situation. The following are general questions to help analyze access and disclosure requests:

• Does the person requesting access or disclosure have legal authority? For example, is it the client’s own lawyer requesting access on behalf of the client? Is it a custodial parent requesting the record of their child who does not have capacity to decide for themself?
• Does the client need to be informed of any risks? For example, if the file is being requested for a legal proceeding, could some of the information be upsetting or irrelevant?
• Do any redactions need to be made? For example, if one member of a couple requests access to their own therapy record, the registrant cannot provide access to information about the other member of the couple without that person’s consent.
• Will a summary or report suffice instead of the record? Consider asking the requester if the entire record is required versus an alternative.
• Is it necessary to oppose release of the records? In contentious situations where individuals disagree about disclosure of the record, registrants should seek legal advice, including whether to oppose legal requests to disclose the record.

When providing access or disclosure, the custodian keeps the original record and sends copies to others who have authorization. The only exception arises when there is a legal requirement to provide the original record (e.g., if required in a police, Coroner’s, or College investigation, or with a summons). In such a circumstance, the custodian should keep a legible copy of the record. RPs are encouraged to review relevant legislation, guidance from the IPC, and seek legal counsel to ensure they are upholding their legal responsibilities.

Administering fees involves issuing invoices and receipts. The following are examples of improper billing:

• indicating that a clinical supervisor provided therapy to a client when the supervisee did;
• indicating that the registrant’s practice is supervised when no actual supervision meetings take place;
• indicating the wrong date for the service;
• indicating that one service was performed when, in fact, another service was provided; e.g., indicating that the fee was for psychotherapy when in fact personal fitness training was provided;
• billing for services at more than the registrant’s usual rate because the service is being paid for by an insurance company;
• indicating that a service was performed when, in fact, no service was performed; e.g., indicatingthataclientvisitoccurredwhen,infact,theclientmissedtheappointment; and
• issuing a receipt implying services were provided to someone who was not present during a session, e.g., to access insurance benefits.

A recently graduated RP (Qualifying) is setting up their online profile on a well-known psychotherapy directory. The directory has a pre-populated list where therapists can select and advertise the mental health conditions they treat. Wanting to attract as many clients as possible, and having learned about these conditions in various lectures, the Qualifying registrant chooses most of the options, including eating disorders, borderline personality disorder, suicidality, and self-harm.

The registrant is advertising inappropriately. Advertising needs to be accurate and verifiable. Treating the serious conditions or situations noted above requires extensive training and supervision, which is generally not completed upon graduation from one’s initial training program.

A common source of questions to College staff and investigations of RP conduct is in the area of psychotherapy with parents and children involved in custody disputes. This topic can present a variety of dilemmas for registrants, including the following:

• whether to provide therapy to children when parents are actively engaged in child custody and access disputes;
• what to do when one parent presents with a child for therapy without the knowledge of the other parent;
• whether and how to proceed when one parent opposes treatment, and the other parent or child supports it;
• how to determine capacity to consent with children of different ages and abilities;
• what constitutes a child’s best interests in such complex cases;
• what to document in the child’s file in light of who may have access to it;
• being asked to write a report or serve as a witness in a family law proceeding; and
• being accused of favoring one parent and alienating another in a child’s treatment.

In general, therapy with children and youth is most successful when important adults in the young person’s life are involved in change; when all parties are informed, in agreement, and in support of the therapy; and when the best interests of the child are the focus. When faced with ethical and legal dilemmas, RPs should consider the following questions based on the Practice Standards:

• Does the registrant have the appropriate training and competence to work with children, families, high-conflict couples, custody and access disputes, or potential domestic abuse? (Standard 2.1 Consultation, Clinical Supervision and Referral )
• Are there conflicts of interest to be aware of (e.g., providing family therapy to a child and two parents, then working with the child and one parent amid their custody dispute against the other parent who is now a former client)? (Standard 1.6 Conflict of Interest)
• Is therapy with the child in the child’s best interests?
• Has the registrant clarified their role and responsibilities with all parties involved?
• Does the child client have the capacity to provide their own informed consent to treatment? If so, is it prudent to suggest involvement in treatment of one or two parents?
• Has the registrant engaged in age-appropriate informed consent conversations with all parties including about confidentiality and its limits? (Standard 3.1 Confidentiality; Standard 3.2 Consent)
• Does the registrant have a policy in place regarding whether, under what circumstances, and for whom they will write reports of a child’s therapy for use in a custody proceeding? Has this been clearly communicated to all involved?
• If asked to write a report for use in a custody proceeding, does the registrant have a clear understanding of whose consent is required for the release of their personal information and has the registrant sought that consent? Does the registrant have a clear understanding of whose consent is required for release of the child’s information? Do parents need to provide informed consent as the child’s substitute decision-makers? If so, which parent(s)?
• If writing a report for use in a child custody proceeding, has the registrant ensured separation of facts from interpretations? Are facts and opinions reasonable, supportable, and within the RP’s scope of competence? As an example, the statement that one’s client is “a good parent” is an unclear opinion and unverifiable by the RP. (Standard 5.2 Report-writing)

