“Modernization”
“Modernization”: The College of Psychologists and Behaviour Analysts of Ontario’s (CPBAO) Decision to Reduce Training and Examinations
Along with the majority of psychology practitioners and members of the public (90% of nearly 10,000 responses), I deeply oppose the CPBAO’s submission to the provincial Minister of Health to severely reduce required training and licensing (knowledge and competency) exams for those wanting to be called psychologists. “Modernization” changes mean new master’s level practitioners, who will be permitted to perform psychotherapy and communicate diagnoses, will have substantially less training. The risk to the public is far too high to justify allowing undertrained practitioners to work independently without receiving years more careful supervision to ensure both breadth and depth of experience of practitioners.
Background: Previous and Newly Approved Standards
Until recently, master’s level practitioners, who registered as “psychological associates” were required to complete five years of “hands on” experience after obtaining their master’s degree in order to be registered psychological associates. It was thought that several carefully supervised years of experience, provided by psychologists adhering to the CPBAO’s supervision standards, would promote both knowledge and experience to a level consistent with what is acquired through formal doctoral training educational pathways. For years, this model has produced many competent MA-level practitioners.
While a doctoral degree does not provide a guarantee that the psychologist is going to be right for every client or guarantee they have expertise to assess and treat each client’s particular concerns, moving forward, the title of “psychologist” will include individuals with highly variable training and experience. Doctoral psychologists do not just complete research as part of their doctoral training; they complete advanced course work, comprehensive examinations that are often clinically focused, multiple clinical practica, and a one-year clinical residency—gaining both course-based and practical knowledge and experience with a wide range of clients and concerns. This training pathway to become a doctoral psychologist means that these practitioners have more advanced formal education about ethics, mental health, therapy, and assessment as well as years more hands-on training where they are carefully evaluated for competency by multiple supervisors in a range of client-care settings.
It is prudent to note, there is no master’s program approved by either of the national accrediting bodies that set the standards for clinical psychology training programs in North America (i.e., the Canadian Psychological Association, the American Psychological Association). Newer master’s level practitioners in psychology who will be allowed to use the title ‘psychologist’ will be required to complete much less hands-on training. They will also have lower stakes licensing processes—previously more stringent processes have been in place to ensure practitioners have the requisite knowledge and competency to practice independently (without supervision). Notably, in the absence of a residency year, several practicum placements, and additional graduate courses relevant to clinical psychology that doctoral psychologists complete, master’s level psychologists in Ontario who were previously designated as “psychological associates” also completed several years of “hands on” supervised work experience supporting their competency before becoming licensed to practice autonomously. The concerns of most who oppose these changes pertains to the registration of master’s level practitioners completing (often online) degrees with lower entrance requirements and lower standards for courses and limited training experiences who will then be permitted to practice with the full scope of services. Education and experience helps practitioners learn skills required to practice competently and learn limits of their competence. A brief review of various MA-level practitioners transferring from other jurisdictions listing scopes of practice broader than most doctoral psychologists raises concerns about their understanding of limits of competency.
Self-Serving Psychologists! Really?!
Many who support the college’s proposed changes question whether Ontario psychologists are serving self-interests because of what this potential flood of less-trained practitioners could mean for supply and demand, and the hourly rates psychologists set for services. Psychologists have been charged with (a) being concerned about our pocket books more than public safety and (b) being elitist. To that I offer these points:
1) Partial agreement: Advocating for the standards for entry into the profession to remain high is not without some benefit to current psychologists.
Designation as a psychologist is something practitioners work hard to achieve and maintain. Professional identity is meaningful. Achieving a high bar of training and knowledge can be a source of pride. But, in my opinion, the title is more important in its function to society than it is as a professional identity. I know I am competent and ethical and am duty bound to practice within my scope of expertise regardless of what I am titled.
However, for the Ontarian public seeking mental health support, the title of ‘psychologist’ has come to mean something more broadly. ‘Psychologist’ is a title that conveys that the professional is someone who can generally be trusted to be knowledgable, highly qualified, experienced, capable, and caring. It means they can be trusted to work with you with your goals with your best interests in mind. They can be trusted to know when they are not the best option for meeting your needs because they have enough training and knowledge to know what they do not know and to refer to another practitioner when client concerns are beyond the psychologist’s competency.
