Medical Psychology in Canada

Journal of Clinical Psychology in Medical Settings PP017-291152 December 16, 2000 5:14 Style file version Oct. 19, 2000

Journal of Clinical Psychology in Medical Settings, Vol. 8, No. 1, 2001

Medical Psychology in Canada

Alisha Ali1,2

This article discusses the state of medical psychology in Canada and explores some currentcontroversies and challenges for the future of the field. The practice of psychology in Canadianmedical settings is influenced by the country’s universal healthcare system and by the needto provide adequate care to a diverse and widely dispersed population. Although Canada’slicensing system does not include registration within specific subspecializations of psychology,the practice of health psychology has been growing over recent years, particularly in the areasof heart disease, chronic illness, pain, neurological disorders, rehabilitation, and stress man-agement. Medical psychology has been especially influential in the fields of women’s mentalhealth and immigrant health. Current areas of controversy include the issue of prescriptiveauthority and the advent of the Psy.D. degree. Future challenges include providing adequatecare to the country’s underserviced rural areas and to the various aboriginal communities.

KEY WORDS: health psychology; clinical training; aboriginal health; immigrant health.

OVERVIEW

Canada covers a diverse range of regions measur-ing over 3,849,674 square miles in size and covering sixtime zones. Approximately 77% of its total populationof 30 million live in cities and towns; the remainderof the population is distributed across rural regions,many of which are organized around the variousindustries for which they were originally settled, mostnotably pulp and paper, mining, fishing, and farming.Governance is based on the British parliamentarysystem and is conducted through both provincial/territorial and federal elected governments. Thecountry’s vastness poses particular challenges tothe provision of adequate healthcare. Furthermore,the healthcare system aims to accommodate a diversepopulation representing multiple languages as wellas a range of immigrant and aboriginal communities.

Based on the principle that healthcare is a fun-damental human right, Canada follows a system ofuniversal healthcare. Under this system, medical care

1University of Toronto, Toronto, Ontario, Canada.2Correspondence should be addressed to Alisha Ali, Women’sMental Health Program, Centre for Addiction and Mental Health,Clarke Division, 6th Floor, 250 College Street, Toronto, Ontario,Canada M5T1R8; e-mail: alisha)[email protected].

is provided without charge to all Canadian citizensand landed immigrants. However, psychological ser-vices provided outside of hospital settings must gen-erally be covered through an individual’s health planthrough their place of employment, or through a fam-ily member’s health plan. Therefore, individuals whochoose to see a psychologist in private practice mayhave to pay for a portion of the service, depending onthe types of health benefits they have.

PSYCHOLOGISTS IN CANADA’S HEALTHCARE SYSTEM

The Canadian Psychological Association (theCPA) founded in 1939 represents psychologists inCanada. The driving force behind the establishmentof this Association was the need for a centralizedbody to oversee the role of psychology as part ofthe war effort. Today, the CPA plays a crucial role inmaintaining standards of excellence for all aspects ofCanadian psychology, including psychological prac-tice, research, and education.

Within the CPA and in the discipline of psy-chology in general, health psychology is a grow-ing field of specialization. The majority of practicingpsychologists who deal with medical or health-relatedissues are situated in university-affiliated hospitals or

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clinics. Among these, there is a large range of sub-specializations, the most common of which are heartdisease, chronic illness, pain, neurological disorders,rehabilitation, and stress management (CanadianPsychological Association [CPA], 1996). However,Canada has no process for registration within a partic-ular subspecialization; instead, a practicing psycholo-gist is licensed as a “registered clinical psychologist”once he/she has completed the requirements for li-censing. The current perception is that Canada hasan adequate supply of practicing psychologists, withregistered psychologists outnumbering psychiatriststhree-to-one (CPA, 1999). It is estimated that approx-imately 1,200 psychologists work in medical settings,representing 10% of the estimated total of 12,000 psy-chologists practicing in Canada (Canadian Psycholog-ical Association, 1999).

