Background

From its inception, social work has placed health and mental health as a foundational locus of practice across a multitude of institutional and community settings (Ruth & Marshall, 2017). Social workers are the largest group of mental health professionals in Canada and the United States (US) (Harkness, 2011; O’Brien & Calderwood, 2010) and are essential for the assessment and treatment of a broad range of mental health concerns (Ashcroft et al., 2018; Kourgiantakis et al., 2020). Although social work’s scope of practice has continued to evolve over time to meet the needs of clients, inconsistencies in social work’s ability to diagnose mental disorders continue to exist (de Saxe Zerden et al., 2019; Harkness, 2011).

Social Work and Diagnosis

Diagnosis refers to the procedure used to identify the presence and cause of a disorder from the onset, course, and combination of signs and symptoms (Harkness, 2011; Othmer & Othmer, 2002). The purpose of diagnosis is to guide a course of treatment, and relies on sound assessment skills (Harkness, 2011). The Diagnostic and Statistical Manual of Mental Health Disorders (DSM) remains a primary method used by regulated professionals to diagnose mental health conditions (American Psychiatric Association [APA], 2013a). The characteristics of the mental health issues is specific to each person’s psychosocial, relational, and social functioning. The context in which these diagnostic encounters take place is also specific to the presentation of symptoms or chronic problems (Forrest et al., 2002). Having diagnostic privileges are instrumental for social work to help clients access needed mental health services (Austin, 2017; Rudoler et al., 2019). The challenge; however, is that social work’s scope of practice dramatically varies across geographic jurisdictions in terms of ability to diagnose and treat mental disorders.

In the US, social workers are critical to the mental health infrastructure. In 2006, there was an estimated 170,790 clinical social workers in the US, certified or licenced to assess, treat, and diagnose mental health disorders (Center for Health Workforce Studies, 2006; Harkness, 2011). Clinical social workers in the US have advocated over the past two decades to ensure that state regulatory bodies recognize assessment and diagnosis as part of social work scope of practice (Shah et al., 2019). These efforts have largely succeeded, with all but three states permitting master’s level clinical social workers to provide mental health diagnoses, given they meet experience and training requirements (Shah et al., 2019).

In Canada, the provinces of British Columbia, Alberta, Saskatchewan, and New Brunswick have incorporated diagnosis as a component of social workers’ scope of practice (New Brunswick Association of Social Workers [NBASW], 2017; NBASW, 2019). Both New Brunswick and Saskatchewan emphasized that extending diagnostic privileges to social workers would increase access to mental health services and decrease wait times (Austin, 2017; NBASW, 2017). In Ontario – Canada’s most populous province – social workers do not possess diagnostic privileges as part of their scope of practice, despite the precedence set in other jurisdictions (Austin, 2017). Instead, mental health diagnosis is a controlled act customarily carried out by physicians and psychologists (Canadian Mental Health Association Ontario, 2021; Government of Ontario, 2020). Increasing social workers’ capacity to conduct diagnosis would help improve access to needed mental health services (Harkness, 2011; Ratnasingham et al., 2012).

Building Social Work’s Capacity for Diagnosis

Legislation is a key component to enable social work’s ability to do diagnosing. For example, the Regulated Health Professions Act defines controlled acts as activities that can cause harm if not performed by a qualified person (Regulated Health Professions Act, 1991). The authority to perform controlled acts comes from legislation. Developing social work’s capacity for diagnosis requires legislation and the support of professional regulatory bodies (Harkness, 2011). Building a consistent foundation for social work to engage in diagnosis across all jurisdictions; however, requires more than just legislation. Across the US and Canada, a code of ethics unifies the profession of social work (Canadian Association of Social Workers [CASW] 2005; National Association of Social Workers [NASW], 2021). The values and principles laid out in this code informs all facets of social work practice, and this naturally extends to the role of diagnosis within the scope of the profession. Values such as service to humanity, integrity, and competence in professional practice (CASW, 2005) guide social workers to ensure that diagnoses serve patient and client needs and provides a frame for selecting and delivering effective interventions.

In addition, developing capacity for social workers to be successful diagnosticians requires diagnosis training in social work education, ongoing professional development, and adherence to a determined standard of care (Harkness, 2011; Kourgiantakis et al., 2020). Competent use of the DSM is beneficial to social workers, clients, and communities across a variety of settings (Kourgiantakis et al., 2020). Some jurisdictions have demonstrated commitment to regulating diagnostic privilege among social workers through academic coursework and training, clinical experience, and written examinations to assess competence (Austin, 2017; NBASW, 2017). Given the vast differences that exist in terms of social work’s diagnostic roles, there continues to be limited guidance regarding how to implement diagnosis abilities and build capacity for social workers.