Most psychologists are proud to be a part of this profession and to have earned the public’s trust. Many of us volunteer our time to give back to the profession and the public (e.g., to train/supervise students or new psychologists, to be part of the oral examination licensing process, and to be part of the disciplinary proceedings when members may have stepped amiss). We work hard to make sure those entering and working in the field have worked hard and earned the knowledge and competency that will uphold the public’s trust. We feel the weight of the responsibility to ensure quality care.
When members of our profession transgress and their ethics falter, we know it is our responsibility to address those shortcomings and to work harder to earn back the public’s lost trust. It is also our responsibility to try to ensure we let only those into the profession who are the least likely to transgress. We do this by seeking evidence of the knowledge and capability of our applicants, vetting their education and training experiences and through licensing examinations focusing on broad-based knowledge, legal and ethical knowledge, and clinical knowledge and competency. Excluding those who do not meet the minimum education, experience, and licensing performances is a proactive approach to public protection (client safety). We take a proactive rather than reactive approach to public safety because failing to avoid reasonably foreseeable harm is a failure of a system that is supposed to be primarily concerned with public protection.
2) It has been argued that flooding the market will reduce the number of people seeking the services of doctoral psychologists and will result in lower hourly fees.
Is this likely?
Since the development of the College of Registered Psychotherapists in Ontario in 2018, which has since registered 17,000+ members, hourly fees for psychotherapy have not appreciably changed. Private pay services are still costly and, unfortunately, out of reach for many who do not have insurance and must pay out-of-pocket.
Access is an issue mostly driven by a lack of funding: A lack of funded psychological services in health care and schools, a lack of adequate insurance coverage through employers and higher education institutions, and a lack of funding for doctoral training programs that produce capable clinicians. Chronic underfunding of training programs and service delivery programs (i.e., continued cuts to psychological care in the health care and school systems) causes access issues. Making more low-trained ‘psychologists’ does not solve these issues, but it is likely to cause more problems related to quality of care.
The problem of inadequate public access
to psychologists will not be solved by
churning out more
but less well-trained practitioners.
Less trained practitioners will then still charge as much as psychologists with substantially more training. The public will still have to pay out of pocket to gain access to services, but now there will be greater burden on those with mental health difficulties to learn how to differentiate between practitioners, their education and experience and ability to deliver quality care. The term ‘psychologist’ will lose its meaning; the title of psychologist up to this point has generally conveyed that the practitioner has met a high bar for knowledge and competence.
3) Many psychologists, including myself, also work on a sliding scale or provide pro-bono therapy when insurance coverage is lacking. We do this because (a) our regard for ongoing clients and their wellbeing means continuing to deliver services even when reimbursement is not expected and (b) offering some level of pro-bono/sliding scale work is consistent with our ethics code.
In fact, psychologists have an ethical obligation to contribute to public good, through “beneficial activities.” Our Canadian Ethics Code for Psychologists (4th edition) includes a standard (IV.12) that requires us to “contribute to the general welfare of society (e.g., improving accessibility of services regardless of ability to pay) and/or to the general welfare of their discipline by offering a portion of their time to work for which they receive little or no financial return.”
Many psychologists provide services to some of our clients at reduced rates or for free.
Many engage in supervision and consultation to trainees or other clinicians
free of charge or for minimal compensation.
Assessments in particular are time intensive beyond what most psychologists feel they can reasonably charge. Many a colleague has shared they do not complete assessments because they are time consuming and practitioners are not often compensated for a substantial portion of time required to write detailed reports. I consistently provide hours of pro-bono services so my assessment clients receive detailed feedback in a document that is thorough and, hopefully, maximally helpful to them. I also opt to complete assessments more than therapy, despite the disproportionate amount of unpaid hours assessment entails, in large part becasue I know a solid, thorough assessment can make an important difference in terms of accommodation and receiving appropriate pharmacological care and therapy and because I am aware of the high unmet need for this service (there are more psychology practitioners who provide therapy services than assessment services). Assessments are in high demand and I want to help where I can be most helpful.