It is important to note that despite the theoret-ical and practical influence of American psychologyon Canadian psychology (Dobson & King, 1995), onemajor difference between the two countries in thepractice of medical psychology is that Canada doesnot follow a system of managed health care as theUnited States does. The implications of this differ-ence for Canadian psychologists can be great. In cer-tain respects, Canadian psychologists are consideredto have more autonomy over the course of treatmentfor their patients. Furthermore, their treatment deci-sions are not as closely scrutinized by nonclinical orga-nizations such as those responsible for administeringthe system of managed care in the United States.

Within the Canadian healthcare system, psychol-ogists are valued for both their clinical and theoret-ical expertise. Increasingly, psychologists are servingas experts and consultants for legal proceedings re-lating to medical issues, and for government surveysaimed at increasing the efficiency of healthcare pro-vision in Canada. Psychologists are also becomingmore involved in community-based advocacy aroundhealth issues, often playing a liaison role betweenmainstream hospitals and community health centers,focusing on issues such as AIDS prevention, antiracisthealthcare, and aboriginal rights. Psychologists alsocontribute through their research expertise that is cru-cial for the success of both clinical and research de-partments in university-affiliated medical settings.

EDUCATION, TRAINING, AND REGISTRATION

Canada has 17 doctoral training programs in clin-ical psychology, all of which are accredited by the

CPA. There are also 21 CPA-accredited predoctoralinternships in clinical psychology. Each province orterritory has instituted its own licensing system. Inmost provinces, the process of becoming a registeredclinician requires both a written examination and anoral examination. A specified number of supervisedclinical internship hours is usually required for regis-tration, and most provinces allow Master’s level prac-titioners to become registered clinicians.

The Canadian Council of Professional Psychol-ogy Programs (CCPPP) is the organization that rep-resents Canadian graduate programs that provideclinical psychology training. It plays a necessary unify-ing role across the widely dispersed clinical programs,and it allows for communication of standards andregulations regarding professional psychology train-ing in Canada. The Council is an important mech-anism for coordinating internships and facilitatingthe transfer of information between graduate pro-grams and prospective trainees. With respect to med-ical psychology in particular, the Council fulfills thecrucial role of maintaining consistently high stan-dards across hospital-based psychology internshipprograms. These programs are often the trainee’s firstdirect experience in providing clinical services in amedical setting, and the excellence of the various clini-cal internships is well-recognized within the disciplineand amongst health practitioners in general.

It is important to note that although the prac-tice of psychology in Canada is closely regulated, anyindividual can without any specific training call himor herself a “therapist,” “psychotherapist” or “coun-selor.” It is also common for family doctors withoutspecific training in therapy to engage in individual psy-chotherapy with their patients. Many psychologistsbelieve that there is currently a need to raise aware-ness about the regulated nature of psychological prac-tice in Canada to educate and protect the public.

The Practice of Psychology in Medical Settings

Although different clinical training programsemphasize different theoretical models for psycholo-gists working and training in university-affiliated med-ical settings, the traditional biomedical model tends todominate. This orientation has historically led to animbalance of power among clinicians in many hospi-tal settings, wherein psychiatrists are granted greaterdecision-making power and are perceived as hav-ing greater clinical expertise than psychologists have.Psychologists also do not have medical admitting


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privileges in hospitals. In recent years, however, amore integrative biopsychosocial model has becomeprevalent; this model, which aims to account for theinterplay between biologically based and sociologi-cally based factors in conceptualizing health and ill-ness, is favored by most psychologists because it is con-sistent with current perspectives in health psychologyand related subdisciplines. The biopsychosocial orien-tation in medical settings has contributed to greateracknowledgment of psychologists’ expertise. This ac-knowledgment is reflected in part through recent ap-pointments of psychologists to leadership positions inprograms and departments within medical faculties.As a result of such appointments, formal promotionof psychologists though the academic ranks has in-creased, and interest in psychological approaches tohealthcare and illness prevention has been growing.

