3.1 Characteristics of Included Academic Articles
More than half of the selected academic literature (59 percent; N = 29) focused on the United States (US), followed by Canada (20 percent; N = 10), Australia (12 percent; N = 6), ‘other’ (6 percent; N = 3) which had a multi-country focus, and a there was a single study from an OECD-European country (2 percent).
Mental health service providers as a general group made up the vast majority of providers discussed in the articles (36 percent; N = 18). The next most mentioned providers were psychologists (22 percent; N = 11), other/mixed (16 percent; n = 8), peer support workers (8 percent; N = 4) and social workers (8 percent; N = 4). Four provider groups (counselling therapists, clinical counsellors, psychotherapists and harm reduction workers) were the focus of one article each (2 percent each). Very little substance use health providers were noted explicitly in the literature.
The most frequently used method for included papers was qualitative, including policy analysis papers (30 percent; N = 15), those employing interviews (14 percent; N = 7) as well as those (18 percent; N = 9) adopting other qualitative methodological approaches (e.g., content analysis, reflection, multiple qualitative methods, etc.). The remaining articles were split between different methods (see Fig. 2 below).
3.2 Key Findings
We identified four key findings from our thematic review of the academic and grey literature on this topic: (1) a fragmented regulatory landscape and trends towards harmonization/standardization of regulatory frameworks across jurisdictions; 2) need to modernize training to improve equity in service provision; 3) the value of reducing regulatory barriers and enhancing interjurisdictional mobility; and 4) the need to improve visibility and integration/support for unregulated providers. In addition to these four themes, our review has also identified some leading innovation practices.
3.2.1 A Fragmented Regulatory Landscape and Trends Towards Harmonized Frameworks
The fragmented landscape related to the regulation of MHSUH providers in some countries impacts MHSUH service provision and equitable access to services. For example, the regulation of psychology varies across Canada, resulting in significant differences between jurisdictional licensure requirements (e.g., number of hours needed for licensure or types of training experiences) [9]. Additionally, Vandette and Gosselin [10] note inconsistent guidelines within and across professions that use clinical supervision for training and administration. Even though in some professions (e.g., psychology) clinical supervision has been well established as a professional competency, few standards or guidelines refer to clinical supervision as such; indeed, such standards have not been systematically or consistently implemented for supervisors, supervisors-in-training and trainees in the MHSUH workforce in Canada and within North America more broadly.
Another area where there are inconsistencies in regulatory frameworks is related to scope of practice variations and MHSUH workforce training across jurisdictions. For instance, in the US, some states have moved to allow psychologists prescriptive authority given that this may enhance the quality of services provided to individuals with psychological and behavioural disorders [11]. Also, in some contexts (e.g., US), jurisdictional regulations for peer worker training and credentialing requirements differ significantly [12], which can present challenges for supporting these providers in practice. Similarly, some Canadian scholars [13] note a lack of standardized training for MHSUH providers and recommend that provincial policies mandate core competencies for these workers, particularly in rural and isolated areas.
Some sources of literature reveal a trend towards simplification and harmonization of health workforce legislation and practice standards. In the UK, the current framework had been deemed inefficient [14], prompting calls for a single regulator to govern all regulated mental health and substance use health practitioners. In the case of Canada, the Cayton (2018) report called for modernization of healthcare regulation in British Columbia. This report catalyzed the current reforms in this province to reduce regulatory authorities from 20 to six [15].
The reviewed literature also identified cross-jurisdictional variation among unregulated MHSUH provider groups in Canada and the United States. However, for this particular sector of the MHSUH workforce, the variance of approaches may allow the sufficient flexibility needed in these distinct roles. Flexible approaches to certification of unregulated providers are recognized across Canada: for example, fourteen certifications in substance use and behavioural addiction are endorsed by the Canadian Addiction Counsellors Certification Federation [16] under a common framework. In the United States, state-to-state regulations for peer worker training and credentialing requirements differ significantly [12]. Beck et al. [17] identified 216 different credentials for addiction counselling specialists and 63 unique credentials for peer recovery specialists across the United States [18].
In some contexts, the trend toward harmonized competency frameworks for MHSUH workforce relates to an expressed desire for innovation and an increased interjurisdictional mobility which could be supported by the expansion of virtual care. For instance, in Canada, several organizations identified the need for policy development and service enhancement to address and mitigate the opioid crisis[19, 20] and noted the crucial role that cross-jurisdictional virtual health can play [20]. The Mental Health Commission of Canada [21] identifies potential in developing a National Telehealth Service like the one developed in New Zealand.
