This is the third instalment in a five-part series looking at what Ontario can do now to address systemic issues that the COVID-19 pandemic has brought into sharp relief. Read Part 2 here. Watch for Part 4 on Thursday.
Last month, here at TVO.org, I interviewed a series of experts on big, system-wide challenges the province will be facing as it exits the pandemic. But there was so much more that could have been covered, so we’re doing it again: five more articles about specific challenges the province faces today — this time, with a greater emphasis on what can be done now. It will take many years to build new hospitals and train thousands of new nurses, but what can be done in weeks, months, or even just a few short years?
Today, TVO.org speaks with Deepy Sur, CEO of the Ontario Association of Social Workers, about the crisis in mental health.
Matt Gurney: I’ve been starting all of these with the same question, basically, but what did the pandemic mean for mental-health care in Ontario?
Deepy Sur: It’s super-important for you and your readers and followers to know that we weren’t on solid footing to begin with, before the pandemic. So rather than getting back to normal, we actually need to continue adapting to the new circumstances that further complicated things that had been left unaddressed for a long time.
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We need a much greater focus on mental supports. So we learned a lot of lessons about mental health during this pandemic. Think of it this way. There are three important things I like to highlight. The first is, we learned about the importance of mental health and talking about mental health — for children, for families, for communities, racialized populations. Those needs were always there, and then we needed to ensure swift access.
And then we began talking about recovery. Once the pandemic is over, we’ll have a recovery, right? And we’ll talk about mental health, but it’s largely separate from overall health — we treat it separately. Now we’re talking about integrating it, and mental-health-care providers, like social workers, are contributing to addressing the impacts on trauma, intimate-partner violence. We heard over and over that our families and communities and children were facing increased complexity because of trauma impacts. And then we heard about access, we had wait-lists that were long and where even people in group plans might not have had equal access. We heard about people in sectors and racialized populations not being able to access things.
The pandemic had outsized impacts on already marginalized groups. So people with low or no incomes, people experiencing homelessness or unstable housing, and populations such as immigrants, newcomers, people with disabilities, they’ve been hit twice as hard — maybe three times as hard.
We’ve been worried about what the recovery will be since last year. And that was only in the second wave. We conducted a poll of Ontarians during Social Work Week, which was just after the second wave, and our theme this year was “You are not alone.” Ontarians are not alone. Social workers are not alone. Communities we work with are not alone, as well as the providers we work with within the systems. The survey actually told us how Ontarians are doing and how social workers are essential in the path forward. Nearly 45 per cent of people said the pandemic has caused a negative shift in mental health, especially significant in those under 35.
We need to do all that we can do to enable access, because nearly 45 per cent also said they’d seek support from mental-health professionals — in particular, a social worker. For our recovery, we will need thoughtful and innovative ways to transform care. We need social workers as part of team-based solutions as we begin to recover.
Gurney: I want to come back to the team-based thing in a minute. Just before the pandemic — like, weeks before — here at TVO.org, I did an exploration of mental-health services in Ontario. And I only really know the system from the outside. I don’t have any lived experience getting sustained mental-health care outside the context of a check up or as part of a broader evaluation. So I really had to learn about it, and, wow, it’s complicated. People struggle to get into it, and then they sometimes struggle to stay in it.
I wrote in my original series about a friend of mine who was under the care of a psychiatrist for some fairly serious issues — but issues that were managed. And then her psychiatrist, who was paid for by OHIP, retired, and my friend was sent right back onto a wait-list. And she wasn’t someone who could really just pause and go without — her issues were quite complicated and severe but could be kept in check with regular treatment. So even before COVID-19, things were really rough.
And then we had this pandemic. I spoke not long ago in a different context, a political context, with my friend John Wright. He’s a pollster. And he told me in the context of the federal election that the national mood is sour. It’s garbage. We are grumpy and stressed out after 18 months of living in a crisis. He was talking about that in terms of politics — volatile electorates, change narratives, stuff like that. But it made me think of all this. What was the pandemic like for those who were already in the system, and then all this happens? When whatever problems you already had are now compounded by a massive global catastrophe?
Sur: It meant longer wait times for care. And it also meant a change in the type of care. Obviously a big part of this was a shift to virtual care, as we’ve seen in other sectors and industries. People had been resistant to digital care or telephone care but gave it a chance, and in many cases we’ve seen great success. That’s here to stay. But it has real limits. It doesn’t work for homeless populations. It doesn’t always work for remote Indigenous communities, nor is it in sync with the values of some communities.
