Introduction

The mental health and substance use health (MHSUH) workforce is in critical demand [1], not least because of the widespread MHSUH challenges and needs exacerbated during the COVID-19 pandemic [2–8]. The pandemic heightened mental health concerns, social isolation, and financial stress while fuelling the pre-existing overdose and toxic supply crises [9–11], all of which can have serious and long-lasting MHSUH impacts [6,12]. These pandemic impacts have equity implications because they disproportionately affect key groups with higher risk factors, including women with younger children, people who live alone, those with a previous diagnosis of a mental health or substance use disorder, people who identify as 2SLGBTQ+, people who have a low income or are unemployed, and Indigenous peoples [7,13,14]. Adolescents and young adults with a history of adverse childhood experiences were also more likely to exhibit pandemic-related symptoms and stressors [15]. Access to virtual service delivery mitigated some of these impacts but remains highly variable and inequitable across the country in the absence of national service standards [16,17].

Key to addressing the growing gap in meeting service needs is the availability and accessibility of qualified MHSUH providers [18]. While the long-term impacts of the pandemic are still uncertain [12], there is evidence that MHSUH service needs are not being met. According to the latest data from Statistics Canada [19], half of the people who need MHSUH services have not talked to a health professional about their mental health in the past year. Almost two-thirds of people in Canada recently gave mental health services a failing grade regarding access, public confidence, satisfaction and effectiveness and 60% gave substance use health services a similarly poor grade [18].

A key factor impacting MHSUH workforce and service availability, accessibility, and quality is the effectiveness of workforce regulatory frameworks [20]. Regulatory frameworks can impact decisions regarding funding for services, including employment-based benefit plans, public health insurance, and direct public funding, affecting access to health care providers and their services [21]. In the broader health workforce literature, statutory regulation has been connected to optimizing the workforce [22–25]. Right-touch or risk-based regulatory frameworks have also gained momentum during the COVID-19 pandemic, focusing on matching the strength of regulation with the level of risk to the public in a way that does not create unnecessary barriers to practice [26–30]. For example, cross-jurisdictional licensing and registration requirements were loosened and scopes of practice of regulated providers in hospital settings were expanded as part of pandemic response measures [31,32].

In Canada, regulatory modernization efforts for the MHSUH workforce vary across the country and include, for example, statutory changes to regulation of counselling therapy in Nova Scotia [33], New Brunswick [34], and Prince Edward Island [35], and to psychotherapy in Ontario [36]. Alberta and British Columbia have advanced towards statutory regulation of counselling therapy and psychotherapy in 2024 [37]. Voluntary certification programs for the peer support and addiction counselling workforces have been developed in Canada, along with competency frameworks for the substance use health and psychosocial rehabilitation workforces [38–42].

This variable regulatory landscape for MHSUH providers in Canada can negatively impact equitable access to care and workforce mobilization. The inconsistencies in statutory regulatory frameworks, especially for virtual care, include variable practice standards for documentation and privacy [43,44]; confusing and uncoordinated reciprocal licensure and liability insurance requirements [45,46]; and new licensure categories specific to virtual care that only apply to certain MHSUH providers in certain provinces [47]. In addition to improving the availability and accessibility of MHSUH service providers regulated by statute, international literature identifies a need to improve the visibility, integration, and support for MHSUH providers that are not formally regulated [1].

Finding the appropriate regulatory framework that protects the public without undue barriers to practice for different MHSUH provider groups is a complex endeavour. Currently, occupational regulation in the MHSUH workforce exists on a spectrum from voluntary to statutory. While regulation is often narrowly associated with statutory regulation, for this study, we define regulation more broadly as the legal or occupational rules governing entry, membership, and conduct within these MHSUH service provider groups [48]. Within this broad definition, the main regulatory frameworks include voluntary certification, co-regulation, and occupational licensing models [49]. In voluntary certification, members join an association and agree to abide by rules of conduct and codes of ethics. The association may publish a register of members and operate a complaints mechanism, but the system is voluntary and not underpinned by statute [49]. While voluntary certification meets the broad definition of regulation used in this paper, some certification bodies may explicitly reject the notion of regulation, given the association with top-down government statutes. Co-regulatory models are similar to voluntary certification, but the certification functions offered by provider associations are delegated or recognized by government (for example, as an eligibility criterion for public funding). Occupational licensing or statutory registration systems are the most prescribed, referring to regulatory schemes with a regulatory body established through legislation and often including protected titles and scopes of practice. These various regulatory frameworks serve to mitigate risk through various functions, generally divided into ex ante functions (directed at entry to practice competencies and requirements, which may include specific education or academic credentials) and ex post functions (focused on addressing competence and conduct after entering practice, such as maintaining certification, setting standards, monitoring competence, and addressing complaints about providers) [50].

