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INSIGHTS FROM THE FRONT-LINE: SOCIAL WORKERS
WORKING WITH CLIENTS WITH MENTAL HEALTH
AND SUBSTANCE USE ISSUES
by
Celena Christine Camps
Bachelor of Arts – Political Science, University of Victoria
Bachelor of Social Work, University of Victoria
MAJOR PAPER SUBMITTED IN PARTIAL
FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SOCIAL WORK
in the
School of Social Work
©Celena Camps 2018
UNIVERSITY OF THE FRASER VALLEY
Spring 2018
All rights reserved. This work may not be
reproduced in whole or in part, by photocopy
or other means without permission of the author.

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Approval
Name: Celena Camps
Degree: Master of Social Work

Title of Thesis: Insights From the Front-Line: Social Workers Working With Clients With
Mental Health and Substance Use Issues

Examining Committee:
Anita Vaillancourt, BSW/H, MSW, PhD
Faculty, School of Social Work and Human Services
MSW Chair

Leah Douglas, BSW, MSW, PhD, RCSW
Senior Supervisor
Faculty, School of Social Work and Human Services

Lisa Moy, BA, BSW, MSW, PhD, RSW
Supervisor
Faculty, School of Social Work and Human Services

Date Defended/Approved: April 12, 2018

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Abstract
For social workers that work with clients who have Mental Health and Substance Use (MHSU)
issues, this profession can be both very rewarding and very challenging. This paper examines the
experiences of front-line social workers in a Victoria, B.C., as these experiences relate to
working with clients with mental health and substance use issues. The role of Anti-Oppressive
Social Work theories and practices relevant to MHSU, and how they influence field-work, will
also be examined. For the purposes of this project, social workers were asked to participate in
both verbal and written interviews. As a result of the interviews, several common themes
emerged, including the stigma against mental health and substance use clients, Harm Reduction
strategies currently in use, and the importance of working from a Housing First philosophy. This
research provides valuable first-hand knowledge for social workers, other professionals who
work with MHSU clients, and the community at large.

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Acknowledgements
I want to thank Dr. Robert Harding (supervising professor at the University of the Fraser Valley)
for all of his support during this lengthy process.
Kara (with a ‘K’) Cunningham – Thank you for taking on the daunting task of editing my paper.
I am fortunate to have found someone who can edit my papers, whom I have also known for 30
years.
I also want to thank all of my co-workers who have given me words of encouragement
throughout this process. I work with a very compassionate and dedicated group of individuals
who are always willing to go “above and beyond for our clients.”
A special thanks to Jamie Godwin for being a “neutral third party” when I initially had to contact
people for interviews.
I also want thank the anonymous individuals for participating in the interviews. I am always
impressed with all of the dedication, compassion, and hard-work that social workers have
working in this field.
Most importantly, I would like to thank my family for supporting me through this process. I want
to thank my husband for all of his love and support. I also appreciate all of the time he has spent
reading what I have written, and his much-needed words of encouragements. I also want to thank
my kids, Arianna and Kaden, for their patience while I spent hours on the computer. I look
forward to having more fun time to spend with them. Finally, I also want to thank Shadow (our
beloved dog and Tasmanian Devil) for all of the hours she spent lying at my feet keeping me
company while I typed.

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Table of Contents
Title of Thesis: Insights From the Front-Line: Social Workers Working With Clients With
Mental Health and Substance Use Issues................................................................................ - 2 Abstract ...................................................................................................................................... - 3 Acronyms and Symbols ............................................................................................................ - 7 Literature Review ................................................................................................................... - 12 Models of Care in the Mental Health Field .......................................................................... - 12 Explanatory Models of Care – ............................................................................................... - 15 Housing First. .......................................................................................................................... - 15 Harm Reduction. ..................................................................................................................... - 15 Homelessness and the Impact on Clients With MHSU Issues ............................................ - 18 Task Force on Breaking the Cycle of Mental Illness, Addictions and Homelessness. ...... - 20 The Current Housing Situation in Victoria. ......................................................................... - 22 Theoretical Framework .......................................................................................................... - 24 Government Approaches to Treating with People with Mental Health and Substance Use
Issues in Canada...................................................................................................................... - 24 Medical Colonialism. .............................................................................................................. - 25 Deinstitutionalization.............................................................................................................. - 25 Neoliberalism and the Reduction of the Welfare State. ...................................................... - 28 The Stigma of Mental Health and Substance Use (MHSU) ................................................ - 30 Anti-Oppressive Practice (AOP) in Social Work ................................................................. - 33 Anti-Oppressive Social Work Practice and their connection to the Mental Health Field- 36
Design and Methodology ........................................................................................................ - 37 Anti-Oppressive Social Work Research (AOSWR) ............................................................. - 37 Data Collection and Interviews.............................................................................................. - 37 Ethical Considerations............................................................................................................ - 39 Limitations of the Study ......................................................................................................... - 40 Findings.................................................................................................................................... - 41 The Teams’ Mandates and Compositions ............................................................................ - 42 Community Resources Used to Help the Clients ................................................................. - 45 Language and Terms for the Clients ..................................................................................... - 46 Client Engagement and Building Rapport ........................................................................... - 47 Stigma towards Clients ........................................................................................................... - 48 -

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Housing First Approaches ...................................................................................................... - 50 Harm Reduction and the Overdose Crisis ............................................................................ - 52 Social Worker’s Success with Clients ................................................................................... - 56 Challenges for Social Workers .............................................................................................. - 56 Additional Services and Legislative Changes that Would Help ......................................... - 59 Conclusions .............................................................................................................................. - 62 -

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Acronyms and Symbols
ACT Team – Assertive Community Treatment Team
AOP – Anti-Oppressive Practice
AOSWR – Anti-Oppressive Social Work Research
BCSS – British Columbia Schizophrenia Society
CAMH - Centre for Addictions and Mental Health
CASH – Centralized Access to Supported Housing
Cool Aid – Victoria Cool Aid Services – Access Health Services
DSM V – Diagnostic and Statistical Manual of Mental Disorders Version V
IH – Island Health
MHA – Mental Health Act
MHCC – Mental Health Commission of Canada
MHSD – Ministry of Social Development and Poverty Reduction
MHSU – Mental Health and Substance Use
PSR – Psychosocial Rehabilitation
SPO – Social Program Officer
S2H - Streets to Homes Program
VATS – Vulnerability Assessment Tool

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Introduction
I have worked in the mental health field for 15 years in various capacities, and I have
spent the last ten years working as a mental health social worker (case manager). Professional
social workers have very complicated jobs that involve, among other tasks, balancing the needs
of their clients, managing caseloads, and fulfilling organizational responsibilities. Social workers
also have to adhere to the various policies and guidelines that are attached to their jobs. In a
typical work week, social workers help clients in various aspects of their lives, which can include
medical care, financial assistance, liaising with other professionals on the client’s behalf, and
working with housing staff, probation officers, and other government agencies.
The role of social workers in the mental health and substance use (MHSU) field
specifically is also very complex. The following information is from my own experience as a
mental health social worker within Island Health. Mental health social workers also need to have
a basic understanding of the various mental illnesses (i.e. Schizophrenia, Bipolar Disorder,
Mania, Depression, and Anxiety), and they must also be familiar with the symptoms of the
illness, medications, and their side-effects. If clients are really unwell, staff may also need to
prepare suicide risk assessments and other interventions. Unfortunately, some clients may need
to be hospitalized if they are a risk to themselves or others. As a result, social workers need to be
familiar with B.C.’s Mental Health Act (MHA)1.
1

The Mental Health Act is an important legislation in British Columbia that outlines when people are
deemed voluntary or involuntary under the MHA. In other words, if a person is deemed to be a threat to
themselves or others in the community, the MHA provides strict criteria for when they can be brought
into hospital for assessment by the police (at the discretion of the psychiatrists). The MHA also provides
strict parameters on how long a person can be deemed involuntary under the MHA, with a regular
review period.

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In addition, many clients with mental health issues also have substance use issues
(alcohol or drugs). The terms dual diagnosis, comorbidity and concurrent disorders are all used
to identify clients who have mental health and substance use issues. According to the CAMH
Centre for Addictions and Mental Health (2018) website,
concurrent disorders is a term used to refer to co-occurring addiction and mental health
problems. It covers a wide array of combinations of problems, such as anxiety disorder
and an alcohol problem, schizophrenia and cannabis dependence, borderline personality
disorder and heroin dependence and bipolar disorder and problem gambling (para, 1).
Furthermore, the CAMH website also states that “concurrent disorders are also sometimes
called: dual disorders, dual diagnosis (However, in Ontario, this term is used when a person has
an intellectual disability and a mental health problem.), and co-occurring substance use and
mental health problems“ (para 1).
In addition to the complexities outlined above, mental health issues can affect people
from all different backgrounds and mental health intersects with other identities/social locations.
In other words, mental health clients can also be transgendered, immigrants and refugees, and
individuals who are physically and cognitively impaired. Social workers can also link these
issues to Anti-Oppressive Practice (AOP), which helps connect individual oppressions and
barriers to structural issues and power dynamics such as racism, feminism, disability rights,
heterosexism, and Marxism (to name a few). Young (1990) argues that “racism, sexism, ageism,
homophobia, some social movements asserted, are distinct forms of oppression with their own
dynamics apart from the dynamics of class, even though they may interact with class oppression”
(p. 42). Furthermore, AOP makes the connections between social work practice and the broader
systemic issues and oppressions that people also deal with. Finally, the role of social workers in

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this field is further complicated when one works with clients who are also experiencing
substance use issues, poverty, homelessness, and a multitude of other barriers, often on a daily
basis.
As a result, working in this field is very complex and the work is constantly changing due
to clients’ individual needs and current mental health status (as well as mental health policies/
legislation and initiatives). As mental health social workers, we are providing ongoing
assessments of clients and adjusting our clients work as needed. For instance, clients who are
diagnosed with Bipolar Disorder may have Depression and or Manic phases. This can become a
very complex situation as the treatments and medications are different for each phase of the
illness. At the same time, mental health social workers are also helping clients with their
housing, education, financial and legal issues (to name a few). Therefore, mental illness adds
another layer of complexity to all of the other issue that other social workers address with their
clients.
Working as a Social Worker in the MHSU Field in Victoria
As discussed above, working in the MHSU field is very complicated. Throughout this
paper, I will be examining how might services to vulnerable populations with mental health and
substance use issues be improved to increase positive outcomes for clients? In particular I will be
examining the work of front-line social workers in Victoria and the strategies and approaches
that their respective agencies use. Curiosity about the social workers experiences is what led me
to this research project. I am curious about the roles of social workers in different agencies (e.g.
Island Health and non-profit agencies) and how this impacts their work. I am also curious as to
what the similarities and differences are for people doing similar work in this field. For the
purposes of this project, I interviewed six front-line social workers who work directly with

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clients who are considered the “vulnerable populations,” or the “hard to reach” populations. For
simplicity, I will be using the term social worker throughout this paper to refer to staff in social
work and similar positions.
Given my experience working with an Assertive Community Treatment Team (ACT)2 for
eight years, the Housing First mandate is something that I strongly believe in. Housing First3
emphasizes the importance of providing housing for people as the first step of the recovery
process. One of our primary responsibilities was to find and secure housing for our clients.
However, the reality of finding and maintaining housing for our clients is not as simple as the
research suggests. There are many barriers (individual, and systemic) that can make it difficult
for people to find and maintain housing. For instance, in Victoria the rental market is very
competitive, with high rents and low vacancies. This situation is further complicated for people
who are on income assistance as the majority of their income goes towards rent. Clients may also
have trouble searching for rental places (e.g. not having access to a computer) or having
difficulties getting to apartment viewings.
The opportunity to blend both my research interest and my work experience is
compelling. Gitterman (2014) argues that “social work academics must pay more attention to the
realities of social work practitioners who struggle daily with expanding caseloads, everincreasing time pressures to help clients whose lives are embedded in poverty, unemployment,
oppression, racism, homelessness and violence” (p. 921). The goal of this project is to learn from
the experiences of social workers in order to affect positive change. Using insights gleaned from
2

Assertive Community Treatment (ACT) Teams are a multi-disciplinary team that can provide intensive case
management supports to clients in the community. The best description of an ACT Team is a hospital without
walls. In other words, ACT Teams can provide all of the supports of a hospital setting in the community.
3
Housing First is a theory that advocates helping clients to find housing, regardless of where they are in their
substance use cycle. This is in direct contrast to previous models that emphasized clients had to be sober before
looking for housing. Housing First Models also utilize Harm Reduction strategies and intensive case management
supports (such as ACT teams).

