The Practice Advice Service provides information to College members and members of the public about relevant Legislation, Regulations, Standards of Professional Conduct, 2017, and other practical considerations. Answers are provided by College staff in response to specific inquiries and may not be applicable or generalized to all circumstances. Information is provided to support College members in exercising their professional judgment and is not an appropriate substitute for advice from a qualified legal professional.
QUERIES
During the third quarter of this fiscal year (December 1, 2022- February 28, 2023), the College’s Practice Advice Service addressed 411 queries. The five most common topics queried during this period, in descending order, were:
1. Mobility and practice in other jurisdictions, mostly relating to member practice outside of Ontario;
2. Release of and access to information, mostly relating to the client’s right of access and consent to access or disclose information;
3. Supervision, primarily concerning the supervision of non-members;
4. Fees and billing, most frequently relating to the setting of fees and prepayment of fees;
5. Records, mostly focusing on file contents and file retention.
Answers to many of these queries can be found on the Professional Practice FAQ page of the College website which includes the following recent additions.
Psychological assessments when norm-based scores are not available for a client:
Q: When Scoring and Analyzing tests for which there are norm-based results, how should one proceed when the patient does not belong to the group upon which the norms are based?
A: This can be the case with respect to such factors as age, language, race, culture, or gender diversity and is a legitimate concern. In the absence of appropriate norms, one would need to use clinical judgment to interpret the client’s response to items and, in accordance with the following Standards:
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.
An American Psychological Association article about assessing people who are transgender provides one example of how to conduct an assessment where no appropriate norms have been identified. In the absence of specific guidance concerning an identified group, registrants are advised to document their approach to interpreting test responses. This can be helpful in the event that assessment results are challenged and, of at least as much importance, the exercise of writing out a rationale can help make the activity as objective as possible.
When a client does not want to use their legal name:
Q: I have been asked to identify a client in a report by a name different than their legal name and worry about whether this may be misleading and lead to confusion. How can I ethically honor the person’s wishes in this situation.
A: Most of the queries we have received related to this problem have been asked in the context of an individual who is transgender, where a client may be capable of making their own decisions may not be in a position to effect a legal name change, due to age or an institutional or family situation. Ideally, such issues should be discussed as part of the informed consent process, as early as possible and preferably before beginning the assessment. If the client agrees to have both their legal and preferred names in the report, that would avoid any confusion to readers of the report with respect to who the report is about. If the client does not provide permission to note both names and there is a need to include the client’s non-preferred name, or to indicate that the name used in the report is not the same as the client’s legal name, this will require careful navigation, in order to protect the client’s dignity and to avoid making a potential misrepresentation. In such a case, it would be prudent to obtain independent legal advice before proceeding.
When addressing issues related to a trans person’s identify, the Ontario Human Rights Commission provides the following guidance:
- Preventing discrimination because gender identity and gender expression – 9 reasonable bona fide requirements
2. Preventing discrimination becasue gender identity and gender expresion – 7 forms of discrimination
3. Preventing discrimination because of gender identity and gender expression – preventing and responding to discrimination
This article, by the APA provides some guidance for how to determine when treating two ‘related’ individuals could become problematic.
In summary, the decision about whether or not to take on individual clients who are related either through family, friendship or are involved with each other in any other way will depend on a critical evaluation of the circumstances, nature of that relationship and the potential for cross involvement at any time.
Working with clients that are known to know each other
Q: A client has referred a friend to see me and ask me whether I am available to treat them. From my review of our standards, there is nothing that prohibits seeing two clients that know each other. Is this correct?
A: We recognize that ‘word of mouth’ is often how clients find their therapists, so it is likely that many members have clients who know each other. Each situation will likely present different risks and degrees of risk. When separately treating individuals who are friends with each other, there is a possibility that one client may want to discuss the other client for a variety of possible reasons. This could be problematic if the information they want to share is related to the issues you are treating the other person for and that information may be relevant to your formulation of the other case, regardless of whether or not it is verifiable information. In other words, this could be seen as a problem with respect to protection of both confidentiality and objectivity. Working with clients who you know to be friends with each other should be avoided whenever possible due to the complications that can arise. and increase the possibility that you may contravene the following Standards of Professional Conduct:
8.1 Collection, Use and Disclosure
Members are responsible for ensuring that consent is obtained with respect to the collection, use and disclosure of personal information and personal health information in a manner required by legislation applicable to the relevant service.
10.5 Freedom from Bias
Members must provide professional opinions that are clear, fair and unbiased and must make best efforts to avoid the appearance of bias.
13.1 Compromised Objectivity, Competence or Effectiveness Due to Relational Factors
Members must not undertake or continue to provide psychological services with an individual client when their objectivity, competence or effectiveness is, or could reasonably be expected to be, impaired. This could be due to the members present or previous familial, social, sexual, emotional, financial, supervisory, political, administrative, or legal relationship with the client or a relevant person associated with the client. This prohibition does not apply if the services are delivered to an organizational client and the nature of the professional relationship is neither therapeutic nor vulnerable to exploitation.
This article, published by the American Psychological Association provides an example of the difficulties which could arise when treating two ‘related’ individuals could become problematic.
A decision about whether to take on individual clients who are related either through family, friendship or are involved with each other in any other way will depend on a critical evaluation of the circumstances, nature of that relationship and the potential for cross involvement at any time. While treating individuals who are associated with each other is not strictly prohibited, if the community is large enough, it would be better to find another practitioner who would not be in such a potentially challenging situation.
Multiple Service Relationships
Q: Would it be problematic if I were to conduct an assessment of a client I provided therapy to last year?
A: As you likely know, dual relationships are not strictly prohibited but should be avoided, unless the client is unable to find another competent and available service provider.
Before agreeing to provide the service, you may wish to think about whether your previous professional relationship could lead to any concerns that this assessment was anything less than highly objective. While you are likely to work hard to remain objective, this can be difficult if you do hope for a particular outcome for a client you have supported through their struggles. Even if you can be perfectly objective, if your findings were to be challenged, it could be alleged that you weren’t, due to your previous alliance with the client.
It would also be important to consider whether there is any possibility that the client may seek intervention from you in the future, and whether your role as an assessor might prevent them from doing so. This could be the case if they were unhappy with the outcome of the assessment and this prevented them from returning to therapy with you, causing them to have to “start all over again” with another therapist.
Although multiple relationships are not strictly prohibited, the College has observed that members trying to be helpful by having multiple different service relationships with the same clients have inadvertently entered into challenging situations.
Retention of Records:
Q: I want to destroy some client files of mine and was looking through the Standards but didnt see anything about what, if any information, must be retained. I had thought we had to keep a list of the names, dates of birth and date of last contact for each client file destroyed. Is that correct?
A: While the College Standards set out the minimum length of time for record retention, there are no rules against keeping information indefinitely. It is not advisable though, to keep information which is not likely to be useful any longer than one needs to, due to the risks associated with unauthorized access to any record.
It’s our understanding that many members do keep a log of the files they have destroyed, with information such as you have outlined in your question. It is important to know that the information in such a record is considered Personal Health Information and that these lists themselves are subject to the same privacy legislation and Standards as the records themselves were, because they identity individuals who have received health care. If you do decide to keep such a record you might also consider including the date of destruction.