3.2.2 Need to modernize training to improve equity in service provision
The reviewed literature identified a need for additional training in areas not covered by the curricula of some training programs [22, 23]. For instance, specialized education and credentialing in substance use health services [22] was identified as one such need. Of required courses in the standard curricula of US social work programs, only 10 out of 210 schools (4.7%) had one required course with a focus on alcohol and other drugs [23]. Some more recent literature [24] suggests that previous findings of a deficit of explicit, formal substance use education in social work academics are true, concluding that there is “a high degree of need for the expansion and improvement of substance use education in a large proportion of MSW programs” (p. 311). Moreover, the results of one US survey suggest “a continued urgent need to train psychologists across subfields in foundational geropsychology competencies that all psychologists should possess to be prepared for the rapidly growing and increasingly diverse population of older adults” [25].
In addition to issues with curricula, identified gaps in training of MHSUH workforce (and especially those located in rural and isolated areas) also include the lack of mandated supervision across the career span of practitioners, a general lack of postgraduate support, and an insufficient number of satellite training facilities [13, 26]. Interprofessional collaboration is also an important source of practice support, especially in underserviced areas [26, 27]. In the context of psychology in Canada, training recommendations include formal teaching of interprofessional collaboration competencies as part of accreditation standard requirements for psychology programs and internships, including meaningful involvement of lived experience perspectives [26].
Additionally, the reviewed literature advocates for the establishment and provision of cultural competency training for MHSUH service providers [28–32] and its inclusion in accreditation standards [33]. One US study examining providers’ perspectives on barriers and facilitators to treatment retention among adolescents with substance use disorders noted the importance of implementing the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care [28]. Also, in their commentary that reviewed models to address diversity in mental healthcare in Canada, Kirmayer and Jarvis [33] argued that “cultural safety, competence and antiracism training need to be systematically incorporated into professional education and corresponding accreditation standards developed and applied to the governance of healthcare institutions and delivery of services.” (p. 19). Similarly, McCray and Rosenberg [31] called for establishing grant funding mechanisms to develop rapid and widespread cultural and clinical competency training for mental health providers in the US as a short-term response to COVID-19. They argued that such training should be implemented along with other changes (e.g., training Black, Indigenous, (and) People of Color (BIPOC) individuals as mental health providers, including peer supporters)).
3.2.3 The value of reducing regulatory barriers and enhancing interjurisdictional mobility
The COVID-19 pandemic has shown how relaxing certain licensing and regulatory rules can be beneficial in ensuring access to services [34]. For instance, in US, there were some pandemic induced changes to scopes of practice and staffing in SUD facilities (e.g., allowing supervised counseling interns to deliver telehealth counseling; permission for staff supervision (e.g., by medical directors or senior nurses) via telehealth)) [34].
In Canada as well as internationally, the pandemic response included temporary exemptions for prescribing controlled substances. For example, in Vancouver, Canada, restrictions were loosened on take-home opioid agonist treatments (i.e., methadone, buprenorphine, slow-release oral morphine) and while initiated before the pandemic, providers were encouraged to consider prescribing pharmaceutical alternatives to illegal substances to ensure a safer supply (e.g., hydromorphone tablets for consumption and not treatment of opioid use disorder), in line with promoting physical distancing [35]. Additionally, some regulatory bodies in Canada enabled licensed psychologists to support established clients who were temporarily unable to return to their home province without needing to acquire a license from the jurisdiction in which the patient was located [9]. Similarly, within some Canadian jurisdictions where counselling therapists are regulated, policies were developed to facilitate cross-jurisdictional service provision. For instance, the regulatory body governing counselling therapy in Prince Edward Island (PEI) developed a policy that allows a counsellor who is physically located outside of PEI, and who holds the counselling therapist title in another jurisdiction, to work with a small number of clients in PEI without registering in the province [36].
Some countries increased interjurisdictional mobility through legislative changes prior to COVID-19. For instance, New Mexico Senate Bill 105, which expedites the licensure of applicants already licensed in good standing in other US jurisdictions, was passed in 2016. All regulatory boards in the state have since been expected to review their processes and decrease administrative barriers for qualified clinicians applying from other states [37].