Another trend that coexists alongside the move-ment toward a biopsychosocial model is a movementtoward multidisciplinary perspectives in medical set-tings. This trend has brought about profitable col-laboration among psychologists, psychiatrists, nurses,social workers, and occupational therapists withina team-based model of care. However, as a conse-quence of this approach, many psychology depart-ments within teaching hospitals have been dissolvedas psychologists are now “housed” within particularprograms defined by the types of diagnoses or pa-tients in which they specialize. This eventuality hasbeen a cause for concern for many psychologists, es-pecially around issues of unity and collegiality withinthe profession. It has also caused many psychologiststo leave hospital settings to establish private practices;they often choose this option because, in many teach-ing hospitals, they are paid through external researchgrants for specific research protocols. Private practiceallows psychologists more flexibility and control overtheir clinical work.

Because of this potential fracturing of the dis-cipline within medical settings, national conferencesand journals that deal with issues of concern to psy-chologists are of growing importance. Among theseare the annual convention of the Canadian Psycho-logical Association, and three main journals: Cana-dian Psychology, Canadian Journal of BehaviouralScience, and Canadian Journal of Experimental Psy-chology. Psychologists also attend training seminarsand workshops on specific clinical issues as part ofthe current system of informal Continuing Education.This system will be formalized over the next 2 yearsthrough the establishment of specific Continuing Edu-cation requirements for psychologists. The regulatorybodies of each province will conduct regulation and

monitoring of these requirements. Another possiblemeans of unifying psychologists across Canada is therecent proposal by the Canadian Psychological As-sociation to expand the membership of its Board ofDirectors to include designated officers from three na-tional organizations: the Council of Canadian Depart-ments of Psychology (CCDP), the Council of Provin-cial Associations of Psychologists (CPAP), and theCanadian Society for Brain, Behaviour and CognitiveScience (CSBBCS).

In addition to these sources of education andcommunication, many psychologists in medical set-tings maintain strong links with psychology depart-ments in their city or region. These links most oftentake the form of adjunct appointments as course in-structors and as thesis committee members for grad-uate students. They teach and supervise most oftenon clinically relevant issues and teach undergradu-ate courses on such topics as abnormal psychology,health psychology, personality theory, and applied re-search methods. Clinical psychologists also maintaintheir integration in the academic community by mak-ing presentations at conferences and getting their pa-pers published in peer-reviewed journals. A 1990 sur-vey of clinical psychologists in Canada (Hunsley &Lefebvre, 1990) revealed that over a quarter of re-spondents had published in professional journals and16% had published 10 or more articles. Over 70% ofthose surveyed had made at least one presentation ata professional meeting.

In an extensive study, Arnett and colleagues(Arnett, Martin, Streiner, & Goodman, 1987) sur-veyed the role of psychologists in Canadian hospitals.They reported a national average of approximatelyone full-time psychologist for every 131 hospital beds,with teaching hospitals reporting a larger number ofpsychologists than nonteaching hospitals. The authorsalso reported that approximately one-third of teach-ing hospitals expected psychologists to engage in re-search as part of their responsibilities, although 8%of teaching hospitals did not consider research tobe within their mandate for psychology. With regardto the specific clinical activities of psychologists inCanadian hospitals, the authors found a broad rangeof clinical programs in which psychologists partici-pated; the most common of these were sleep disor-ders, pain, child development, child abuse, forensic,and obesity. They also found that in 43% of the hospi-tals, patients received psychological services only onthe referral of a physician.

Regarding the theoretical orientation ofCanadian psychologists, the study by Arnettet al. (1987) found that 43% of the hospital staff


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psychologists reported their orientation as eclectic,25% as behavioral, 9% as psychodynamic, 3% asclient-centered, and 5% as “other.” In a 1991 study,Warner surveyed psychologists’ orientations as wellas their rankings of the most influential psychother-apists. He found the most common orientations tobe 33.2% eclectic, 27.5% cognitive-behavioral, 9.5%psychoanalytic, 8.4% person-centered, and 5.3%humanistic (which includes existential and Gestaltorientations). The psychotherapists ranked by re-spondents as the most influential were Albert Ellis,Carl Rogers, Aaron Beck, Milton Erickson, SigmundFreud, and Donald Michenbaum. Warner reportedthat, in general, popularity of the psychoanalyticorientation appeared to be on the decline amongCanadian psychologists.

