The College of Psychologists provides information to members of the College and members of the public regarding relevant Legislation, Regulations, Standards of Professional Conduct and other Guidelines. Information is provided in response to specific inquiries and may not be applicable to all circumstances. Information is provided to College members to support them in exercising their own professional judgement and is not an appropriate substitute for advice by a qualified legal professional.
Over the past many months, about half of the inquiries received from members related to practicing in the context of the pandemic. The evolving nature of the pandemic is reflected in the kinds of questions posed. Many of the most recent questions relate to the difficult judgment calls members must make in resuming in-person services.
The answers provided to members reflect the flexibility in the way in which the Ministry of Health requirements and recommendations are set out. Ministry guidance is meant to apply generally to all health care professionals and reflect the wide variety of services provided within a broad range of settings.
It is recognized that decisions made by one member may not be as applicable to others. Members are expected to make reasoned decisions based upon the ethical principles underlying the usual rules they are subject to, the evolving information about COVID-19 precautions, and the particular circumstances of their clients, practices and communities.
The pandemic remains an active threat to community safety. The College, therefore, continues to recommend that members provide services virtually when this can be done effectively. When clients require in-person services, as a general principle all safeguards that members can provide should be applied. In situations where there is ambiguity about the requirements, we urge members to take a conservative approach to minimize the risk of community spread as much as reasonably possible.
The following is a summary of the most frequently asked questions received:
Q: Must masks be worn in the office, particularly when it’s possible to maintain a physical distance of at least 2 metres?
A: Regulated Health Professionals are subject to Directive #2 of the Chief Medical Officer of Health. This directive states that: In the gradual restart of services, Health Care Providers must comply with the requirements as set out in “COVID-19 Operational Requirements: Health Sector Restart” (May 26, 2020 or as current), including, but not limited to, the hierarchy of hazard controls.
The hierarchy sets out the following measures, in order of priority:
- Elimination and Substitution – examples include not having patients physically come into the office/clinic, use of telemedicine, etc;
- Engineering and Systems Control Measures – examples include physical barriers like plexiglass partitions;
- Administrative Control Measures – examples include active screening, passive screening (signage), and visitor policies;
- Personal Protective Equipment – examples of PPE include gloves, gowns, facial protection (including surgical/procedure masks and N95 respirators), and/or eye protection (including safety glasses, face shields, goggles, or masks with visor attachments).
As noted previously, the Ministry recommendations must be general enough to apply to all health care providers. As a result, some of the examples provided may not be applicable to psychological services.
The Ministry is clear that PPE controls, such as masks, are the last tier in the hierarchy of hazard controls. Accordingly, they should not be relied on as a stand-alone primary prevention program. The Operational Requirements clearly state: Given community spread of COVID-19 within Ontario and evidence that transmission may occur from those who have few or no symptoms, masking (surgical/procedure mask) for the full duration of shifts for HCPs and other staff working in direct patient care areas is recommended.
Some local areas have enacted by-laws requiring mask use in indoor public settings, with exceptions to this requirement for health care providers. It is likely that such exceptions have been made in order to enable some health care procedures which cannot be performed while a mask is being worn.
The College continues to recommend that services should be provided virtually when possible. When in-person services are required, members should wear masks and require clients to do so in enclosed spaces, unless this is clinically contraindicated.
Q: What can be done if an employer refuses to provide supplies, like plexiglass screens, that a member deems necessary to use when testing clients?
A: This can be a difficult situation to navigate and we are advising members to make best efforts to negotiate resolution of such problems.
The Standards of Professional Conduct, 2017 require:
2.1 General Conduct
A member must conduct himself/herself so that his/her activities and/or those conducted under his/her direction comply with those statutes and regulations that apply to the provision of psychological services.
3.1.2 Employment Settings
A member must assume responsibility for the planning, delivery, and supervision of all psychological services he/she provides to a client. Members working as employees must make best efforts to ensure that their work setting adheres to the Standards of Professional Conduct, 2017 in the planning, delivery, supervision and billing practices of all psychological services provided.