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the interviews in this study, how might services to vulnerable populations with mental health and
substance use issues be improved to increase positive outcomes for clients?
Literature Review
Throughout the Literature Review, I will be reviewing some of the literature related to
working as a social worker with clients with mental health and addictions issues. The
information discussed will also be geared to working in Victoria specifically. Models of care in
the mental health field will be discussed. Social workers in the mental health field have to be
familiar with specific information including diagnoses, treatment plans, and the British Columbia
Mental Health Act. Explanatory Models of Care are also examined including: Housing First,
Harm Reduction, and Trauma Informed Practice. These models are also used to help wok with
vulnerable populations in the mental health and substance use field. All three of these models are
used by mental health professionals (social workers, nurses, occupational therapists etc). The
Literature Review will also examine the mental health, addictions and homelessness in Victoria
specifically. Some of the topics will include Mayor Alan Lowe’s Report on this issue and the
current housing situation in Victoria. This information will also provide a background for the
theoretical framework.
Models of Care in the Mental Health Field
Models of care are used to explain why mental health issues exist, and the best way to
treat these issues. The dominant models of care used within the mental health field are the
Medical Model and the Recovery Model. Davis (2014), defines the Medical Model as “a practice
used by physicians in the Western world, where through physical examination, diagnostic tests,
and patient history an illness is diagnosed, which then forms the basis for treatments that are
often very pharmacological” (p. 16).

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The Medical Model
Within the Medical Model, medications have a very important role to play. Having
worked as a mental health social worker and attended hundreds of psychiatrist appointments with
clients, I have witnessed first-hand the role of medications in the clients recovery process. On the
one hand, medications can help to reduce clients’ symptoms and stabilize their moods. On the
other hand, clients may experience side effects from their medications. As a result, due to the
changing nature of mental health issues, medications often have to be regularly adjusted at
doctor appointments. The role of assessments is another critical aspect of working within the
Medical Model. Davis (2014) argues that “an assessment provides the basis for a planned
intervention, whether the intervention is medical or involves some other life domain” (p. 322).
Finally, The Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM-5) is
another example of diagnostic tools used in the Medical Model. The DSM is an extensive
medical classification system used to diagnose patients with mental health issues.
There are many criticisms regarding the Medical Model. Goemans (2012) argues that
“the main danger of the biomedical model is that while we pretend that madness can be cured
with pills, we can conveniently ignore all the massive social problems within our communities,
which directly impact upon mental wellbeing” (p. 92). This is an important point, as the Medical
Model does not account for other structural barriers that may also affect the client. Goeman’s
observation is instructive, as medications are only a small part of helping people recover and
stabilize their mental health.
Criticisms of the Medical Model have led to the development of other models of care.
The Recovery Model is the other dominant model of care and is currently endorsed by the
provincial and federal governments. The Recovery Model is more holistic, and it looks at many

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aspects of a client’s care. Davis (2014) refers to the works of Schrank and Slade (2007) who
argue that recovery “is seen [instead] as a process of personal growth and development
overcoming the effects of being a mental health patient, with all its implications, to regain
control and establish a personally fulfilling, meaningful life” (p. 88). Hyde (2007) refers to
Ramon’s definitions of recovery which includes “the recognition of trauma, the concepts of hope
and the right to fail, the move to a strengths model and the inclusion of users’ self-agency” (p. 6).
This definition is important, as it is relevant to some of the explanatory models of care, which
will be discussed later in this section.
The Recovery Model
The Recovery Model has also encountered criticisms. Khoury and Rodriguez (2015)
argue that “social workers and other front-line workers implement policies after they have
trickled down various managerial levels. It is often they, along with service users, who stumble
upon problems with action” (p. 129). Khoury and Rodriguez’s point is significant because the
various policies, procedures, and best practices that have been developed at the managerial and
government levels have a direct impact on the practices of front-line staff. This is especially true
in large organizations, such as health authorities, where there is often a disconnect between how
policies are developed versus how they are implemented. However, it is often through direct
practice or implementation of the policies that the issues become apparent. For instance, some of
the policies that are implemented by Island Health (and other organizations) may not have the
intended consequences for the front-line work being done in the MHSU field. Finally, there is a
large antipsychiatry movement that disagrees with the medical model and the primary focus on
medications as the primary treatment for people with mental health issues.

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The Mental Health Act is an important piece of legislation that also impacts work within
the mental health system. In 2005 the Ministry of Health published the Guide to the Mental
Health Act. According to the Guide (2005), “the current Mental Health Act became law in 1964
and the legislation has been updated many times since then” (p.11). The MHA has very clear
provisions on how and when a person can be brought into hospital for assessment. If a client is
unwell, social workers can be involved in the process of bringing a client into hospital for
assessment. Once a person has been admitted into hospital on an Involuntary basis they have to
be assessed for mental health issues and safety by a Psychiatrist or Doctor (physician) before
they can be discharged. If a physician thinks that the person needs additional supports, they can
be admitted into hospital. Working in the mental health field, the MHA is an important piece of
legislation that is used to help clients who are a danger to themselves or others. In the following
section I will examine some of the issues related to mental health, addictions and homelessness
in Victoria specifically.
Explanatory Models of Care
Explanatory Models provide frameworks for dealing with specific issues as they relate to
the clients. Some of the Explanatory Models that are also used with MHSU clients include
Housing First, Harm Reduction, Trauma Informed Practice and Cultural Competency. Current
research delivers the very clear message that Housing First policies are an effective way of
helping homeless people (and those with concurrent disorders) find and maintain housing.
Housing First.
Housing First Approaches have several key components. Polvere (2013) states that one of
the goals of Housing First projects is to “provide opportunities for participants to choose and
access housing immediately, without requiring psychiatric treatment or sobriety as determinants

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of housing readiness” (p. 1). Proponents of Housing First argue that when treating mental health
and or substance abuse clients, the first priority should be to find stable housing for them. Once
housing is in place, clients and staff can start to work on other issues that are affecting their
clients. The Housing First Model also advocates that clients receive case management support.
Clients may be linked with an Intensive Case Management Team (ITM) or an Assertive
Community Treatment (ACT) Team. Polvere (2014) states that “these supports are aimed at
promoting community integration and improving quality of life and independent living” (p. 15).
Some of the services that the ITM or ACT may be involved with include finding and maintaining
housing, finances, medication management, vocational rehabilitation, and Harm Reduction
support. The Housing First Model is pivotal to the work being done with vulnerable populations
within the MHSU field in Victoria. This will be further discussed by the Interviewee’s in the
Findings section of this paper.
Harm Reduction.
Substance Use and the Harm Reduction Model is another important component of
working in the mental health system. The Harm Reduction model is the recognizes and accepts
that many clients also have addictions or substance use issues. The terms comorbidity or dual
diagnosis are often used to refer to the people who are struggling with both mental health and
addictions issues. The Mental Health Commission of Canada (2015) states that “the relationship
between mental illness and problematic substance use is complex. For some people mental health
problems can be risk factors for problematic substance use; for others problematic substance use
contributes to the development of mental health problems” (p. 13).
Harm Reduction on Vancouver Island. Hasselback’s definition of Harm Reduction is:
“reducing risk when risk behaviours continue. Service provision engaging without

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judgment/expectations. Often associated with substance use. Many other Harm Reduction
interventions: Seatbelts, Helmets, Condoms and other contraceptives” (p. 5).
British Columbia`s current Fentanyl Crisis underscores the devastating impact of illegal drug
use. This subject will also be addressed discussed by the Interviewee’s in the Findings section of
this paper.
The current Fentanyl overdose crisis that British Columbia is undergoing is also relevant
to the research. Tyndall (2017) argues that “British Columbia is in the midst of a public health
crisis, with 914 documented overdose deaths in 2016” (p. 89). Unfortunately many of the frontline staff working in this field have been directly impacted by the Fentanyl crisis. Tyndall states
that
There are myriad reasons and events that launch people into habitual drug use – trauma,
personal tragedy, injuries, sexual abuse, racism and mental illness to name a few. But one
thing is consistent – no one started using drugs to become isolated stigmatized, destitute,
and criminalized” (p. 89).
Tyndall also argues that Harm Reduction strategies “must be scaled up, including supervised
injection sites, low-barrier supportive housing, better access to primary-care based opiate agonist
therapy (OAT) and an expansion of prescription opioid programs” (p. 89). Finally, Tyndall states
that “our approach to reducing the death and devastating health consequences of drug use must
be based on engagement, social supports, housing, Harm Reduction and health care” (p. 89).
Hyshka (2017) also discusses Harm Reduction models and their implications within a
Canadian context. Hyshka discusses the impact that liberal and conservatives governments have
on Harm Reduction strategies. For instance, under the conservative federal government Hyshka
argues that “political hostility to Harm Reduction at the federal level meant that during the

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Conservative government’s 10 years in power, stewardship of Canadian Harm Reduction policy
fell almost entirely under the perview of the provinces and territories” (p. 2). Hyshka argues that
“the election of a new federal government in 2015 and a dramatic rise in overdose deaths in
multiple provinces and territories has made implementation of new Harm Reduction policies and
related services likely” (p. 2). Hyska also discusses the impact of external sources and pressures
on policy (e.g. Harm Reduction strategies). Hyska argue that “renewed interest in Harm
Reduction .. also reflects the influence of researchers, healthcare providers, advocacy groups and
organizations of people who use drugs who are pressuring government to significantly strengthen
existing Harm Reduction approaches” (p. 2).
Trauma Informed Practice.
Trauma Informed Practice is another theoretical lens that is also used within the MHSU
field. Uruquart and Jasiura (2012) helped to prepare a Trauma Informed Practice (TIP) for Island
Health staff. Uruquart et al defines trauma as” experiences that overwhelm an individual’s
capacity to cope” (p. 6). Some examples of trauma include: “trauma early in life, including child
abuse, neglect, witnessing violence and disrupted attachment, as well as later traumatic
experiences such as violence, accidents, natural disaster, war, sudden unexpected loss and other
live events” (p. 6). TIP can be used in a variety of different settings with MHSU clients. A lot of
the work that is being done by the front-line staff and social workers is helping clients to work
through the trauma and the impact on their lives. Throughout this research project, the impacts of
trauma were discussed by many of the staff in their front-line work with clients.
Homelessness and the Impact on Clients With MHSU Issues
Throughout the research for this topic, the issue of homelessness and the impact on
clients’ lives is a key factor. Gatez published an article for the Homeless Hub focusing on the

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costs of homelessness and other options to solve the problem. According to Gaetx (2012), “the
cost of homelessness encompasses direct costs, including shelters and services as we all indirect
costs .. such as increased use of health services, policing and the criminal justice system” (p. 3).
Gaetz also refers to work of Hulchinski et al (2009) and argues that “when homelessness
emerges as a problem, as it did in Canada during the 1980s and 90s, the first response is to
expand emergency services. This includes, for the most part, emergency shelters, day programs
and soup kitchens” (p. 4). Gaetz also discusses the health impacts for people who are homeless.
Gaetz argues that “homelessness incurs staggering health costs measured in terms of increased
illness, use of health services and early death” (p. 7). Gaetz also refers to Ambrosio who makes a
similar point. Ambrosio argues that “homeless men and women do not have “different” illnesses
than the general population. However, their living circumstances and poverty affect their ability
to cope with heath problems” (p. 7). Finally, Gaetz also makes the connections between
homelessness and incarceration (prison rates). Gaetz refers to a study by Kellan et al (2010),
arguing that their research “shows that 22.9%, or roughly one in every five prisoners was
homeless when incarcerated” (p. 10). Unfortunately, Gaetz further argues that “within the
general prison population, there is an even higher likelihood of becoming homeless after
discharge” (p. 10).
Keller, Goering, Hume, McNaughton, Campo, Sarang, Thompon, Vallee, Watson and
Tsembris (2014) also discuss homelessness and housing first strategies in Canada. Keller et al
state that “homelessness is a significant social problem that affects thousands of Canadians .. the
prevalence of mental health problems, physical health conditions, and addictions among
homeless people is extremely high” (p. 277). Keller also argues that ”homelessness among
individuals with mental illness represents a serious social inequity, as members of this group face

