Community-Informed Practice for Health & Well-being

This unique graduate specialization provides tools for social workers, practicing in mental health to critically question the current medically dominated, diagnostic view of mental health. 

Dr. Rick Enns, who leads this specialization, practiced in residential, psychiatric care settings for more than 30 years, and suggests that social workers may benefit from interrogating the dominant medicalized, diagnostic approach to mental health and incorporate a more holistic, community-informed approach to working with clients. 

Interview by Faculty of Social Work Communications Director, Don McSwiney 

Don McSwiney

So, first of all, can you explain what this the specialization is. What will people learn? And how would they apply that to their practice when they graduate?

Rick Enns

We thought there was a need for a mental health concentration that was significantly different from the way social work practice in mental health is often taught. There's a growing interdisciplinary or cross disciplinary critique of dominant, diagnostically driven mental health practice, and social work practice in mental health settings.

Diagnostic approaches are based on the idea that we take “patient” histories or client histories and make a diagnosis. And then treatment is really driven by the diagnosis. Some social workers are involved in the process in that way, and others aren't.

But if we practice in the area, we're certainly engaging with other professionals who center the diagnosis and with cases have been defined on those terms. So, we wanted to introduce and make accessible a critique of mental health practice, for master's-level social work students, and extend the invitation for them to consider what their practice might look like, if we incorporate critical perspectives in practice.

These anti-psychiatry perspectives might broadly be defined on a spectrum. There's a whole history of anti-psychiatry that sees psychiatry as a further or additional tool of colonization and marginalization. And there’s a continuum there. You can talk about critical psychiatry, which recognizes that the system is there, it's influential, it's likely there to stay. But our practices can be interrogated quite aggressively against this critique of diagnostically and medically driven models of intervention.

The impetus behind this is that many of our students come from a background of working in the mental health system, and have questions about the way that system works, and how we can, in some way, disentangle ourselves, or liberate ourselves a little bit from fully subscribing to the current, medically dominated view of mental health.

How far students want to take that critique for refashioning their own practice is up to them. Behind all this is a recognition that psychological and emotional distress is very real. So, it's not an attempt to suggest that this is all made up or that people aren't suffering in the way that they're suffering. But really, that this suffering, this anguish, is real. And because it is, I think it's incumbent upon social workers to critically analyze the way we engage; the way we practice in those settings and the way in which we engage with or challenge the dominant models of practice.

Don McSwiney

So, to unpack this a little, would community-informed practice involve a more holistic view of mental health? I recall a conversation with one of our researchers, Dr. Régine King who, in her research came across a woman whose children were a world away in a refugee camp. She was basically sleeping on a concrete basement floor and sending every penny she could to them. In that context, for example, it would not be surprising for a diagnostic mental health approach to, for example, prescribe anti-depressants, but not deal with the actual issue?

Rick Enns

That's a great example, and Régine was one of the faculty members who helped to develop the curriculum. And that's a great example because it contrasts a medical way of practicing that focuses on the individual outside of any contextual factors versus looking at what is the context for that individual.

It’s possible that if this woman had gone to a physician and reported how she's feeling, at that moment, in the office – a prescription for an antidepressant might be offered, or maybe a referral to a mental health clinic, where the prescription might be offered. And all of that proceeding without a good understanding of the circumstances. Circumstances that I think any social worker who works with someone like this woman would ask about.

We try to consider these contextual pieces and historical pieces. The challenge for us as social workers is how do we do that? Then how do we extract ourselves from the automatic, medicalized, treatment responses, which is diagnosis, often followed by some kind of pharmaceutical intervention – and social workers might be left with the task of encouraging or monitoring medication compliance; although they would also try to attend to the contextual pieces even if the treatment plan centered diagnosis and medication.

So that's a great example and leads to how the courses in the Community Informed Practice specialization are set up.