Risk assessment and safety planning are integral aspects of the work of Registered Psychotherapists. Risk assessments are structured analytical tools to identify ”red flags” indicating risk of harm. Safety planning involves responding to identified risks by taking into account the client’s needs and circumstances.

Risk Assessment

Risk assessments, while useful, are not infallible. Their reliability depends on the client feeling comfortable and safe enough to be honest about their situation. Additionally, harm or victimization can occur even when an individual is considered ”low risk.”

Registrants conduct risk assessments and safety planning in response to various concerns including suicide, self-harm, harm to or by third parties, and medical risk (e.g., knowing the signs when an eating disorder or head injury requires emergency medical attention). Using the context of intimate partner violence as an example, risk assessments may include the following or similar elements:

1. perpetuator-focused factors, which include, but are not limited to,

a) history of abuse;

b) escalation of violence;

c) criminality;

d) substance abuse; and

e) attitudes supporting violence.

2. victim-focused factors, which include, but are not limited to,

a) concerns about future violence;

b) barriers in accessing support;

c) victims who have a biological child with a different partner; and

d) victims who have been assaulted by the perpetuator while pregnant.

Safety Planning

Safety plans should be highly individualized, but will often take the following circumstances into consideration:

• immediate escape plans;
• creating safe environments at home, at work, and in the neighborhood; and
• guidance for active violent incidents.

Using risk assessments and safety plans can help registrants fulfill their obligations under the CRPO Practice Standards. This includes, but is not limited to, the following Standards:

• only treating individuals within a registrant’s area of competence, recognizing when an individual’s case is either too complex or falls outside the registrant’s practice area, and making appropriate referrals (Standard 1.9: Referral; Standard 2.1: Consultation, Clinical Supervision and Referral);
• understanding when it is necessary to breach confidentiality under the duty to report (Standard 1.3: Mandatory Reporting; Standard 3.1: Confidentiality); and
• sharing relevant information with the permission of a client to the other members of a client’s circle of care (Standard 3.3: Communicating Client Care).

CRPO does not have specifically developed tools for registrants; however, the following resources may be useful:

• Inventory of Spousal Violence Risk Assessment Tools Used in Canada
• Safety Planning Resources from Victim Services Toronto
• Ontario Domestic Assault Risk Assessment Training Program
• Canadian Domestic Homicide Prevention Initiative
• Ontario Hospital Association and Canadian Patient Safety Institute Suicide Risk Assessment Guide
• Nunavut Guide to Risk Assessment and Safety Planning for Victims of Family Violence
• British Columbia Guide to Safety Planning

Research continues to advance, along with public and professional interest, in drug-assisted therapies. For some presenting issues, clinical literature supports the use of therapist-guided client administration of psychedelic substances such as psilocybin, MDMA, and ketamine. Registrants have asked about CRPO’s position. The existing Practice Standards shed light on this issue, as follows:

• The registrant must be appropriately trained and competent in the therapy modality to be used (Standard 2.1: Consultation, Clinical Supervision and Referral).
• The psychoactive substance must be possessed legally. Depending on the substance and state of the law, this could be through a clinical trial, Health Canada Special Access Program, or exemption granted by the Minister of Health to the Controlled Drugs and Substances Act (Standard 1.5: General Conduct).
• The registrant collaborates appropriately with the prescribing physician (Standard 1.4: Controlled Acts; Standard 3.3: Communicating Client Care).
• Claims made about the therapy are regarded as reasonable professional opinion. Comply with laws prohibiting advertising of controlled substances (Standard 6.2: Advertising).
• As with any therapy, registrants maintain professional boundaries (Standard 1.7: Dual or Multiple Relationships; Standard 1.8: Undue Influence and Abuse).