Client care is at the core of who I am as a psychologist. I don’t drive a Benz and I don’t sleep on a dragon’s hoard. I recognize I am also quite fortunate and live comfortably, and I can afford not to charge for all of the time I put into client care. I also believe I am more of the rule than the exception in my profession. This fight against the proposed changes is not about money for many psychologists who are deeply opposed to them.
For the vast majority of us, our opposition to the deregulation of, or lowering of standards in, the profession of psychology, is driven primarily by concerns for public safety. Our advocacy is not fake altruism masking a desire for elitist guild protection as some have accused; our advocacy stems from knowing clients will suffer if less trained practitioners are licensed to practice independently without greater exposure to clients concerns under careful supervision and without having their competency and knowledge thoroughly evaluated through supervision and licensing exams.
Mental health work is complicated already. It stands to become much more complicated as lower standards generate increased practitioner errors. Correcting misdiagnosed conditions can be extremely challenging as a practitioner and very difficult for clients who may have leaned in to, and thoroughly identify with, a diagnosis that is not accurate. Misdiagnosis can also mean clients seek inappropriate treatment that does not help and can make the treatment process much longer (more time spent trying to determine why there is limited responsiveness to treatment then course-correcting).
4) It has been claimed our advocacy is about “elitism” and “guild protection.” Most professionals do not care if any qualified professional (i.e., any rigourously-trained clinician, who has demonstrated ability through objective examinations of knowledge and competency) is called a psychologist. Most psychologists want to welcome more psychologists colleagues into the profession too.
Psychological associates under the previous standards of requiring 5 years of supervised clinical work post-graduate degree met a high standard for training experience. Collectively, psychologists are concerned about how much rigour there will be in the training of new master’s level psychologists because those new clinicians will be required to complete far fewer hours of clinical “hands on” training during their degree as well as as much as 75% fewer hands-on supervised work experience post-degree before becoming registered as an autonomous practitioner. New master’s level members with the CPBAO will have far less experience required of them than doctoral psychology students are required to complete before doctoral psychologists apply for one year of supervised practice with the CPBAO. But, under this grand new licensing plan, all master’s level and doctoral-level psychologists will have the same scope of responsibilities and licensed capabilities according to the CPBAO.
Does it make sense that would-be master’s level psychologists, without the extra years of course-based training, will also be held to a lower bar of supervised clinical experience while still being licensed to provide the exact same scope of services that doctoral psychologists provide?! If competency could be achieved in so much less time with so much less hands on and course-based training, why has this not been the standard of education approved by national accreditation bodies across Canada and the United States? Do accreditation bodies not want the public to access care? Or, could there be another reason?
Not even one master’s degree-only clinical program is approved by either of the two North American national accreditation bodies (i.e., Canadian Psychological Association, American Psychological Association). These accreditation bodies serve to set the standards for knowledge and competence required by training programs. Their decisions and standards are grounded in science. Over the years, the training requirements and domains of competency required by accrediting bodies have expanded not decreased. However, master’s level graduate programs do not meet the breadth and depth requirements accreditation bodies set. Moreover, some online master’s level graduate program do not generally reject applicants: All who can pay the high fees are accepted, including those applicants with no undergraduate, foundational knowledge of psychology.
As a supervisor of excellent doctoral students in clinical psychology (who already have a master’s degree from a phenomenal clinical program), my experience is that there is still substantial knowledge and skills development needed—far more than what might be achieved in just two years of work experience following a master’s degree. Statistical and research findings from other health fields back up the need for more supervised hands on experience. College complaint data in medicine supports the notion that a longer path to training decreases risk: Far more patient complaints to medical colleges are made against residents in earlier years of training than those in later years or those who are fully licensed. Thorough training helps protect members of the public.
In sum, the cynical who argue in support of lowering training and licensing standards are partially correct: Psychologists advocating against these “modernization” changes are likely to have some self-serving interests. But, those interests are not the primary reasons for our advocacy. Client care and public protection are deeply ingrained foundational and ethical values for our profession. These changes risk public safety—and the majority of the public who weighed in on the CPBAO’s survey resoundingly rejected these changes.
Psychologists stand to lose a little, but the public will lose more. The accusation that psychologists are being self-serving elitists is a red herring masking a potentially more important question about these changes:
who else stands to gain?
