• 1. Scope of Practice
• 2. Use of Title Psychotherapist
• 3. Competence
• 4. Psychotherapy Supervision
• 5. Maintaining Competence
• 6. OTs Acting as Supervisors
• 7. Supervision of Students
• 8. Occupational Therapist Assistants
• 9. Consent
• 10. Risk Management
• 11. Record Keeping
• 12. Professional Boundaries
• 13. Discontinuation
• Appendix 1: General Characteristics of Psychotherapy and Counselling
• Appendix 2: Supervision Agreement Considerations

The purpose of this document is to ensure the safe, effective, and ethical delivery of psychotherapy services including the controlled act by occupational therapists (OTs) in Ontario. The Standards for Psychotherapy describe the minimum expectations for OTs to provide competent and safe psychotherapy intervention within the scope of practice of the profession of occupational therapy.

The College defines psychotherapy as follows:

Psychotherapy refers to planned and structured interventions aimed at influencing behaviour and function, by psychotherapeutic means¹. Psychotherapy is delivered through a therapeutic relationship to change an individual’s disorder of thought, cognition, mood, emotional patterns, perception, or memory that may impair the individual’s judgement, insight, behaviour, communication, or social functioning as it relates to the performance of daily activities.

The College recognizes that this definition may not conform to all the published models or philosophies of psychotherapy and mental health care. The Standards for Psychotherapy are not based on any one psychotherapy theory or approach. This definition of psychotherapy is intended to apply in all circumstances in which OTs are practising psychotherapy.

Psychotherapy concentrates on the client’s emotional problems for the purpose of changing defeating patterns of thought, emotion, and behaviour. Psychotherapy through a therapeutic relationship aims at promoting positive personality change, growth and development, and re-organizing the personality. Psychotherapists frequently work with a variety of theories or combinations of theories and may use one or more procedures or models to try to achieve desired results². Psychotherapy intervention can be delivered in individual, group, family, or couple formats. Psychotherapy may be a long-term intensive process that identifies emotional issues and their cause with a focus on a deep, fundamental process of change, and the development of insight about thoughts, feelings and behaviours.

The practice of psychotherapy is broad and can be performed in different clinical settings with diverse client populations. For this reason, the Ministry of Health & Long-Term Care (MOHLTC) directed the College of Registered Psychotherapists of Ontario (CRPO) to make regulations prescribing therapies involving the practice of psychotherapy including the development of policies, guidelines and other supporting resources that outline the activities that are not considered to be part of the controlled act of psychotherapy. In the provision of occupational therapy service, the following are examples of activities considered to fall outside the practice of psychotherapy: advocacy; providing education; counselling and support; teaching and problem solving; learning and re-learning skills to carry out activities of daily living. The College acknowledges that OTs perform many interventions with their clients; an OT who performs these interventions in the absence of having a formal psychotherapeutic relationship is considered not to be performing psychotherapy³.

Appreciating that psychotherapy can pose an increased risk to clients with serious disorders, a subset of psychotherapy has been defined as a controlled act under the Regulated Health Professions Act, 1991 (RHPA). The controlled act of psychotherapy can only be performed by certain regulated health professionals including OTs.

Controlled Act

Controlled acts are procedures or activities which may pose a risk to the public if not performed by a qualified practitioner. The Regulated Health Professions Act, 1991 (RHPA) grants OTs the authority to perform the controlled act of psychotherapy. The controlled act of psychotherapy is defined in the RHPA as follows:

“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, behavior, communication or social functioning.”

The following elements must be present for a psychotherapy activity or intervention to fall within the controlled act of psychotherapy:

1. You are treating a client
2. You are applying a psychotherapy technique
3. You have a therapeutic relationship with the client
4. The client has a serious disorder of thought, cognition, mood, emotional regulation, perception or memory
5. This disorder may seriously impair the client’s judgment, insight, behaviour, communication or social functioning

The Standards for Psychotherapy apply to all psychotherapy practice and are not limited to the controlled act. OTs are required to perform all psychotherapy in accordance with the laws, regulations and standards of practice. For assistance in understanding when these standards may apply in a specific practice context, refer to the resource “Determining When the Standards for Psychotherapy Apply”.

Psychotherapy and Counselling

Psychotherapy and counselling are often viewed as interrelated. Whether the OT is practising psychotherapy or counselling with a client, the OT must understand that there are some distinctive differences⁴ in the level of risk between the two approaches. Counselling can involve education, guidance, encouragement, supportive problem-solving or informational advice. Counselling formats vary and can include: individual, group, family or couple. Counselling can be used in all areas of occupational therapy and is typically considered a lower risk activity for the client. The focus of counselling is on specific problems or changes in life that can impact occupational performance.⁵ Counselling may or may not require grounding in a specific theory.