These coming months are going to challenge us all in different ways. So if you were experiencing adaptation issues before, depression or anxiety, which we know are common, along with mood disorders, think about all the added burden now — whether you can manage your anxiety about commuting to work, or a child who’s going to school for the first time without meeting their teacher or peers, or how will students manage starting university or they’re in their second year and they’ve never been on campus. People are worried about their resilience.
But you know, Matt, our poll showed that people still have hope that their resilience will kick in. Recovery will require government supporting mental health. So putting mental health in places that we hadn’t always thought of, not just hospitals or psychiatric clinics, but in workplaces, in schools — access to mental-health supports is critical for our children’s success.
What does it mean for folks that were really suffering before? Many of them continue to suffer. But we did see an uptick in virtual care. So we want to ride that wave around digital innovation as well. But virtual care does pose its own challenges for access, privacy, and screening for suicidal ideation or substance abuse. We need to think about addressing barriers and facilitating timely access. And that means integrating more of us across the system, in all parts of life.
Gurney: I want to ask you two quick follow-ups here before we move on. First, you mentioned the challenges of virtual care — are we better at that now?
Sur: Oh, yes. Not perfect. But we learned a lot of lessons. This is true across all of health care, and we’ve all gained more experience. Nurses and doctors and everyone. We’re trained to do this, right? We’re trained as providers not only to intake, assess, and treat, but also to set some clear boundaries and parameters around the scope of work we can do and how far we can take that. And don’t forget, even though social workers pivoted hard to offer virtual care, many of them were still out there in the front lines. Many of them were in shelters, in communities, and in schools and health-care settings. They were targeting and supporting as needed. They were essential, just as many other workers were, in order to get us through this crisis.
I talk a lot about this next phase really being chock full of momentum for integration and targeting. We’ve already seen momentum around reducing stigma and access to mental health. The mental-health commission estimated that $6 billion is lost every year to mental-health issues, accounting for about 70 per cent of all workplace-disability costs. So we need to advance the discussions around employee wellness in a whole new way.
Gurney: Okay, and the other one — you said you saw an uptick in virtual care. Did that account for new patients? Are more people now in the system than before, or did we just bump people out of one form of care into virtual care but at a net wash … or maybe even a loss?
Sur: Good question. Our poll didn’t ask that, so I can’t tell you specifically — we don’t know how people would break out by prior treatment status. But we do hear all the time from our social workers on the job, we’ve surveyed our own members, and they’re seeing new patients, more than usual. So we do believe more people are taking part in virtual care or are now on wait-lists for care.
Gurney: You mentioned “team-based” care earlier. What did you mean by that?
Sur: Social workers already are part of teams. We could be part of a community based team or part of a team at a school or in a hospital facility. We work in long-term-care facilities. Some employers have social workers. We’re also in crisis centres and shelters and correctional facilities.
Gurney: Let’s actually drill down into something now — I want to talk about the economics of this. So, in Ontario, psychiatric services are covered by OHIP — that can include medication and therapy. And then there are two additional ways to get mental-health care: psychotherapists and social workers. And the latter two are not covered by the province, necessarily. Like I told you before, when I researched this years ago, I realized it was complicated.
Sur: It is. Social workers are the largest provider of mental-health care in Ontario. I really want your readers to know that. There’s about 20,000 of us, and we’re delivering a lot of care. And our funding can come in different ways. If we’re part of a team, as I mentioned above, we can be part of that funding envelope. Often not a secure part, though, which is a challenge. The funding can be cut. But that’s one source. We can be paid directly by a patient or by an insurer that covers mental-health care. Employers and insurance companies do not always include social workers or mental health. So a large percentage of people out there don’t have access to mental-health care, or they wait on a long wait-list — tremendously long. On average, eight months to a year.
Gurney: And at the end of the wait-list, they see, what? Someone in a subsidized spot?
Sur: Even some social workers in entirely private practice have wait-lists, but if you’re thinking about a community-funded government program, you’re sitting on a wait-list for some registered counselling or social worker to provide mental support. And you may sit on that list for either an assessment before you can enter some group or individual counselling or family counselling, or you can go into and get limited counselling services. We are putting boundaries around mental-health care, but we don’t do that for physical health. And our mental health is directly linked to things like increased depression, diabetes ... research upon research that tells us that our physical and mental health is integrated.