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multiple barrier (including racial discrimination, poverty and other systemic barriers) to stable
housing” (p. 277).
An-Pyng (2013) argues that “homeless individuals with co-occuring disorders (CODs) of
severe mental illness and substance use disorder are one ofd the most vulnerable populations” (p.
2). An-Pyng (2012) also discusses strategies for mental health clinicians who work with this
vulnerable population. First, An-Pyng states that practitioners should “ensure.. an effective
transition for individuals with CODs from an institution (such as a hospital, foster care, prison, or
residential program) into the community”. An-Pyng also provides concrete examples of how
practitioners can help clients to make a smooth transition between institutions. Some examples
that An-Pyng discusses include: “discharge planning, critical time interventions, motivational
interviewing, engaging clients early and allocating funds” (p. 3). Second, “increasing the
resources for homeless individuals with CODs by helping them apply for government
entitlements or supported employment”. Third, An-Ling emphasizes “linking homeless
individuals to supportive housing”. Finally, the fourth strategy is “engaging homeless individuals
in COD treatment” (p. 1). An-Pyng provides examples of COD treatments including: “assertive
community treatment, motivational interviewing, psychoeducation and counselling on illness and
Harm Reduction” (p. 6-7). An-Pyng’s article is important as many of the strategies that are
discussed in this article are also used by the teams and interviewees practicing in Victoria.
Mental Illness, Addictions and Homelessness in Victoria
Task Force on Breaking the Cycle of Mental Illness, Addictions and Homelessness.
Victoria is a small city situated on Vancouver Island. The downtown core has struggled
with meeting the needs of the business community, tourism industry and addressing poverty and
homelessness. In 2007, a lot of attention (both positive and negative) was focused on the issues

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of homelessness and the impact on the downtown core of Victoria. The mayor of Victoria, who,
at that time was Alan Lowe, set up a task force to address the issue and to research the impact of
homelessness, mental health and addictions. The final report, known as The Mayor’s Task Force
on Breaking the Cycle of Mental Illness, Addictions and Homelessness: A Victoria Model, was
published in 2007.
The Report stated that there were over 200 organizations in the Greater Victoria area
working to address the issues of homelessness, mental health and addictions:
Over 20 funding agencies already spend an estimated $76 million annually on housing,
mental health and addiction services to support them.” However, “by not addressing the
needs of the homeless people in greater Victoria, we are spending at least $62 million in
other services, such as policing, jails, hospital services, emergency shelters, clean up, etc.
(p. 3).
These figures are significant, as they illustrate the cost to various other systems (i.e. police and
hospitals) that accrue when homelessness is not adequately addressed. The report also found that
although Greater Victoria had numerous social service agencies, there was no united body to
help co-ordinate them. The Mayor’s Task Force (2007) also examined the impact of government
cutbacks on affordable housing. It noted the growing resentment of the public: “There is a great
deal of public frustration and anger about the public disorder, damage to private and public
spaces, chaos and violence in the downtown streets” (p. 6). The Report also criticized the legal
system for being ineffective: “The public and the police are frustrated by a legal and court
system that does not seem to provide effective tools to deal with criminal activity related to
drugs” (p. 6). Finally, the Mayor`s Task Force (2007) determined that contributing factors for the
rise of homelessness included “deinstitutionalization in the mid-1990s, and a lack of sufficient

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and appropriate community supports…” (p. 7). The ACT Teams in British Columbia were set up
to address the issue of community support for mental health and addictions clients.
The Current Housing Situation in Victoria.
In 2016, City Spaces (a consulting company in Victoria) also provided an in-depth review
of the current housing situation in Victoria. Numerous agencies were involved in the Process
Mapping including: BC Housing, Capital Regional District, Island Health, and the Greater
Victoria Coalition to End Homelessness. The City Spaces report also provides important
information on the current housing situation in Victoria, as well as an overview of the
Centralized Access to Supported Housing (CASH) program. As of May 2016, there are “a total
of 745 supportive housing beds” (p. 11). The Supported Housing Sites in Victoria are run by
Island Health, BC Housing, the Victoria Cool Aid Society, Pacifica Housing Society, the PHS
and Our Place.
BC Housing and Pacifica Housing are also involved in the Streets to Homes (S2H)
Program in Victoria. According to the City Spaces Report, the “S2H uses a Housing First
approach to move individuals who are experiencing cyclical homelessness directly into housing
in the private market through a comprehensive landlord support system” (p. 16). The housing
situation is further complicated by high rent and low vacancy rates in the rental market. The City
Spaces Report states that “the organizations that receive rent supplement funding say these are
too low to secure adequate affordable housing for their clients” (p. 16). The City Spaces
document is significant because it illustrates the current status of the lack of affordable housing
issue in the city.
The ongoing homelessness issue in Victoria finally culminated in tent City (October 2016
to July 2017). The issue of Tent City was also discussed by a couple of the interviewees which

- 23 -

will be discussed in the Findings section of this paper. Tent City was another issue that reflected
the ongoing problems of homelessness in Victoria. Due to the fact that this is a very recent issue
the information on Tent City is predominantly from Journalists and newspaper articles. Tent City
was a local example of the increasing homeless problems and lack of affordable housing in
Victoria. Tent City was a very controversial housing camp that set up on the grounds of the
Court House in Victoria BC. Most of the background information on Tent City was provided by
journalists and news coverage. According to Forget (2016), “tents started sprouting in October
2015 when a group of homeless Victorians discovered a legal loophole that allowed them to
camp on the lawn of the Victoria courthouse” (p. 8). Tent City remained for approximately a
year, with much controversy.
Victoria residents began to recognize that homelessness was a huge issue and needed to
be addressed. At the same time, there were many problems that arose from Tent City itself. In
December 2015, Woo stated that “in the past few days [Tent City] has seen a stabbing and fatal
overdose” (p. 1). Related issues resulted in two separate court cases as concerns about the
ongoing problems resulting from Tent City grew. Neighbours complained about damages to their
buildings and drug paraphanelia being left on their property. Residents also felt unsafe walking
by Tent City at night. There were also problems within Tent City including a drug overdose and
concerns about underage teenagers living there. Forget (2016) states that “after months of legal
wrangling, a July 5 court injunction authorized the provincial government to clear the camp. It
was demolished August 14, after alternate housing was found for its 300 residents” (p. 1). Since
the closing of Tent City (relocation), there have been several improvements to the housing
problems. Many groups of people worked together to find alternative housing sites for the Tent
City residents. Community agencies, the provincial government, Island Health Authority and

- 24 -

Greater Victoria municipal governments worked together to come up with housing options to
address Tent City.In 2015, the Capital Regional District (CRD) and the provincial government
both agreed to provide money ($30 million each) to address the housing problems in Victoria.
In the Theoretical Framework section, I will examine the roles of social workers in the
MHSU fields. I will also discuss Anti-Oppressive Practice and the implications for social
workers in the mental health and substance use field. Finally, I will examine the impacts of
Neoliberalism and the reduction of the welfare state and the direct impact on MHSU clients.
Theoretical Framework
The intention of this Literature Review is to demonstrate the complexities of being a social
worker within the mental health and substance use field, and to convey the importance of the
Housing First model in Victoria. In the Theoretical Framework, this information will be
expanded. In this section, I will initially examine the government approaches to treating people
with mental health and substance use issues. Some of the topics covered include: Medical
Colonialism, deinstitutionalization and the Neoliberalism and the reduction of the welfare state.
Once this political framework has been discussed I will examine the impact on clients and social
workers in the mental health and substance use fields. I will discuss the stigma that pervades the
MHSU field and the direct impact on clients. Finally, I will discuss Anti-Oppressive social work
Practices as this relates to working in the MHSU field. The Literature Review and Theoretical
Framework will the lay the foundation for the Findings section of this paper where the results
from the interviews will be examined.
Government Approaches to Treating with People with Mental Health and Substance Use
Issues in Canada

- 25 -

In this section, I will provide an overview of Canadian government responses to working
with people with mental health and substance use issues. As social workers often our work is
directly or indirectly affected by government strategies, legislations and funding. The
government approaches also provide a historical overview of the changes that have occurred in
treating people with mental health and substance use issues in Canada.
Medical Colonialism.
Medical Colonialism, which is clearly manifest in the historical “asylums” in North
America. Roman, Brown, Noble, Wainer and Young (2009) discussed the Medical Colonialism
that existed at the Woodlands School (Victoria Lunatic Asylum from 1859-1872). The
Woodlands School originated in Victoria, and then it was relocated to New Westminster, British
Columbia. Roman et al. provided an overview of the horrific treatment of individuals in the
prisons and “Asylums” of the 1800s: “the colonization and segregation of First Nations people in
residential schools also involved judges, doctors, and psychiatrists confining those deemed as
medically or psychiatrically “unfit” whether First Nations or not – to asylums and hospitals” (p.
18). Roman et al. illustrate the role that professionals played in perpetuating the evils that
occurred in asylums and residential schools. This troubling history is also a reminder of the
importance of being conscious of the power that comes with professional roles, and our
responsibility to us that power to help society, especially its most vulnerable members.
Unfortunately, medical colonialism has contributed to the negative perceptions of the
MHSU system that still persist today. When people think of the mental health system in Canada,
they may conjure up images of large psychiatric institutions or asylums of yesteryear. The term
“asylums” is a very negative one, and further contributes to the negative stereotyping and stigma
of the mental health system. Davis (2014) makes a similar observation, stating that “the word

- 26 -

‘asylum’ now has a strong negative connotation although part of this may be a reaction to the
physical image, sprawling red-brick buildings with high ceilings, long hallways, and large
dormitories” (p. 194). Popular culture further perpetuates negative images of asylums with
movies such as “Shutter Island" with Leonardo DiCaprio. Modern psychiatric facilities are much
less oppressive then the ones in the movies. For instance, the Seven Oaks Tertiary Mental Health
Facility in Victoria is located on 20 acres at the base of Mount Doug (a local park).
Deinstitutionalization and the Closing of the Asylums.
The asylum era provoked numerous and valid criticisms of the treatment of the mentally
ill and led to the closing down of the large asylums in the 1960-1980s. Deinstitutionalization is a
term that describes the process of closing down these asylums and transferring mentally ill
patients into community-based settings and tertiary care facilities. Jutras (2017) also discusses
some of the factors that impacted the deinstitutionalisation movement. Jutras (2017) argues that
some of these factors included ``the advent of antipsychotic drugs and the recognition that mental
health expenses could be reduced by using community-based outpatient settings in favor of
inpatient care in psychiatric hospitals`` (p. 87).
Livingston, Nicholls and Brink (2011) also discuss the impact of deinstitutionalization in
British Columbia. Livingston et al argue that
deinstitutionalization is a multicomponent process involving shifted resources (that is
funding), reduced service capacity of psychiatric hospitals (for example beds and
staffing), increased capacity of general hospitals and alternate facilities to provide
psychiatric care, increased capacity of community-based psychiatric services,
decentralization of psychiatric services and resources and reduced reliance on long-term
psychiatric hospital care” (p. 200).

