Social Workers’ Role in the Canadian Mental Health Care System

Abstract

Objective: Using Canadian survey data this research provides social workers in Canada with a better understanding of their role in the Canadian mental health care system. Methods: By analyzing data from the Canadian Community Health Survey, Cycle 1.2 Mental Health and Well-being, the role of social workers in the Canadian mental health system was determined. Results: Findings indicated that social workers were accessed third most frequently for mental health care. While a variety of individuals accessed care from social workers, those of different sexes, ages, education, and income levels did so at significantly different rates. Conclusion: Social workers should adjust services to include those less likely to access care who may benefit from it, while maintaining services for current clients.

Keywords

mental health Canadian Community Health Survey Cycle 1.2

Introduction

Role of a Social Worker in Mental Health Care

Social workers have played a substantial role in the mental health field since the early development of service delivery in Canada. Many authors see social work skills and knowledge as being ideally suited to the practice of mental health intervention (Davis, 2006; Regehr & Glancy, 2010), especially since they are trained to work at the micro- and macro-levels, (Fellin, 1996) including advocacy in mental health care reform (Everett, 2000; Gonzales, 2005; Hair, 2006) and community-based practice (Rosenberg & Rosenberg, 2006). In the United States, social workers hold top appointed positions as commissioners or directors in state mental health agencies, prominent administrative and management positions in state agencies, executives in community mental health centers and superintendents in state hospitals (Watkins & Callicutt, 1997). In spite of this, and their history in the field, social workers face the challenge of clarifying (Campbell, Brophy, Healy, & O’Brien, 2006) and justifying (O’Brien & Calderwood, 2010; Proctor, 2004) their contribution to the delivery of mental health services.

Although the need to justify their presence in the mental health field exists, social workers play an important role in incorporating social context, an important aspect of treatment, into the mental health setting (Heinonen & Metteri, 2005). The inclusion of social context helps the treatment team go beyond the biomedical perspective to address social inequities and structural issues affecting the individual. Incorporating the social context allows social workers to help individuals address their own situation as well as the structural and public problems affecting them.

While the literature discusses the role that social workers play in the mental health system, conceptualizing their role and what services they can provide, there is little understanding based on empirical evidence of their role in the Canadian mental health system.

Current Study

This study will analyze data from the Canadian Community Health Survey, Cycle 1.2 Mental Health and Well-being (CCHS 1.2), to determine the role of social workers in the mental health system in Canada. Knowing who accesses care and who does not, provides social workers with an understanding of their client base. The study will also determine if there is equal access to care from social workers. The findings of this study have implications for social work practice and policy.

Methodology

Secondary Analysis of Data

A secondary analysis of data from the CCHS 1.2 was conducted. The CCHS 1.2 “is a cross-sectional survey that collects information related to health status, health care utilization and health determinants for the Canadian population” (Statistics Canada, 2004, p. 1). The survey was established by the Canadian Institute for Health Information (CIHI), Statistics Canada, and Health Canada who developed the National Health Information Roadmap in order to address concerns cited by the National Task Force on Health Information (Statistics Canada, 1991). As the study was a secondary analysis of previously collected data, an Institutional Review Board did not review this project.

Between May and December 2002, the survey was administered to “persons aged 15 or older, living in private occupied dwellings” in the 10 provinces (Statistics Canada, 2004, p. 1). The sample of people surveyed “excludes individuals living on Indian reserves and on Crown Lands, Health care institution residents, full-time members of the Canadian Armed Forces, and residents of certain remote regions” (Statistics Canada, 2004, p. 1). This administration methodology excludes the homeless, and people living in shelters, nursing homes, and rooming houses, who often suffer from mental illness and live in poverty.

The survey was administered using computer-assisted interviewing techniques, which are very efficient for a number of reasons. First, the survey is customized as it is administered, skipping questions that are not applicable to the respondent; second, it checks for inconsistent answers, to ensure that respondents understood the questions being asked; and third, it provides prompts on screen when an entry is invalid, which significantly decreases entry errors.

Data Analysis

All statistical analyses were conducted using SPSS (SPSS, Version 17, IBM Corporation). In order to gain a preliminary sense of the data, basic frequencies and percentages were calculated for a variety of factors related to accessing mental health care. Once preliminary trends were established, the significance of these trends was assessed. Since the majority of the data was nominal level, limited statistical analyses were possible. Chi square tests were used to determine whether a particular factor, such as age, sex, level of education, or level of income, was significantly associated with access to mental health care. The frequencies and percentages of respondents in each category were used to understand the results of the chi square tests.