Prescriptive Authority

Psychologists in Canada do not have authority toprescribe medication. The question of whether to pur-sue prescriptive authority is perhaps one of the mostdivisive issues among Canadian psychologists today.Clinicians in favor of having the right to prescribe ex-tended to psychologists argue that it would constitutean increase in the respectability of professional psy-chology and would lead to greater autonomy for prac-ticing psychologists. They also argue that the right toprescribe would allow psychologists to use the entirerange of possible mental health interventions in aneffective matter, and that it would increase psycholo-gists’ earning potential. Those opposed to prescriptiveauthority claim that it is inconsistent with the propsy-chotherapy stance, which states that the key to a pos-itive outcome for the patient lies within the patienthimself or herself. They further argue that the right toprescribe would jeopardize psychology’s identity asa distinct knowledge-based science. Opponents alsovoice concerns that prescriptive authority would re-quire significantly more training for psychologists, andthat many psychologists do not favor medication as atreatment option. Clearly, this debate will continue.There is no clear resolution in sight, and the issue ofprescriptive authority is emerging as a threat to thedisciplinary unity of psychology in Canada.

Areas of Influence

Within many medical settings, there are cer-tain areas where psychologists have been particularly

influential. This influence has been most evident insettings where cross-disciplinary collaboration hasbeen fostered and where psychologists assume bothresearch and clinical duties. Recent years have seenthe development and expansion of research-drivenclinical services within university teaching hospitals inwhich psychologists have played a role in redefiningmedical problems through the advancement of theo-retical knowledge and the introduction of progressivemodels of intervention. The impact of this work is es-pecially apparent in areas where the biopsychosocialmodel of care has been most pervasive. These includewomen’s mental health and the growing field of im-migrant health.

Women’s Mental Health

Women’s mental health is a broad field that typ-ically deals with psychiatric or psychological prob-lems that are more prevalent in women than in men.These conditions include eating disorders, unipolardepression, and functional somatic syndromes. Psy-chologists’ influence in developing effective women-centered modes of treatment for these conditions hasbeen considerable. In particular, feminist psychol-ogists are being recognized as experts in women’smental health (Piran, 1993; Stoppard, 1997; Toner &Akman, 2000). In the area of eating disorders, psy-chologists have been largely responsible for an in-creasing emphasis on the etiological role of gender-related societal expectations in body dissatisfactionand disordered eating among girls and women. Sim-ilarly, psychologists specializing in depression havemoved beyond traditional biomedical accounts by in-tegrating socially mediated constructs into their clin-ical work, thereby leading to more holistic modelsof care. In women’s depression, this integrationcommonly involves consideration of the effects ofwomen’s multiple role demands and the conse-quences of various forms of abuse and discriminationin women’s lives (e.g., workplace harassment, partnerabuse, and sexual assault).

The area of functional somatic syndromes isa growing one. It deals with conditions character-ized by physical symptoms that persist in the ab-sence of identifiable biological causes. Such con-ditions, which include fibromyalgia, irritable bowelsyndrome, and chronic fatigue syndrome, predomi-nantly affect women (Toner, 1994). As with other ar-eas of women’s health where a holistic approach isnow favored, psychologists have contributed to the


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field of functional somatic syndromes by implement-ing integrative modes of intervention that address theinterplay between women’s physical and emotionalwell-being and the social environment. Factors in thesocial environment that have been implicated in thesedisorders include stress levels in the home and work-place, unrealistic time demands, and women’s social-ization toward self-sacrifice and denial of their ownneeds. Psychologists have worked to address thesefactors through the development of innovative indi-vidual and group therapies.

