titles, licenses and who can do what to whom under Bill 21

A psychologist teaching at a major Canadian University who prefers to remain anonymous wrote to me because she was concerned that I was claiming that psychologists were “unlicensed and untrained”.

As I explained to her, nobody is disputing that psychologists are licensed and trained as psychologists.  What I am claiming is that psychologists do not always have specialized training or licenses in the specialized areas searched for by the public.

Most psychologists offering couple or family interventions, for example, are not licensed couple and family therapists.  So, when a person searches for a couple or family therapist using the Order of Psychologists' search engine and naïvely chooses "psychologist" as the first search criterion, this filters out all non-psychologist licensed couple and family therapists while leaving in psychologists without a license in couple/family therapy.

I explained to her that, when I said that psychologists were unlicensed in the specialties searched under, this was what I meant.  In the case of couple and family therapy, sex therapy, psychoanalysis, occupational therapy, art therapy and other specialized forms of therapy, professionals earn at least a master’s degree or have another equivalently high level of specialized training, and in many cases also a specialized license in these disciplines, which most psychologists lack. 

She made the interesting comment that, for psychologists, there was no "value added" by getting a couple and family therapy license since it was “covered” by their psychology license.

I reminded her that, although it may be legal for a psychologist to see couples, a psychologist needs to have a couple and family therapy license if she intends to treat them as a "couple and family therapist" or leads her clients in other ways to believe that she is a couple and family therapist when she is not.  So at least the title has some value under the law:

36.  No person shall in any way whatsoever:
(d) use the title “Marriage and Family Therapist”, “Marriage Therapist”, “Family Therapist”, or a title or abbreviation which may lead to the belief that he is such a therapist, or use the initials “M.F.T.”, “T.C.F.”, “M.T.”, “T.C.”, “F.T.” or “T.F.”, unless he holds a valid permit for that purpose and is entered on the roll of the Ordre professionnel des travailleurs sociaux et des thérapeutes conjugaux et familiaux du Québec
[my bold, Professional Code of Quebec; article 36]

Interestingly, my correspondent is not herself licensed to use the title of marital/family therapist but is currently training students to become licensed marital and family therapists in Quebec.  Whether that makes sense, whether it is even legal, is a question I ask myself.  It would be interesting to know how many couple and family therapists are training students to become licensed psychologists.

Finally, I said to my correspondent that, if she meant by "no value added" she meant no economic value, then I completely agreed: there is now *zero* economic value to being a licensed marital/family therapist.  That has been my main point from the beginning: those who have been trained and licensed as couple/family therapists (it used to take three years of post-graduate training and supervision of real clinical value to obtain this license), and who now pay their fees as psychotherapists to the Order of Psychologists and who also pay a fee to be included in the Order of Psychologists' referral system, can yet be excluded by the Order of Psychologists' search engine when the public is searching for a couple/family therapist.

Likewise insurance companies do not cover couple and family therapy offered by licensed couple and family therapists unless they are psychologists, while psychologists (and doctors!) who have no training, expertise or license as a marital/family therapist will be reimbursed for sessions of couple and family therapy.  This is not to say that all those who are reimbursed as psychologists or doctors have no training in this field...  But I never claimed that.

My main point has always been that none of this protects the public from those not qualified to practice, whereas public protection was the very raison d'être of Bill 21, and is now the Order of Psychologists' mandate.

I will end with a quote from my correspondent who said it better than I could:

for many of us, we have spent thousands of hours and thousands of dollars in training, supervision and supervised practice and the thought of getting yet one more license to do something we are already doing seems torturous.

This is exactly how all non-psychologist psychotherapists feel now that Bill 21 has been put into effect.

Bill 21 could have forced psychologists who are qualified to practice couple and family therapy to go to the Order of Social Workers and Couple and Family Therapists to apply for a permit, the way it is now forcing psychotherapists qualified to practice psychotherapy to go to the Order of Psychologists for a permit.  But it didn't.

Please sign my petition.

4.5 million dollars to reduce stigma?

The Toronto Star recently reported that the Canadian Alliance of Student Associations (CASA) released a policy paper asking for “an additional $4.5 million a year earmarked for the Mental Health Commission of Canada (MHCC) to ramp up its anti-stigma campaign in schools, colleges and universities.”

The MHCC already has 65 anti-stigma partners and 45 active anti-stigma projects.  By the end of this fiscal year, 210 million dollars will already have been spent on the MHCC, with anti-stigma projects being a primary focus.