The College is not authorized to regulate workplaces, only the conduct of individual members. As stated above, members are required to make best efforts to ensure that the work setting adheres to the Standards. This may involve escalating the issue within their organization and seeking outside assistance where necessary. Hopefully, in most cases, collaborative communication will help to resolve any “standoffs”.
Members may wish to advise those with the authority to grant their requests that Directive #2 has been issued to all Regulated Health Providers under Section 77.7 of the Health Protection and Promotion Act, 1990 and requires Health Care Providers to consider which services should continue to be provided remotely and which services can safely resume in-person with appropriate hazard controls and sufficient PPE.
Q: Must all clients be actively screened, even in a setting such as a school or social service agency?
A: The COVID-19 Operational Requirements: Health Sector Restart indicates that health care professionals should perform active screening, although we understand this can be assigned to a staff person. Screening should be done with the client. If it is believed that a client is unable to answer the screening questions reliably, it should be done in discussion with a person’s parent or caregiver.
The Operational Requirements state: Patients should be screened over the phone for symptoms of COVID-19 before coming for their appointments. If possible, any visitor accompanying a patient to an appointment, should also be screened prior to the appointment. The latest COVID-19 Patient Screening Guidance Document on the MOH COVID-19 website should be used and may be adapted as needed and appropriate for screening purposes. If a patient screens positive over the phone, the appointment should be deferred if possible and the individual referred for testing.
Q: If an assessment is conducted virtually, instead of in-person, may members violate the standard administration protocols for tests. Will norm-based scores be applicable and what effects will the stressful context of the pandemic have on test performance?
A: The College’s expertise and role is limited to professional regulation. It is beyond the purview of the College to provide clinical guidance to members. The College trusts that members practicing the profession have the knowledge, skill and judgment required to make appropriate clinical decisions.
With the large number of tools, techniques and tests in use, members should obtain current guidance from the test publishers about the administration procedures and the applicability of norm-based scores. At those inevitable times when answers are not clear, members may find it helpful to discuss these issues with other clinicians who they believe have relevant expertise.
As in all cases, interpretation of test results includes consideration of the context in which an assessment is conducted. The Standards of Professional Conduct, 2017 which guide members in making such judgments include:
10.1 Familiarity with Tests and Techniques
Members must be familiar with the standardization, norms, reliability, and validity of any tests and techniques used and with the proper use and application of these tests and techniques.
Practical Application: At times, a member may provide services in what would be considered an emerging area of practice. In such situations, a member should inform clients that the services being offered may not, yet, have been subjected to extensive research and validation. As with any informed consent process regarding the provision of services, clients would be informed of the risks, benefits and alternatives available.
10.2 Familiarity with Interventions
Members must be familiar with the evidence for the relevance and utility of the interventions used and with the proper use and application of these interventions.
10.3 Rendering Opinions
A member must render only those professional opinions that are based on current, reliable, adequate, and appropriate information.
10.4 Identification of Limits of Certainty
A member must identify limits to the certainty with which diagnoses, opinions, or predictions can be made about individuals or groups.
We have become aware from members that test publishers are providing guidance about how measures which rely on standardized administration procedures may be utilized. It is a member’s responsibility to ensure that they are using the tools properly, based on empirical evidence and good clinical judgment.
Q: Is there an obligation to release a client’s name and contact information to Public Health if a client attends a session in-person and soon after tests positive for COVID-19? What information (if any) should be disclosed to other clients or professionals who may have crossed paths with the infected individual in our workplace?
A: If someone has tested positive, the local Public Health agencies are expected to follow appropriate protocols with respect to notifying those who must be notified.
There does not appear to be a requirement for a member of the College to make a mandatory report of someone who has identified themselves as, or is suspected of being, COVID-19 positive. There are, however, provisions in the Health Protection and Promotion Act, 1990 that authorize the Chief Medical Officer of Health to make an Order requiring the release of confidential information, as specified in that Order. If ordered to provide information, the College would not expect a member to put themself in contempt of the Order. To date, we have not heard about any members receiving such Orders. If one is unsure of the nature of such an Order or the information it may require by released, one should seek legal advice.
If concerned about individuals who may have crossed paths with an infected person, it would be permissible and reasonable for a member to provide general de-identified information to other clients and suggest they may wish to be tested. One should, however, take care not to provide any information that could identify the other person.
