Lesley Cooper and Richard Freeland, Kitchener/Ontario (Canada)
The Ontario Association of Social Workers, (Canada) after an extensive and hard fought classical political campaign with strong support from practitioners and educators has succeeded in its campaign to have recognition of social workers as psychotherapists incorporated into Bill 171 (Health System Improvements Act, 2006). Social workers lobbied their provincial members, prepared submissions, and appeared before the Ontario Legislature Standing Committee on Social Policy. Social workers are now on an equal footing with other professional groups seeking to use the title, psychotherapist. These groups include occupational therapists, nurses, psychologists, mental health therapists together with physicians and surgeons.
The legislative background
The Ontario Legislature introduced the Health System Improvements Act (2006) to strengthen and improve health care in Ontario. There are multiple schedules within this act many of which are not relevant to either social work or psychotherapy. One relevant schedule is the Psychotherapy Act which is firmly based on principles of consumer protection and safety, choice for consumers, quality of services and accountability within the profession of psychotherapy. Prior to the introduction of this act, psychotherapy was not regulated. Anyone could, and did, practice psychotherapy and call themselves psychotherapists including social workers. There was no way the public could have confidence in the qualifications of psychotherapists or be assured of the quality of services provided.
The Psychotherapy Act enabled establishment of the College of Psychotherapists of Ontario. This college will be a statutory, not for profit organization to regulate members’ professional conduct. The act restricts the use of the title, psychotherapist. The public interest is served through this college by its regulation of psychotherapy practice, setting registration requirements, and maintaining quality assurance programs such as continuing professional education to ensure competence of members. It is expected that the college will develop standards of practice including ethical practice and use these standards to discipline members and respond to consumer complaints. In addition to these standards educational qualifications will be established. This is relevant to the Ontario College of Social Work and Social Service Workers (OCSWSSW) which has members holding a range of academic qualifications. One challenge for this new college will be to negotiate a common standard of practice amongst diverse professional groups each of which has very different intellectual traditions and training experiences.
Several elements to this bill are of particular relevance. The bill defines the scope of practice as, the assessment and treatment of cognitive, emotional or behavioral disturbances by psychotherapeutic means, delivered through a therapeutic relationship based primarily on verbal or non verbal communication. Only those registered with the college will be able to perform these acts. The final aspect of the broader bill is a change in the way harm is defined. The previous threshold was “serious physical harm” which has been changed to “serious bodily harm”. It is not clear if this includes both psychological and physical harm to clients and others. This distinction has yet to be tested and determined by the courts. Until this is clarified by the courts, practitioners will need to work within the practice standards of their profession.
Duplication of regulatory systems
Duplication of systems within and across provinces appears to be a characteristic of government and regulatory arrangement in Canada. Whilst the Health System Improvement Act (2006) will regulate the profession of psychotherapy, the Social Work and Social Service Work Act (1998) has already established the OCSWSSW which restricts the use of the title of social worker and social service worker. This means that social workers and social service workers in Ontario are regulated and have been for the past seven years. This earlier act has similar objectives to those of the Psychotherapy Act which also aims to protect the public interest. There is however one fundamental difference.
Whilst the Social Work and Social Service Act does not define the scope of practice the College of Social Workers and Social Service Workers has prescribed the scope of practice. This scope of practice is outlined in College by-laws stating that the profession of social work is the assessment, diagnosis, treatment and evaluation of individuals, interpersonal and societal problems through the use of social work knowledge, skills, interventions and strategies to assist individuals, dyads, families, groups, organizations and communities to achieve optimum psychosocial functioning and social functioning (Ontario College of Social Workers and Social Service Workers 2007). As these by-laws reflect a similar scope of practice to that found in the Health System Improvement Act it could rightfully be assumed that social work does encompass psychotherapy. When viewed from a macro practice standard stance, this scope of practice has a range of deficits. It can be argued reasonably and strongly that this definition has limited applicability to social planning, community work, program development, social work research or social policy. These latter areas of practice operate from a participatory framework which is somewhat independent of the expertise of the social worker in assessment, diagnosis and treatment.
Why then did the Ontario Association of Social Workers together with the College of Social Workers and Social Service Workers make such strenuous efforts to gain the inclusion of social workers (albeit as psychotherapists) in the health sector regulatory system? The Ontario College of Social Workers and Social Service Workers has 11,500 members of whom 7000 are social workers working in psychotherapeutic services. A very small percentage of members are social service workers.
The case put by the College in its submission does not appear strong and no evidence was provided. The Ontario Association of Social Workers argued that: social workers are the largest group providing psychotherapy and that in many communities; social workers are the only profession providing these services. OASW is very concerned that failure to recognize social workers as equal partners to other professions authorized to provide psychotherapy will cause members of the public, employers and insurance companies to erroneously perceive the profession to be less qualified to provide these services than members of the existing regulated professions listed in the Psychotherapy Act. (Legislative Council of Ontario, Standing Committee on Social Policy 24 April 2007).
There was very little choice but to argue that social worker should be regarded as psychotherapists.
The case against the professional proposals was never presented and there was little debate about the appropriateness of this action. One can only assume strong consensus in the professional community. Approximately ten per cent of college members are in private practice and it is commonly assumed that at least this ten percent is working as psychotherapists. The public case presented for inclusion of social workers as part of the College of Psychotherapists was based on the premise that; social work includes psychotherapy and that its members are already practicing psychotherapy, therefore, social workers should be registered as psychotherapists. The case presented by some members of the Ontario Association of Social Workers was much clearer with one member arguing that if social workers are not allowed to do the tasks for which they were trained then clients will be worse off (Ware 2007, 6).