Presumably one reduces stigma so that people are more likely to seek help, but we are also told that there are “long waiting lists” for those who seek help now. 

So the question arises: before giving another few million dollars to the MHCC so it can urge students to get help they are not seeking, wouldn’t it make more sense to use this money to get help for those already seeking it?  The 4.5 million dollars requested could buy five psychotherapy sessions for every student at the University of Toronto.  The MHCC budget to date could have paid for 21 million psychotherapy sessions.

Another question: who really benefits from making stigma the focus of the mental health conversation?  Is it a coincidence that this whole campaign was led by “one student from the University of Moncton” who now sits on the MHCC’s Board of Directors?

Is it another coincidence that psychotherapy is simultaneously being transformed by Bill 21 into a therapeutic specialty of doctors and psychologists to the exclusion of non-medically-based therapeutic models?

What if de-stigmatizing “mental illness” really means adopting a medical treatment model that pathologizes all psychological suffering?  What if it really means meeting psychosocial problems with psychological testing and psychiatric diagnoses?

After all, once mental illness is “de-stigmatized,” won't publicly funded programs and insurance companies quite logically require a psychiatric or psychological diagnosis of mental illness before covering psychotherapy?  Yet isn’t it that diagnosis which carries the very stigma that so many fear? And won't more people then be discouraged from simply going to talk to someone, from seeking help in the form of psychotherapeutic support and advice?

Something tells me that the MHCC won't be spending the 4.5 million dollars on considering these questions but on funding another "anti-stigma project" run by someone now sitting on their BOD.

Please sign my petition.

psychotherapy- diversity and freedom of choice

I spoke yesterday with Mme Andrée Thauvette-Poupart, Président of la Société Québécoise des Psychothérapeutes Professionnels (SQPP), who told me about some of the initiatives the SQPP has recently undertaken to promote psychotherapists and various modalities of psychotherapy practiced in Quebec.  (To sign the petition asking for better access to psychotherapy services, click here.)

The SQPP has been doing amazing work collating resources to promote psychotherapy as well as sensitizing and educating insurance companies, unions and employers in Quebec so that they take steps toward a more equitable representation of psychotherapists within their organizations.  

I wish to express solidarity with the SQPP’s initiatives, its overall commitment to the diversification of the practice of psychotherapy, and its representation of all licensed psychotherapists regardless of professional order.  

I also wish to express solidarity with those therapists who may not qualify for a psychotherapist’s permit because they are not members of any professional order and with those who, in the near future, will no longer be able to apply for the acquired right to practice psychotherapy as a psychoanalyst, sexologist, etc.  

Many competent professionals with backgrounds in creative arts therapy, somatic therapy, psychoanalysis, sexology or toxicology are uniquely qualified to offer certain forms of psychotherapy to the public.  Under Bill 21, however, the public will no longer have access to their expertise as psychotherapists.

It is very curious when the people publicizing a crisis in mental health and promoting access to psychological services ("Mon cheval de bataille, c'est d'améliorer l'accès aux services psychologiques, quel que soit le niveau de revenu") are the very same people limiting access to those services. It is a public policy error to limit public access and choice of psychotherapy, and wrong of the OPQ to appropriate all therapies when psychologists are not trained or qualified in them.

The regulation of psychotherapy by the Order of Psychologists (OPQ) was justified on the grounds of 'public protection' and was followed by a campaign by the OPQ to 'not let just anyone into your head'.  But in fact this "evidence based" community has no evidence that permit-holding therapists are any less dangerous or more effective than others.  On the contrary:

...there is evidence and substantive argument that [regulation] will do more harm than good, both in the matter of public protection and to the field generally.  A number of full-length books have undermined the ‘common sense’ public protection assumption... no such extensive, thoroughly researched and cogently argued literature exists to support the decision to regulate. (Therapy Today; vol. 20/6, 2009)

petition to the Ordre des Psychologues du Québec and Office des Professions

CLICK HERE TO SIGN THE PETITION

The Order of Psychologists of Quebec is responsible for the licensure of psychotherapists, and its mandate is to protect the public.

The Order of Psychologists of Quebec is not meeting this mandate.  Its online referral service favours members of its own order who are often less trained in the psychological treatments sought by the public than other psychotherapists who are specialized in those psychological treatments.

We are opposed to this.

The Order of Psychologists of Quebec is misleading consumers when it fails to refer them to all of the qualified providers of the psychotherapeutic services they seek and refers them to the less qualified.  This is contrary to public interest.