Results

Demographics

There were a total of 36,984 respondents to the CCHS 1.2 from across Canada. Of these respondents 16,773 (45.0%) were male and 20,211 (54.6%) were female. Respondents ranged in age from 15-years-old to 80-years-old or greater with the majority of respondents in the 45 to 49-year-old age range. There were 5,673 (15.3%) respondents aged 15–24, 12,813 (34.6%) aged 25–44 years, 10,762 (29.1%) aged 45–64, and 7,736 (20.0%) aged 65 or older.

Access to Mental Health Care

The CCHS 1.2 asked respondents about their experiences with not only social workers but a variety of different professionals who provide mental health support, including: psychiatrists, general practitioners, other medical doctors (such as a cardiologist, gynecologist, urologist, and/or allergist), psychologists, nurses, religious advisors, and other professionals (such as, an acupuncturist, chiropractor, energy specialist, exercise/movement specialist, herbalist, homeopath, hypnotist, massage therapist, relaxation expert, and/or dietician). The survey also asked respondents if they had ever been hospitalized overnight for reasons related to mental health, alcohol, or drugs. Respondents may have seen more than one professional and/or been hospitalized overnight.

Of the 36,984 respondents, 3,070 (8.3%) saw a social worker for reasons related to mental health, making social workers the third most commonly visited professional, after general practitioners and psychiatrists, whom 5,953 (16.1%) and 3,318 (9.0%) respondents sought help from, respectively. Respondents accessed mental health care, less often, from psychologists (805, 7.6%), religious advisors (1,483, 3.2%), nurses (758, 2.0%), other medical doctors (533, 1.4%), and other professionals (425, 1.1%). There were 868 (2.3%) respondents hospitalized overnight for reasons related to mental health, alcohol, or drugs.

Many respondents sought mental health care from multiple professionals. The majority of those who spoke to a social worker also spoke to at least one other professional about their mental health status (2,234, 72.8%). Similar to findings for all respondents, those who saw a social worker saw general practitioners most frequently (1,854, 60.4%), followed by psychiatrists (1,167, 38.0%), psychologists (924, 30.1%), religious advisors (603, 19.6%), nurses (456, 14.9%), other medical doctors (216, 7.0%), and other professionals (160, 5.2%).

Access to Social Workers

Overall 3,070 of the 36,984 (12.0%) respondents spoke to a social worker about their mental health status. Although social workers were accessed for mental health care in all provinces, the national rates at which individuals received mental health care from social workers varied depending on the characteristics of the individual.

Survey respondents in each age group were able to take advantage of social work services for mental health purposes, although at significantly different rates, χ² (3, N = 36,984) = 592.6, p < .001, η² = .016. Those who were 25 to 44-years-old (1,490, 48.5%) obtained services from a social worker most often, followed by those in the 45 to 64-year-old age range (923, 30.0%) and those who were 15 to 24-years-old (502, 16.4%). Those least likely to access social work mental health care were 65 years or older (146, 4.8%).

Males and females both sought mental health care from social workers. Females (2,027, 66.0%) were more likely to access mental health care from social workers than males (1,043, 34.0%). This difference was significant, χ² (1, N = 36,984) = 175.2, p < .001, η² = .005.

The likelihood of receiving social work mental health care differed significantly by level of education achieved, χ² (5, N = 36,984) = 94.9, p < .001, η² = .003. Those most likely to see a social worker earned a trade certificate, college diploma, or university certificate (1,030, 33.6%) followed by those who were secondary graduates or attended some postsecondary education (820, 26.7%) and those who did not graduate from high school (658, 21.4%). Those least likely to access a social worker achieved a Bachelor’s degree (362, 11.8%) or a postgraduate degree (181, 5.0%). There were 19 (0.6%) respondents who saw a social worker but did not report their level of education.

Income, reported as total household income from all sources, also significantly predicted the likelihood that a respondent would access mental health care from a social worker, χ² (5, N = 36,984) = 125.9, p < .001, η² = .0053. Those in the upper middle-income category (934, 30.4%) were most likely to obtain mental health care from a social worker. Those in the highest income category (675, 22.0%) were next most likely to accept mental health care from a social worker, followed by those in the middle-income category (613, 20.2%). Those least likely to access mental health care from a social worker were in the lowest (264, 8.6%) income category, followed by those in the lower middle-income category (366, 11.9%).