Social media is an extension of everyday conduct and communication, though the audience and impact can be greater than in other communication forums. As outlined in the examples below, CRPO’s Practice Standards apply as much in the realm of social media as they do in other forums:

• Accepting a ‘friend’ request from a client, or ‘liking’ a client’s content could be considered a boundary crossing or dual relationship (Standard 1.7: Dual Relationships).
• Posting information online about a client without their informed consent violates their confidentiality. Even if the client’s name is not mentioned, people with partial knowledge could ascertain the client’s identity (Standard 3.1: Confidentiality).
• Publicly posting violent images or spreading hate online could constitute conduct unbecoming a registrant. Using one’s RP credential at the same time would aggravate the situation by explicitly linking the profession to the conduct (Standard 1.5: General Conduct).

CRPO received a complaint about an RP from a member of the public, who was never a client of the RP. They alleged that the RP publicly mocked them on social media, including by stating a diagnosis they might have. The registrant denied authoring the posts, claiming that they were being impersonated. The registrant did not provide evidence to support this claim.

CRPO’s Inquiries, Complaints and Reports Committee (ICRC) required the registrant to attend for an oral caution and to complete ethics education. While the author of the posts could not be proven definitively, the ICRC noted that the registrant did not appear to take prompt action disclaiming the posts after they were written. The ICRC also noted the registrant did not demonstrate insight into the inappropriateness of the posts.

The Canadian constitution includes the Constitution Act, 1867 and the Constitution Act, 1982. All laws in Canada must be consistent with the constitution. The Constitution Act, 1867 indicates that the regulation of professions is within the jurisdiction of each province. The Canadian Charter of Rights and Freedoms, which is part of the Constitution Act, 1982, requires laws not to unreasonably limit certain rights such as freedom of expression, inter-provincial mobility, and equality under the law. The Constitution Act, 1982, recognizes and affirms aboriginal and treaty rights.

Judy lives in Chelsea, Québec, is registered with CRPO, and practices both physically and electronically with clients who live in Ontario. The constitutional right to inter-provincial mobility means she does not need to live in Ontario to be registered with CRPO. Since the regulation of professions is under each province’s jurisdiction, Judy is restricted in the work she can do with clients who live in Québec. If she wants to practise as a psychotherapist in Québec, she would need to qualify for and obtain a psychotherapist permit from the Ordre des psychologues du Québec.

Legislation refers to written laws passed by provincial legislatures or the federal Parliament. When draft legislation is first introduced in the legislature or Parliament, it is known as a bill (e.g., Bill 141). After a bill is passed into law, it becomes an act, also referred to as a statute. A number of acts are discussed throughout this manual.

Many acts include clauses that provide for the subsequent creation of regulations under the act. Regulations provide more details on how the act will be implemented. Under the RHPA, regulations can be proposed by the College (e.g., regarding registration, professional misconduct, and the Quality Assurance Program) or by the Minister of Health (e.g., regarding controlled acts or professional corporations).

Court decisions, also referred to as case law, are used as a guide by lawyers and judges when similar issues arise at a later date. Case law is particularly important in guiding the procedures of College committees (e.g., investigations by the ICRC and decisions of the Discipline Committee).

The RHPA and CRPO’s Professional Misconduct Regulation restrict some of the ways RPs may express themselves. For example, RPs are not permitted to use testimonials in their advertising. RPs are also not allowed to use the title “doctor” when offering or providing healthcare (though registrants with a PhD may use the doctor title in an academic setting). Several other health professionals are also subject to these rules. Ontario courts have found restrictions on testimonials and the doctor title to be constitutional, specifically that they do not unreasonably restrict freedom of expression (Yazdanfar v. The College of Physicians and Surgeons, 2013 ONSC 6420 (CanLII); Berge v College of Audiologists and Speech-Language Pathologists of Ontario, 2016 ONSC 7034 (CanLII)).

By-laws are made by the College Council and deal primarily with internal operations. They also address some administrative matters relating to registration, such as the payment of annual fees, information on the public register, and requirements for professional liability insurance.