In Canada, there are wide variations in the regulation of the MHSUH workforce along this spectrum. Some provincial or territorial licensing models cover physicians, psychologists, social workers, and occupational therapists across the country, leaving uneven statutory registration of psychotherapists or counselling therapists and psychiatric nurses, and reliance (in part as a matter of preference, in part as a result of policy neglect) on voluntary certification models and competency frameworks for addictions counsellors, harm reduction workers, peer support workers, and psychosocial rehabilitation workers [38,39,51–54]. These regulatory differences complicate the provision of care, whether in person or virtually delivered [45,55], highlighting the critical need for flexible and nuanced frameworks across the country to support equitable access to MHSUH services. Such regulatory frameworks seem to be necessary to support growing trends in MHSUH reform such as provider diversification, appreciation for the role of the peer support workforce, more flexible scopes of practice, decriminalization, stigma reduction, integration and person-centred care, and parity with physical health [56]. These changes are all occurring in the context of a MHSUH system that has long faced gaps and inequities in public insurance coverage under Canadian Medicare [1,24,57,58].

This study gathered perspectives from a range of subject matter experts on two focus areas: (1) how regulation and potential regulatory reform impact the safety and quality of services, access to services, and the workforce; and (2) how flexible, modern regulatory reforms in the MHSUH workforce can facilitate more equitable access to MHSUH services. Our research was guided by our pan-Canadian advisory committee composed of leaders and subject matter experts from different sectors related to the MHSUH workforce, including those with lived and living experience. This research builds on our recent scoping review on regulating the MHSUH workforce, which aimed to identify promising practices for regulatory reform in this sector [1].

Methods

This study used an exploratory qualitative design [59]. We conducted interviews with subject matter experts recruited in consultation with our pan-Canadian advisory committee. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) [60] to guide the reporting of our methods and findings (see S1 Table, COREQ Checklist).

Results

We constructed four themes from the data: (1) the impact of policy exclusion, criminalization, and stigma; (2) gaps in regulation limit access and public protection; (3) the dynamic tension between standardization and flexibility; and (4) policies to support the integration of lived experience into the MHSUH and broader health workforce. These four themes underscore the need to re-imagine regulatory approaches for the MHSUH workforce in Canada in a way that makes room for the dynamic tension between standardization and protection of the public on the one hand, and flexibility and respect for the value of lived expertise on the other. A summary of themes and illustrative quotes are provided in Table 1.

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Table 1. Themes and illustrative quotes.

https://doi.org/10.1371/journal.pmen.0000168.t001

Discussion

Our goal in this research was to gather perspectives from a range of subject matter experts on two focus areas: (1) how regulation and potential regulatory reform impact the safety and quality of services, access to services, and the workforce; and (2) how flexible, modern regulatory reforms in the MHSUH workforce can facilitate more equitable access to MHSUH services. Two themes were identified in relation to the first research question: impact of policy exclusion, criminalization, and stigma; and gaps in regulation limit access and public protection. These themes identify how stigma and a legacy of exclusion have created gaps in public protection and uneven access to care across jurisdictions. Two additional themes were identified in relation to our second research question: the dynamic tension between standardization and flexibility; and supporting the integration of lived experience.

While all participants agreed about the importance of quality assurance and expanding access, we found a dynamic tension between calls for standardization to better protect the public and calls for flexibility to better support the lived experience workforce. Gaps in statutory regulation contribute to gaps in access by constraining the pool of MHSUH service providers that meet eligibility criteria for employment-based benefits and Medicare coverage. Gaps in statutory regulation also contribute to gaps in quality assurance, leaving many people living in Canada with limited recourse for unsafe MHSUH care.

These gaps in regulation, access, and protection are themselves shaped by policy legacies. Without full inclusion under Canadian Medicare, MHSUH services and service providers have been neglected in terms of funding and regulation relative to physical health care. This policy neglect has been compounded by stigma around mental illness and substance use disorders, and by a long history of criminalization of substance use and some mental illnesses. The decentralized health system under Canadian federalism [67–69] has also contributed to confusing variations in regulatory frameworks and constrained accountability for the quality of MHSUH services. While the variability in MHSUH regulatory frameworks reflects these Canadian policy legacies, it also reflects fundamentally different views of the roles of regulatory structures and processes for different kinds of MHSUH services.

Other societal factors are at play beyond these policy legacies, particularly regarding the dynamic tension between standardization and flexibility. The distribution of power, autonomy, and risk also shapes values in health care [70] and contributes to gaps in regulation, access, and protection of service users and providers, particularly when integrating lived experience and expertise into the MHSUH workforce. Risk management strategies may “obscure the value of risk-taking activities” [71] (p. 104). Under this paradigm, the autonomy of people living with MHSUH challenges is seen as particularly problematic, as both their capacity and morality can be called into question: “People with mental health needs become designated either as good/responsible or deviant/irresponsible” [71] (p. 179).

There are signs of progress in addressing the gaps and policy legacies we identified in our research. Alberta and British Columbia advanced toward statutory regulation of counselling therapy and psychotherapy in 2024 [37]. Peer support is increasingly integrated into MHSUH services, including in Canada, the U.S., the U.K., and Australia [56,72–76]. Public funding supports addiction counsellors and harm reduction workers, though under different models [54,77]. Voluntary certification programs for peer support workers and addiction counsellors exist in Canada, along with competency frameworks for the substance use health and psychosocial rehabilitation workforces [38–42]. The legalization of cannabis since 2019 has begun to ease the burden of criminalization [78].