Rationale

The existing legacies of these efforts in both the US and Canada demonstrates that the movement towards diagnostic privileges for social workers is not a novel one. Yet, vast variations exist within social work pertaining to diagnosis. By conducting a scoping review of the literature, our aim is to help bring clarity by identifying the nature and extent of knowledge regarding social workers diagnosing. The findings from this review may inform social work’s response to changing mental health needs and address existing barriers preventing timely access to services (Ratnasingham et al., 2012). The following research question guides this scoping review: What can the literature tell us about social work’s scope of practice pertaining to diagnosis in Canada and the United States?

Methods

The purpose of our study is to chart and synthesize the literature on social workers engaging in activities of mental health diagnosis in Canada and the United States. This work will be disseminated to researchers, policy makers, educators, and practitioners to inform their practice. We chose a scoping review as our literature synthesis methodology, drawing from Colquhoun et al. (2014) who describe scoping reviews as “a form of knowledge synthesis that addresses an exploratory research question aimed at mapping key concepts, types of evidence, and gaps in research related to a defined area or field by systematically searching, selecting, and synthesizing existing knowledge” (p. 1294). Additionally, in their influential article describing scoping review methods, Arksey and O’Malley (2005) argue that scoping reviews cover the literature in a broad, yet comprehensive manner, and are an effective way to collate and share the findings from a particular area of research with policy makers and practitioners. We followed Arksey and O’Malley (2005)’s five-stage scoping review process: (i) identifying the research question, (ii) identifying relevant studies, (iii) study selection, (iv) charting the data and (v) collating, summarising, and reporting the results (p. 22). For this study, we continuously built on existing scoping review frameworks with a focus on the proposed research questions as a foundational guide for this work. To promote research transparency, the team developed a scoping review protocol and shared it via the open platform, Open Science Framework (Sur et al., 2020). Throughout the process, consultations with key stakeholders of the Ontario Association of Social Workers, including the President, Board of Directors, staff and a membership based advisory group assisted in providing additional social work perspectives and expertise on the data collected.

Search Strategy for Relevant Studies

We employed a broad scope in the present review to capture a wide range of study designs and publication types. Two members of the research team who are social sciences librarians (NT/JW), developed the pilot search strategy to yield a broad and comprehensive coverage of the topic. The search strategy was developed with three main components in mind: social workers AND diagnosing AND mental illness. The pilot search string was developed for PsycINFO (OVID interface) and reviewed by a third non-affiliated librarian using the PRESS Peer Review of Electronic Search Strategies Guidelines (McGowan et al., 2016).

The reviewed and revised search string was translated into six databases, selected for their thorough coverage across health and social sciences content: Social Services Abstracts (ProQuest), MedLine (OVID), CINAHL (EBSCO), Social Work Abstracts (OVID), and Applied Social Sciences Index and Abstracts (ProQuest). Searches in all six databases were run and results exported to Covidence software on May 3, 2020.

The database searches yielded 8,081 publications. The bibliographic citations for the 8,081 publications were imported onto Covidence, a web-based software that manages and streamlines systematic reviews. An additional eight articles retrieved from a hand search by RA/DS were also included for a total of 8,089 publications. After removing duplicates, 5,747 studies remained. Figure 1 presents a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart of the search and screening process.

Fig. 1
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PRISMA Chart

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Study Selection

To select studies for examination, we conducted a two-stage screening process: (1) title and abstract screening and (2) full-text screening. The relevancy of studies for this scoping review was based on the following inclusion criteria: (i) the focus was on social work in Canada or the US, (ii) written in English or French, (iii) published between January 1980 and April 2020 iv), and focused primarily on social workers doing diagnosis.

Following an article title and abstract review by two research assistants supervised by two members of the primary investigator team (RA/DS), 664 articles were selected for a full-text review. Four research assistants conducted the full-text review, supervised by two members of the primary investigator team (RA/DS). The review was conducted using Covidence software, and a member of the primary investigator team (RA) resolved screening conflicts. Following full-text review, 189 articles met the inclusion criteria.