In addition to developing regulations and by-laws, the College publishes official documents such as professional practice standards, policies, and position statements. Policies are not actually law; however, they may be considered as evidence in interpreting whether a registrant met their professional obligations, and to assist in consistent decision-making. CRPO’s Professional Misconduct Regulation states that it is professional misconduct to contravene a standard established by the College. CRPO also issues guidelines, which provide additional information and direction for registrants, to help them understand how to meet practice standards. Policies and position statements generally provide guidance to Registrants on specific issues or share CRPO’s position on issues with the public.

In 2007, the United Nations General Assembly adopted the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP). UNDRIP “establishes a universal framework of minimum standards for the survival, dignity and well-being of the indigenous peoples of the world”.* UNDRIP touches on healthcare in various ways, including by affirming that “Indigenous individuals have an equal right to the enjoyment of the highest attainable standard of physical and mental health.”** In 2021, the Government of Canada passed legislation committing itself to the implementation of UNDRIP in Canadian law.***

*United Nations Department of Economic and Social Affairs Indigenous Peoples, online: https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html.

**Art 24, para 2.

***See Government of Canada, Implementing the United Nations Declaration on the Rights of Indigenous Peoples Act, online: https://www.justice.gc.ca/eng/declaration/index.html.

In 2015, the Truth and Reconciliation Commission (TRC) published several reports following its inquiries into the pervasive consequences of Canada’s system of residential schools for Indigenous people. The TRC issued its Calls to Action, including for governments to establish goals and report on progress to close gaps in health outcomes between Aboriginal and non-Aboriginal communities, including for indicators such as mental health and addictions.*

One aspect of closing health outcome gaps is ensuring appropriate competencies are held by RPs interested in working with Indigenous communities, including familiarizing themselves with mental health trends that may differ from the general population to ensure appropriate care. For example, Call to Action #33 acknowledges Fetal Alcohol Spectrum Disorder (FASD) as a high priority health need in Indigenous Communities.

In 2019, the National Inquiry into Missing and Murdered Indigenous Women and Girls issued Calls for Justice, including for governments “to ensure that equitable access to basic rights such as employment, housing, education, safety, and health care is recognized as a fundamental means of protecting Indigenous and human rights, resourced and supported as rights-based programs founded on substantive equality.”** The Calls for Justice also include cultural competency training for public servants and service providers.***

*Calls to Action 19, 55.

**Calls for Justice 1.1.

***Calls for Justice 17.8, 18.18.

In Canada, health policies pertaining specifically to Indigenous communities tend to fall under the general theme of access to care and ensuring equity in accessed services. RPs should be aware of programs available to Indigenous clients and be able to suggest resources where necessary. RPs should also be aware prior to making any suggestions that Métis people are often excluded from federal health benefit programs.

RPs should make themselves aware of other programming offered locally or provincially to support clients.

NIHB provides eligible First Nations and Inuit individuals with coverage for health benefits that are not ordinarily covered through social programs, private insurance, and provincial or territorial health plans. This includes mental health counselling, in addition to vision care, dental care, medical supplies, prescriptions, and medical transportation. RPs providing services through NIHB must be authorized for independent practice, which means being registered in the full RP category, having completed 1000 direct client contact hours, 150 clinical supervision hours, and having this confirmed by CRPO.

An eligible client must be a resident of Canada and any of the following:

• a First Nations person who is registered under the Indian Act  (commonly referred to as a status Indian) as may be expressed by a status card;
• an Inuk recognized by an Inuit land claim organization, as may be expressed by an ID card; or
• a child less than 18 months old whose parent is a registered First Nations person or a recognized Inuk.

Every 12 months, an eligible client can receive 22 hours of counselling performed by an eligible provider, including Registered Psychotherapists, on a fee-for-service basis. Additional service hours may be approved on an individual basis.

Beneficiaries of the program may use the client reimbursement process or may request that service providers directly bill the program through Express Scripts Canada.

Jordan’s Principle is a legal principle that seeks to ensure substantive equity for First Nations children in accessing products, services, and supports they need, including health, social, and educational services. Depending on the needs of an individual, psychotherapy may potentially be covered by Jordan’s Principle.

The principle was put in place following the death of Jordan River Anderson (October 22, 1999-February 2, 2005) from Norway House Cree Nation in Manitoba. Jordan was born with complex medical needs, which spurred a conflict between the provincial and federal government as to which body was responsible for paying for the at-home care suggested by his medical team. As a result of the conflict, Jordan was kept in the hospital until his death in 2005.

