On January 10, 2020, as a health-sector stakeholder, FACTBC provided feedback to the Ministry of Health and its appointed Steering Committee in response to the November 2019 “Modernizing the provincial health profession regulatory framework: A paper for consultation”, for their consideration on modernization of health professional regulation.
You can view FACTBC’s feedback as a PDF on the Resources page of our website: https://factbc.org/resources/
The Federation of Associations for Counselling Therapists in British Columbia Response to Modernizing the provincial health profession regulatory framework: A paper for consultation
I. Introduction
The Federation of Associations for Counselling Therapists in British Columbia (FACTBC) consists of fourteen professional counselling associations, each of which have established rigorous registration requirements, a code of ethics, standards of practice, and a complaints investigation process. Some FACTBC associations, typically the larger ones, provide accountability for counselling therapists on a general basis, while other member associations are more focused on specialized modalities and advanced competencies. All FACTBC member associations share a common set of core competencies that define counselling therapy, and all agree that public safety, competent care, and professional accountability are best served by making “Counselling Therapist” a protected title under the Health Professions Act.
FACTBC supports the Ministry of Health initiative to modernize the provincial health profession regulatory framework as outlined in the Steering Committee’s report: Modernizing the provincial health profession regulatory framework: A paper for consultation (the “Consultation Paper”). FACTBC agrees that a reduction in the number of colleges, standardization of college governance practices, and an increase in public accountability and transparency of college investigations and complaints resolution processes are important steps towards an improved provincial health system.
Our response provides specific suggestions regarding proposed governance structures and a short list of profession-specific colleges that we consider to be even more consistent with right touch regulatory philosophy within the British Columbia context. We also provide suggestions regarding inclusion of the role and rights of clients and patients, and conclude with some points of clarification relating to the composition, role, and history of FACTBC.
II. Reduction in the Number of Regulatory Colleges
In principle, FACTBC is supportive of the efficiencies, standardized processes, and improved administrative transparency associated with having fewer colleges. We anticipate that this will result in fewer decision-making bodies, fewer bylaws, and more consistent approaches to generic issues of professionalism. Clarity and efficiency serve the public interest.
Achieving these high-level goals requires effective structures. The Steering Committee has proposed leaving the larger professions—physicians, nurses, pharmacists, and oral health professionals—essentially unchanged, while putting all of the remaining professions into a residual college, which may be analogous to the Health and Care Professions Council in the United Kingdom (“U.K.’s Council”). However, the consultation paper suggests an immediate exception to this two-part structure—traditional colleges, plus a council-type regulator for all others—in the form of the diagnostic and therapeutic professions, a group with at least four different professional titles. We think that, to be consistent with the goals of modernization, the administrative structure should be more consistent and coherent.
A. Multi-Title Professional Colleges in a Parallel Structure
FACTBC suggests that it would be preferable to have a small series of multi-title professional colleges, with all colleges having the same or very similar governance structures. While FACTBC is supportive of th regulatory philosophy, sometimes called “right touch”, embodied in the U.K.’s Council, we believe modern practices can be more readily achieved by having a coherent system that fits better with the legislative structures of British Columbia and Canada.
Consideration, in our view, should be given to grouping the health care professions by function in multititle colleges. The speech and hearing professionals already represent such a grouping, as does the diagnostic and therapeutic professions. Another logical grouping involves those providing physical therapies: chiropractors, dieticians, massage therapists, occupational therapists, opticians, optometrists, naturopathic physicians, traditional Chinese medicine practitioners and acupuncturists. Mental health concerns are prominent in health care: British Columbia now has a dedicated Ministry of Mental Health and Addictions, which has developed the ground breaking document, A Pathway to Hope: A roadmap for making mental health and addictions care better for people in British Columbia, while physicians report that a third of their patients’ issues are about mental health and substance use. A logical category of mental health professionals might include social workers, counselling therapists, and psychologists.
B. Appreciation for the U.K.’s Health and Care Professions Council and “Right Touch”
The U.K.’s Council provides a strong model for how to put the principles of right touch regulatory philosophy into practice. In British Columbia, we have much to gain from following this example. However, we should be cautious about wholesale adoption of this particular administrative structure for enacting modern regulatory practice. We would like to point out just a few of the ways that the U.K.’s Council structure is specific to the regulatory context of the United Kingdom, when compared to the federal and provincial context in Canada.
The U.K.’s Council is designed for a national system of professional regulation, whereas in Canada, professions are regulated provincially because of our constitutional division of powers. National mobility is ensured through the Canada Free Trade Agreement (formerly the Agreement on Internal Trade), and provincial legislation gives effect to labour mobility, and lays out the general conditions for such things as creating titles, setting registration standards, and the reporting of complaints and good standing of registrants.
The U.K.’s Council’s approach has been to protect a large number of titles (thirty two titles in fifteen categories), a situation that does not fit the Canadian tradition of title protection, which is to have a minimal number of readily identifiable titles indicating that the holder is a professional and an accountable fiduciary. The risk is that too many titles will dilute the effectiveness of title protection because there are too many to be readily recognizable. This is one of the reasons why FACTBC has long recommended the single protected title of “Counselling Therapist”.