Looking ahead, opportunities include the potential for all provinces and territories to regulate psychotherapy and counselling therapy, with five provinces already doing so and two more in progress. Emerging paradigms in substance use health and structural stigma could challenge existing norms and support flexible regulation, particularly for the lived experience workforce [79,80]. The Stepped Care 2.0 model of MHSUH system transformation [81], which distributes risk across providers and agencies, and the concept of right-touch regulation, which aims to balance regulatory intervention with the level of risk, may guide future reforms so long as emphasis is placed on not creating undue barriers to practice. This approach aligns with recent recommendations from the World Health Organization to first understand the social and environmental context when introducing, evaluating, or updating regulatory frameworks for health practitioners [82].

The findings from this study suggest that right-touch regulation requires a different approach for peer support workers and other MHSUH service providers who draw primarily on lived experience. A lighter touch may not work since these MHSUH service providers are employed across the continuum of risk (from outreach and health promotion to in-patient hospital settings to crisis response, including suicide prevention) [83]. Here, the critical consideration shifts to minimizing the unique barriers to practice for this workforce, given their unique contribution, while supporting self-governed regulatory approaches such as voluntary certification and competency frameworks. Co-regulatory approaches are also possible, to the extent that funders set out certification and competency requirements for peer support workers, harm reduction workers, addiction counsellors, and psychosocial rehabilitation workers. For example, certified peer support workers are increasingly recognized as eligible Medicare providers by state governments in the U.S., with support from the federal government [84].

In our study, participants suggested more disruptive approaches to quality assurance that warrant exploration, including using competencies as entry-to-practice requirements and having service users play a leadership role in evaluating the quality of services received. Participants also pointed to the need for workforce policies to protect MHSUH providers from harm following disclosure of lived experience (including harms for ‘hidden peers’ in occupations such as nursing and medicine that are regulated by statute) [85–87] and to promote fair remuneration and career advancement opportunities for the lived experience workforce.

Limitations

While this study captures a range of perspectives reflecting the broad and diverse MHSUH workforce landscape across Canada, these findings may not be transferable to MHSUH provider groups in different geographic, policy, and regulatory contexts. As this project focused on occupational groups that have limited or uneven access to statutory regulation, it did not include the full range of occupational and specialist groups that work to address MHSUH issues, particularly those with a longer history of statutory regulation (e.g., psychiatry, addictions medicine specialists, family physicians, nurses, psychology, occupational therapy and social work). Further, regulatory approaches for registered psychiatric nurses vary across the country in a manner similar to psychotherapy and counselling therapy, but were not included in the scope of this research [88]. Members of these other occupational groups may hold different perspectives on quality assurance.

Additionally, there is potential for researcher bias with the use of key informant interviews and our chosen participant selection and sampling strategies. Researcher bias may also come from three team members’ work as service providers and users in the MHSUH sector. Their unique experiences within their field and with regulation may have shaped their understanding of the data and its results. The potential for these biases was reduced through research team deliberations, advisory committee consultations, and rigorous analysis procedures. Moreover, thematic saturation was reached with our sample size [89]. Furthermore, while our use of qualitative description presents another limitation, the methodological flexibility it offered permitted us to explore issues related to regulation and quality assurance of the MHSUH workforce and describe what we found.

Future research

Future research could focus on evaluating the outcomes of regulatory frameworks, expanding this area of research to include competency approaches for entry to practice, peer-led quality assurance (e.g., service users leading evaluation of services), and distributing risk among different system partners to achieve the ‘right touch’ in regulation. Comparative research might examine and contrast regulatory structures related to MHSUH workforces in different countries to highlight the contexts with the most promising regulatory approaches. To capture the full range of perspectives across the MHSUH landscape, a wider canvassing of MHSUH service providers not included in this study could be included in future studies.

Conclusion

Regulation impacts the quality, availability and accessibility of the MHSUH workforce and the services it provides. Gaps in statutory regulation constrain the pool of MHSUH service providers that meet eligibility criteria for employment-based benefits and Medicare coverage and leave many Canadians with limited recourse for unsafe MHSUH care. Current regulatory frameworks reflect the impact of policy exclusion, criminalization of substances and stigma, and limited policies to support the integration of lived experience into the MHSUH and broader health workforce. Our findings indicate a need to re-imagine regulatory approaches for this workforce to accommodate the dynamic tension between standardization and public protection and support flexibility for lived experience providers and approaches to care. In addition to ensuring equitable access to MHSUH services and providers, re-imagined regulatory approaches are needed to address critical gaps in MHSUH workforce planning. There is potential for the concept of right-touch regulation to guide future reforms so long as not creating undue barriers to practice is emphasized along with matching regulation to the level of risk.

Supporting information

Acknowledgments

We thank members of the project advisory committee and study participants for graciously sharing their time and expertise. The authors also thank Colby Fraser for his research assistance.