Jordan’s Principle seeks to ensure that First Nations children can access needed products, services, and supports. It requires federal and provincial governments to resolve payment issues separately without acting as an impediment to care.

A child under the age of majority in their province/territory of residence can access funding through Jordan’s Principle if they permanently reside in Canada and meet one of the following criteria:

• They are registered or eligible to be registered under the Indian Act.
• They have one parent or guardian who is registered or eligible to be registered under the Indian Act.
• They are recognized by their nation for the purposes of Jordan’s Principle.
• They are ordinarily a resident on a reserve.

The Government of Canada has information on accessing Jordan’s Principle. The First Nations Child and Family Caring Society has also published information on Jordan’s Principle. In addition, a 2019 Canadian Human Rights Tribunal ruling discusses the implementation of Jordan’s Principle.

The Inuit Child First Initiative seeks to ensure Inuit children have access to services when they need them. It covers health, social, and educational products and services.

All Inuit children can request funding through the Inuit Child First Initiative provided they are

• recognized by an Inuit land claim organization; and
• under the age of majority in their province/territory of residence.

Information on the Inuit Child First Initiative from the Government of Canada can be found on this Government of Canada web page.

The federal government has committed to developing distinction-based Indigenous health legislation. The goals of the initiative are to

• establish overarching principles as the foundation of federal health services for Indigenous peoples;
• support the transformation of health service delivery through collaboration with Indigenous organizations in the development, provision, and improvement of services to increase Indigenous-led health service delivery; and
• continue to advance the Government of Canada’s commitment to reconciliation and a renewed nation-to-nation, Inuit-Crown and government-to-government relationship with Indigenous peoples based on the recognition of rights, respect, co-operation, and partnership.

Consultations have been initiated, but as of the date of this publication, no substantive announcements have been made.

The RHPA establishes the governing framework for regulated health professionals in Ontario. It also sets out exemptions for “aboriginal healers,” defined in the Act as an aboriginal person who provides “traditional healing services to aboriginal persons or members of an aboriginal community.”

Even though traditional Indigenous healing is outside the scope of the RHPA, CRPO has established a voluntary registration pathway that recognizes those trained in Indigenous practices that overlap the scope of psychotherapy.

Every person is entitled to access and receive health care services in a manner that respects their human rights. The Ontario Human Rights Code requires every RP to treat clients, potential clients, employees, and others equally, regardless of the person’s race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex, sexual orientation, gender identity or expression, age, marital status, family status, or disability.

If a person feels that a therapist or organization has violated the Human Rights Code, the person may make a complaint (called an “application”) with the Human Rights Tribunal of Ontario. If the Tribunal finds that a psychotherapist has violated the Human Rights Code, it may order the psychotherapist or organization to pay damages. It may also require the therapist or organization to take other action, such as completing training or implementing a human rights policy.

Since the Human Rights Tribunal does not have the power to suspend or revoke a registrant’s certificate of registration, a person who believes their human rights have been violated may also file a complaint with CRPO.

A registrant must not discriminate against any person on any prohibited ground. Examples of discrimination may include the following:

• refusing to accept or continue to treat a new client for a prohibited reason, such as race, gender identity, or sexual orientation;
• making a treatment decision for a prohibited reason;
• insulting a client in relation to a prohibited reason;
• refusing to allow a client with a disability to attend an appointment with a support person, assistive device, or service animal; and
• making assumptions, not based on clinical observation or professional knowledge and experience, about a person’s health or abilities because of their age or another prohibited reason.

It is not discrimination to make clinical decisions for reasons other than prohibited grounds. For example, if an RP does not have the competence to treat or continue to treat a person, a registrant should not initiate or continue therapy with a client. Such a decision to refuse or discontinue services must be made in good faith, communicated sensitively, and documented. It is discriminatory to claim one lacks competence as a pretense for refusing to provide service based on protected grounds.

RPs are similarly entitled to rely on professional knowledge, judgment, and experience to comment upon clinically relevant matters that relate, for example, to a person’s age, gender, or cultural background.

The Human Rights Code requires that persons with disabilities be accommodated, unless the accommodation would result in undue hardship (e.g., because of a real risk to health or safety or because of undue cost). The duty to accommodate also applies to other prohibited grounds of discrimination.