The U.K. Council handles entry-to-practice requirements by accrediting educational programs, a situation that applies well to the relatively closed and nationalized system in the U.K. However, this is at odds with Canadian mobility agreements that stipulate competency-based assessments for entry-to-practice that allow for the multiple educational pathways available across Canada and internationally.
The U.K.’s Council also embodies the principles of right touch regulation, one of the leading philosophies of regulation with an influence felt worldwide. Right touch principles include making regulation proportionate to the risk and the vulnerability of patients, regulations that are consistent, regulations that are targeted to problems, decision-making that is accountable, and regulation systems that are agile and that can anticipate, adapt, and change.
FACTBC believes that the principles of proportionality, consistency, accountability, and administrative agility should be consistent for all health profession regulatory bodies. Regulation that is targeted to actual problems faced by health professions in B.C. assists in facilitating these principles. We believe that the proposed independent oversight body will provide such a mechanism.
C. Title and Profession-Specific Regulatory Sub-Committees
Robust practice standards are critical to enable colleges to prevent harm, ensure quality care, and respond to complaints when harm has occurred. Such standards must be informed by the subject matter expertise of the profession itself and from the academic disciplines that inform that profession. A specific protocol for setting, publishing, and updating standards of practice is essential if regulation is to work at all.
FACTBC believes that profession-specific expertise is needed in the adjudication of certain categories of complaints against registrants, particularly those that raise concerns regarding clinical competence. Adjudicating competence requires informed judgement that includes the professional process and its context. In counselling therapy, examples of profession-specific knowledge abound. For example, what might appear to a naïve observer to be an example of fragmented communication, may turn out to be, to a professionally informed observer, a clinician breaking up a narrative in order to protect against retraumatization. What might appear to be withholding of information, may be appropriate maintenance of privacy and confidentiality in a counselling therapy relationship.
Professional expertise provides a necessary lens for considering such complaints. Profession-specific responsibility is needed for creating, maintaining, and interpreting practice standards, as well as for adjudicating questions of clinical competence.
III. Improved Governance
FACTBC supports the Ministry’s proposal to implement competency-based appointments to college boards of between eight and twelve members based on functionality. Elections for board members implies responsibility to the membership that has elected the member, and experience has shown time and again that board members can easily lose track of their overarching responsibility to protect the public interest when they are elected by members of their own profession. Unfortunately, boards of some colleges have focused on representing the interests of their profession rather than those it serves, as reflected by the recent Cayton Report. Having half the board membership bring profession-specific knowledge as well as the public interest will assist boards in understanding the public interest context of the decisions they are making and provide an invaluable safeguard to ensure that they do not stray from that objective.
FACTBC also supports the recommendation for fair and uniform compensation for board members. The Board of FACTBC and the boards of its member associations have experienced that it is challenging to recruit people who are competent and available to volunteer their time for services that would normally be professionally remunerated. These changes will be a strong move toward a larger pool of competent representatives who can focus on the public interest.
FACTBC would also like to suggest other dimensions of board governance in addition to competence, board size, and compensation. New legislation and new standards for board governance will benefit from being patient and client-centered. This principle carries board governance beyond public interest where complaints, investigations, and discipline functions are concerned. A patient and client-centered governance ethic includes an emphasis on prevention of harm, reduced number of complaints, restoration where harm has occurred, and on more fully modernizing the regulatory system by including alternative complaints resolution processes.
IV. Oversight of Regulatory Colleges
FACTBC is broadly in support of an articulated, policy-informed, and accountable process of oversight for the health colleges that incorporates a direct link of accountability to the provincial Legislature. Reporting to the Legislature through the Minister of Health is, in our view, consistent with parliamentary procedures, and follows the successful precedent of making such issues as Seniors, Children and Youth, and the Ombudsperson’s office subject to reporting requirements.
The proposed oversight body contains features that should be helpful to patients, clients, and citizens in general. A centralized registry of all regulated health care professionals is commendable because citizen seeking to confirm the registration status of their health care provider can do so expeditiously. Having a macro-oversight body provides a point of accountability when the subject of a complaint from the public is the performance of the college itself. This may be particularly helpful when the issue is responsiveness or timeliness in a college process.
FACTBC also supports the distinction between generic issues of professionalism and profession-specific competencies. Having shared standards of professionalism is consistent with the goal of supporting interprofessional teams.
V. Complaints and Adjudication
FACTBC emphatically supports the separation of complaints investigation functions from disciplinary functions. FACTBC also supports the notion of transparency, and particularly public disclosure of disciplinary processes and outcomes. However, the publication of inquiry and discipline processes has some profession-specific implications.
In counselling therapy, privacy and confidentiality are central, not just to clients’ rights, but also to the method itself. Central to the practice of counselling therapy is that subjectivity, inner experience that is often conflicted and deeply personal, becomes communicable. Complaints about competence often involve the way in which points of very personal psychological vulnerability have been handled by the professional involved. Concerns about disclosure of such issues are also at the core of why many clients do not bring forward complaints. When making counselling therapists transparently accountable for their actions, care will need to be taken to ensure that the confidentiality and the privacy of clients are upheld at the same time.