Although there is some overlap between counselling and psychotherapy, it is important for OTs to be able to identify when they are practising psychotherapy given the increased level of risk posed to the client. See Appendix 1 for additional information.

---

¹ Adapted from the World Health Organization,2001
² Corsini et. Al, 2008
³ College of Registered Psychotherapists of Ontario. (2018). Controlled Act Task Group Consultation Documents
⁴ Appendix 1
⁵ Psychotherapy & Counselling Federation of Australia

• The following standards describe the minimum expectations for OTs when performing psychotherapy.
• The performance indicators listed below each standard describe more specific behaviours that demonstrate the Standard has been met.
• It is not expected that all performance indicators will be evident all the time. It is expected performance indicators could be demonstrated if requested.
• There may be some situations where the OT determines that a performance indicator has less relevance due to client factors or environmental factors.
• It is expected that OTs will always use their clinical judgement to determine how to best meet client needs in accordance with the standards of the profession.
• It is expected that OTs will be able to provide reasonable rationale for any variations from the Standard.

In the event of any conflict or inconsistency in these Standards for Psychotherapy with any other College standards, the standards with the most recent issued or revised date prevail.

College publications contain practice parameters and standards which all OTs practising in Ontario should consider in the care of their clients and in the practice of the profession. College Standards are developed in consultation with OTs and describe current professional expectations. College Standards may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained.

Pursuant to the RHPA, the College is authorized to make regulations in relation to professional practice. The College’s Professional Misconduct Regulation establishes that “contravening, by act or omission, a standard of practice of the profession or failing to maintain a standard of the profession” constitutes grounds for professional misconduct.

Standard 1

The OT will perform psychotherapy within the scope of practice of the profession of occupational therapy.

      Performance Indicators

In Ontario, there are protected titles that only regulated health professionals are legally permitted to use. The protected title "occupational therapist", the designation “OT Reg. (Ont.)” or any variation or abbreviation can only be used by individuals registered with the College of Occupational Therapists of Ontario. Occupational therapists (OTs) who practice psychotherapy in accordance with the Standards for Psychotherapy are also permitted to use the protected title “psychotherapist” (RHPA, s. 33.1(1)). When using the title “psychotherapist”, OTs are responsible for making sure people understand they are accountable to the College of Occupational Therapists of Ontario.

If choosing to use the “psychotherapist” title, OTs must use the protected title “occupational therapist” or identify themselves as a member of the College before the title “psychotherapist” in both oral and written communication.

While OTs have legal authority to use the title psychotherapist, they are not required to use this title. Alternative means for conveying this area of practice may be: Andrew James, OT Reg. (Ont.), practising in the area of psychotherapy.

Standard 2

The OT will use the protected title for occupational therapists in Ontario or identify themselves as a member of the College first when also choosing to use the title “psychotherapist”.

      Performance Indicators

OTs will ensure that they have adequate knowledge, training, skills, and judgement to perform psychotherapy interventions safely and effectively. OTs are expected to have completed training and coursework in psychotherapy. This may include recognized psychotherapy courses, training offered to OTs at their work sites, and professional development activities. Psychotherapy training programs must contain both theoretical and practical components and be taught by an individual who is qualified to practise psychotherapy.

Standard 3

The OT must have successfully completed training in psychotherapy and demonstrate competence prior to practising psychotherapy.

      Performance Indicators

Psychotherapy supervision is a process where an individual is professionally supported by another psychotherapy practitioner who has a minimum of 5 years of psychotherapy practice experience and is qualified to practise psychotherapy. In this supervisory relationship, the supervising OT or other psychotherapy practitioner will discuss decision-making processes and provide support for complex or stressful situations to protect the client’s well-being and facilitate the OT’s professional growth in psychotherapy practice.

Standard 4

The OT must engage in psychotherapy supervision that is appropriate to their level of competence and aligns with their psychotherapy approach for the duration of their psychotherapy practice.

      Performance Indicators

OTs are expected to maintain competency through ongoing professional development as it relates to the psychotherapy services being provided. Maintaining competency enables OTs to refine and build on the skills developed through training.

Standard 4

The OT will maintain competence by engaging in ongoing psychotherapy-based learning activities.