CLICK HERE TO SIGN THE PETITION

To:
Mme. Rose-Marie Charest, Order of Psychologists of Quebec
Commissaire aux plaintes, Office des professions du Québec

Dear Mme. Charest,
When I consult the Order of Psychologists of Quebec for a referral, I want access to the full range of licensed psychotherapists qualified to provide the psychological treatments that I seek.
I am signing this petition so that you will take action in the public interest by facilitating better access to all professionals licensed by the Order of Psychologists of Quebec who are authorized by law to provide psychological treatment.
Specifically, I am asking that:
1) The Order of Psychologists of Quebec cease interfering with the public’s freedom to choose its providers of psychological treatments,
2) The Order of Psychologists of Quebec refer the public to all psychotherapists qualified to provide the type of treatment sought,
3) The Order of Psychologists of Quebec's online referral service cease filtering search results using criteria to exclude specialized permit holders in the field searched under, and
4) The Order of Psychologists of Quebec provide me and the public at large with complete and relevant information on all meetings, discussions, negotiations and agreements with government organizations, insurance carriers or third parties, that determine how and in what matter psychotherapeutic services are to be provided to the public. 

Sincerely,
[Your name]

CLICK HERE TO SIGN THE PETITION

a psychologist accuses Rose-Marie Charest of conflict of interest as President of the OPQ

[translated from French]

As president of the Order of Psychologists, Rose-Marie Charest has a responsibility to protect the public, to represent the profession and psychologists. Promotional ads for her program On the Couch have alluded to the fact that she is president of the Order of Psychologists. Because of the credibility this title lends her, Rose-Marie Charest may be giving the public the impression that the analyses she offers on her program reflect what most psychologists would say. This is not the case. It can also give the impression that psychologists are first and foremost psychotherapists. This is not the case either.
[...]
The Order of Psychologists bought advertising messages that are inserted in the program In Therapy which is broadcast daily on TV5. It is deplorable.
[...]
Rose-Marie Charest promotes the profession of psychology as essentially a profession of psychotherapist. There are many psychologists who do not practice in the field of psychotherapy and who believe not only that we are licensed to protect the public but to also provide the public with accurate information about the profession of psychology. There are more and more psychologists who are not psychotherapists and who are not comfortable in the Order of Psychologists. Currently, Rose-Marie Charest's self-interest is fused with the interests of the Order of Psychologists. Rose-Marie Charest must choose.

Martin Courcy 

For the original article in its entirety, click here.

private meetings in the public interest

I recently learned from Diane Côté, Director of Communications at the OPQ, that their Legal Advisor is currently attending private meetings with four major third party subsidizers of psychological services in Quebec (SSQ, the CSST, Health Canada –Aboriginal Program, and IVAC).

The purpose of these meetings, according to Côté, is "to determine whether or not [these third parties] accept that services be delivered by psychotherapists and under what conditions.” [my translation]  She also specified that these meetings were not "inter-professional" and "not public."  Apparently, the OPQ will be the sole professional Order to determine, in  private meetings with the above government agencies, whether and how public funds are going to be made available to consumers seeking subsidized psychotherapeutic services in Quebec.

In the same (June 16) communication, Ms. Côté also confirmed that, when members of the public consult the OPQ’s online referral service in search of subsidized services by these third party payers, they are currently provided with only "the names of psychologists" even though many other psychotherapists are qualified to provide these services.  Mme Côté did not seem concerned about that, or about whether it was in the public’s interest to exclude these other providers from the referrals offered by the OPQ's site to the public at large.  I can only assume this is because, as she told me in a previous email exchange, the Order of Psychologist’s online referral service is "not regulated by their professional code". 

One can only hope that, regardless of whether their meetings with government agencies are “regulated by the professional code” or not, the OPQ will make every effort  in the public interest to promote the services of all psychotherapists licensed by their Order, including non-psychologist providers who are, not only as qualified as psychologists to provide these services to the public, but who have specialized licenses in the types of treatment sought by the public which most psychologists lack, namely: licenses in marital and family therapy, social work, occupational therapy, nursing, psycho-education, career counseling, and sexology.  