Social work services were accessed in a variety of different locations, at different rates. Respondents were most likely to see social workers in a health professional’s office (447, 14.6%) followed by other clinics (135, 4.4%), in schools (135, 4.4%), on the telephone (92, 3.0%), in the home (91, 2.9%), outpatient clinics (52, 1.7%), while hospitalized (25, 0.8%), in church (16, 0.5%), and the emergency room (8, 0.2%).

Barriers to Accessing Mental Health Care as Assessed by the CCHS 1.2

The CCHS 1.2 asked respondents if they wanted to obtain mental health care but were unable to, what type of care they were unable to take advantage of and the reasons why they were unable to, or did not access the care that they desired.

Of the 36,984 survey respondents, 1,798 (4.9%) wanted mental health care but reported that they were unable to obtain it. These respondents were asked about the type of mental health care they wanted but were unable to take advantage of and why they did not do so. The majority (937, 52.1%) of respondents, were interested in getting involved in therapy or counseling. Individuals were also interested in information about mental illness and treatment (354, 19.7%), information about mental health services (259, 14.4%), and/or help with personal relationships (334, 18.6%).

There were many reasons that respondents were unable to access the mental health care that they desired. Most individuals chose to manage themselves (567, 31.7%) as opposed to seeing a professional. Other common reasons were that the individuals did not get around to it (334, 18.6%), did not know how to (318, 17.7%), or were afraid to ask for help (298, 16.6%).

Discussion and Application to Social Work

Based on the analysis of the CCHS 1.2 social workers are the third most commonly accessed professional for mental health care, with a total of 3,070 out of the 36,984 respondents (12.0%) receiving care from a social worker. This finding indicates that, despite social worker’s need to justify their role in the mental health field (Campbell et al., 2006; O’Brien & Calderwood, 2010; Proctor, 2004), they have a significant role to play.

Among the respondents of the CCHS 1.2, 72.8% of those that spoke to a social worker also spoke to another professional about their mental health. Similar to the frequency at which all respondents accessed mental health care, those that spoke to both a social worker and another professional, most often sought care from a general practitioner (1,854, 60.4%).

Findings of this study also indicate the characteristics of respondents who were likely to access care from social workers, which will help to clarify their role in the mental health care system in Canada. Social workers are most likely to see those in the 25 to 44-year-old age group, females, those who have earned a trade certificate, college diploma or university certificate, and/or are in the upper middle-income category. This is not the group commonly thought of as recipients of social work services, however, it is not surprising as mental health services were most likely to be provided in a health professional’s office and social work services are usually not covered by insurance companies in Canada, making these services accessible to this group of respondents. Others typically seen by social workers such as the homeless and residents of shelters, rooming houses, and nursing homes were excluded from the survey. If they had been included, we would expect to see that they also used social work services. In general, these findings will help social workers clarify their role in the mental health system as it is clear that they not only see the expected clients, but based on the setting, they see others as well.

Findings from the analysis of the CCHS 1.2 data indicated that social workers were least likely to see seniors, males, those who earned a postgraduate degree and those in the lowest and lower middle-income categories. It is possible that the individuals who are significantly less likely to access care from social workers, might be being systematically excluded from care, whether intentionally or not. For example, as social work services are not typically covered by insurance those in the lowest and lower middle-income categories may not be able to afford their services. Social workers can take this information and reach out to marginalized groups or, with further research, determine methods to adjust their services to ensure that these individuals are included.

Another key area of focus for this study was in determining barriers to accessing mental health care as assessed by the CCHS 1.2. Results of this study indicated that there are certain individuals who are significantly less likely to access care from a social worker than others. In order to improve services, it is important to know what barriers are preventing these individuals from accessing care. The CCHS 1.2 asked respondents a variety of questions regarding their desire for and ability to obtain mental health care. By looking at the responses to these questions, it is possible to understand more about self-confessed inability to access mental health care.

Findings indicated that respondents were most interested in getting involved with therapy, counseling, treatment, and/or other services, but were unable to access information on these services. This indicates a need to increase awareness of mental health services. Developing better ways of sharing information about the types of services available and who provides care would be a good way to start addressing the lack of availability of these services and ensuring those least likely to access care are no longer excluded. If general practitioners or family health teams are the primary referral point for people seeking mental health services they may need better education in directing their patients to these services.

There were many reasons respondents listed as to why they were unable to access the mental health care that they desired. Many individuals chose to manage themselves, or they did not get around to it. Most interestingly, almost one fifth of the respondents who wanted mental health care but did not get it, were unable to access care because they did not know how to obtain it. Education is an important factor in helping not only medical professionals but also individuals to understand what they can do to improve their mental health status and where they should go for care. Social workers can play an important role in educating their communities, including health professionals.