Immigrant Health Issues

Canada has long been considered open and re-ceptive to immigration from other parts of the world,and the country’s immigrant communities have his-torically formed an integral part of its social and cul-tural life. Canada is home to approximately 5 mil-lion immigrants (Statistics Canada, 1996). Meetingthe healthcare needs of this diverse segment of thepopulation is currently a crucial issue, and psychol-ogists are at the forefront of designing interventionsaimed at meeting these needs. Present initiatives in-clude designing research-driven interventions thatmatch the language and ethnicity of patients and clini-cians, developing referral networks and consultationswith community health centers that serve specific im-migrant groups, and conducting workshops to trainmainstream practitioners on the delivery of culturallysensitive care. Medical psychologists have also beeninstrumental in designing graduate training coursesthat specialize in the principles of antiracist healthcarewithin medical faculties, psychology departments, andfaculties of nursing.

FUTURE CHALLENGES

Although psychologists will no doubt continue tobe influential in Canadian medical settings, there arecertain challenges on the horizon with which medicalpsychologists must contend to maintain the strengthand unity of the profession. There are also ongoingchallenges that will become more serious in the nearfuture; such challenges are matters for psychologistsand other practitioners and policy makers to contendwith collaboratively.

The Scholar–Practitioner Model

The “scholar–practitioner” model, more com-monly identified as the Doctor of Psychology (Psy.D.)

degree, is currently a matter of serious contentionamong psychologists in Canada. This model is basedin part on training programs in the United Statesthat grant professional doctorates with a very appliedbent rather than following the traditional scientist–practitioner model. The Psy.D. degree generally takesabout a year and a half less to complete than doesa Ph.D. in psychology. In 1997, the Canadian Psy-chological Association organized a Task Force toconsider the possible role of the Psy.D. degree inCanadian graduate training programs. This task forcehas found strong sentiments on either side of thisdebate (Canadian Psychological Association, 1998).Those in favor of the Psy.D. cite the popularity andsuccess of Psy.D. training programs in the UnitedStates, claiming that Canadian universities are los-ing clinical trainees to American schools. They alsoargue that there is a need for appropriate trainingprograms for masters level clinicians who want totrain at the doctorate level without completing sig-nificant scientific requirements. Those opposed to thePsy.D. degree argue that its advent will damage theintellectual and scientific integrity of the discipline.They are also concerned that the development ofPsy.D. training programs in Canadian universities maylead to the development of independent freestand-ing Psy.D. training programs outside the universi-ties, which would be held to lesser standards. De-bate around this issue will no doubt continue to bea divisive force among psychologists, although indi-viduals on both sides of the argument believe thatthe eventual establishment of university-based Psy.D.programs across Canada is inevitable.

Under-Serviced Rural Areas

A major concern in Canada’s healthcare systemis that the country’s vast, isolated rural areas are se-riously underserviced. Many individuals in need ofmedical services must travel great distances by car orby air to receive the care they need. Compounding theproblem is the fact that university-trained clinicianssuch as psychologists often do not want to live far frommajor urban centers. However, medical psychologistsare beginning to develop innovative, responsive solu-tions to this crisis. One initiative involves the estab-lishment of outreach centers affiliated with large es-tablished hospitals; psychologists at the main hospitalarrange among themselves to divide time to serve atthe outreach site along with other clinicians. Typically,this system involves living in staff housing provided


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on-site for one week every few months. Other initia-tives involve workshops conducted by urban-basedpsychologists to train family doctors in remote areason the psychological aspects of health. These work-shops usually see the psychologist travelling to differ-ent sections of his/her province or territory. Distancelearning workshops over the internet are also becom-ing increasingly prevalent.