But, in light of how the OPQ dissimulates conflict of interest as public protection on its website, it would be wise to view its need for secret meetings with a healthy dose of suspicion .

letter to employer

Below is a sample letter that you can forward to your employer's Department of Human Resources simply by copying and pasting the text into an email and adding your name at the bottom of the page.
Please copy me on each email you send at patricia.i.ivan@gmail.com
Thank you! 
[This letter was edited on October 22, 2014 for reasons stated in this blog post- link to come]

Dear Employer,

I am writing to you about my insurance coverage for psychological services.

Under a new law in Quebec, Bill 21, all professionals qualified to provide psychological treatment (psychotherapy) are licensed by the Order of Psychologists of Quebec as psychotherapists.  These professionals have training and expertise which many psychologists lack.  Some psychotherapists are experts licensed in marriage and family therapy, others in social work, occupational therapy, psycho-education, career counselling, nursing and sexology.  Others are highly trained in unique forms of therapy like somatic therapy, art therapy or psychoanalysis, and many others.

Currently, however, the services of these experts are excluded by many insurance policies which only cover the services of psychologists.

When the consumer needs a psychological treatment, these policies force the consumer to choose between:

1) reimbursed sessions with a psychologist who may have little or sometimes no clinical training in the type of intervention sought, or

2) non-reimbursed sessions with a psychotherapist who, while not a psychologist, may have a license and/or many years of clinical experience and, like any psychologist in Quebec, is accredited by the Order of Psychologists.

More rational insurance provide clients coverage for the psychological services of all licensed psychotherapists.

It makes no sense that some policies continue to do otherwise. When an insurance policy limits the consumer's choice of providers, there is no cost containment of the services used. On the contrary, the value of their policy decreases.

An insurance policy that gives access to the largest pool of qualified providers helps reduce service costs.

I want access to all qualified providers authorized to provide the services I need.  For psychological services, this means that I want psychotherapy sessions covered with all psychotherapists accredited by the Order of Psychologists of Quebec who are legally licensed to provide them.

Please note: I am not requesting that a new psychological service be added to my current coverage. I am merely requesting access to a larger pool of providers licensed to provide that service.

Please inform me how my current policy provides coverage for psychological services, especially whether it covers all professionals qualified to provide these services: psychotherapists. If this is not currently the case, please rectify that situation with our insurance carrier.

Thank you for your attention to this matter.

Sincerely,
[Your name]

psychotherapy; one title, many specialties

[cliquez ICI pour la version française]

Introduction
Since the adoption of Bill 21 in Quebec in 2009, both the use of the title of psychotherapist and the practice of psychotherapy have been restricted.  

Bill 21 defines psychotherapy as follows:

A psychological treatment for a mental disorder, behavioural disturbance or other problem resulting in psychological suffering or distress, and has as its purpose to foster significant changes in the client’s cognitive, emotional or behavioural functioning, interpersonal relations, personality or health. Such treatment goes beyond help aimed at dealing with everyday difficulties and beyond a support or counselling role.

The Order of Psychologists of Quebec (OPQ) has been given the mandate to issue permits to psychotherapists and thereby protect the public from just anyone claiming to be a psychotherapist and/or offering psychotherapy. 

This blog documents my conversation with the Order of Psychologists of Quebec on the subject of psychotherapy and the OPQ's mandate to protect the public, which began with my initial conversation with Mme Marie-Hélène Bertrand, and was followed by subsequent email exchanges with Krystelle Larouche and Diane Côté of the OPQ.

Public protection or self-promotion?

The Office des Professions defines the Mission of an order as follows:

The main mission of a professional order is to protect the public, namely all persons who use the professional services in the various spheres of regulated activities. The order protects the public by adequately meeting its role and responsibilities.

PLEASE NOTE*

It is false to assume that a professional order is an association that protects the interests of its members.  The latter can subscribe to separate and independent organizations that will represent its members in this way.

[*original bold]

It is specifically stated here that the mission of a professional order is to protect the public, not to represent the interests of its members.

Nevertheless, the Order of Psychologists of Quebec is doing just the opposite by marketing its own members on its online site.  

Their online referral service filters its search results so that the public is frequently referred to privileged members of the OPQ over other psychotherapists who are, in many cases, more qualified in the type of psychological treatment sought.  To find out how exactly it does this, click here.

The result is information that is misleading:

When consumers, in good faith, consult the Order of Psychologists's website to find a psychotherapist, they will not necessarily be referred to those with specialized licenses in the fields searched under.  But they will always be referred to those without any specialized license to practice in those fields.  They will not systematically be referred to the professionals best trained and qualified in the type of psychological treatment sought.  But they will always be referred to certain privileged members of the OPQ. 