So think about the critical role employers have in increasing mental health by choosing benefit plans that include benefits for mental-health care. We could make huge strides in access. We talk about this with the government all the time, and this is something I have some optimism about.
Gurney: Yeah, that’s part of why I asked. I was reviewing the benefits my wife and I share, and I realized I could spend more money on a massage therapist than a therapist. I’d be better off getting a sore neck that needed treatment than getting depression. But another reason I asked about the economics is that there’s no real limit on the number of social workers we could have. As I said, psychiatry is funded under OHIP, so there’s a limit on how many will be funded and how much service can be provided. But a social worker or a psychotherapist doesn’t have a budgeted limit in the same way. There’s nothing stopping someone from doing the education, becoming registered, and then hanging their hat out, ready for business. I know not everyone could afford to pay, but there isn’t a legislated limit or some hard budgetary cap on how many social workers Ontario could have.
Sur: That’s right. There’s no legislated cap or financial limit. But, generally, it would be rare for someone to just hang their hat out at the outset. There’s nothing stopping them, and many of our members assist with private care, but most social workers will not graduate with their MSW and hang their hat out to be a private practitioner right off the bat. Clinical experience means more expertise and growth. And working within communities and racialized populations is a large part of social-work expertise. That’s generally acquired through years and years of experience and partnership and collaboration with other professionals.
Gurney: I want to come back to all this, but I have a specific question that we alluded to a bit above. You mentioned how you’re in schools, or in some businesses, but also in the community. Teachers are on the front lines of this. They’re really a first line of defence. They can see when a student is struggling and sound the alarm about, perhaps, a dangerous situation in a troubled home. And you’ve mentioned intimate-partner violence as well. Well, the pandemic locked us all in our homes, took already stressful or violent situations and made them worse, and cut people off from access to support, or a way to ask for help, from a teacher or coworker or whatever. How did you guys respond to that?
Sur: The organizations that deal specifically with intimate-partner violence had to pivot to find new ways to support individuals who are trapped, literally trapped. We needed new ways to promote crisis lines, help lines, virtual help lines, and all could contact 911.
But I have to just say it. Intimate-partner violence increased, and access to support decreased, thanks to the pandemic. What we’ve seen is a lot of organizations who have had to become very, very smart and thoughtful about their programming. It is hard to provide care to someone in the home, through some virtual or telephone system, if the problem is in that home, right? They may not have safe access.
If you’re accessing a mental-health provider, like a social worker, you’re probably still heavily focused on your safety and your children’s safety or your family safety or whoever else is involved. So can you imagine what it would be like for both provider and client to consistently be doing that and worried about someone’s safety and care during a period of quarantine and isolation? And if you’re racialized, you may have had other impacts or community impacts. That’s resulted in increased anxiety, increased depression, increased traumatization. And this will cause burdens down the line — in health care, in hospitals, with the police, and with the courts.
Gurney: I have so many questions for you, but you’re giving me amazing stuff, and I keep getting distracted with follow-up questions. I’m going to try to get back on track. I’m curious about how good virtual care is. I’m sure it’s fine sometimes and totally ineffective other times. Can you give me three broad, made-up examples of scenarios when virtual care is just as good, and maybe even more convenient, than traditional in-person care? And when it’s a workable but not ideal stopgap? And when it’s just totally not going to work at all?
Sur: So a great example of where virtual care worked really well was medical appointments with your doctor, your social worker, and your diabetes team. Just think of the time savings, with no commuting. So it worked well, where a wellness visit could happen more quickly and frequently. It also certainly worked well when we were talking about mild to moderate anxiety and depression.
When we’re talking about psychosis or extreme mood disorders or extreme diagnostic mental-health issues where you really need team-based care, that becomes more difficult. You might be able to do a virtual initial assessment for a complex case, but so much more is required in terms of follow-up, whether it’s walking people through testing and through intake and through assessments, filling out forms ... that’s extremely difficult in the virtual setting. And really difficult for children. Some kids responded really well and formed good social connections — it was similar to what they were doing at school with Zoom.
But also imagine family counselling virtually, with everyone involved all at home. Or couple’s counselling. It’s possible. But it’s a tough dynamic virtually, and it needs a lot of coordination, and it adds complexity. So when you’re assessing for mood, and you get some signalling of suicidal ideation, you have some concerns about threats to safety, that becomes increasingly complex and difficult.