      Performance Indicators

The College expects that OTs who agree to perform a supervisory role for OTs and other practitioners will possess the knowledge, training, skills, experience and judgement to safely, effectively and ethically provide psychotherapy guidance. OTs who are providing psychotherapy supervision must be clear that they are not taking accountability for client care; the supervisee remains responsible for the psychotherapy provided to their client(s).

Standard 6

The OT will ensure they have the knowledge, skills and required experience to safely and effectively provide psychotherapy supervision to OTs and other practitioners who are performing psychotherapy.

      Performance Indicators

Student Occupational Therapists

Student OTs may be included in the delivery of psychotherapy as part of their student placement. However, due to the sensitive nature of some psychotherapy treatments, it may not always be in the client’s best interest or be appropriate for a student to be present in the session. As student OTs are often in placements for a short period, they may be present for only a portion of the psychotherapy intervention. OTs should use clinical judgement to determine when it is appropriate for students to be included in their psychotherapy sessions. Student OTs may participate in psychotherapy sessions with the client’s consent and may take part in post-session discussions and case reviews. Student OTs who participate in the psychotherapy treatment with clients must be directly supervised by the OT, or another qualified member of the team during the session. OTs supervising students must comply with the Standards for the Supervision of Students.

Other Students

In a multidisciplinary setting, where the OT may participate in the supervision of students from other professions in the process of providing psychotherapy, the performance indicators below also apply.

Standard 7

The OT will, ensure they have the knowledge, skills and abilities to safely and effectively supervise students and provide direct supervision when performing psychotherapy.

      Performance Indicators

Due to the knowledge, training, skills, and judgement required in the practice of psychotherapy, an OT may not assign or delegate components of psychotherapy to occupational therapist assistants (OTAs). OTAs may be involved with clients in mental health programs, carrying out other interventions.

Standard 8

The OT will not delegate the whole or parts of the controlled act of psychotherapy or assign psychotherapy interventions to occupational therapist assistants.

      Performance Indicators

OTs practising psychotherapy are expected to comply with the Standards for Consent. Consent is an ongoing process to be re-evaluated throughout the intervention process.

Standard 9

The OT will ensure that informed and ongoing consent is obtained from the client to perform psychotherapy, in accordance with the Standards for Consent.

      Performance Indicators

OTs practising psychotherapy should take reasonable measures to recognize and minimize the risks to client safety. OTs should be aware of contraindications and be responsive in managing adverse reactions that may occur during psychotherapy. When considering alternative methods of delivering psychotherapy interventions, such as telepractice, OTs should have a process in place to manage any risks, or unexpected events.

Standard 10

The OT will be responsible for recognizing, minimizing, and managing the risks associated with performing psychotherapy.

      Performance Indicators

OTs practising psychotherapy are expected to comply with the Standards for Record Keeping.

Standard 11

The OT will document the provision of psychotherapy in accordance with the Standards for Record Keeping.

      Performance Indicators

Professional boundaries are crucial to the maintenance of a respectful client-therapist relationship. OTs should adhere to the Standards for Professional Boundaries when providing psychotherapy to their clients. Due to the OT’s position of authority and professional knowledge related to the client’s health status, vulnerability, unique circumstances, and personal history the client-therapist relationship has a power imbalance in favour of the OT. The power imbalance exists due to the OT’s ability to influence a client’s access to care or services. A client’s desire to improve his or her health results in trust being established much more quickly and completely than might occur otherwise. OTs should be aware of this power imbalance during the provision of psychotherapy treatment. It is not appropriate to develop a personal relationship with a client at any time during psychotherapy treatment or once psychotherapy is discontinued. There may be situations where an OT may encounter a client in the community; however, these casual contacts are not considered personal relationships.

In relation to the topic of professional boundaries, transference and counter-transference are important considerations. Transference is generally defined as the set of expectations, beliefs, and emotional responses that a client brings to the therapist-client relationship. Countertransference is the emotional reaction of the OT to the client’s behaviours. It is important that OTs are consciously aware of these feelings and emotions and reflect on what may be the result

Standard 12

The OT will take full responsibility to establish and maintain appropriate professional boundaries in accordance with the Standards for Professional Boundaries.

      Performance Indicators

The OT’s decision to discharge a client from psychotherapy begins with the referral and is an ongoing consideration throughout the intervention process. It is recognized that an unplanned, unanticipated, or unintended end to the client-therapist relationship can also occur, prior to the completion of the intended treatment plan. This is termed “discontinuation of service” as outlined in the Guide to Discontinuation of Service.

