ONTARIO REGISTERED PSYCHOTHERAPISTS DISCIPLINE TRIBUNAL
Tribunal File No.: 26-003-RP
BETWEEN:
College of Registered Psychotherapists and Registered Mental Health Therapists of Ontario
College
- and -
Christopher Lee Chang-Duffet
Registrant
FINDING AND PENALTY REASONS
Heard: May 28, 2026
Panel:
Jay Sengupta (panel chair)
Kathleen (Kali) Hewitt-Blackie (registered psychotherapist)
Kenneth Lomp (registered psychotherapist)
Henry Pateman (public)
Kevin Sack (public)
Appearances:
Emily Graham, for the College
Christopher Lee Chang-Duffet, self-represented
RESTRICTION ON PUBLICATION
Pursuant to Rule 2.2.2 of the HPDT Rules of Procedure and ss. 45-47 of the Health Professions Procedural Code, no one shall publish or broadcast the names of clients or any information that could identify clients or disclose clients’ personal health information or health records referred to at a hearing or in any documents filed with the Tribunal. There may be significant fines for breaching this restriction.
Introduction
1The College of Registered Psychotherapists Ontario (the College) alleges that the registrant, Christopher Lee Chang-Duffet, committed professional misconduct by contravening s. 51(1)(c) of the Health Professions Procedural Code, Schedule 2 to the Regulated Health Professions Act, 1991, (RHPA) SO 1991, c. 18 (Code), as set out in the following paragraphs of s. 1 of Ontario Regulation 317/12 made under the Psychotherapy Act, 2007, SO 2007, c.10, Sched, R by:
failing to maintain the standard of practice in respect of his general conduct (paragraph 1);
performing a controlled act that he was not authorized to perform, specifically administering a substance by inhalation (paragraph 10);
contravening s. 27 of the RHPA and s. 4 of the Psychotherapy Act (paragraph 42); and
engaging in disgraceful, dishonourable or unprofessional conduct (paragraph 52).
2The College alleged, and the registrant did not contest, that the registrant administered a potent psychedelic, 5-MeO-DMT, by inhalation to Mr. X and Mr. Y at a cottage retreat, thereby performing an unauthorized controlled act. While doing so, the registrant did not monitor, measure or record the amount of the substance he administered to participants at the retreat. Both Mr. X and Mr. Y became unwell, and Mr. X lost consciousness and was unresponsive for a period of time.
3The registrant did not contest the allegations, and the parties made a joint submission in respect of penalty and costs, seeking a seven-month suspension of the registrant’s certificate of registration, a reprimand, and terms, conditions and limitations on the registrant’s certificate of registration that require successful completion of instruction on psychedelic-assisted psychotherapy and prohibit the administration of any substance by inhalation. Finally, the parties jointly sought an order for costs based on the tariff rate, payable in installments.
4For the reasons that follow, we granted the order sought by the parties.
Misconduct
5The registrant has been registered with the College since August 2022.
6Mr. X and Mr. Y are military veterans who have experienced trauma and PTSD as a result of their military service. They met the registrant in February 2023, during a psychedelic-assisted therapy retreat operated by physicians in which the registrant was acting as a volunteer. They stayed in touch with him and the registrant had two psychotherapy appointments with Mr. X in March 2023.
7The registrant invited both Mr. X and Mr. Y to a retreat that he described as a “3-day boot camp” and a “wellness initiative for veterans” in which he would act as a “psychotherapist” and “qualified therapist able to identify and work with trauma to resolution.” He told Mr. X that he would be administering 5-MeO-DMT, which he described to both Mr. X and Mr. Y as a psychedelic substance, to see what effects it would have and how they could integrate it into their personal healing processes.
8As indicated above, 5-MeO-DMT is a potent psychedelic that can induce visual and auditory hallucinations, distortions in time perception and amplification of emotional states. It often causes rapid heart rate, nausea, and pressure in the chest; when vaporized or inhaled, effects begin almost instantaneously. In moderate to high doses, the substance often leaves the user incapacitated.
9Before the January 2023 retreat, the registrant purchased the substance in powder form online. It was clear from the website that the substance was a research chemical for educational, scientific, in-vitro laboratory research use only and not intended for human consumption.
10The registrant administered the substance to Mr. X and Mr. Y as a nasal spray that he had made himself, in powder form to snort through a straw, and in smoking devices such as an electronic cigarette and a bong. He also showed them how to make the nasal sprays themselves and gave them supplies to do so.
11When Mr. X and Mr. Y were unaffected by the initial doses administered to them by nasal spray, the registrant encouraged them to take increasing amounts in powder form and by smoking. The registrant did not monitor, measure or record how much of the substance he administered to any of the participants at the retreat.
12Mr. X became unresponsive and lost consciousness for a period of time after he inhaled the substance by nasal spray, took it in powder form and smoked it. After his condition stabilized, Mr. X remained at the retreat, but he felt unwell for the rest of the weekend with gastrointestinal symptoms; he also could not eat. The registrant did not tell him to seek medical attention. Mr. Y left the retreat in the middle of the first night.
13We find that the College has established that the registrant performed a controlled act outside the scope of the registrant’s practice.
14Section 27 of the RHPA defines 14 controlled acts that may only be performed by registrants of authorized health professions or persons with the appropriate delegation from an authorized registrant. The list includes the following controlled acts:
a. administering a substance by injection or inhalation; and
b. 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, behaviour, communication or social functioning.
15Under s. 4 of the Psychotherapy Act, the registrant was only authorized to perform the controlled act of psychotherapy. He was not authorized to administer a substance by inhalation, nor had performance of that controlled act been delegated to him by any other regulated health professional.