- 27 -

Livingston also makes the observation that “significant problems were produced by early
deinstitutionalization reforms when the contradiction of traditional institutional psychiatric care
outpaced the expansion of community-based services and supports” (p. 200). Furthermore,
Livingston argues that “it is generally recognized that a small subset of people with severe and
persistent mental illness will continue to require access to tertiary-level, hospital-based
psychiatric care” (p. 201).
Unfortunately, the process of downsizing did not go as well as original planned. The
deinstitutionalization process had long-term negative effects on clients, and the repercussions are
still visible today. Many former patients of the institutions did not receive the community-based
psychiatric supports that they needed once they left the institutions. Jutras (2017) argues that
“throughout Canada, the increase in community-based mental health services has not kept pace
with the closure of the psychiatric hospitals contributing to problems of homelessness and crime
among many sufferers of mental illness” (p. 88). Jutras also provides the example of Riverview
Hospital which was closed as a result of deinstitutionalisation. However, due to ongoing public
pressures and recognition that some clients benefit from psychiatric institutions that respect their
rights and afford humane treatment, Riverview Hospital will be re-opening in 2019.
Postmodernism and the Critiques of Modern Democratic and Capitalist Societies
Postmodernism is one of the foundations for anti-oppressive practice. Caputo, Epstein,
Stoesz and Thyer (2015) discuss the importance of postmodern thought and its impact on the
social work profession. Caputo et al discuss the origins of postmodern thought during the
Enlightenment. As capitalism and democratic societies developed, there were unforeseen social
and political issues that arose which Postmodernists questioned. Caputo et al. (2015) argue that
“the spectacular achievements of democratic political institutions, market economics, and

- 28 -

industrial technology during the 18th and 19th centuries were not without economic and social
costs that lingered well into the 20th century” (p. 639). Furthermore, Caputo et al. (2015) state
that “Postmodernists, to their credit in our view, implicated the grand narrative of social progress
in the modern era with a host of perverse outcomes, among them colonialism, global capitalism,
exploitation of peoples of color, and dehumanizing technology” (p. 639).
Postmodernist critiques of society are an important aspect of Anti-Oppressive Social
Work Practice. Caputo et al (2015) further argue that “broadly skeptical of established
institutions, their agents, and explanatory accounts of how the world works, postmodernism
offered the disenfranchised groups license to invent their own versions of events to legitimize
their experiences” (p. 640). Throughout the theory section of this paper, some of these
Postmodern critiques will discussed in terms of their relationship to MHSU clients specifically.
As a social worker, one must also examine the impact of government decisions and how this
impacts our work. Rush and Keenan (2014) examine Anti-oppressive social work practices
within the context of welfare states. Rush et al (2014) argue that “the social politics of social
work are related to the welfare regimes in which they are embedded” (p. 1436). Keenan points
out that “these welfare contexts enable and constrain the manner in which social work is
practiced” (1436).
Neoliberalism and the Reduction of the Welfare State.
Another focus of AOP is neoliberalism and the reduction of the welfare state. According
to Baines (2011), neoliberal governments “promote policies that expand opportunities for
businesses and corporations to increase their profits while simultaneously shrinking the funds
available for human services” (p. 29). Baines also defines the welfare state as “a series of social
programs and policies aimed at reducing inequity through redistribution of goods and services

- 29 -

and correcting for the inequality of the private market to provide sufficient good employment”
(p. 29). This reduction of the welfare state, along with reduced government support, has also
resulted in increasing poverty, homelessness, and other social problems for people in the MHSU
field. As previously discussed there is an increasing number of homeless people in the urban
centres in British Columbia. There are a number of reason for this situation. However, lack of
affordable housing in British Columbia is one contributing factor.
Rush and Keenan (2014) also examine the evolution of anti-oppressive social work
theories which differ on “practice ideologies” (p. 1438). Rush et al also make the connections
between the decline of the social work profession and the rise of neo-liberalism. Rush et al argue
that “Muncie’s critique of neo-liberalism from a social work perspective traces the contemporary
demise of social policy and social work’s influence all the way back to theories of economicliberal critiques of welfare state interventions” (p. 1447). Furthermore, Rush et al argue that “the
idea that neo-liberalism has been undermining post-Second World War welfare states as a social
settlement between capital and labour since its very inception is not confined to social work
debates” (p. 1447). Finally, Rush refers to the works of Dominelli (2010) who “suggests that
social workers have bene slow to theorize the impact of neo-liberal globalization, despite having
front line experience of the impact of neo-liberal policies and despite the major challenges that
neo-liberal policies pose for social work practice through increased unemployment and
migration” (p.1448).
I will also briefly describe the evolution of Social Housing in Canada to give an example
of Neoliberalism and the impact on government services. At the federal level, social housing
policy was a focus of government policies from 1964-1978. Beginning in the 1980s,
conservative ideology took over from liberal ideology and there was a move to reduce the federal

- 30 -

deficits. Consequently, the federal government began to implement cutbacks on social programs
(including housing). Mah and Hackworth (2011) argue that in 1993, there was a push by the
federal government to reduce their deficit. As a result, “federal subsidies for many programs
were cut.” Social housing programs were also affected by the new budget cuts (p. 58). Mah
(2011) concludes that the costs of social housing was ”downloaded to the provinces, which then,
with the exceptions of Quebec and BC, subsequently downloaded that responsibility to the lessfiscally capable municipalities” (p. 58). In terms of timelines, the cuts to social housing occurred
after the process of deinstitutionalization. In other words, less services and funding was available
when mental health clients needed the supports the most.
As government services and supports have been reduced for mental health clients, there
has been a direct correlation in the increase of social problems that clients are experiencing.
This is evidenced in two specific ways: (a) the impact of deinstitutionalisation on clients, and (b)
the increase in poverty and homelessness for clients. As a result, there is a growing population of
clients deemed “hard to reach” that have emerged. Many of these clients may have mental health
issues, addictions issues, poverty, and lack of adequate housing. At the same time, there has also
been an increase in homelessness in large urban centres in British Columbia. One could question
whether or not this is also linked to the reduction of the welfare state and cuts to social services
and affordable housing in British Columbia. In the next section of this paper, I will discuss the
research process and the results of the interviews. The interviews also bring together many of the
issues discussed above including: stigma, Housing First, and Harm Reduction strategies.
The Stigma of Mental Health and Substance Use (MHSU)
The complicated roles that social workers have within the mental health and substance
use (MHSU) field need to be addressed. Before delving into the roles of mental health social

- 31 -

workers, it is important to examine the stigma that pervades the mental health system—against
clients, professionals, and the system as a whole. According to Davis (2014), stigma is defined as
“the negative beliefs and attitudes held about mental illness, which can lead to public prejudice,
stereotyping and discriminatory behaviors” (p. 60). Unfortunately, stigma directed towards
people with mental health issues, and the MHSU system in general is huge issue. The topic of
stigma was evidenced throughout the interviews which I will discuss later in this paper. Davis
also refers to research by the Canadian Mental Health Association (CMHA) outlining some of
the negative perceptions about mental health clients:
The most common of these beliefs were that people with mental disorders are dangerous
or violent, lack intelligence, cannot be cured, cannot function or hold a job, are lazy and
lack willpower, are unpredictable and cannot be trusted, and are to blame for their illness
and should ‘shape up’ (p. 60).
Tu and Cole (2017) also discuss the problems surrounding stigma against clients with
substance use issues. Tu uses the term “people who use drugs (PWUDs) (p. 1). Unfortunately,
people who have substance use issues are further stigmatised by the general public. Tu and Cole
argue that “substance use disorders are more highly stigmatised than other health conditions as
society generally considers drug use to be a “choice” and repeated use to be a result of poor “self
control” (p. 21).
For people with a mental illness or substance issues, stigma can have an impact on many
different aspects of their lives. Corrigan (2003) argues that clients with mental illness may
“perceive themselves as being stigmatized by others, expect to be treated poorly by the public
because of this stigma, and suffer demoralization and low self-esteem due to the internalization

- 32 -

of the stigma” as cited in Davis text (p. 60). Stigma can also be felt when trying to look for work,
apply for housing, or even dating.
Finally, the stigma against the mental health system extends to professionals as well.
Bailey (2011) argues that “there is a reduced status associated with being a MSW when
compared with colleagues from other disciplines” (p. 113). This issue also ties into the
legitimacy of social workers within the Medical Model. For instance, there is often pressure on
social worker to prove why they are needed in the mental health system versus nurses.
Fortunately, this pressure has subsided over the years, as the roles and responsibilities of social
workers have become more defined. For instance, Island Health has undergone an extensive
South Island Review in Greater Victoria, which was a systematic overview of the entire mental
health system. This has resulted in role clarification throughout the system including the roles of
social workers (and Social Program Officers). The role clarification has also helped to ease the
tensions and competing interests of various disciplines (i.e. at the inter-discipline MHSU office
where I currently work).
The Provincial Health Services Authority (PHSA) wrote an article on “Respectful
Language and Stigma Regrading People who use Substances”. The PHSA article (2017)
provides an overview of the impact of stigma on clients with substance use issues in particular.
The PHSA states that ”substance use disorders are more highly stigmatized than any other health
conditions as society generally considers drug use to be a “choice” and repeated use to be a result
of poor “self-control” (p.1). Furthermore, the PHSA argues that “the negative attitudes towards
drug use are further ingrained by in the law where illegal drug use is a criminal offence” (p. 1).
The Provincial Health Services Authority also provided some suggestions on how to
combat stigma in their article. The PHSA article (2017) states that “stigma is a societal, cultural

- 33 -

and moral process, and therefore undoing stigma takes time and a concerted effort from all
stakeholders” (p. 2). The PHSA article also refers to Broyles, who recommends four guidelines
“on using non-stigmatising language:”
1. Use ‘people first language’ (referring to the person before describing his or her
behavior or condition)
2. Use language that reflects the medical nature of substance use disorders and treatment
3. Use language that promotes recovery
4. Avoid slang and idioms (p. 2)
The PHSA article provides useful guidelines that social workers and professionals can use to
help combat the stigma against clients with substance use issues. This topic will also be
discussed throughout the interviews.
Anti-Oppressive Practice (AOP) in Social Work
In this section, Anti-Oppressive Practice will be examined, as well as its connection to
the MHSU system itself. Rush and Keenan (2014) discuss the roles of social workers and antioppressive practice. The international definition of social work is commonly referred to. In July
2000, the international Federation of Social Work (IFSW) adopted the following definition of
social work,
The social work profession promotes social change, problem solving in human
relationships and the empowerment and liberation of people to enhance well-being.
Utilising theories of human behavior and social systems, social work intervenes at the
point where people interact with their environments. Principles of human rights and
social justice are fundamental to social work” (p. 1438).

- 34 -

Finally, Rush et al makes the connection between anti-oppressive practice and modern
welfare state. Rush et al refer to the works of “Singh and Cowden’s promotion of the concept of
social workers ‘as transformative intellectuals who do not succumb to power, but engage in
uncovering, confronting and resisting power” (p. 1450).
AOP is a broad topic that incorporates various social work theories and practice skills.
Both Baines (2011) and Young (1990) provide thorough overviews of Anti-Oppressive Practice.
The concepts of power, oppression and social justice are central to AOP theory. AOP helps link
individuals and their experiences of oppression, to broader groups and social movements. Young
(1990) argues that “Racism, sexism, ageism, homophobia, some social movements asserted, are
distinct forms of oppression with their own dynamics apart from the dynamics of class, even
though they may interact with class oppression” (p. 42). There are several other experts who
have examined the concept of oppression as it relates to anti-oppressive social work. Oppression
can be experienced on both the individual and structural levels. Baines (2011) defines the impact
of oppression on individuals and groups of people as a process:
Oppression takes place when a person acts or a policy is enacted unjustly against an
individual (or group) because of their affiliation to a specific group. This includes
depriving people of a way to make a fair living, to participate in all aspects of social life,
or to experience basic freedoms and human rights. It also includes imposing belief
systems, values, laws, and ways of life on other groups, through peaceful or violent
means (p. 2).
Baines point is that oppression can have an impact on many areas of peoples’ lives, and he
provides strategies to work with clients from different backgrounds.

- 35 -

Another focus of AOP is overcoming structural oppressions. Young (2000) further argues
that structural oppression
refers to the vast and deep injustices some groups suffer as a consequence of often
unconscious assumptions and reactions of well-meaning people in ordinary interactions,
media and cultural stereotypes, and structural factors of bureaucratic hierarchies and
market mechanisms … the normal processes of everyday life (p. 41).
This type of oppression becomes embedded into our political systems, government agencies and
political and cultural institutions. Young (2000) also argues that “we cannot eliminate this
structural oppression by getting rid of the rulers or making some new laws, because oppressions
are systematically reproduced in major economic, political and cultural institutions” (p. 41).
This view of oppression is important when one thinks about the all of the barriers and
stigma that clients with MHSU issues encounter on a daily basis. The stigma that clients with
mental health and substance use issues face on a daily basis is an example of this structural
oppression and is reinforced in many different ways. For example, the struggles that clients face
around homelessness, lack of affordable housing and treatment by other professionals. This
underlying structural oppression that MHSU clients face will also be further discussed in the
interviews from the front-line social workers.
Finally, one of the main focuses of AOP is to reflect on our own identities, and our own roles in
perpetuating privilege and oppression. In her article, The Matrix of Domination, Fay (2011)
describes the issue:
One’s socio-economic position in the matrix of domination confers power and privilege
in direct relation to the number of dominant positions one holds. White, Anglo, middle-

- 36 -

class, heterosexual, able-bodied people have a lot of power and prestige that is largely
invisible and gets taken for granted (p. 69).
Anti-Oppressive Social Work Practice and their connection to the Mental Health Field.
As discussed previously, AOP is a broad umbrella term that incorporates several other
theories (Postmodern Theories). As previously discussed, Young (1990) and Baines (2011) both
provide overviews of Anti-Oppressive Practice which I have discussed throughout this paper. I
will also discuss their theories more thoroughly later in this section. Some of the theories related
to AOP include feminism, Marxism, disability rights, indigenous theories, antiracist and colonial
theories, and queer theories, to a name a few. When working in this field, one engages with
clients of all different backgrounds, ethnicities, and abilities, etc. As a result, social workers are
constantly applying different lenses depending on who they are working with at that time.
As I went through the process of researching this paper and conducting the interviews I
noticed that people are using AOP practices consistently without even acknowledging this
framework. At the same time, the daily struggles that client with MHSU issues face (such as
poverty and homelessness) can take precedence over other issues. For instance, much of the
work of social workers in this field involves helping clients meet their basic needs such as
housing and food, as well as addressing their mental health and substance use issues.
The purpose of this section is to explore the numerous theories that have an impact on the
mental health field, and how they affect social work. There is a great deal of information on
Housing First and Harm Reduction theories available, including numerous articles that address
working with Indigenous and Aboriginal populations specifically. However, there were only a
couple of articles that connected queer theories and MHSU clients. It is important to note this
gap, because although the front-line workers referenced in this paper focused on the issues of