Further research, likely qualitative in nature, would be beneficial in understanding these findings. Survey data often does not allow respondents to elaborate on their responses, resulting in further questions that need to be answered before an enhanced understanding of the situation can be had. A qualitative study using interviews to gather data would allow for respondents to expand their responses and, in this case, delve into details with respect to why they were unable to access mental health care. Qualitative studies with those least likely to access care are recommended.

While the findings of this study provide insight into the role of social workers in the mental health system in Canada, it is not without limitations. One such limitation is the age of the data. Survey respondents were interviewed in 2002 and while it is likely that the general trends are consistent today, it is possible that there are differences. Understanding the role of social workers in the recent past is a strong basis for developing an understanding of their current role.

There were several limitations as a result of the data-collection methods. For example, only those with a home address and telephone number were surveyed excluding those who are homeless or living in shelters, rooming houses, or nursing homes. Individuals who were institutionalized, in prisons or hospitals, at the time were also left out of the survey results. Not surveying these populations misrepresents the situation. Those who are homeless have been found to have a very high prevalence of mental illness and substance abuse and are not likely to access care (Hwang, 2001). Individuals who were incarcerated also have a higher prevalence of mental illness than the general population, and mental health care in prisons is known to be lacking (Lamb & Weinberger, 1998). Future research should incorporate the populations excluded here in order to determine other aspects of the role of social workers.

Another limitation of the survey was the lack of information collected on respondents’ race. Past versions of the survey asked respondents outright which race they identified with, however this question was removed from Cycle 1.2. Other studies have found differential use of social work services by people from different ethnic groups. Meltzer, Fryers, and Jenkins (2004) found that members of Caribbean and African groups appear to use therapists, social workers, and alternative healers less frequently than White and Asian groups. Future research should include information about race to determine if there are differences in access to care based on race in Canada. Knowing this information could help social workers to ensure that their services are inclusive.

Overall, results of this research indicate that certain individuals are potentially systematically excluded from social work care. Understanding who is currently underserved by social workers and the mental health care system in general, makes it possible to develop initiatives to increase accessibility to services for these individuals, while maintaining services for others. In particular, this includes increasing access to services for seniors, males, those who earned a postgraduate degree and those in the lowest and lower middle-income categories.

Further research to determine what the barriers are is necessary in order to begin addressing them. Just by being aware of those who do not typically receive the care they need, social workers can attempt to improve their access and then work with them to help them feel and be more empowered in their situation. For example, it has been found that having social workers available in family health teams reduces the anxiety seniors feel in later being referred to a social worker (Banyard, Jones, Hampshaw, & Dunn, 2002). More research to determine other barriers to accessing care for those who are underserved is necessary so that solutions such as having social workers on family health care teams can be supported by research and used to improve care. By doing this, the barriers to accessing mental health care will begin to breakdown.

This study also found that there is a lack of information and knowledge about available services and where to access them. As structural social workers, knowing the barriers to accessing mental health care makes it possible to begin breaking them down. In this case, education would be a valuable tool. Informing health professionals (the gatekeepers to the mental health system), social workers, and the general public about a variety of issues will increase the likelihood that people will be able to access the services of value to them. As well, knowing how to identify if someone is in need or would benefit from care, is as important as being able to direct these individuals to the appropriate mental health professionals (Mazzer & Rickwood, 2009).

The findings of this research show that even as social workers struggle to define and clarify their role in the mental health system, they are clearly important. Mental health care continues to be based on physical health care models, which limits the type of care available as well as who receives care. When individuals are only treated for biological issues, the contextual causes of their illness are ignored. Here is where social workers play an increasingly important role. More and more, social workers are part of interdisciplinary care teams that help individuals deal with all aspects of both physical and mental illness. Social workers need to continue to integrate themselves into care teams in order to ensure that the whole person is treated.

Social workers are an important part of the mental health care system in Canada, as is evidenced by the proportion of survey respondents who sought mental health care from them. More research on these topics is required to enhance social work practice and policy. It is important to adjust services to include those who are currently less likely to access care but may benefit from it, while maintaining services for current clients. By using Canadian survey data, this research provides social workers in Canada with a better understanding of the overall role they play in the mental health system and the characteristics of the individuals they typically work with. It also provides a basis from which to conduct further research into particular barriers preventing certain individuals from accessing mental health care.

Footnotes

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The authors received no financial support for the research, authorship, and/or publication of this article.

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