A. The Important Question of Consent Agreements
While FACTBC recognizes consent agreements as an important option for resolving complaints, we would also like to emphasize that for some professions, alternative complaints resolution processes, including well-established options like mediation or restorative processes, are ways for clients to achieve appropriate resolution and redress. In general, we recommend consideration of a broader range of remedial statutory
tools and more emphasis on complainant rights and due process.
VI. Prevention, Quality Assurance, and Response to Harm
FACTBC has already commented on possibilities for more patient and client participation in the complaints, investigation, and discipline process of professional regulation. We would also like to make the point that the foremost objective of regulators should be to prevent harms that give rise to complaints in the first place.
We understand that it is axiomatic that if there were no risk of harm, then there would be no need for professions or for the regulation of professions. That said, one of the hallmarks of modernizing regulation is FACTBC – the principle, articulated in right touch philosophy, of solving problems close to the site of the problem. At least half the complaints that occur in the practice of counselling therapy arise out of problems of competence, and we know that competencies, if not systematically maintained, deteriorate over time.
Consequently, quality assurance programs and continuing competency requirements are basic tools for regulators when addressing issues of registration, inquiry, and discipline.
We highly recommend that it become a standard for regulators to analyze their complaints and discipline data in order to create targeted efforts to reduce harm to patients and clients, while at the same time emphasizing right touch “agility” in the form of maintenance of competence.
VII. Understanding FACTBC
A. The Meaning and Mission of FACTBC
Counselling therapy is currently unregulated in British Columbia. The member associations in FACTBC have in common that they have attempted to fill the gap left by the non-regulation of counselling therapists by holding their members to registration standards, codes of ethics, and standards of practice. FACTBC’s member associations also process complaints against their members according to standards of procedural fairness. As non-statutory regulators, FACTBC member associations face significant limitations in attempting to regulate their members. They can only assert standards for their members and for their clients, and only within the limits of their status as associations, and in the presence of the conflict of interest inherent in protecting the rights of complainants and association members at the same time.
FACTBC was created to address this inequality, conflict, and lack of public protection.
FACTBC is the voice of all counselling therapists in British Columbia who have given their time, their attention, their commitment, and their dollars to make themselves professionally accountable.
FACTBC associations represent core competencies as well as advanced practice. Some of the member associations in FACTBC represent counselling therapists in general, while other associations, like art, music, and drama therapists, are organized around advanced competencies or modality specializations. All FACTBC associations support the same core competencies that define counselling therapy as one profession.
FACTBC is the successor to the Task Group for Counsellor Regulation, the group that united the counselling therapists of British Columbia and created the Competency Profile for the Counselling Therapists, the validated entry-to-practice national standard. FACTBC has gone on to: (1) prepare a major update of the competency profile; (2) create comprehensive recommendations for standards in registration, inquiry, clinical supervision, and discipline; (3) support other federations across the country; (4) include Indigenous practice in the core and advanced competencies; and (5) develop policies consistent with B.C.’s Health Profession’s Act and the Canada Free Trade Agreement (formerly the Agreement on Internal Trade).
FACTBC’s efforts have been recognized by similar associations and provincial governments across Canada.
B. A “Collection of Occupations”?
There exists a narrative about FACTBC that it is merely a collection of different occupations without a common educational orientation and no definable entry-to-practice standard. As such, it is believed that
counselling therapists cannot identify a risk of harm or a body of specialized knowledge that qualifies it as a profession. We assert that this narrative is not just inaccurate, it is a caricature. It qualifies as a caricature, rather than a simple inaccuracy, because it defines the very problem that FACTBC exists to solve. In British Columbia, any person with any education, without being registered anywhere to any standard, and who is not accountable to a code of ethics and standard of practice, can call themselves a counselling therapist. This is a profound failure of the province’s regulatory system.
We are hopeful that informed participants in the shared effort to modernize the provincial health profession regulatory framework will understand that counselling therapists in this province, like their
provincially regulated counterparts in Alberta, Ontario, Quebec, New Brunswick, and Nova Scotia, and the FACT organizations in Saskatchewan, Manitoba, Prince Edward Island and Newfoundland, are ready to take on their share of responsibility for accountability, safety, and fairness.
VIII. Conclusion
FACTBC strongly supports the three main objectives of the Ministry of Health in bringing about modernization of health profession regulation: patient safety and public protection; improving efficiency and effectiveness of the regulatory framework; and increased public confidence through transparency and accountability. We also fully support the Ministry’s commitment to reconciliation with Indigenous peoples, and the recognition that cultural safety, diversity and accessibility are key to improving public trust and ensuring public protection.
Our response includes commentary on some additional ways we believe modernizing the health professions in British Columbia could better serve a broader range of citizens in the province, especially those who are primarily seeking support for mental health issues. We also provide a slightly different perspective on the composition of multi-professional colleges, and how and the eleven different health professions, with seemingly quite diverse scopes of practice, might be placed into multi-professional Colleges.
Finally, given that the time is right for regulating counselling therapists across the country, we provide an update on FACTBC activities over the last five years, and the current situation nationally.