- 37 -

Harm Reduction and Housing First, it must be noted that clients may also be facing other
challenges.
Design and Methodology
Anti-Oppressive Social Work Research (AOSWR)
Anti-Oppressive Social Work Research (AOSWR) takes the principles of AntiOppressive Practice (AOP) and directly applies the principles to social work research. Strier
(2010) argues that anti-oppressive social work aims to change the structure and procedures of
service delivery through macro-systemic changes at the legal and political level” (p. 858). This
analysis has been expanded to include social work research methods. In other words, it strives to
ensure that social work research itself is not “oppressive.” According to Strier (2010), “the quest
to liberate social work research from oppression is based on the assumption that any intervention
or research project, regardless of its benevolent and progressive nature of its goals and intentions,
may replicate the structural conditions that generate oppression” (p. 859). Throughout the
research process I have tried to use Anti-Oppressive Social Work Research principles.
Data Collection and Interviews
There is actually very little research on the role of social workers and front-line staff who
work in the mental health field, and most available information is predominantly from the
perspectives of nurses. As a result, the research project focuses on the experience of front-line
social workers in the MHSU field. Initially I went through two rigorous Ethical Approval
Processes (University of the Fraser Valley and Island Health) to conduct the interviews. A
detailed Participant Consent Form (see Appendix A) was developed. Once I received Ethics
Board Approval for the interviews, I contacted the Managers of the agencies to have approval to
contact employees of their respective agencies. A neutral third party then contacted the social

- 38 -

workers directly to see if they were interested in the interview process. Once people were
interested in the interviews, I contacted them (via email initially) to set up interviews. I also sent
out a copy of the Participant Consent Form and Interview Questions (is this Appendix B). A few
people responded that they would prefer to do a written interview (answering the interview
questions in a written format), as they were very busy. In this situation, the people still signed the
Participant Consent Form. Finally, I met with three people for in-person interviews, which were
audio-recorded and transcribed (at a later date).
For the purposes of this research project, six interviews were conducted with social
workers in the Victoria area. The goal of the interviews was to obtain information that other
social workers, front-line staff, and managers in the field might find useful about working with
vulnerable populations with mental health and substance use issues. Knowing what is working or
not within other agencies or services may help MHSU organizations improve their own services.
In addition, the interviews may provide useful information on how Island Health and the nonprofit agencies can continue to work together to provide great care to MHSU clients.
In terms of sampling techniques, this study was based on criterion sampling, as it was a
very specific group of people that I wanted to interview. Dudley (2011) defines criterion
sampling as “a study [that] has particular criteria to follow in selecting a sample” (p. 145). The
front-line social workers who were interviewed for this project were the key informants. A very
broad scope of staff was included in this project, since the people who work in this sector come
from diverse organizations, including government institutions and non-profit sectors. As a result,
staff from both Island Health and the non-profit sector in Victoria were interviewed. In terms of
selecting people to be interviewed, I contacted the Managers of the respective Teams and asked

- 39 -

to be connected with the social workers (SPOs) on the teams. The two Managers who
participated in the interviews, also continues to do front-line work as part of their jobs.
People participated in either written interviews or audio-taped (in person) interviews.
During the interview, a copy of the questions was brought for people to review ahead of time.
The interviews were audio recorded and transcribed, and the data was analyzed at a later date.
This research was conducted between 2016 and 2018. Any information that was disclosed during
the interview was kept confidential and anonymous.
Tapes and any relevant paper copies were kept in a locked filing cabinet, and any
information stored on a computer was password protected. In addition, all hard copies of the data
were destroyed, and all information deleted from the computer upon completion of this project.
Upon completion of this project, participants were also encouraged to contact the interviewer for
the results. A short summary of the results will also made available. It is also the intention of the
interviewer to make this project’s research results available to other professionals in the field,
with the hope that the information will prove useful in the field.
Ethical Considerations
There were several ethical issues to consider with respect to this research proposal - the
first being the potential impact of this interviewer’s own personal biases and experiences
working in the field. Fay (2011) both emphasized the importance of researchers becoming aware
of the impact of their social locations and biases on their work. To avoid becoming part of the
problem (oppression) one must recognize that one’s experience will affect one’s research. One
needs to become conscious of the privilege in one’s own life - for example, I am a white,
educated, middle-class, heterosexual female. At the same time; however, it should be noted that

- 40 -

this “privilege” has also motivated me to work in a field where I can help others who are not as
fortunate as I am.
The second issue involved the question of how to balance the anonymity of the front-line
social workers with some specific questions regarding their work sites. For instance, during the
interviews, it is important to discuss the different agencies where people worked. At the same
time, there are only a small number of agencies that do this type of work. Despite best intentions,
maintaining anonymity can become an issue. For instance, Victoria is a small city and people in
the MHSU know most of the works at the respective agencies. Therefore, anonymity cannot be
guaranteed in this process, despite the best of intentions. This issue has also come up as many
people in the MHSU field have asked to read my results once they are completed.
Limitations of the Study
As I went through this lengthy research process, several issues began to emerge. For
instance, the length of the ethics process became problematic, as it took about a year to complete.
Two ethics approval processes were required - one for the University of the Fraser Valley, and
one for Island Health. In the beginning, it was necessary to acquire each managers’ approval to
interview any staff members from these respective agencies. Several people came forward at this
time that expressed interest in being interviewed. However, by the time I was ready to do the
actual interviews (a year later), many of these people were no longer interested. In addition, I
also did not receive as many interviews from the non-profit agencies as I would have liked.
Another unexpected limitation that arose was the preference of interviewees to participate
in written interviews versus in-person interviews. The written interviews were easier for people
to participate in due to time commitments. However, the written interviews did not provide as as
much information. For the written interviews I specifically performed these with people who

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worked on the ACT Teams, as I knew this service well. One of the manager also preferred the
written interviews. However, in this case, the interviewee provided me with a detailed overview
of the services provided for by their team.
Finally, I had one more concern - one that involved the goal of making this research
project relevant. The issue of relevance ties into the concept of social justice, and the goal of
utilizing this research for the greater good (or helping the oppressed). Other questions evolved as
a result. For instance, how do you have an impact on social justice while working within a large
organization such as Island Health? In addition, how could this research help staff working with
the “hard to reach,” or social workers already involved in social justice issues on a daily basis?
Findings
In this section, the results of the interviews conducted as a part of this study will be
examined. Six people were interviewed during this process. All of the interviewees signed the
Participant Consent Forms at the beginning of the process. Three of the interviews were done inperson, and they averaged 50 minutes each. Three people also submitted written answers to the
questions via email. Two of the interview subjects were in manager roles, and four worked for
Island Health as Social Program Officers (SPOs) or social workers. One of the managers had a
Master of Counselling Psychology degree. The second manager was one semester short of a
university degree, majoring in Economics and Religious Studies. In terms of demographics, two
of the interviewees were female, and four were male. Of the six interview subjects, five worked
for various agencies in Island Health (IH), and one worked for a non-profit. Throughout the
findings section, I will be referring to the interviewees as: Alex, Bob, Cody, Darren, Ethan and
Frankie.

- 42 -

All of the interviewees were asked the same questions for the interviews. Numerous
topics were discussed including: team mandates and composition, community resources, and
client engagement strategies. Some of the topics from the Theory Framework were also
addressed throughout the interviews including: housing first approaches, Harm Reduction
strategies and stigma against mental health and substance use clients. The interviewees also
discussed successes and challenges working with this population. Finally, the interviewees made
suggestions for future changes that would benefit the MHSU clients. Many of themes were
discussed throughout all of the interview. For instance, the topics of Housing First and Harm
Reduction strategies were brought up in all of the interviews.
The Teams’ Mandates and Compositions
In this section I will briefly describe the different teams that the interviewee’s worked on.
Victoria has a variety of different teams working with the MHSU clients. The interviewees
worked on various Island Health Teams, ACT Teams and with a non-profit housing society.
However, for the purposes of anonymity, I will refer to the teams as Team 1, Team 2, Team 3
and Team 4. Each of the teams had specific mandates and staff composition which were
discussed during the interviews. The mandates of the teams also impacted the front-line work of
the social workers. Finally, each of the teams had specific types of MHSU clients that they
worked with. I will briefly describe the different teams that the interviewees worked on.
Team 1 was a hybrid between Island Health, and a couple of non-profit agencies. It was
located in the same building as these agencies. The interviewee (Alex) described the benefits of
working with other non-profit agencies. Alex states that “as an Island Health staff, I appreciate
having that community-based non-profit voice in our work, and it provides more flexibility in
what we are able to”.

- 43 -

Team 2 was developed to work with clients with substance use issues. According to the
Teams’ handout, their goals “include engagement with clients who have severe and problematic
substance use, leading to assessment and care planning focusing on client-identified goals”. One
of the main differences of the Team 2 from the other services, is the transitional nature of the
team, not exceeding 90 days. Team 2 also has peer support workers from the Umbrella Society
attached to their team. These additional supports provide a very important community voice or
lens to the work being done on the front-lines.
Team 3 refers to people who worked on the Assertive Community Treatment Teams
(ACT Teams). Of the all the people interviewed for the purposes of this study, four had worked
on the ACT Teams. One person has worked casually on the team for about 10 years, and another
had just started. One of the ACT Team staff members was a new hire but had left the team within
a month. Another person had worked on similar teams in Alberta, and then moved to Victoria to
work on an ACT Team there. Interviewees provided several descriptions of the work on the ACT
Teams. Darren described their responsibilities as “outreach, crisis response, resolution,
medication monitoring, psychiatric social supports, securing and maintaining housing, support
with family, and liaising with other service providers.” Bob stated that
As a SPO on ACT, we’re providing medication, Harm Reduction education, wellbeing
check-ins, helping find/keep housing, facilitating treatment opportunities, assessments,
meals, ADLS/IADL assistance, money management, helping with bills, getting to
appointments, court dates, liaison between various organizations. Basically, we’re here to
help clients manage their day-to-day and make sure they’re safe and provided for.
Linking clients up with other community resources.

- 44 -

One of the interviewees also discussed the impact of having staff with lived experiences on their
team. She states that “we have an addictions counselor now, he is the go to person for treatment
and helping with Harm Reduction ..clean their rigs etc .. He has lived experience as well, I think
that piece is important … We have a peer worker as well with lived experience .. (they do
everything we do) that piece is nice”.
One of the interviewees had worked on both the ACT Teams and another Island Health
Team. Alex said that one of the primary differences between them is that the Team 1 is voluntary
“so people apply to work with us and having a person’s consent for a referral is the first thing we
look at when we triage a referral.” Another difference is the presence of law enforcement. Alex
also states that “obviously we interact with the police now and then, but we don’t have a police
officer embedded in our team”.
Finally, one of the social workers was a Manager at a non-profit housing society in
Victoria. The non-profit housing society is also referred to as Team 4 in the paper. Cody stated
that
My title is Senior Manager of Housing in Victoria, but my role is all over the place. I
have a lot of meetings with our founders – BC Housing, VIHA, and all of the community
partners whether it be the police, paramedics, other non-profits, the City, the neighbours
The non-profit housing site also had a variety of people who worked in their building including:
mental health workers, a manager (40 hours a week), two cooks because we have other
projects that we provide meals for, a safe consumption site which is staffed by a mental
health worker. There are also medical services provided by a Dr. on staff (two days a
week) and then an LPN every day.