Confidentiality provisions under the Personal Health Information Protection Act, 2004 (PHIPA) prohibit the disclosure of personal health information without authorization by the client, other than in specified circumstances. Exceptions to the duty of confidentiality are set out in sections 39 (regarding certain health programs) and 40 (regarding risk of serious bodily harm). It is important to remain aware that these exceptions permit one to make disclosure but do not require this. When one uses the discretion to make a disclosure without a client’s permission, only that information which is necessary for the purpose of eliminating or reducing a significant risk of serious bodily harm to a person or group of persons should be disclosed. Additionally, such information should only be disclosed to a person who is in the position to eliminate or reduce the risk.
If unsure about whether a disclosure is permissible, it may be useful to obtain the opinion of a qualified legal professional. Many professional liability insurance policies entitle the policy holder to pro-bono legal advice.
In addition to the challenges presented to members due to the pandemic, members continue to experience ‘everyday’ practice challenges. Sample frequently asked questions are answered below:
Authorized Practice Areas and Populations:
Q: What is the exact age range of clients that may be treated by someone authorized in Adult Clinical Psychology?
A: The College doesn’t specify hard borders between age ranges for the different population groups but recognizes that there are not always clear demarcations with respect to population groups, particularly with respect to age. Members are expected to use their professional judgment to determine whether, in all the circumstances, the person’s status is consistent with the status of those for whom they are authorized to provide service. For example, when trying to determine whether a client, at a border age, is an “adult”, “adolescent”, or for that matter a “senior”, it would be important to consider whether the person’s abilities, life circumstances and challenges are consistent with those which would normally be expected within the population groups for which the member is authorized to work.
Q: May a member authorized in Clinical Neuropsychology conduct a psychoeducational assessment, or must they be authorized in School Psychology?
A: As members know, the College has defined Authorized Areas of Practice. The definitions for the authorized areas of practice focus on the nature of difficulties the services are intended to address, as opposed to the specific type of service offered. In order to answer questions like this it may be most helpful to keep this distinction in mind.
The Practical Application posted with Standard of Professional Conduct, 2017 5.1 states: In deciding whether one is authorized and competent to provide a service, the nature of the client’s presenting difficulties will generally determine whether the member has the appropriate and required authorization. For example, if a client who has suffered a traumatic brain injury has been referred because of a need to assess the nature of their neuropsychological deficits, it is expected that the member providing the assessment would have clinical neuropsychology as an authorized area of practice. If the person was referred because of difficulty performing activities of daily living or occupational requirements, it is expected that the member would be authorized to work in the area of rehabilitation psychology. If the person was referred because of suspected anxiety or depression, then it is expected that the member would be authorized to practice in clinical psychology…
It’s likely that most of what are often called “psychoeducational assessments” are meant to help identify the reason an individual has difficulty learning in an educational environment and to provide information for the purpose of planning for remediation of these difficulties. If there is reason to believe that the nature of difficulties is neuropsychological in nature, then it would appear reasonable for someone with authorization in the area of Clinical Neuropsychology to assess the client.
At the same time, authorization in School Psychology requires certain knowledge not generally required for the practice of Clinical Neuropsychology, including knowledge of:
- academic, instructional and remedial techniques;
- interdisciplinary team approach for case management, program planning and crisis intervention;
- consulting, counselling, and primary, secondary and tertiary intervention programs and techniques;
- systems and group behaviours within, and related to, the school organization, including school climate and culture.
If making specific recommendations which require such knowledge, it’s expected that a member who has not acquired this knowledge would seek the professional guidance of another member who is authorized to practice School Psychology.
Interjurisdictional Practice, Unrelated to the Pandemic
Q: Is a member permitted provide virtual family therapy, where one family member is located outside of Ontario during the sessions?
A: Members may provide services to an individual located in another jurisdiction, but only if they have been authorized by the College or Board in that jurisdiction to do so. If the psychology regulator in the other jurisdiction permits this practice, it would also be important to confirm that one’s professional liability insurance coverage extends to one’s work with an individual in the other jurisdiction.