Lastly, when you’re assessing day-to-day functioning, behavioural patterns, or severe anxiety or depression with maybe suicidal ideation, it’s really hard to do this in a virtual setting. Not impossible, but really difficult.
Gurney: This is a very specific question, kinda touchy-feely, but for your line of work, how much added burden is working virtually? How much do you lose when you aren’t there to see body language, sense tone, watch for little fidgety gestures and stuff?
Sur: I love the question, because we’re trained to really think about that, right? To really think about voice and elevation and body language. Empathy is baked into so much of the work we do, as well as emotional intelligence. And so we’ve actually been doing a lot of training around delivering good care virtually, because it’s a pivot for some folks that have never done that work. They’ve only ever connected in person, and they’ve done it super well. And so it’s a change.
Outreach and connectivity involves more than just words, right? We know that it involves voice, it involves intonation, and it involves expression. “Lost in translation” moments can come through having just a face on a screen and not seeing the rest of the person’s interactions. And people who are typically marginalized and isolated, including elderly or immigrant populations or newcomers, they don’t look at the screen the same way or access the virtual care the same way as others. Think about our homeless persons or people with mental-health diagnoses that are severe — their interactions or virtual experience look really different.
And, so, for our social workers that we had surveyed across Ontario, they talked about a loss and some sadness associated with the lack of connection and having to find new ways. But here’s what’s remarkable about really good mental-health care. When you can connect to a client, community, or family, you can plug in resources, quick supports, and coping strategies, and you can really do that work well when the opportunity is right. And the other cases, well, yeah, like I said, stuff can get lost in translation, where there are language barriers or family dynamics or dealing with immigrant or marginalized communities.
There’s something to be said for developing a new way of building a rapport. That’s what I’ve called it. It really is a new way of building connectivity. Relationship building is what we do, right? This has been disruptive, and it’s new, and it’s different. But we’ve had to do it. And we’ve had to do it really well.
Gurney: I know that this is going to be a hard question to answer, because it’s not like you can give me a number or something, but I want to try to quantify something in at least general terms. Since the pandemic began, as you’ve noted, treatment has been in some cases harder. We’ve already talked about how isolation has probably meant that some people who might have entered treatment if not for the lockdowns and whatnot didn’t pursue it. Plus we have the fact that the pandemic itself has been awful and an added stressor that has created a need for care that wouldn’t have existed otherwise.
So, look, no one knows what the future holds — a fourth wave, a fifth wave, whatever. But when we do get back to something more like normal, how much of a “care deficit” will we have accumulated?
Sur: You’re right, there’s not a number. I want to think about this thoughtfully for you. We’ve been talking about virtual care and how it can be very helpful. But to establish the ability, courage, and trust to establish a first-time connection through telephone or video or online, is terrifying for some. We have been working to assist counsellors with tips and strategies to manage the anxiety of even asking for help in the first place, and we know it’s a big obstacle. So the deficits have been huge.
Think about the number of kids who were at home, out of school, with very little access to social-work support that was dedicated to them. Every school has access to social-worker supports, but that doesn’t mean in a reasonable ratio. Now you have to access supports through your home where your family is, to talk about the stressors or about the family. That would be difficult, right? So think about the number of people who turn that down. So our deficits will be huge. And no matter how many waves we have, there’s going to be an echo pandemic of mental-health issues. A bigger one.
Gurney: Only 4 per cent of us have had COVID-19; 100 per cent of us lived through a pandemic. So, okay. How do we fix this? You’ve already said that social workers are doing a huge share of the work. And that there are 20,000 of you. Do you need 30,000 more?
Sur: I love this question. Because, you know, we’re not just talking about mental health — we’re also talking about addictions and substance abuse. And we’re talking about mental wellness, as well, and employee health, and a lot of people facing economic stress from job loss or changed work environments due to the pandemic.
So what do we do? We’ve really got to be very targeted. I would love to see more registered social workers across the province. But more than that, I would want to see our strategic deployment. Ratios in schools are low. Not every long-term-care home has a social worker present. And, if they do, then they have one for every 200 residents. Not every child or young adult and university has access to a mental-health provider.