- 45 -

Cody also stated that “I worked the front desk for 7 of my 10 years ... and so I really enjoy being
a part of that … I don’t get to do that a lot, but I still try”. One example of this dynamic was that
the day of the interview, the non-profit housing manager also accompanied a client to the
hospital and sat with them in the emergency room until they were seen. As a result, we
conducted the interview at the hospital (instead of the housing site).
Community Resources Used to Help the Clients
There was a long list of community resources and services that Island Health teams and
the non-profits used. Throughout the interviews, the staff referred to numerous community
resources that their clients accessed. Some of these included CASH, VIHA resources (detox,
stabilization, AOT and housing), non-profit groups including Coolaid, Pacifica, Shelters, MHSD,
probation and Victoria police and courts (Integrated Court). One of the interviewees from Team
3 also discussed local organizations their team worked with including the GROW Program,
British Columbia Schizophrenia Society (BCSS). The GROW Program is run by Island
Community Mental Health and has variety of day programs for people with mental health issues.
The BCSS program also provides community supports including family counselling and peer
support programs for clients. The Soupermeals Program was also mentioned which provides
healthy frozen meals for clients at an affordable price. In addition, the Soupermeals program also
provides paid training for mental health clients who want to learn how to work in an industrial
kitchen. The social workers also made referrals to other services within Island Health such as the
CASH Program, Addictions Outreach Programs and the Mental Wellness Program (a Psychiatric
Day Program). This is only a partial list of all of the services that the social worker and MHSU
clients can access.

- 46 -

Several of the interviewees also mentioned the Integrated Court system in Victoria,
which was established to deal specifically with people who have mental health issues. Integrated
Court sessions occur once a week at the Court House. In the morning, the Crown Counsel,
Defense Lawyers and representatives from the 713/ ACT Teams meet before the court session to
discuss sentencing options. Alex gave an example of how the Integrated Court works:
When Crown gets a report stating that… — stole a mickey from the liquor store for the
fifth time this year, it doesn’t look great. But when we can say that they attended their
probation appt, [are] stable on methadone, maintaining their housing and they are
meeting with us three times a week... that adds a lot more to the picture”.
Both lawyers then present their case to the Integrated Court judge. Ultimately, the judge makes
the sentencing decision, but there is more focus on community involvement and recovery versus
strict jail time for minor offences. Integrated Court is a very innovative program to help merge
the mental health and legal systems and to find alternative sentencing arrangements for clients
who are caught between both systems.
Language and Terms for the Clients
Another subject that was of interest to the interviewees was how each staff member used
different language and terms when working with the same clients. For example, the interviewees
in this study all worked with the same clients, but they used very different language or terms to
refer to them depending on where they worked. The terms they used included: “hard to reach,”
“hard to house,” “vulnerable populations,” and “low barrier clients.” As discussed throughout
this paper these labels contribute to the stigma that people with MHSU issues experience.
Unfortunately, the labels can also be another example of “othering” people or making them
different from ourselves. Despite the different labels and terms that are used by the agencies, the

- 47 -

terms are all referring to the MHSU clients. However, the non-profit interviewee shared another
important insight about the potential negative impact of the use of language and terminology
among social work professionals. Cody stated:
I really dislike terminology. Because we are low barrier (and I do say that) ... but when
our residents hear that, it is something they have to carry with them, and I don’t like it .. I
feel like often times we get lost in these things, and they just become another thing that
we hear and that we acknowledge [of course the trauma] … And then we just skip it
because we have heard it so many times.
The potentially negative impact of labelling cannot be underestimated or dismissed. Labeling
people’s experiences as trauma or psychosis (etc.) can also help to distance social workers from a
client’s experiences. The terms can place artificial barriers to people’s experiences, and also
detracts from their experiences as complete individuals. Caution should be used when labelling
clients, as it is easy to label people with terms as a way of “othering” them. However, these
terms do not address the underlying issues of poverty, homeless, substance use issues etc. The
terms can also be problematic as one can easily stereotype people based on the labels attached to
them.
Client Engagement and Building Rapport
Throughout the interviews staff discussed the importance of establishing a safe place for
clients to talk and the importance of establishing trust with clients. For social workers in this
field, building trust and rapport with clients is the key to moving ahead with recovery goals or
client engagement. One interviewee discussed the importance of initial client meetings to regain
their trust:

- 48 -

Whether our folks have been let down by the system since foster care, and in and out of
jail and that kind of stuff and have lost faith in the system. We work to rebuild that and so
a lot of your initial rapport building is going out for food and some form of bribery.
Another interviewee who worked in a non-profit housing building discussed the work that he
does in terms of “customer service work, and it is just about being able to relate to people on an
individual level all of the time.” This approach places the focus of client and field-worker
interaction on the wants and needs of the client. It also helps to diminish some of the power
dynamics between the clients and the social workers.
Establishing trust can become more difficult when clients have trauma histories that they
need to work through. Working with clients with trauma, staff have to recognize when clients are
ready to address these issues. For instance, many female clients have experienced sexual assault
or abuse throughout their lives. Many clients would benefit from undergoing trauma therapy for
these issues. However, the clients have to be psychiatrically stable before they are ready to
participate in the trauma therapy or counselling. Another problem was the lack of affordable
counselling or Dialectical Behavior Therapy available for clients to access. For instance, Frankie
discussed the benefits of DBT for clients. Dialectical Behavior Therapy is an intensive therapy
used in mental health settings. This therapy has proven very effective for clients with Borderline
Personality Disorder. Clients participate in a lengthy process (several months) where they
attended group therapies and have weekly homework assignments that help them learn better
coping skills for problematic behaviors. Despite the effectiveness of Dialectical Behavior
Therapy, it is very hard to access in Victoria due to a long waitlist and lengthy process for
participants.
Stigma towards Clients

- 49 -

Several interview subjects addressed the issue of stigma which has been discussed
throughout this paper. In many cases stigma against MHSU clients can become synonymous
with negative stereotyping of MHSU clients. Ethan stated that there is “stigma in almost all areas
of health care, especially acute care.” Unfortunately, there have been numerous examples of
negative attitudes that clients have encountered when dealing with hospital staff. Another
interviewee gave a very poignant example of the impact of stigma on clients. Cody stated that:
Honestly if every store you go in people stare at you to see if you’re going to steal, you
just get pushed out more and more. We forget that if I want to go into a restaurant and
buy a sandwich I can, I have the money to, nobody will say anything or wonder if I have
the money and I’m not going to be made to feel uncomfortable. But that’s not the
experience with most of these folks. They are constantly being pushed out and only be
made to feel comfortable around drug users, if that’s the case I don’t know why should
expect to people to come back with anything else.
Peoples’ judgements (consciously or unconsciously) towards those who are homeless or living in
poverty have a long-term impact. Stigma and stereotypes marginalize this vulnerable population
more than it already is, undermining the possibility of a more positive outcome. Other
interviewees discussed the impact of client experience with stigma from other care providers.
One interviewee stated: “our folks face a lot of stigma and it sucks because we can work so hard
to get somebody to go to the hospital and they have one shitty experience with a nurse who
doesn’t understand where our folks are coming from and then they are gone.”
Another prominent stigma that was evidenced throughout the interviews, was the one that
exists between substance use versus mental health. Compassion is more often expressed towards
people with mental health issues versus addictions. In one interview, Cody explained why

- 50 -

“because everyone thinks it’s a choice, I think we are starting to get to a place where people are
starting to understand it’s not a choice”.
Finally, stigma between clients and professionals was also addressed. Alex stated:
[This] should not be that way but it is ... I do my best to level with people (i.e. you can
say one thing to a doctor, etc., and they won’t hear you, but if I say it. If I say exactly the
same thing, it might get heard). It is not okay, but I am happy to exploit that loophole to
get you whatever you need”.
Unfortunately, this there are many instances when a client may not be heard or listened to until a
professional intervenes. This type of dynamic can occur in many different situations where the
client is unseen, ignored, or unheard, unless they have a credible advocate. This is a problem
because this experience further dis-empowers the client and reinforces the idea that the client is
unable to advocate for themselves. This is also another example of being aware of our role as
social worker and professionals and the impact that we can have (directly or indirectly).
Housing First Approaches
One of the most significant themes that emerged during the interview process was the
importance of helping clients find and maintain housing. All of the interview subjects agreed
about the importance of housing without putting a theoretical label (i.e. Housing First) on the
issue. Throughout the interviews, the interviewees often discussed their clients’ various housing
situations. For instance, people lived in shelters, non-profit housing, or market rent. Alex stated:
“We would try and identify what their goals were for housing. We do have clients who straightup [state] I don’t want to be housed. So, supporting them around making that choice easier for
them”.

- 51 -

Depending on where a client wants to live (i.e. market rent or supported housing),
referrals are made to different agencies and programs. For instance, Alex stated that “some of
our folks are suitable for market rent, and some are not. So if they are suitable for market rent,
[we] try to connect them with Streets to Homes or other programs”. The fact that these
interviewees’ place so much focus on housing demonstrates the importance of having a stable
home base to help enable clients to address other issues over time.
The role of the Centralized and Supported Housing Committee (CASH) was also
mentioned by several staff. The CASH referral process itself can be lengthy one (in terms of
waitlist times for people to find housing). Once clients were housed, the interviewee thought that
the housing sites staff did a good job. Ethan stated that “supported housing sites really work well
for clients.”
One of the issues of concern to the interviewee subjects was the Historical Records of
Violence (Purple Dots) designation on CASH applications. When applying for housing, social
workers have to include a Historical Record of Violence for people who have a Purple Dot
(violence alert) on file. This practice has always been a very problematic part of the CASH
application, as many clients have incidents of violence in their histories. This Historical Record
of Violence does not always give a clear picture of how a client is doing currently. According to
Alex:
There is a big disconnect... a lot of our clients are Purple Dotted. Our folks, virtually all
of them, have never had a violent experience with a service provider. Anybody can act
violent when they are put in a certain situation. Not to say that all of their histories of
violence are warranted [but are] over-represented on paper.”

- 52 -

The problem of getting past the Purple Dot problem, however, is a persistent challenge for frontline workers trying to assist clients with housing. The Historical Record of Violence can also
further stigmatize clients when one looks at their past incidents of aggression.
The topic of Tent City was discussed in a couple of the interviews. Two of the
interviewees were involved with Tent City. One interviewee worked on an Island Health Team
that initially worked with clients in Tent City providing supports as needed. In addition, the PHS
Society was originally from Vancouver and did work with clients on the downtown eastside.
According to one of the interviewees:
We were originally asked by BC Housing to come with outreach … I think that the Tent
City was changing, it was getting a bit— they were having issues with fire codes, and a
lot of pressure was really going on, and it is my understanding that they were having a
hard time connecting with the residents of Tent City... Our organization (PHS) is known
for really low barrier work, and so we were asked to come over and see if we could make
any inroads and make any progress and build some rapport.
The interviewees discussed the buildings that have opened as a result of the Tent City including
Mount Ed, Choices, My Place, First Mat (shelter), and the PHS Building on Johnson Street.
Harm Reduction and the Overdose Crisis
Throughout all of the interviews, Harm Reduction strategies were discussed. Several
interview subjects discussed different Harm Reduction strategies that their respective agencies
used. Alex stated that “I think that our Naloxone program is working really well for clients ... We
have got a lot of feedback from clients that they have saved friends lives. That is really important
to us.” Cody discussed the Harm Reduction strategies that are used by the agency for clients. For
instance, he discussed the safe consumption site that one of their buildings has for residents and

- 53 -

their friends. His agency also works with SOLID a non-profit agency who provides peer support
for people struggling with substance use issues. According to the SOLID website, “we are an
organization of current or former illicit drug users in Victoria, British Columbia. We challenge
personal and systemic injustice by promoting practical Harm Reduction strategies in our
communities and our individual lives.” Team 2’s mandate is also connected to Harm Reduction.
According to the Team 5 mandate that Ethan provided, clients “have severe and persistent
substance use which may include mental health issues”. Finally, the Team 2 mandate also states
that clients “are living at risk in the community due to their substance use (may be housed or
homeless)”.
In addition, the current Fentanyl Crisis was also discussed by several of the interviewees.
The Fentanyl Crisis has shown the devastating impact of substance use on people and their
families. One of the interviewees also discussed the stigma and barriers that clients face
regarding their substance use issues. She states that “the way that people view people with
mental illness and substance use problems .. it is the you made your bed attitude, that our culture
practices which causes a lot of disconnect and so they face so many barriers”.
The Mental Health Act
Issues surrounding the British Columbia Mental Health Act (MHA) were also discussed
by a few interviewees. A thorough discussion of the MHA was provided in the Literature
Review. However, due to the complexity of the Mental Health Act, I will provide a very brief
overview of the MHA key components. To review a person may be brought into hospital and be
deemed as a risk to themselves or others. Under the MHA if a person is deemed a risk to
themselves or others they can be further assessed by a Psychiatrist and be admitted into the
hospital system as an involuntary patient. There is a 48-hour assessment period in which a

- 54 -

second Doctor further assesses the individual to determine if they are still at risk and in need of
Involuntary treatment. If clients are under the influence this can become difficult to assess, as a
person may be at risk initially but then be stable by the time the second doctor assess them. This
can be frustrating for social workers and MHSU staff who are concerned for the safety of their
clients and also frustrating for the hospital staff and police as well.
One of the interviewees stated that the mandate of Team 3 “ is that we work with clients
who are on Extended Leave from hospital. They have been admitted into hospital because they
were a danger .. to themselves or others.” When clients are released from hospital on Extended
Leave, the Psychiatrist may attach specific leave conditions to the discharge. For instance, clients
may have to attend meetings with Psychiatrists and their respective mental health teams, take
medications as prescribed or attend substance use counselling. If clients are not meeting these
criteria they may be brought back to hospital under a Director’s Warrant. However, Psychiatrists
and mental health professionals tend to not bring clients back into hospital unless it is a last
resort. In addition, Psychiatrists can let the Mental Health (Involuntary status) lapse if a client is
no longer considered a risk to themselves or others. At this point, clients become voluntary and
can choose to participate or not participate in their mental health programs.
Frankie also discussed the challenges of working with clients on Extended Leave as this
creates an inherent power imbalance. She states that
I think it is challenging to work in this kind of environment where sometimes it is
adversarial in that we have power and they don’t .. I find it challenging that we hold their
money and their medication [when they are] on Extended Leave from hospital and that
they are an Involuntary client, I find it really challenging to connect with them
sometimes.

