OHS Canada Magazine

In Canada’s two-tiered mental health system, access to care is especially challenging in rural areas

Avatar photo

April 3, 2023
By The Conversation

Human Resources Mental Health Psychological Safety

(blacksalmon/Adobe Stock)

By Conor Barker, Mount Saint Vincent University; Krista C Ritchie, Mount Saint Vincent University; Sara King, Mount Saint Vincent University, and Veronica Hutchings, Memorial University of Newfoundland

Rural Canadians face mental health concerns to the same degree as their urban counterparts, but rural communities have less access to psychologists, and that access may be eroding. Psychologists can be found in the public system (for example, schools, hospitals, public health offices), but increasingly are choosing to work in private practice, in fee-for-service clinics.

Despite increasing discussion about investment into accessing mental health services, as trainers of psychologists, we are observing fewer psychologist positions and reduced focus on retaining psychologists within the public mental health system in Canada.

Not addressing these issues may have detrimental results for Canadians, such as:

  • receiving services from non-psychologists who may not have the needed expertise to address present mental health challenges
  • participating in a two-tier system where only those who can pay for mental health care can receive it; and
  • exacerbating these issues for rural Canadians.

Where is the public investment in Canadians’ mental health?

Problems retaining psychologists are particularly evident in rural regions, where issues like professional isolation, role confusion and burnout are contributing to a crisis in mental health care access.

Rural clinicians are reporting increased demand for mental health services. This might be quickly interpreted to signal a higher degree of distress rates. However, it might instead be a sign that there are not enough psychologists — let alone integrated inter-professional mental health teams — to meet rural Canadians’ needs.


In rural settings, specialized mental health services are often not locally accessible, particularly in terms of early screening, treatment, tertiary care, teletherapy, integrated health services and community approaches. All these approaches have been suggested by policymakers to improve mental health service access in rural spaces.

Access to needed services for all Canadians is central to the Canada Health Act. So where are they for rural Canadians?

While the Canadian government has announced billions in additional funding for mental health care and addictions, experts and practitioners acknowledge that the public system has not kept up with needs.

This leads us to ask: is mental health a responsibility of publicly funded health care, like a broken leg or cancer? Or has it fallen into a category of services that are necessary yet have limited coverage, such as dental care? The lines delineating what constitutes health seem arbitrary.

Sarah Kennell, director of public policy at the Canadian Mental Health Association, has stated, “We can no longer continue to view mental health as not on par with physical health.”

Investment is needed so that we can address the exodus of psychologists exiting the public system for private practice.

What is a psychologist?

Psychologists are experts in mental health and provide essential services in identifying and treating behavioural disorders and difficulties. In collaboration with physicians and nurse practitioners, both of whom can prescribe pharmacological therapies, best outcomes for mental illness treatment are observed when medications are paired with evidence-based psychological interventions.

Psychologists are a regulated profession requiring graduate training, clinical supervision and comprehensive examination to enter practice, and continuing professional development to sustain competency over their careers. Psychologists have at least six to twelve years of focused post-secondary training accredited by provincial boards that align with national standards for competent and ethical practice.

Within rural areas, psychologists may often be asked to provide a range of services that are beyond their training and expertise. This results in a rural practice of psychology that is generalist in nature, requiring rural psychologists to know a little about a lot.

Rural psychologists also need to work collaboratively with other health-care providers and mental health practitioners including counsellors, social workers and physicians. Noting of course, that these professions are also disproportionately allocated to urban settings.

In the public system, many psychologists are frustrated by a failure to appropriately distribute responsibilities between licensed psychologists, and other practitioners and counsellors with minimal training in therapy. That means resources are poorly deployed and people may not get a suitable mental health practitioner for their needs.

This results in fewer psychologists working in the public system and subsequently more opting to work in private practice.

Ultimately, this movement means that experts in mental health are accessible only to those who can afford them. Further, the private system tends to provide service in an out-patient setting to clients who are generally functioning in their day-to-day lives, whereas the public system serves a wider range including inpatient and high-needs care.

This exodus of psychologists from the public system results in a service-expertise mismatch, in that psychological care is more available to mild to moderate mental health concerns through private practices, and less psychological care is available for severe to profound cases within the public system.

Brain drain to Canada’s cities

Our team observes that these impacts are more directly felt within rural spaces in Canada. Rural citizens often find it difficult to access psychologists who work within the public system. Many psychologists have increasing wait lists, and are administratively forced into assessment-only diagnostic practice, preventing opportunities to provide direct therapeutic services. Once a diagnosis is made, counselling therapy is provided by less-trained practitioners.

Issues of isolation also impact the availability of psychologists in rural areas. This contributes to the burnout experienced by several rural psychologists, resulting in their leaving the rural or public system within five years of practice, further exacerbating the disproportionate prevalence of psychologists between rural and urban/suburban regions.

Our team is concerned the rhetoric of increased investment in mental health does not address the systemic issues impacting psychologist engagement in the public system. Ultimately, leaving these issues unaddressed may further erode both access and standard of care for those seeking mental health services, and limit services to those who are able to pay for them. Rural Canadians are already affected.The Conversation

Conor Barker, Assistant Professor, Department of Psychology & Faculty of Education, Mount Saint Vincent University; Krista C Ritchie, Associate Professor, Faculty of Education, Mount Saint Vincent University; Sara King, Associate Professor, Faculty of Education, Mount Saint Vincent University, and Veronica Hutchings, Associate professor, Psychology, Memorial University of Newfoundland

This article is republished from The Conversation under a Creative Commons license. Read the original article.


Stories continue below