Some literature published before and during the COVID-19 pandemic recognized licensure standards and regulation as a barrier to the use of virtual MHSUH services [38–40], and has advocated for policy and regulatory changes to facilitate their use [39, 41, 42]. For instance, Brooks and colleagues [38] argue that limitations related to licensure (e.g., the requirement that virtual mental health providers must be credentialed in each hospital or clinic in which a patient is seen) greatly impede the use of virtual services particularly in post-disaster environments where there is a significant increase in mental health needs and a simultaneous decrease of mental health providers. Zhao et al. [40] similarly find that virtual MHSUH service adoption may be discouraged by the legal or regulatory burden for cross-state practice. To overcome regulatory barriers to virtual MHSUH provision, the reviewed literature highlighted certain reforms, including adopting telehealth-specific licenses, temporary licenses, reciprocity and endorsement, entering into compact agreements with other states (interstate compacts), licensure compacts [39]; establishing a national interstate licensure agreement, or creating exceptions for MHSUH virtual-based care [38, 39], as well as ensuring funding to train and equip providers to administer MHSUH treatment through virtual care provision [43]. Interstate legislative compacts, known as PSYPACTS, have been developed in the United States for psychologists [44] to allow them to help patients in other states and could offer a model to consider when imaging how registration and licensure functions (e.g., to facilitate mobility and virtual care provision) for MHSUH service providers could be harmonized across Canada. Indeed, changes to virtual MHSUH service provision regulation as a COVID-19 pandemic response were recognized as promising. Many countries (such as Canada and the US) had relaxed restrictions on virtual MHSUH service provision (e.g., restricting rules related to types of providers that can deliver substance use health services virtually, virtual MHSUH service reimbursement and locations where patients can receive services have been relaxed and suspended state/provincial licensing requirements for its delivery) [9, 43]. Some scholars (e.g., [43] have advocated for such changes to be permanent, given their efficacy in ensuring adequate access to MHSUH care for all.
3.2.4 The need to improve visibility and integration/support for unregulated providers
Some sources identified the near-crisis level need for more mental health services and providers [45, 46]. Yet, unregulated, under-regulated, and near regulated (including, counsellors, additions worker, peer support workers) provider groups are very rarely mentioned despite being a sizable workforce. The British Columbia Association of Clinical Counsellors identified 6000 clinical counsellors who have registered voluntarily [47] and would likely become regulated under new legislation [48]. In Alberta, there are 1279 clinical counsellors and addictions counsellors who are ready to be regulated [49]. While the urgent need for increased capacity in MHSUH services is frequently identified, most government mental health plans refer only to the regulated workforce (i.e., social workers, physicians, psychologists, and psychiatric nurses) [50–52].
Some literature we reviewed recognized the value of unlicensed or unregulated MHSUH providers in addressing MHSUH workforce shortages and improving capacity and access to services [12, 53, 54]. For example, Kunik and colleagues [54] suggest that effectively using non-licensed mental healthcare providers may result in the increased capacity of the mental healthcare workforce providing services to older adults in US context (p. 956). In addition to potentially improving cost-effectiveness by task shifting, “non-licensed providers from within a community may be able to reach patients traditionally less likely to access mental healthcare by developing trust through shared language, culture, and experiences" (p. 957). There is a growing international trend “to adopt peer support workers within addiction and mental health services” [55]. The lived experience workforce [56] and peer support workers [57, 58] were mentioned as resources that could be expanded upon in the future. However, some literature notes that peer support providers encounter boundary issues as their work intersects peer (non-clinical) and clinical support roles [12]. Indeed, the lack of role definitions and clarity for peer support workers is an important challenge faced by this segment of the workforce [12, 55].
3.2.5 Some leading innovation practices
To demonstrate these key findings, our review highlighted the UK, New Zealand and BC as exemplars in which systemic innovation has been achieved, contributing to more equitable access to mental health and social care. Often thought to embody regulatory excellence, the UK’s Professional Standards Authority for Health and Social Care employs right touch regulation involving a two-step risk evaluation process that aims to ensure that “the minimum regulatory force is applied to achieve the desired effect” [59]. In 2020, New Zealand enacted the Education (Vocational Education and Training Reform) Amendment Act which facilitated a proliferation of comprehensive training programs for support workers, or Kaiāwhina, which is the overarching term to describe non-regulated roles in the health and disability sector [58]. The pedagogy places Maori values at its core. The BC government recently committed to funding ten new Peer Assisted Care Teams; this initiative is supported by the Canadian Mental Health Association [60] and fortifies access to mental health services by pairing trained peers with lived or living experience with a Registered Clinical Counsellor, Social Worker, or Nurse. This innovation exemplifies the type of commitment needed to address the MHSUH workforce human resources crisis. This is of critical importance given the acute global shortages of MHSUH providers and unprecedented gaps in access to MHSUH services that have been exacerbated during the COVID-19 pandemic.