The first course is an introduction to this critique of mental health practice which can be critiqued on numerous levels, starting with the Diagnostic and Statistical Manual of Mental Disorders (DSM) and its claims of diagnostic reliability and validity; and the tortured history of the manual along with the political, social, and cultural influences and interests that permeate that document.

It's a clinical document but I argue in class that it's also just as much a sociological and political document. So, what happens when we begin to see it that way? There are many other critiques that we consider in that course as well.

The second course considers how social workers can take that critique into “assessment.” How do you foreground community? How do you foreground experience, including the push-pull factors of immigration, the history of colonization, the history of racism? How do you foreground that in your assessment? So that assessment is no longer just or only about taking a client history and making a diagnosis.

You know, assessment is something very different, so, to get back to your example, how do we really get to understand this woman’s situation when she's sleeping on that cold floor and sending money back to her kids?

While the first course is quite theoretical. The second course - the assessment piece - moves from the theoretical into the practice piece around assessment. Really challenging the idea or even the term assessment – as opposed to learning or getting to understand rather than “assessing”. How do we begin to change our terminology.

The last two courses focus on specific practice contexts within specific communities. What does culturally-situated, community-informed practice look like? For example, we’ve had Val Gervais, one of our strong sessional instructors has focused on indigenous and 2SLGBTQIA+ clients or practice settings in one of those courses, while the other course has primarily focused on racialized populations, refugees, and immigrants. And what does it look like if we liberate ourselves from the DSM and whole complex that has been built around that document? What does that look like? And if that practice community informed or community driven? What does community mean in that context? And sometimes community is a welcoming place, sometimes it's not. So how do we begin to look at what are our helping response should look like within the context of community.  And to critique that context.

I was thinking about what I might say today, and I don't want to overstate the case. But when I look at how we try to explicitly question the foundations of our practice, and question the things that we've always taken for granted – I think this certificate lines up really nicely with the faculty's efforts to move to inclusive and welcoming models of practice, and decolonizing practice and paying attention to equity, diversity and inclusion, and we try to operationalize those statements in the content.

Don McSwiney  

This certificate certainly feels uniquely rooted in social work values and should really help people working with, for example, vulnerable populations to inform their practice?

Rick Enns

Yes, I think so, and that's our hope. As we move from the theoretical discussion in the first course, the questions raised should be guiding us going forward. And even in that theoretical course the question is, what difference does that make in practice? The conversations we try to have are, ‘Okay, this is what I'm doing now. These are the assumptions that I have always made but now I'm aware of this substantial critique, what does that mean for me in terms of my practice? And changing my practice?’”

It's a practice-focused specialization that focuses on the skills around working with clients, either at the assessment stage or at the intervention stage. What does it mean for social workers?

I try to be careful in the first course to say that this doesn't mean that you have to come out of this specialization thinking in this way, you know? I want to be clear about my perspective on this.

I realize that this may be a journey for people and that, based on past experience, they may be receptive to this and want to look at how they can change their practice in response to this critique. Others might be more wary or more skeptical. Others might have situational or organizational constraints on how they can operationalize some of these ideas. Others may think, ‘No, I don't I don't agree with this. I'm not convinced.’ Or, ‘I think I'm doing better work or being more responsive by following conventional models.’

Another thing is that some of our students have gone through the mental health system and been diagnosed. That may have happened in the past, or it may have been very recent, and it may have been a very liberating thing for them to have a diagnosis. And they may feel that, if they've been prescribed medication as a result, that the medication has been very helpful.

So, so there's a need to, to have that conversation in a way that respects everybody's journey, and everybody's decision about where they're going to end up around this critical view of social work practice in mental health. You know, that at the end to respect those who say, ‘I hear you. But this is what I need to do. There might be a mix of personal and professional pieces going into that. And that's fine. I don't want to disrupt the way people may have navigated their own personal or family situations.