To accommodate persons with disabilities, accommodation must be individualized. Individual accommodations should be discussed with the person where possible and must be provided in a manner that respects the person’s dignity and autonomy. However, a registrant is not required to provide the exact accommodation that a person requests if another form of accommodation is reasonable and acceptable.

Examples of accommodation may include the following:

• permitting a client who uses a wheelchair to reschedule an appointment with less than 24 hours’ notice if the elevator in the RP’s office is temporarily out of service;
• offering an extended appointment time to a client with an intellectual, learning, or mental health disability who may need a longer time to explain their concerns;
• permitting a person with a disability to enter your premises with a support person, service animal, or assistive device; and
• communicating in writing if a person with a hearing impairment or other disability requests this.

The Accessibility for Ontarians with Disabilities Act (AODA) provides standards for accessible customer service, information and communications, transportation, employment, and built environment (i.e., physical facilities). The intention of the AODA Standards is to achieve accessibility for Ontarians with disabilities by 2025. An RP, or an organization the therapist works for, may be fined for not complying with the AODA.

The AODA Standards currently apply only to persons and organizations with at least one employee in Ontario. Different standards apply depending on the number of employees an organization has. Neither a sole proprietor nor a group of persons in a partnership are considered employees. Therefore, the AODA standards currently do not apply in these situations. However, if a psychotherapist has incorporated as a business, they may be considered an employee of the corporation along with any other employees the RP has.

Accessibility standards are found in regulations and have the status of law. A breach of an AODA standard is not necessarily a breach of the Human Rights Code. However, it is possible that the AODA standards will be used as a reference point in Human Rights Tribunal hearings.

Relevant accessibility standards are listed below.

Customer Service Standard

Therapists with at least one employee in Ontario must comply with the accessible customer service standard. For organizations with fewer than 20 employees, the AODA requires therapists to

• implement policies, practices, and procedures regarding the provision of goods and services to persons with disabilities, that are consistent with the principles of dignity, independence, integration, and equal opportunity, and that deal with the use of assistive devices and the availability of any measures that make services accessible (e.g., teletypewriter or TTY, elevator);
• permit service animals and support persons in public areas of A service animal includes an animal that is readily identifiable as being used for reasons relating to a person’s disability. It also includes an animal for which a health professional, such as an RP, has provided documentation confirming that the person requires the animal for reasons relating to disability;
• provide reasonable notice of any temporary disruptions to any accessibility features or services, including the reason for the disruption, the anticipated duration, and a description of any alternate services;
• provide training to all employees and anyone else who deals with members of the public or third parties, which must include the following:

1. a review of the purposes of the AODA and the requirements of the Customer Service Standard;
2. how to interact with persons with disabilities who use assistive devices, use a service animal, or are assisted by a support person;
3. how to use accessibility equipment and devices that the business makes available; and
4. what to do if someone with a particular type of disability is having difficulty accessing the providers’ goods or services; and

• establish a process for receiving and responding to feedback about accessibility and make information about the process readily available to the This process must permit people to provide feedback in person, by telephone, in writing, or electronically, and the process must specify actions that will be taken if a complaint is received.

For organizations with 20 or more employees, there are additional requirements, including putting any policies, practices, and procedures in writing and making them available upon request; filing publicly available accessibility reports; and keeping records of the training that has been provided.

Integrated Standard

The Integrated Standard includes standards on information and communications, transportation, and employment. For organizations with fewer than 50 employees, the general requirements under this Standard include the creation and implementation of policies, practices, and procedures regarding how the organization will meet the Integrated Standard. It includes requirements for training of all employees, volunteers, and others on the Integrated Standard and the Human Rights Code.

Information and Communication Standard

The Information and Communication Standard requires organizations to ensure that information available to the public, and the organization’s communications with the public are accessible or may be made accessible. This includes making any feedback system accessible upon request, ensuring that any emergency or public safety information available to the public is made accessible upon request, and providing accessible information formats and communication supports upon request.

For example, this Standard may require therapists with at least one employee to provide intake forms, charts, and other health information in accessible format (e.g., large print, audio, or Braille). It may also require therapists to provide sign language interpretation. The therapist must consult with the person making the request regarding an accessible format or communication support, and then must provide an accessible format or communication support in a timely manner, without increasing the cost to the client.

For organizations with 50 or more employees, additional steps are required, including ensuring that websites are compliant with web accessibility standards, and filing accessibility reports.