In practice this means that, when I consult the OPQ’s online referral service in search of help for couple issues, for example, I am very likely to come away with a long list of providers that includes professionals who are not licensed couple therapists, i.e., psychologists who have no specialized license in the field, but that excludes professionals who are licensed with a specialized permit to practice couple therapy. And this, in the exclusive interest of OPQ members who are not licensed couple therapists.

Imagine consulting a referral service for the College of Physicians and Surgeons because you have a sore throat, only to be provided with a list of doctors excluding those with specialized licenses in ear, nose and throat medicine, because including them would not be in the best interest of general practitioners!

This makes no sense and is not in the public interest.

Moreover, by preventing public access to specialized providers of psychological treatments, the Order of Psychologists of Quebec is enabling the irrational practices of the insurance industry.

Currently, some policies reimburse the cost of a specialized psychological treatment when offered by psychologists with no specialized license to practice in this discipline, but do not reimburse when offered by other psychotherapists who do hold a specialized license in this discipline and who are licensed to provide psychological treatment by the same professional order as psychologists: the OPQ. 

This discrimination against qualified psychotherapists does nothing to contain insurance costs, is not in the public interest, and should be immediately rectified.  

When the coverage for a “psychological treatment” is limited to treatment provided by a psychologist, the public’s choice of providers is irrationally limited to professionals who may have no specialized training in the type of treatment sought.  Coverage for a psychological treatment, which is the definition of psychotherapy by law, should include services from the complete range of qualified providers of that treatment: psychotherapists.

One would expect the Order of Psychologists to educate and accurately inform the public, if not to correct insurance inequities, then at least to not reinforce them with their referral service.  But apparently the OPQ is too busy promoting its members to be protecting consumers; so we have to take action to protect ourselves.

Action  
On May 21, 2014, I wrote to the Order of Psychologists of Quebec asking them to review their online referral service so that consumers could make more informed choices about the professionals they choose to consult than what they are currently able to do using this service. 

I received an answer from Mme Larouche on May 26, 2014  which gave some general information about the Order of Psychologist’s public protection mandate and the history of its referral service.

I replied to Mme Larouche on May 30,2014, asking her two specific questions.  These were:

1) whether she thought that the OPQ, by offering the public a referral service that excludes the majority of psychotherapists specialized in the field searched under, was adequately fulfilling its “public protection mandate applied precisely by informing and sensitizing the public,” as she said in her letter [my translation].

2) whether, by asserting that "searching by problem type is the best way to inform the public so that people can find the right professional according to their needs"[my translation], she was admitting that the OPQ, by offering the public a referral service that is not organized in this way, was providing an inferior service.

I did not receive an answer from Mme Larouche.  Instead, on June 6, 2014, I received an email from Dîane Côté in which she defends the Order of Psychologists’s online referral service, claiming that it is "not regulated by their professional code" [my translation] and informing me that it will not be changed in the near future.

My two questions were left unanswered.

The Order of Psychologists of Quebec is not adequately meeting its public protection mandate.  This is unacceptable for both consumers and providers of psychotherapy services.

Petitions
I have drafted a petition addressed to Mme. Rose-Marie Charest, President of the Order of Psychologists of Quebec, asking that, in the public interest, the OPQ’s online referral service cease interfering with the public’s freedom to choose its providers of psychological treatments, that it refer the public to all psychotherapists qualified to meet the type of treatment sought, that it cease filtering search results using criteria to exclude specialized permit holders in the field searched under, and that it provide the public with complete and relevant information on all meetings, discussions, negotiations and agreements with government organizations, insurance carriers or third parties, that determine how and in what matter psychotherapy services are to be provided to the public.

When you sign here, the petition is automatically forwarded to Mme. Charest and a copy sent to the Office de Professions du Québec, which assigns the Order of Psychologists its public protection mandate. 

For those who wish to take action to ascertain that their insurance policies cover all licensed psychotherapists qualified to provide psychological treatment, you can send a letter to your employer simply by clicking on this link and sending the sample letter to your employer's Department of Human Resources.

Some may fear that rectifying coverage in this way will increase insurance costs. This fear is unfounded.  The change requested is not for the coverage of an additional psychological service, but for access to a larger pool of providers licensed to provide that service.  This is actually more likely to reduce the cost of these services.

Your feedback in the form of comments, questions and criticism is welcome on this blog.
All original documents can be consulted here. 

Please forward to friends and colleagues.