Don McSwiney  

Having said that, it seems to me that, if, for example, a client has medication for a condition like schizophrenia, could it really hurt to approach them from a culturally aware approach? I don't see how it could harm, by taking a holistic perspective.

Rick Enns

Even in that case, if you sort of stay within sort of a dominant cultural frame, if you look at the research conducted by the World Health Organization and other very reputable researchers that has shown that – over the long term – people who have been diagnosed with schizophrenia do better in in non-western countries – the majority of the world outside of that Western sphere of influence – where medications are often not readily available.

And it doesn't mean that that people's journeys through that illness or disruption, are any better or easier to navigate. But coming through it, one of the differences seems to be that our heavy reliance on medication and the longer term, cumulative debilitating effects that can come from the multiple and different medications over time – as opposed to going through that journey without the assistance of western systems – end up doing better. That’s not to romanticize, and say, ‘Oh, well, over in this country, these people are doing fine. That's not the case. It's a struggle there too. But over the longer term, to think about the possibility of recovery from schizophrenia. The data that shows that, that we don't have to think of schizophrenia as a lifelong, debilitating, degenerative kind of condition, that people do recover. Some of those recovery journeys are, through medication and careful work with medical professionals and the dominant system. However, others are outside of that, or recovery occurs when people decide to challenge the treatment that they're experiencing. So, there are different stories and different outcomes. And, at the very least, I think as social workers we need to be aware that these other stories are out there, and how do we reconcile them? Or how do we incorporate that into our own evaluation of our practice?

Don McSwiney  

Who might would really benefit from this? People working in mental health counseling who might want to inform their approach or get an entirely different perspective on the western approach?

Rick Enns

I think people working in not-for-profit organizations in the community, the resettlement or settlement sector, the community development sector, you know, working in the areas of, you know, addressing homelessness, or people involved in in community development, anti-racism initiatives … people working with Indigenous clients.

Years ago, I wrote a paper on what was called at the time, Regina Industrial School. The industrial schools were a precursor in terms of the agenda and the terminology to residential schools. Regina ran for 19 years starting in 1891. One of the reviewers came back and said, ‘Could you speak about the psychological and diagnostic consequences for students who had attended there?’ I saw that as their invitation for me to step back into the dominant psychological frame that would define other people's experiences in a way that was congruent with our view of the world.

I said that that was precisely the problem with the residential schools – that the government and the churches were trying to fit all the students into a very particular frame, that reflected western values and culture and didn't honor the Indigenous frame. So, to turn around and try to define the effects of that, in terms of, of Western notions and categories was just an extension of the attitudes and the efforts that were being made in the world, that were evident through the industrial and residential school systems.

I think for social workers need to think critically about what we're doing, and whether or not we're engaging in a different kind of colonization. You know, a variation of the impulse that was behind residential schools, in redefining the experience of Indigenous peoples and the possibilities of Indigenous peoples. This is similar to what we do when we try to impose a very questionable – I would argue – and certainly a contested psychological or diagnostic frame on individuals.

So, I’ve found in the classes, in this graduate specialization, and in other courses, even at the BSW level, there are always students who are receptive to a more radical critique around practice. Not just, ‘Well, how do we then address the shortcomings of the DSM?’  and this is how some students and people approach it. ‘Okay, well, it's not the best thing, but it's the only thing we’ve got. So, what can we do differently and sort of work with it?’   But other students are hoping for a conceptual and theoretical frame that helps them challenge that diagnostic, medicalized frame, and that whole set of assumptions altogether.

So, there were certainly some who were very receptive to that more radical critique, and, while I'm not sure where they're coming from, their perspective may be a result of many years working in the health care system.  When I came through the system, it was the Alberta Mental Health Board, you know?  Too many years of that.  Or maybe it comes from their work at the community level, and their frustrations and concerns – to use your earlier example of the mother sleeping on the cold floor –  about what might 

Don McSwiney  

You hinted at your background earlier. What did you do before you became a professor? What was your personal background that led you to help create this specialization?