Employment Standard

The Employment Standard requires employers to provide an accessible workplace. This includes the following:

• providing public notice regarding accessibility practices in hiring employees;
• providing accessible workplace information; and
• providing, on request, any individualized emergency response information to employees who require this individualized information because of a disability.

Built Environment Standard

The Ontario government has not yet developed a comprehensive standard on the built environment. Once developed, it will apply to the construction of new buildings and to major renovations.

Voluntary Admission

A person may go to a psychiatric facility voluntarily and be admitted upon the recommendation of a physician. A voluntary client may leave a psychiatric facility at any time and has the right to refuse treatment if they are capable of making treatment decisions.

The MHA does not authorize any person to detain or restrain a voluntary client; however, there is a common law exception that applies to emergency situations where there is a risk of serious bodily harm to the client or another person.

Informal Admission

An informal client is a person whose substitute decision-maker has consented to admit them to a psychiatric facility. If the client is 16 years old or over and objects to admission, consent may only be given on the client’s behalf in limited circumstances.

An informal client has the same rights as a voluntary client, except that the client’s substitute decision-maker may be responsible for making certain decisions for the client, including a decision to leave the psychiatric facility.

Involuntary Admission

A person becomes an involuntary client when a physician completes a Certificate of Involuntary Admission (Form 3). An involuntary client does not have the right to leave a psychiatric facility as long as a valid Certificate of Involuntary Admission (Form 3) or Certificate of Renewal (Form 4) is in effect. Through the HCCA, an involuntary client does have the right to refuse treatment if they are capable of making treatment decisions.

A person may be brought involuntarily to a psychiatric facility for assessment, which may result in the client being admitted as a voluntary, informal, or involuntary client. A voluntary client may become an involuntary client if a physician completes a Certificate of Involuntary Admission (Form 3).

The test for involuntary admission is that the physician, upon examining the client, is of the opinion that

1. the client is suffering from a mental disorder of a nature or quality that will likely result in serious bodily harm to the client or to another person, or serious physical impairment of the client, unless the client remains in the custody of a psychiatric facility; and
2. the client is not suitable for admission or continuation as an informal or voluntary client.

A Certificate of Involuntary Admission is valid for up to two weeks. A person may be detained for more than two weeks if a Certificate of Renewal is signed. A first Certificate of Renewal is valid for up to one month; a second for up to two months; and a third for up to three months. Upon the expiry of a Certificate of Involuntary Admission or a Certificate of Renewal, the client automatically becomes a voluntary client unless a new Certificate of Renewal has been signed.

An involuntary client has the right to obtain legal advice, to speak to a rights advisor, and to seek review of the decision before the CCB regarding any decision to issue a Certificate of Involuntary Admission or Certificate of Renewal.

Restraints may be used only for involuntary clients. There is a common law exception that permits the use of restraints on voluntary or informal clients in emergency situations, where there is a risk of serious harm.

Any use of a physical or chemical restraint must be clearly documented in a client’s record, including a description of the means of restraint and behaviour that required the use or continued use of the restraint. In the case of a chemical restraint, the entry must include a statement of the chemical employed, method of administration, and dosage.

It is an offence to violate any provision of the MHA, including the provisions regarding use of restraints. If found guilty, a person may have to pay a fine of up to $25,000.

A physician who believes a person meets the legal test for a psychiatric assessment under the MHA can complete a Form 1 application for a psychiatric assessment. Only a physician is authorized to complete a Form 1 and can do so only if they have examined the person within the past seven days. Once signed, a Form 1 authorizes any person to bring the person named in the application to a psychiatric facility for assessment within seven days of the date the application is signed. Form 1 authorizes the involuntarily detention of the named person for up to 72 hours for the purposes of psychiatric assessment.

Following the psychiatric assessment, the client is either discharged or admitted as a voluntary, informal, or involuntary client.

A physician may complete a Form 1 (Application for Psychiatric Assessment) in the two situations described below.

Situation 1

The physician has examined the person in the past seven days and concludes that the person meets the following tests:

a) the physician has reasonable cause to believe that the person

i. has threatened or attempted or is threatening or attempting to cause bodily harm to himself or herself;

ii. has behaved or is behaving violently towards another person or has caused or is causing another person to fear bodily harm from him or her; or

iii. has shown or is showing a lack of competence to care for themselves; and

b) the physician is of the opinion that the person is apparently suffering from a mental disorder of a nature or quality that likely will result in serious bodily harm to the person or another person, or serious physical impairment of himself or herself.