16The court in Retirement Homes Regulatory Authority v. Wesley Moore, 2023 ONSC 2079, set out certain indicia to establish “administration” in the context of medication. These include assuming responsibility for the substance and ordering, storing, dispensing or giving the substance, all of which happened in this case. The registrant decided which substance would be used, he procured it and was the only source of the substance at the retreat. He controlled the premises, told the participants how to use the substance, mixed it and showed them how to mix it. It is also not in dispute that Mr. X and Mr. Y inhaled the substance by breathing it in by nose or mouth.
17We find that the registrant contravened College Standard 1.5, which governs General Conduct. The standard requires that registrants refrain from disgraceful, dishonourable or unprofessional conduct, practise the profession with integrity and professionalism, consider the impact of their actions on the profession as a whole and assess their actions from the perspective of their peers.
18The registrant exceeded the permissible bounds of psychotherapy by performing an unauthorized controlled act. He displayed extraordinarily poor judgment, and his actions showed a disregard for his responsibilities as a registered psychotherapist. We find that the College has established that he failed to maintain the standard of practice and that his actions amount to disgraceful, dishonourable or unprofessional conduct.
19Accordingly, having reviewed the statement of uncontested facts and considered the submissions made by the parties, we find the registrant has engaged in professional misconduct as alleged by the College.
Penalty and costs
20The parties jointly sought the following:
a seven-month suspension of the registrant’s certificate of registration;
a reprimand;
terms, conditions and limitations on the registrant’s certificate of registration (requiring completion of education in psychedelic-assisted psychotherapy and a prohibition against administering any substance by inhalation); and
costs in the amount of $4,700 (payable in quarterly installments).
21While the Tribunal has the discretion to accept or reject a joint submission made by the parties, we must exercise restraint and should not reject a joint submission unless it meets the “undeniably high threshold” that the proposed penalty “would be viewed by reasonable and informed persons as a breakdown in the proper functioning of the justice system” (see R. v. Anthony-Cook, 2016 SCC 43 at paras. 34 and 42; Ontario College of Teachers v. Merolle, 2023 ONSC 3453 (Div. Ct.) at paras. 27 and 28).
22We find that the proposed penalty is appropriate and reasonable in the circumstances and that it accomplishes the usual penalty goals of public protection, maintaining the public’s confidence in the College’s ability to regulate the profession, specific and general deterrence and remediation of the registrant.
23The misconduct is very serious. The registrant performed a controlled act that he was not authorized or delegated to perform. He exceeded the authorized scope of practice of a psychotherapist. One of the complainants lost consciousness and became unresponsive.
24The College acknowledged that the registrant had taken steps to proceed by way of a joint submission. This has allowed the matter to proceed without having to call evidence from vulnerable complainants and without the associated costs of a lengthier proceeding. The College also pointed out that the conduct occurred on a single occasion, in respect of two people, and has not subsequently been repeated.
25The seven-month suspension is proportionate to the misconduct and the circumstances of the case.
26In College of Physicians and Surgeons of Ontario v. Boroujeni, 2020 ONCPSD 25, a physician treated over 1,300 adult patients despite having a restricted certificate of registration that permitted her to only treat pediatric patients, inappropriately used OHIP codes, treated five more adult patients even after being made aware of the investigation and made misleading and inaccurate representations to the regulator during the investigation phase; she was reprimanded, suspended for six months and had terms, conditions and limitations imposed on her certificate that included completion of the PROBE course and monitoring of OHIP billings.
27In College of Physicians and Surgeons of Ontario v. Hadwen, 2024 ONPSDT 19, a third-year medical resident, who was only authorized to practise as part of his postgraduate medical program, treated 30 patients over 3 months and refused to send charts to the regulator for 16 months; he received a reprimand, an eight-month suspension and had terms conditions and limitations imposed on his certificate of registration.
28We note that as part of a resolution of another complaint in August 2025, the registrant entered into an undertaking that he would not administer any drug-assisted therapy until permitted to do so by the Registrar. He is also subject to 24 months of clinical supervision and must successfully complete the PROBE course.
29The terms, conditions and limitations that form part of the jointly proposed order include a practice restriction that the registrant will not administer any substance by inhalation and a requirement that he complete targeted coursework on psychedelic-assisted psychotherapy. These measures, together with the terms of the previous undertaking, will serve the goals of specific and general deterrence, and will allow for necessary reflection by the registrant to ensure a safer return to practice following his suspension.
30The costs sought by the College are in line with the tariff rate.
Order
31We made the following order:
Penalty
The Tribunal requires the registrant to appear before the panel to be reprimanded.
The Tribunal directs the Registrar to:
a. suspend the registrant’s certificate of registration for seven (7) months commencing on the date of this order;
b. place the following terms, conditions and limitations on the registrant’s certificate of registration effective the date of this order:
i. Practice restriction: The registrant shall not administer any substance by inhalation; and
ii. Course/instruction: At his own expense, the registrant shall participate in and successfully complete a formal course on or formal instruction in psychedelic-assisted psychotherapy. The course/instruction must be satisfactory to and pre-approved by the College, in its sole discretion. The registrant shall complete this requirement within twenty-four (24) months of the date of the Tribunal’s Order, or, if no satisfactory course/instruction acceptable to the College is available by that time, by the first possible opportunity thereafter.
Costs
- The Tribunal requires the registrant to pay the College costs in the amount of $4,700.00, by paying the College quarterly installments (i.e. every three (3) months) of $1,175.00 beginning thirty (30) days after date of this order.