- 55 -

She also discussed her struggles around clients having to take medications when they do not
want to. This also ties into the MHA, as Psychiatrists can state that clients have to take
medications as prescribed as a condition of the Extended Leave from hospital. Frankie also states
that this
is a struggle sometimes when someone does not believe that their medication is
supporting them to be healthy and well, and they have every right to express that concern
and it feels unethical for me sometimes .. I know that it is not. I know that is part of the
mental health act and the work but that is when I kind of question the work that we do.
There is always a carrot of .. you may have to go to hospital. But that is a reality, that is
the truth. If you decide not to take your medications, you could possibly go back to
hospital. I am the messenger in that, but it feels uncomfortable sometimes. Where I can
really empathise with their position that I get to decide what I put into my body every
day, and I would not second guess that .. that right that I have
Another issue that came up was the treatment of people with substance use or addictions
within the hospital system. One interviewee related the challenges of bringing someone into the
hospital when they were under the influence of substances:
When people come [in to hospital] on substances they [hospital staff] don’t want to see
them because they are on substances and they can’t get [certified under] the Mental
Health Act it still boggles my mind because the person is still .. in an incredible amount
of distress and a danger to themselves and other people.
Finally, Ethan states that a legislative change that would help would be to ”make it easier for
psychiatrists to use the MH Act with people with damaging substance use. The above examples

- 56 -

show some of the complexities involved with working with Involuntary clients and the Mental
Health Act.
Social Worker’s Success with Clients
Another topic that was discussed in the interviews was success stories involving clients.
Several of the social workers discussed the small moments and success that were meaningful for
the clients. Bob stated:
For some, just having a warm meal and staying clean, off drugs for the day is a success. I
think it’s important to not hold everyone to the same expectations and self-project what
we think is a “success.”
For most interview subjects, success in the job centered around supporting clients with their
individual goals. Some people discussed success in terms of working with clients who were
trying to manage their addictions issues. Darren also gave the example of “supporting some to
abstain from their substances who were once using frequently”. Helping clients reconnect with
their families was also identified as a success. Darren also stated that they “helped many
reconnect with their families once [they are] more stable in the mental health and addictions
issues.” Focusing on the clients’ experiences and goals also ties into the Recovery Model that
was previously discussed in this paper.
Social Workers’ Challenges in the Field
Throughout the interviews, the social workers addressed the challenges of working in this
field. Many of these challenges have already been discussed in this paper. However, other
challenges were also identified, including the power struggles involving money management that
occur on the ACT Teams. This is one main criticisms of working on the ACT Teams that has
come up several times in general conversations and throughout the interviewees.

- 57 -

Interviewees also raised the issue of workload. As one IH interviewee stated “Another
challenge is that I really enjoy the work but there is a lot of it”. Island Health staff also note the
increasing amounts of paperwork (computer work) they have to do. Darren stated:
The agency guidelines and policies can add more paperwork, workload or steps to
properly and safely support clients. Sometimes this can seem redundant – for example duplication of charting for different sources. Ultimately this can hinder the amount of
time spent being able to directly see and support clients 1:1.”
Another problem is that the Pathways Referral system can only be accessed by Island Health
staff. Island Health uses a complicated computer system called Cerner which allows staff to chart
(Power Charting) and make referrals (Pathways) that can be accessed by other Island Health
staff. However, this is only an internal charting and referral system. For the interviewee on Team
1, she was only one of two staff members who had access to this system. This can be
problematic, as it also increases her workload:
One of the challenges we have on our teams is that half of our teams does not have access
to Pathways or Power Chart, or anything like that. Aside from our team lead, I am the
only person who can look up whether someone is in hospital or any consults that may be
relevant. So, I print them off and give them to their case manager. I also do all of the
Pathway referrals to detox, stabilization.
In addition to increasing workload demands, there is also an increasing demand for services for
clients. The interviewee on Team 1 states that there are “sixty clients on our team and fifty
people on our waitlist. We could double our team tomorrow. I wish there was more of us.”
Alex also made the connection to the overdose crisis and the need for more support:

- 58 -

AVI, Rock Bay, Our Place... have their overdose prevention groups. If we could have
more of those with longer hours... I think that they have done an amazing job in reducing
the amount of overdoses and deaths that we are seeing. But we are still seeing a lot .. 4-5
people are dying every day in B.C... and that means that we are doing something wrong.
Several interview subjects also shared challenges related to finding and maintaining housing for
clients. For instance, some clients may be banned from different housing sites, and then social
workers must try to work with other agencies to find them housing. Alex stated that:
We have a few folks that are no longer accepted by CASH. [We are] doing a lot of
wheeling and dealing with PHS [Portland Housing Society] and different shelters. A lot
of work on short-term stuff i.e. trying to get them extensions at Rock Bay or trying to get
them into First Mat or whatever.
The lack of coordination between services was also brought up. Darren stated that “I’ve seen
more collaboration between services since I first started in this field. This still needs to improve”.
Another interviewee discussed the barriers that ACT clients receive from other agencies. For
instance, if ACT clients wanted to access non-profit housing referral agencies, they were usually
declined. Frankie stated that some external services think that
“Oh they have an ACT Team ... that problems is fixed right there ... ie we wont work
with them because they have an ACT Team. Well, we can’t get them into housing any
more then you can. They probably have more linkages into these supportive housing then
we do .. that happens a lot.
This barrier between agencies can also be frustrating when one takes into account the workload
issues that many of the staff discussed.

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The non-profit agency had to deal with the pressures of budgetary constraints. As the
interviewee stated:
[As] non-profits, you’re bidding on things. Money comes in, and right now it seems that
we have a very loving government and I think money is [there]. We’re also very aware
that our funders .. don’t have blank cheque books or anything.
A couple of the interviewee’s discussed the lack of supports for families. One interviewee
stated that there is “not a lot of resources for the families”, whether it is counselling supports or
education. For instance, family members would benefit from more education around treatment
programs for substance use. Additional counselling supports for families would be beneficial.
One interviewee stated that more supports are needed for families to “support to them for the
traumas they may have experienced and have passed on to their loved ones”.
Another interviewee also discussed the complexities that can arise when a person goes to
treatment. For instance, she states that “we referred someone to treatment, he is going to go to
Burnaby but now his housing is at risk because of a violence issue, and so now he is homeless ..
now he is going to go to treatment and get well and then he is going to come back and not have a
place to live? This can be a difficult dilemma for clients who may be at risk of losing their
housing if they go to treatment. A similar problem can arise for clients who receive Income
Assistance from the Ministry of Social Development and Poverty Reduction, as their rent will
not be paid while they are in treatment. Unfortunately, some clients have to make the difficult
choice between going to treatment or keeping their housing. This can be a tough decision in
Victoria where it is so difficult to find affordable housing in the first place.
Additional Services and Legislative Changes that Would Help

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Finally, the interviewees were asked what additional services and legislative changes
would help the MHSU clients. The most common theme that emerged from these interviews was
the need for improved support with respect to finding and maintaining housing for clients.
Overall, the interviewees’ preoccupation with the issue of housing is important, especially when
one takes into account additional funds ($60 million) that are being allocated to address the lack
of affordable housing in Victoria. Hopefully the additional housing will help to improve the
quality of lives for clients and to reduce the homeless problems in Victoria.
Another theme in the interviews was collaboration between service providers. According
to one interviewee, “increased and a better quality of collaboration between all front-line service
providers would help.” Another interviewee emphasized the need for better integration of
services: “more money needs to be spent on coordination of police, hospital, clinics, housing.”
The coordination between services is also an important point due to the complex dynamics
between service providers and staff in different parts of the MHSU system. For instance, helping
to bridge the gap between the hospital staff and mental health and substance use clients. One of
the ACT Teams (last week) came up with an idea of honouring a different community service
each week as a way to bridge this gap—for instance, taking Timbits to the emergency staff one
week. Gestures of appreciation or respect are positive and demonstrate the importance of the
direct relationships between the various community agencies and services.
Another interviewee focused on decriminalizing substance use as an important change
that would help their clients. They recommended “more accessibility to Harm Reduction
supplies and Harm Reduction supports, and supervised consumption.” The interviewee went on
the say, “eventually I think that the biggest change for our folks would be legalizing substances
overall, but we are not there yet”. In addition, improving client access to Harm Reduction

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strategies was another important suggestion for future change. The Team 1 interviewee stated the
following:
The main thing that our folks are talking about is the supervised consumption site and
physician-assisted heroin access. We have lots of folks on methadone, some folks on
Naloxone ... And the next step would be heroin, but injectable heroin. But we are not
there yet in terms of being able to provide those kinds of services.
Interviewees also had creative responses to the question about helpful legislative changes:
Legislation that would be nice, cigarette companies should have to donate a certain
amount of cigarettes to shelters. Smoking’s not good for people but, cigs and coffee. If
someone is having a stressful moment, if you can give them a cig or coffee, so often you
can break through and build rapport with people and that’s where everything has to start.
Small acts of kindness can go a long way to building rapport with clients.
The people who participated in the interviews for this project provided a very informative
overview of the complexities of working with MHSU clients in the Victoria area. Throughout the
interview process, the overwhelming themes of stigma, Housing First policies, and Harm
Reduction strategies were most evident. Another common theme was the importance of
rebuilding trust with many of the clients, and the need to overcome any negative encounters they
may have experienced in the past. At the same time, Victoria is starting to do a lot of great work
with Harm Reduction services and increased funds for housing. There is also a lot of important
work going on between agencies to address these issues—for instance, the Greater Victoria
Coalition to End Homelessness. Hopefully the issues that are symbolized by the Fentanyl Crisis
and Tent City will become a thing of the past as clients, staff, and agencies work together to
address these issues.