Situation 2

The physician has previously successfully treated a person for an ongoing or recurring mental disorder that if left untreated would result in serious harm, and if the physician is of the opinion that the person

a) is apparently suffering from the same or a similar mental disorder;

b) the mental disorder will likely result in serious bodily harm to the person or another person, or serious physical impairment of himself or herself; and

c) is incapable of consenting to treatment in a psychiatric facility and the consent of his/her substitute decision-maker has been obtained.

A physician may issue a CTO, which permits a client to receive psychiatric care and treatment in the community rather than in a psychiatric facility. A CTO is generally made where a client follows a pattern of being successfully treated in a psychiatric facility but destabilizes upon release into the community and must be readmitted.

The client must consent to a community treatment plan. The physician who signs the CTO is responsible for the general supervision and management of the CTO. They may consult with other health care providers to determine whether or not to issue or renew a CTO.

In addition to the physician signing the CTO, a health care provider, including an RP, may be named in a community treatment plan. The health care provider must agree with the plan and is responsible for providing the treatment and care or supervision in accordance with the plan. They may share the client’s personal health information with the physician who signed the CTO, or any other person named in the plan for the purposes of providing the treatment, care, and supervision set out in the plan. This authority to share information prevails over all other law including PHIPA and the HCCA.

If a person subject to a CTO does not comply with its terms, the physician who issued the order may, in some circumstances, issue an order for examination of the person. The examination may result in a Form 1, a new CTO, or release into the community without a CTO. As well, a person may withdraw consent to a CTO, in which case the physician who issued the CTO must review the client’s condition to determine whether the client can live in the community without the CTO. Unless it is renewed or terminated early, a CTO expires after six months.

If a voluntary client in a psychiatric facility reports to an RP that they are having suicidal thoughts and are planning to immediately leave the facility, the RP should

i. Restrain the client and call security.

ii. Provide counselling, immediately notify the person responsible for the administration and management of the psychiatric facility or their delegate (i.e., the officer in charge), and document the incident.

iii. Affirm to the client that they are free to leave and help them pack their belongings.

iv. Provide counselling and document the incident.

The best answer is ii. While a voluntary client can leave a psychiatric facility at any time, it is possible that the client’s circumstances have changed, and the client now meets the test for a Form 1. A physician may assess the client before they leave, and depending on the results of the assessment, this may result in the client’s status changing to involuntary.

Answer i is not the best answer because there is no legal authority to restrain a voluntary client, unless it is clear in the circumstances that immediate action is necessary to prevent serious bodily harm. If it is clearly necessary to restrain the client, the RP must be sure to document the method of restraint and reasons in detail.

Answer iii is not the best answer because, if there is a risk of suicide, encouraging the client to leave would not be appropriate, and may potentially result in accountability for the RP if the client subsequently dies by suicide.

Answer iv is not the best answer because it is possible that the client’s circumstances have changed, and the client now meets the test for a Form 1. A physician may assess the client before they leave, and depending on the results of the assessment, this may result in the client’s status changing to involuntary.

A recurring contractual issue among RPs is non-solicitation. A non-solicitation clause aims to prevent an employee or contractor from asking clients to see them at their other practice. An agency may have valid reasons to discourage this, particularly while the RP is still working at the agency (e.g., to avoid the perception that agency staff is treating the organization as a referral source).

The situation is often different in a group private practice context where the motivation is financial. It is common for an RP to leave a group practice and offer clients to transfer to the RP’s new practice if they wish. Courts have refused to enforce non-solicitation clauses that overly restrict a former employee’s right to earn a livelihood. From CRPO’s perspective, the client’s best interests are paramount. RPs should not enter into agreements that prevent a client from making an informed choice of where to receive care, e.g., RPs should not promise their employer that after their employment ends they will never treat a client who they saw through the employer.

An apology can help repair a relationship; however, people have worried that an apology could motivate legal action or be used against them. Ontario’s Apology Act, 2009, encourages expressions of sympathy, regret, or contrition. The Act prevents apologies being used as evidence in civil lawsuits or as admissions of fault. Exceptions include criminal and certain financial matters.