And so what we need, number one, is strategic deployment and to really treat social workers and mental health as essential, because they’re an essential part of the system. The second thing we need to do is really start thinking about access in terms of resilience. So pay more attention to mental health across the systems that cut across each other: corrections, health, social justice, police — they all intersect. And yet we work in such isolation around how we plug in mental health, and this hurts rates for recidivism and relapse. We need to think about that as one system of care. And then we can think about recovery.
This is an optimal time to ride the wave of innovation. You know, if teams have learned to work together across the world to provide care across cities, across boundaries, then we can really be thoughtful about data collection and aggregated data and race-based data and thinking about how we can be targeted in our focus. And I would be remiss not to say we need to understand how much mental stress has been caused by racial injustice, disparity, disproportionality. We really need to find a way to address communities that have been impacted, that have been racialized, and to find better ways to deliver appropriate care to Indigenous communities, as well.
Gurney: I feel like kind of a jerk now, because you’ve been so lovely and helpful, but you said something that I need to follow up on. You said you want to be strategic in how resources are used. But that usually means deploying resources differently — if you want to put more here, you take them from there. So who’d lose out if we were more strategic?
Sur: No, that’s a totally fair question. I expected it. I would tell you openly and just very clearly, you don’t actually have to move things from one space to another. What you need to do is create a new way of working.
Let me give you a great example. We participated with five large GTA hospitals in a project over a couple of years, where we strategically deployed social workers in emergency departments that didn’t have social workers. And we expected to see some marginal differences. One hospital saved over $1 million by just having a social worker in the ER as part of the team-based care. Adding a social worker reduced stress on the doctors and nurses, and it helped move people through the system faster — some didn’t need to be admitted to the hospital at all but had nowhere else to go. The social worker could help there. So, arguably, you’re saving money by just redesigning how your current systems work.
Take schools, for example. Instead of referring children out to the system and putting them on long wait-lists in the community to access family counselling or support, what if you just gave access to teachers and students right at the right time, in the right place? Teachers could focus on the work they’re doing knowing that their children are coming to school healthy and well and ready to learn. And social workers could actually implement mental-health strategies that work. By and large, social workers are a lot more affordable than other mental-health or caregiver supports or, years into a crisis, health-care supports.
Gurney: Sure. I’d rather spend money on a social worker to help someone with alcoholism now than wait 30 years until he needs a new liver.
Sur: Prevention and promotion. Imagine the money we could save.
Gurney: And you think we could do this with, in general terms, the resources we have? The same rough budgets, with the 20,000 people?
Sur: Put me at the table with the government. For sure. Let’s do this. I’ll happily define that model. And the number of social workers is going up. It was 19,000 a few years ago, and now we’re heading for 21,000. The profession is growing as the need grows. But I don’t hesitate to say that our people are not deployed as effectively as they could be, particularly in government-funded areas.
Gurney: And what could we do about that in the next, just to pick a number, 12 months?
Sur: Start designing the system for access. Open up opportunities that already exist and increase the mental-health coverage in long-term care, schools, and health right off the bat. I would really say the top three challenges around mental health are things like employment, anxiety, workplace stress. So start plugging in mental-health supports where people present with those issues most: school, workplaces, and health care.
And then let’s start thinking about targeted interventions. So we have a number of amazing communities out there doing amazing interventions. Let’s find out what they are and increase them for racialized populations and Indigenous communities.
And then let’s start and continue to address the many shades of substance abuse. I think this is huge. We often forget to talk about substance abuse and addictions along with what we are doing to ensure that our employees stay physically and mentally and emotionally healthy.
The last thing I would say is, as workplaces start to open up, think about employee wellness, which includes so much more than just your physical ability to get to work, or your physical well-being. The number one thing that we can do as a province is to really redefine health to include mental health permanently in all facets and all funding — and really prioritize access.
I want to tell you and everyone else, whether you’ve experienced or had a lived experience with mental health, or you’ve seen someone or known someone, you’re not alone. That really is the theme. Today, you can access mental-health supports and the important work our social workers do. There are ways to get access and get supports. Those things are readily available if you access them through a number of points.
I really do believe that the pandemic has opened up, if nothing else, some opportunity for innovative change that wasn’t available before. We have a chance to build not only on the digital tools we’re using, but also on the fact that, right now, everyone, probably for the first time, is united in wanting to recover from this. This was a collective experience, and we should build on it.
This interview has been condensed and edited for length and clarity.