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Conclusions
This research paper addresses the complexities of working with clients with mental health
and substance use issues. The experiences of front-line social worker working with “vulnerable
populations” in a city on Vancouver Island are the focus. The complexities of this work are
demonstrated through the research and interviews conduct as part of this study. Using an antioppressive social work lens, it was instructive to note that interviewees did not use specific social
work language to describe the work that they we are doing. Instead interviewees focused on their
clients’ experiences and on helping them on their recovery journeys (which were highly
individual).
This project highlights the numerous complexities that front-line social workers face
when working with clients with mental health and substance use issues. Working with this client
population is a tough, challenging, and rewarding job—all at the same time. Front-line workers
are helping clients address a multitude of issue while trying to help them meet their basic needs.
Three dominant themes emerged as a result of this research: stigma, Housing First policies and
Harm Reduction strategies. According to research, stigma is a prominent feature of/factor in
working with this population? Unfortunately, stigma against clients, professionals, and the
mental health system itself can be felt at all levels. At the same time, addressing the problem of
stigma is difficult because it places more responsibility on the individuals and staff members
who interact with MHSU clients daily. This can be a challenge among staff members who are
already overworked or stressed. However, simple acts of kindness and respect can go a long way
to helping bridge these gaps.
This paper also highlights the fact that there is a lot of valuable work being done with
respect to Harm Reduction strategies. The current Fentanyl Crisis is a visible reminder of the

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extent of this issue. Once again, the concept of stigma becomes relevant in terms of recognizing
our own perceptions towards people with substance use issues. Educating ourselves about Harm
Reduction approaches and programs can also help this issue. Compassion can also go a long way
to helping people when they are struggling. If one can remember the impact of stigma, such as
the example given by one interviewee where a homeless person was followed around a store, one
can remember the importance of compassion.
Finally, Housing First approaches are also a key component of the work that social
workers are doing to assist clients. Fortunately, this is one area where a great deal of valuable
work is being done, and changes are coming. The additional $60 million funds from the
provincial and municipal governments for supported housing programs in Victoria will go a long
way to addressing this issue. Given what they have to work with, housing organizations in
Victoria and their staff are also doing a great job working with clients on a daily basis. All of the
dedicated professionals who work in this field should be very proud of the invaluable and
challenging work they are doing and recognize the positive impact that they are having on the
community (whether or not this is ever directly acknowledged).
Throughout this extensive research on the topic of working with MHSU clients a number
of implications emerged for Social Workers and other professionals in the field. Lack of
affordable housing is a huge issue for people in Victoria. Additional services for MHSU clients
was also discussed. For instance, additional counselling supports for substance use clients and
Dialectical Behavior Therapy would help. Family counselling and supports is another topic that
is often brought up as another service that we would benefit from. Easier access to Harm
Reduction services and supports would also be beneficial for people. For instance, there is a long

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wait for people who want to go to treatment. This is a frustrating process for people who are
trying to break their cycles of addictions.
Finally, coordination between services was discussed as both a strength and a limitation.
In Victoria we often talk about the silos that people in the MHSU field work in. In other words,
are work sites are separated from other services. However, the clients are involved with many
different services in Victoria. This situation stresses the importance of working together amongst
the different areas of MHSU.

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Appendix A – Participant Consent Form

PARTICIPANT INFORMATION & CONSENT FORM
(School of Social Work and Human Sciences)
University of the Fraser Valley
33844 King Road
Abbotsford BC V2S 7M8
604-504-7441
WORKING WITH THE “HARD TO REACH” (VULNERABLE POPULATIONS) IN VICTORIA:
UNDERSTANDING THE EXPERIENCES OF FRONT-LINE SOCIAL WORKERS
PRINCIPAL INVESTIGATOR AND STUDY TEAM
Principal Investigator Name and Affiliation/ Title: Celena Camps, Case Manager at the Victoria
Mental Health Center (Island Health) and Masters of Social Work Student at the University of
the Fraser Valley.

You are being invited to participate in a research study. Your participation must be free and
voluntary. You are free to withdraw from the study at any time. Your choosing or not choosing
to participate will have no impact on your employment status.
Purpose/ Objectives of the Study
My name is Celena Camps and I am currently a student in the Master of Social Work program at
the University of the Fraser Valley. I have also worked on an Assertive Community Treatment
Team (ACT Team) for 7 years where we worked with very complex clients with mental health
and substance abuse issues. The combination of my academic interests in mental health and
my own front-line experiences have guided the interest in my research area. I am interested in
the experiences of other people who work within this field. I am inviting you to participate in
my survey WORKING WITH THE “HARD TO REACH” IN VICTORIA: UNDERSTANDING THE
EXPERIENCES OF FRONT-LINE SOCIAL WORKERS. Your participation in this research is voluntary.
The purpose of this Consent Form is to provide the necessary information to help you decide
whether or not to participate.
In terms of my research project, I am interested in the experiences of social workers and frontline staff working with `hard to reach` clients in Victoria. To clarify, the terms ``hard to house``

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and “hard to reach” are often used to identify clients with mental health and substance abuse
issues. My research interest arose from the complexities involved with providing case
management services to these clients. The Housing First Model has often been cited as the
most effective way to work with this client group. The Housing First Model asserts that finding
stable housing should be the first priority for this client group, regardless of where the clients
are at in their addiction or mental health cycles. However, working in the field, I realize that the
realities are not this simple. I am interested in interviewing other staff in this field regarding
their own experiences. I will be interviewing staff working in Island Health and the non-profit
sector (The Greater Victoria Coalition to End Homelessness, Our Place Society, Pacifica Housing
and The PHS Community Services Society). I have been in contact with the managers at these
agencies, and have received written permission that the participants can be contacted.
I am conducting this research project in collaboration with the University of the Fraser Valley,
and supervised by Dr. Robert Harding of the School of Social Work and Human Services.
Procedures Involved in the Research
I have chosen to focus on the experiences of front-line social workers (with this population), as
there is not a lot of research on this group of professionals. I have also decided to specifically
focus on Social Workers in this field. For the purpose of this study, participants do not have to
have a specific “Social Worker” designation. I also recognize that many of these positions are
also performed by Nurses, but for the purpose of this study I will not be interviewing Nurses.
My research project has been approved by the University of the Fraser Valley Research and
Ethics Board and Island Health’s Health Research Ethics Board (HREB). I have also received
written consent from the Managers of the non-profit and Island Health agencies, from which I
hope to interview Social Workers. An neutral third party will send an email out to the various
agencies, asking for voluntary participants in this study. Once individuals express interest, I will
contact them regarding the Informed Consent Forms. I will explain the research process to the
individuals (either in person or over the phone). If people are still interested in participating in
the project I will meet with the people to sign the Informed Consent Form. Once the Consent
Form has been signed, we will set up an interview time.
I will be asking (approximately) five to eight Social Workers to participate in individual
interviews. I have prepared a standardized list of interview questions, which I will ask each of
the participants. For example:
- What types of services are provided by your agency or work place?
- What successes have you had working with the clients you serve?
- What are some of the challenges that you have encountered with your clients?
- What types of resources do you utilize in the community? Are there other types of
resources that would be beneficial?
- What types of barriers do the clients face in the community? How do you and your
agency support clients with these issues?
The interviews will take about an hour. Prior to the interviews, I will send each participant a
copy of the questions, so that people can have time to reflect upon their answers. During the

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interview, I will also bring a copy of the questions for people to review (if needed). I will also be
audio recording the interviews, and transcribing the information at a later date. Once the
interviews have been completed, I will analyze the data. The data will be coded to ensure that
no identifying information is present. The actual research process will occur from 2016-2018.
Once my research has been completed, participants may contact me for the results. I am also
planning to write a short summary of my results, which will be available to participants. I am
also hoping to make my research results available to other professionals working in the field.
My hope is that this research can be beneficial for other staff and managers working in the
field.
Will I be Paid for Taking Part?
There will be no financial compensation for taking part in the Interviews and the research
project. However, I will try to accommodate participants needs when setting up times and
places for the interviews to take place.
Researcher’s Relationship With The Participant’s
I currently work as a Case Manager at the Victoria Mental Health Center. I have worked in the
Mental Health and Substance Use area of Island Health for 15 years. As a result, I may have
met some of the people being interviewed for my research. However, I have put safeguards in
place so that I will be contacting people through a neutral third party initially. I will also be using
mine (and the participants work emails), to ensure that there are no conflicts of interest.
On-Going Consent
If new information becomes available, or if this project takes place over a longer period of time,
I will ask you to renew your consent to participate.
Potential Harms, Risks or Discomforts to the Participants
The interviews are considered minimal risk. I will maintain confidentiality by coding your
responses and making certain to not use any information that will identify you personally.
If participants feel uncomfortable talking about a particular topic, they will be encouraged to
skip to the next question. Otherwise, there are not foreseeable risks involved in this study.
Participating in this study does not waive any of your legal rights to research-related harm.
Participation in my study is purely voluntary. If you withdraw from the study, I will destroy any
record of your interview information immediately. If the withdrawal occurs early in the writing
process of the research project, I will delete the information from the written project.
Unfortunately, if the withdrawal occurs at the end of the research project (and final edits have
been made on my written project), I will not be able to withdraws the data at that point in time.
Finally, the interviews will take place in a secure setting of your choice. The interviews will take
approximately one hour.
Potential Benefits

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Working with the “hard to reach” can be challenging and rewarding at the same time. I hope
that my research can:
1) Help staff to feel connected with other people also working in the same field. As frontline staff we often work in isolation with our clients. I am hoping that staff may feel
connected to other staff (at other agencies) undergoing similar types of work.
2) Uncover services and skills that have worked for other professionals in this field. I am
hoping that sharing this knowledge may improve our own practices and understanding
of our clients.
3) Help other staff also, by connecting them with other services in their own communities.
4) Give staff a better understanding of other service providers working with the “hard to
reach”.
5) At the end of my research, I plan to provide a summary report for people who
participated in the study. I am hoping that other staff and managers can benefit from
this research (i.e. discussing common skills and resources that have helped other staff). I
will also provide a community reference guide for staff to use.
Confidentiality
Your confidentiality will be protected within the limits of the law. Your confidentiality will be
respected. Any information that is disclosed during the interview will be kept confidential and
anonymous. Your name and other identifying information will not be used in the study. I will
develop an anonymous coding system when discussing the result of my study. The interviews
will be coded in a way that protects the confidentiality and identity of the participants. The only
identifying factor will be whether participants are from Island Health or the non-profit sector.
The interviews will be audio taped and then transcribed. I will keep the tapes and any relevant
paper copies, in a locked filing cabinet. The computer itself is encrypted, and my computer is
password protected. Once my research has been completed, I will destroy all hard copies and
paper copies of the data. I will also delete any information from my computer. Raw data and
information will be destroyed by June 2018.
Future Use of the Data
As stated above, any identifying information and data from the research project, will be
destroyed. However, I may wish to publish results of this research at a later date. If this were to
occur, I would ensure that participants confidentiality was protected. As discussed previously,
the initial data from the interviews will be destroyed, so I would be unable to contact people in
the future, if I do publish any of the research information.
Sharing of Study Results
A summary of the study results will be provided to you upon request. A brief report will also be
available to interested individuals/ agencies as requested. However, I will ensure that any
identifying information has been removed from the Report. A copy of the Thesis will also be
placed in the Library at the University of the Fraser Valley.
Disposal of Data

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Any paper forms/ documents will be confidentially shredded upon completion of this the
research project. The audio tapes of the interviews will also be double deleted immediately
upon transcription. The interview notes will also be shredded upon completion of the research
project.
Questions
If you have any questions or require further information, please contact Celena Camps at the
University of the Fraser Valley Celena.Camps@student.ufv.ca. If you have any concerns about
the ethics of this study, please contact Robert Harding at Robert.Harding@ufv.ca or Adrienne
Chan, AVP of Research, Engagement and Graduate Studies at UFV. The contact information for
the Island Health’s Research and Ethics Board (HREB) is researchethics@viha.ca or (250) 5196726). The ethics of this project have been reviewed and approved by UFV’s Human Research
Ethics Board and the Island Health’s Research and Ethics Board (HREB).
Thank you,

Celena Camps, BSW, RSW

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CONSENT FORM
Your signature below indicates that:
1. All sections of this Consent Form have been explained to your satisfaction.
2. You understand the requirements, risks, potential and responsibilities of
participating in the research project, and;
3. You understand the interview will be audio recorded.
4. You understand how the information will be accessed, collected and used.
5. All of your questions have been fully answered by the researchers.

____________________________
Name of Participant
(Print)

_____________________________
Signature

_______________
Date

____________________________
Name of Person Administering
Informed Consent

_____________________________
Signature

_______________
Date

____________________________
Role of Person Administering
Informed Consent

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Appendix B – Interview Guide
Thank you for taking the time to participate in my research. Your response to the following questions is
appreciated and valuable information for the purpose of my research.

ACADEMIC AND PROFESSIONAL INFORMATION
What is your educational background?
How long have you been working in the field?
What made you decide to work in this field?
How did you end up working with the “hard to reach” clients?

INFORMATION ON YOUR AGENCY OR WORK PLACE
What types of services are provided by your agency or work place?
What is the mandate of your program?
What is the mission and/or values statement of your program?
How do the agency guidelines and policies impact your work with the clients?

INDIVIDUAL EXPERIENCES WORKING WITH THE CLIENTS YOU SERVE
What successes have you had working with the clients you serve?
What are some of the challenges that you have encountered with your clients?
Are there any service areas that could be improved for clients?
Are there any service areas that are working well for clients?

- 80 COMMUNITY RESOURCES AND LEGISLATIVE IMPACTS ON THE CLIENTS
What types of resources do you utilize in the community? Are there other types of resources that would
be beneficial?
What types of barriers do the clients face in the community? How do you and your agency support
clients with these issues?
What types of service changes would help support clients better in the future?
What types of legislative changes would help support clients better in the future?

Thank you for taking the time to participate in this interview.