Aboriginal Health Issues

A crucial health issue in Canada is the need toadequately meet the healthcare needs of the coun-try’s aboriginal population. It is now an unavoidablefact that the country’s aboriginal peoples (referredto as Canada’s First Nations peoples) experience cer-tain health problems at far greater rates than dothe general population. Particular health problemsare occurring in the area of mental health, includ-ing depression, suicide, and substance abuse prob-lems (Waldram, 1997). Psychologists have played animportant role advocating for First Nations health is-sues. Specifically, following the scientist–practitionermodel, clinicians have entered First Nations commu-nities to examine health-related difficulties and to de-velop recommendations for effective interventions. Instudies of these communities, it has been found thatthe central issues in these health problems lie largelywithin the treatment of aboriginal communities as awhole within Canada; issues include the derogation oftraditional First Nations healing methods, racism di-rected at First Nations people, and lack of respect foraboriginal land rights (Tookenay, 1996). Such forcesserve to disempower First Nations people economi-cally and emotionally. In uncovering these issues andtheir potential health effects, psychologists have con-tributed to the understanding of the socially mediatednature of health as well as the importance of politicaladvocacy for disadvantaged groups.

CONCLUSION

The profession of psychology has historicallybeen well-respected in Canada both by academic col-leagues and by the public. To maintain the credibil-ity and influence of the discipline, it is necessary forpsychologists to unify and communicate. This will in-

volve increased participation in national meetings, aswell as efforts to educate the Canadian public aboutthe diverse roles played by psychologists in Canadiansociety. Moreover, the profession itself must main-tain the high standards of training and care that havelong characterized Canadian psychology. This will re-quire strategic and cooperative responses to chal-lenges, especially those that will influence the train-ing of the future researchers and practitioners whowill represent the discipline in medical and academicsettings.

REFERENCES

Arnett, J. L., Martin, R. M., Streiner, D. L., & Goodman, J. T. (1987).Hospital psychology in Canada. Canadian Psychology, 8(2),161–171.

Canadian Psychological Association. (1998). Psy.D. Task Force: Fi-nal report to the Canadian Psychological Association Board ofDirectors. Ottawa: Author.

Canadian Psychological Association. (1996). Health psychologytraining in Canada. Ottawa: Author.

Canadian Psychological Association. (1999). Geographic locationssurvey of registered psychologists in Canada. Canadian Psy-chological Association Board of Directors.

Dobson, K. S., & King, M. C. (1995). The Mississauga conference onprofessional psychology: Final report. Ottawa, ON: CanadianPsychological Association.

Hunsley, J., & Lefebvre, M. (1990). A survey of the practices and ac-tivities of Canadian clinical psychologists. Canadian Psychol-ogy, 31, 350–358.

Piran, N. (1993). Working with eating disorder clients in institutions.In C. Brown & K. Jasper (Eds.), Consuming passions: Femi-nist approaches to weight preoccupation and eating disorders(pp. 351–360). Toronto: Second Story Press.

Statistics Canada. (1996). Special tabulations: Immigrant popula-tions. Toronto: Author.

Stoppard, J. M. (1997). Women’s bodies, women’s lives and de-pression: Towards a reconciliation of material and discursiveaccounts. In J. M. Ussher (Ed.), Body talk: The material anddiscursive regulation of sexuality, madness and reproduction(pp. 10–32). London, UK: Routledge.

Toner, B. B. (1994). Cognitive-behavioral treatment of functionalsomatic syndromes: Integrating gender issues. Cognitive andBehavioral Practice, 1, 157–178.

Toner, B. B., & Akman, D. (2000). Gender role and irritable bowelsyndrome: Literature review and hypothesis. American Jour-nal of Gastroenterology, 95(1), 11–16.

Tookenay, V. F. (1996). Improving the health status of aborig-inal people in Canada: New directions, new responsibili-ties. Canadian Medical Association Journal, 155(11), 1581–1583.

Waldram, J. B. (1997). The aboriginal peoples of Canada: Colonial-ism and mental health. In I. Al-Issa & M. Tousignant (Eds.),Ethnicity, immigration, and psychopathology (pp. 169–187).New York, NY: Plenum Press.

Warner, R. E. (1991). A survey of theoretical orientations ofCanadian clinical psychologists. Canadian Psychology, 32(2),525–528.

Medical Psychology in Canada

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