The OT’s practice of discontinuation will vary according to the psychotherapy approach and the context in which the service is being delivered. Although, psychotherapy can be temporarily interrupted or prematurely discontinued due to factors that impact a client’s ability to participate in treatment; unintended discontinuation of psychotherapy intervention can be detrimental to the client. The OT should consider the level of risk when considering discontinuation, ensuring that the client can access the appropriate resources in a timely manner. Where possible, there should be an agreement between the client and OT that the client has achieved what can reasonably be expected from psychotherapy before discontinuation of psychotherapy intervention. Additionally, the OT should consider if the client would benefit from a referral to another qualified practitioner.

Standard 13

The OT will discontinue psychotherapy in a safe and ethical manner.

      Performance Indicators

Psychotherapy	Counselling
Frequently a long-term process, however there are short-term models (i.e. 8-12 sessions); Treatment can range from a few months to years.	Most often a short-term process; Visits may range from 1 to 12 sessions Some models of counselling can carry on over a longer period of time.
Generally associated with a higher level of risk in treatment as the focus may be on past unresolved issues, unpleasant emotions or behaviours.	Generally associated with a lower level of risk in treatment as the focus may be on overcoming obstacles to personal growth.
Examines thoughts, feelings, and actions of chronic and more severe emotional conditions. Encourages changing defeating patterns of behaviour and promotes personality change.	Examines specific problems or changes in life adjustment. Encourages behaviour change. Supports the client to perform day-today activities.
Goals may include gaining self-knowledge, dealing with defenses which are no longer working or useful, behaviour change, change in lifestyle or personality.	Goals may include wellness, personal growth, healing, problem solving, adjustment to life situations, the development of coping skills.
Examples of techniques may include Cognitive Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT), and Solution Focused Brief Therapy.	Examples of counselling may include health teaching, providing information, encouragement and support, giving advice and suggestions.
Requires a greater depth of training and supervision. Practicing with individuals with a serious disorder of thought, cognition, mood or emotional regulation falls under the Controlled Act.	May be practiced by non-health professionals or those experienced in the nature of the specific problem (i.e. addictions, eating disorders) Practice is not a controlled act.

The considerations below are intended to be used as a resource to facilitate discussions about the supervision agreement between the supervisor and supervisee. Not all elements of an agreement are captured below. This resource should be used in conjunction with the Standards for Psychotherapy and any components appropriate to the psychotherapy approach.

In developing a supervision agreement, the supervisor and the supervisee should consider the following:

1. The responsibilities of the supervisor and supervisee;
2. The scope of the supervision
3. The accountability for client care
4. Supervisory notes and agreements for confidentiality
5. Anticipated length of supervisory relationship
6. Fees associated with supervision
7. An alternate plan in case of an emergency and the supervisor is unavailable;

American Psychiatric Association (APA, 2002). Documentation of Psychotherapy by Psychiatrists. Resource Document of the American Psychiatric Association.

Brown, Catana, Virginia Stoffel, and Jaime Phillip Munoz. (2011). Occupational therapy in mental health: a vision for participation. Philadelphia: F.A. Davis Co. Chicago

College of Occupational Therapists of Ontario (2016). Standards for Record Keeping. Toronto, ON.

College of Occupational Therapists of Ontario (2016). Standards for Consent. Toronto, ON.

College of Occupational Therapists of Ontario (2015). Standards for Professional Boundaries. Toronto, ON.

College of Occupational Therapists of Ontario (2014). Guide to Discontinuation of Services. Toronto, ON.

Corsini, R.J. & Wedding, D. (2008). Current psychotherapies. Belmont, CA: Thomson Brooks/Cole. Davies, G. (2009). A contextual overview of counselling and psychotherapy, Counselling and Training Institute, Edinburgh, Scotland.

Gotlieb, M. (1993). Avoiding Exploitive Dual Relationships: A Decision-Making Model. Psychotherapy, volume 30, # 1, pages 41-48.

PEDIAA (2016). Counselling versus Psychotherapy. Retrieved from www.pediaa.com

Psychotherapy Act, 2007, in the Regulated Health Professions Act (1991).

Psychotherapy & Counselling Federation of Australia http://www.pacfa.org.au/

Rice, L.N. (1980). A client-centred approach to the supervision of psychotherapy. In Hess, A.K. (ED.) (2008). Psychotherapy supervision: theory, research, and practice. New York: Wiley.

World Health Organization, (2001). World Health Report: Solving Mental Health Problems.