Rick Enns

Well, there's the academic piece, and then there's the work-related piece. So, I did a joint honours degree at the University of Manitoba, in history and religion. And then after completing that, I did a master's degree in history, looking at the negotiation of treaty five in northern Manitoba. I probably would have gone on to pursue my PhD in history, but at the time, like a lot of our students, I was thinking, ‘What are the job prospects at the end of this?’ And sort of thinking ahead in that way. I decided, instead of doing a PhD in history, because of where I was working, to do a master’s of social work, again at the University of Manitoba, in family therapy. And then I did my PhD at the University of Alberta in educational psychology.

So, I mention that because I've never lost my primary passion for history and criticism. But during that time, I was working in residential, adolescent, psychiatric facilities. So, I started at the aide level in the early 1980s, at the St. Boniface Hospital in Winnipeg and then moved up to different positions through to 1991, when we moved to Alberta. When we moved to Alberta, I started working at Alberta Hospital Edmonton in the adolescent forensic psychiatry program – so, kids in trouble with the law, but also with the mental health piece. So, my practice experience has all been in residential care with adolescents, and psychiatric models of care.

So, from 1980 to 2000, so, about 20 years total working in residential care facilities that were driven by the psychiatric model. And when I talk about the history of the DSM, I tell the story to my students about when the DSM-III-R was released in 1987. So, the DSM-III came out in 1980, and it was meant to address all these questions around the reliability and validity of psychiatric diagnoses. And it was sort of a watershed when compared to the DSM-II.

And I remember working in a program at St. Boniface hospital the week that we were anticipating the publication of the DSM-III, and just how excited we were – a psychiatrist, myself, a psychologist and, you know, the whole the nursing staff – because we thought, ‘Okay, well, they've been working on this for seven years, it's got to be that much better… that much more acute, in its understanding.’ We weren't thinking in terms of validity or reliability, we just thought, ‘Okay, well, now we're going to be able to diagnose our kids even better,’ you know? And, ‘We're going to tweak the diagnosis just a little bit, and that will lead to much better care.’  It was sort of like Christmas morning, you know?  Everybody came, and we had one copy. Of course, it wasn't online or anything at the time, so, just one copy, and that was the psychiatrist’s, but we all ran and looked at it, and looked up our “favorite diagnoses.”

Then, you know, of course, the question was, ‘Well, so should we re-diagnose the kids in our program?’ When you think of it, over the long term, their diagnosis was inconsequential in some ways, but it was also very consequential. Because, certain medications tend to go along with certain diagnose – at least initially - so with a reformulation of the diagnosis, then, you know, ‘Oh, this person isn't depressed, they're anxious. Well then, instead of an antidepressant, we’ll give them an anti-anxiety medication,’ but they're often the same meds anyway!

So just seeing that, and participating in that, and then starting to think, ‘What's really going on here?’, You know?  And starting to read more critically in the area, until I eventually left and “took shelter” in academia.

We're really lucky as faculty to be able to speak about problems without having to confront them in the same way that I did when I was in practice, or that our students have to, on a daily basis. Because they are actively practicing and needing to create a space where they can consider this, but also manage it in a way that's best for them, but also aligned to their own ethical imperatives around practice.

Don McSwiney  

But, you would hope that this specialization might really help in providing additional tools.

Rick Enns

Yes, even if it compels somebody to ask that woman sleeping on the cold basement floor, ‘Well, what else is going on?’ You know? And, ‘what do you really need?’

Or just framing that whole experience in a different way, and doing that instinctively, and not as an adjunct to a referral and a diagnosis and whatever else might come. That maybe the first step is to is to consider how to address those situations. And not to suggest that everything is fine if some of the immediate needs are met, and then everything else will be okay. But, certainly, that's a different way of proceeding and prioritizing, I think.

Don McSwiney  

Thank you for this.