If social workers decide that they are in fact psychotherapists will the result be wholesale migration of social workers from the College of Social Workers and Social Service Workers to the College of Psychotherapists? Will, or indeed can social workers join two Colleges because of their particular work requirements? Where do social workers who have several different roles in their employment, one of which is psychotherapy, stand in this situation? These questions will remain unanswered until more details of the new college are specified.
Psychotherapy and social work
It is some concern that Ontario social workers overwhelmingly perceive their predominant practice specialization as psychotherapy. The position taken in Ontario is somewhat different to that espoused by the Canadian Association of Social Workers (CASW). The scope of practice definition presented by the Canadian Association of Social Workers (CASW, 2000), is much broader than provided by the OCSWSSW with psychotherapy being just one amongst many practice methods.
Psychotherapy in Ontario has been elevated from a tool to be used in some forms of practice with individuals, to become the privileged goal of social work. Will psychotherapist social workers retain any passion for the disadvantaged as they move, possibly inevitably, toward private practice? Will they continue to find any synergy between the psychological, social and political? Can the profession deliver psychotherapy with a strong emphasis on the values and traditions of social work? Specht and Courtney in their book, Unfaithful Angels have argued that social workers have lost their way, having abandoned the mission to help the poor and oppressed to build community (Specht and Courtney 1994).
The profession of social work was born in the social reform movement with core values of social justice, equity, charity and a concern for ensuring basic human needs such as shelter, food, employment and health care. In terms of priority of needs, self actualization achieved through therapy is low in terms of priorities of human needs.
There is extensive debate in both academic and professional literature over the value and desirability of regulation. It is assumed that regulation protects the public against poor practice, making improvement to practice standards and provides a legal definition of practice. Over the past seven years, there have been 255 complaints to OCSWSSW of which, five have been referred to the discipline committee and seven referred to the Complaints Committee for a caution (OCSWSSW 2006). This does not appear to be a large number of complaints and it is debatable whether this fulfils the goal of protecting the public. Given the large OCSWSSW membership, consumers may not be properly informed about their rights to complain about practitioner behavior. One wonders at the probable frequency of complaints to the College of Psychotherapy?
Existing methods for dealing with complaints focus on the individual worker and fall very much into the blame, shame and name category. It is unfortunate that individuals are singled out for complaints. Anyone who has worked in complex social organizations would realize that individual performance problems can also be attributed to system wide issues. Regulation isolates the individual worker. It is hoped that the new college might take a less punitive approach and review problems more openly so that system wide improvements can be made.
Establishment of this College of Psychotherapy elevates the status of psychotherapy and provides an opportunity for graduates to enter private practice. One challenge for Schools of Social Work in Canada is how to respond to the increased pressure from potential students seeking credentials in psychotherapy. There is an emerging opportunity for social work schools to provide a sound clinical social work education allowing graduates membership of the newly formed college. Demand for existing clinical programs is already strong with, for example, approximately 60- 65 per cent of students in one program (WLU) preferring clinical practice. Whilst designing a clinical psychotherapy program, this School would remain competitive with other programs but runs the risk that this emphasis on psychotherapy may result in a one dimensional program that ignores the social reform traditions, social policy, research and community work and planning.
A triumph or illusion
The campaign was a short term triumph for Ontario social workers, but whether this is of long term value remains unanswered. Greater legal regulation may be of value to the public but if the OCSWSSW list of complaints is any guide, this may not become apparent until sometime in the future. Schools of social work in Ontario who choose to respond to potential increase in demand for psychotherapy training may also benefit, but at some potential cost.
Social work as a reforming profession may be coming to an end. The radical movements of the 1970s and 1980s have long been forgotten. The profession is confronting increasing secularization and demand for greater professionalisation. Elements within the profession are pushing for elitist and privatized versions of practice and one can only contemplate what social work will be like when the largest proportion of practitioners are in private practice. Such important practice specialization such as planning, community work, social policy and research may well become weakened in the process, if not lost to social work practitioners altogether.
The question that remains unanswered is whether recognition of the title psychotherapist is a real triumph for the profession, consumers and educators or an illusion leading to loss of professional identity, elitism and centralization of monopoly powers. Why would social workers and their professional association proclaiming their commitment to social justice and concern for oppressive practices and marginalized populations fight so hard to ensure rights to an exclusive but limited practice domain that places power in the hands of one person, the therapist?
CASW (2000), CASW National Scope of Practice Statement, http://www.casw-acts.ca/practice/recpubsart1.htm
Government of Ontario (2006), Compendium: Health System Improvement Act, 2006 http://www.health.gov.on.ca/english/public/legislation/hsib/pdf/compendium.pdf
Legislative Assembly of Ontario (2007), Standing Committee on Social Policy: Committee Transcripts on Bill 171, Health System Improvement Act, 2006 Evidence presented by Ontario Association of Social Workers http://www.ontla.on.ca/web/committee-proceedings/committee_transcripts_details.do?locale=en&Date=2007-04-24&ParlCommID=7430&BillID=519&Business=
Ontario College of Social Workers and Social Service Workers (2006) Annual Report http://www.ocswssw.org/sections/pdf/2006_Annual_Report_FINAL.pdf
Ontario College of Social Workers and Social Service Workers (2007) Submission to the Standing Committee on Social Policy, Bill 171, Health System Improvements Act 2006, 24 April 2007
Specht, H. & Courtney, M. E. (1994) Unfaithful Angels: How Social Work has Abandoned its Mission, Free Press, New York.
Ware, M. (2007) ‘The Regulation of Psychotherapy,’ OASW, Western Branch Newsletter and Journal, Spring 2007.
Lesley Cooper is dean at the Lyle S. Hallman Faculty of Social Work at Wilfrid Laurier University, Ontario.
photo courtesy of www.pixelio.de