Data were charted for the 189 studies that met the inclusion criteria. The charting phase is an opportunity to illustrate the narrative emerging from the data by enumerating data points and generating an analysis of the themes from the charted data (Arksey & O’Malley, 2005). Variables for data extraction in the chart included: (1) authors, (2) year of publication, (3) type of publication (e.x., review, grey literature, journal article, book), (4) journal, (5) geographical location, (6) practice setting, (7) study purpose, (8) study methods, (9) sample, (10) key findings, (11) use of the term and activity for diagnosis, (12) diagnostic tool used, (13) alternative terms for diagnosis, (14) social worker’s role in diagnosis, (15) credentials/educational requirements, (16) barriers to implementing diagnosis, (17) facilitators to implementing diagnosis, (18) scope of practice, and (19) recommendations by the authors.

Data Analysis

Data analysis was completed by one research assistant to derive themes, with close supervision by two members of the investigative team (RA/DS). In addition, all members of the research team had opportunity to participate in the interpretation of themes at regular team meetings. We utilized thematic analysis to appraise and categorize the included studies (Braun & Clarke, 2006; Vaismoradi et al., 2013), which research team members have successfully used for data analysis in previous scoping reviews (Ashcroft et al., 2019). Thematic analysis is a method to guide identification, analysis, and reporting of relevant patterns (themes) in the data (Braun & Clarke, 2006). The six phases of thematic analysis outlined by Braun and Clarke (2006) was adapted to analyze our results. Thus, our analysis included familiarizing ourselves with the data, review of the charted data, written ideas about the charted data, team discussion about the charted data, identification of themes across the articles, categorization of themes in main categories and sub-categories, and a report of the analysis in the form of the results section below.

Results

All of the publications included in the final sample were issued between January 1980 and April 2020. We chose the date January 1980 because it is the year the DSM -III was published and there was a shift towards including other clinicians outside of the psychiatry profession to diagnose. A 20-year span for publications identified for this scoping review provided important historical context with respect to legislation, emerging evidence and to identify and map the evidence available over time. The sample contained full books, select book chapters, empirical articles, theoretical journal articles, grey literature, and both systemic and literature reviews. Based on a numerical analysis, 182 publications were from the US, 4 from Canada, and 3 from both Canada and the US.

The sample covered a wide range of practice settings, with the most reference made to hospital, community medical and specialty mental health clinics, and multiple settings (i.e., a combination of settings such as hospitals, private practice, and community). An analysis of the stated objectives from the journal articles in the sample generated themes around education and training (i.e., assessing Master of Social Work [MSW] students’ confidence in their ability to diagnose), clinical activities (i.e., determining diagnostic concordance between different mental health professionals) and contextual factors (i.e., exploring how social workers view and utilize the medical diagnostic perspective). Our findings show 92% (N = 173) of the publications we appraised explicitly use the word ‘diagnosis’.

Alternative descriptions such as ‘assessment’ ‘screening’ ‘identifying’ ‘detecting’ and ‘evaluating’ were used either separately or in conjunction with ‘diagnosis’. The majority of articles, 85% (N = 161) used ‘diagnosis’ to refer to social workers engaged in clinical activity. Based on a numerical analysis of the relevant publications, social workers diagnosed independently in 58% (N = 110) of the work appraised. The publications we reviewed demonstrated social workers directly diagnosing using the DSM and other methods, providing collaborative consultation on psychosocial issues for the purposes of differential diagnosis, making diagnoses for court/legal purposes, and assigning diagnoses based on case vignettes for empirical research. Of the publications that noted the use of a diagnostic tool, 54% (N = 103) recorded using the DSM (II, III, IV, and V). However, some used terms like assessment in addition to diagnosis. Social workers utilized other assessment and diagnostic tools in several areas of health and mental health practice, such as substance use, mood disorders, post-traumatic stress disorder, child assessment tools, eating disorders, and autism.

Four themes emerged from our thematic analysis of the findings: (i) professional positioning; (ii) intersection of clinical activities and diagnosis; (iii) contextual factors that impact social workers ability or willingness to diagnose; and (iv) education and training.

Professional Positioning

Several publications emphasized that social work’s psychosocial and sociocultural lens during assessment adds value to the diagnostic process. Probst (2013) suggests that social work’s dominance in mental health service provision positions them to ensure that diagnoses draw a balance between psychiatric and ecological considerations. Barrera & Jordan (2011) noted that the post-modern, outside-the-box thinking social workers employ may allow them to gain important information about cultural context, enabling more accurate diagnosis for clients from various ethnic and racial backgrounds (Noël & Whaley, 2012). Building on this idea, Corcoran & Walsh (2016) observe that social workers’ awareness of the limitations of the DSM uniquely positions them to highlight all aspects of a client’s circumstances that could inform a diagnosis (i.e., strengths and resources). Social work is also distinguished by understanding the value of ongoing assessment, even after assigning a diagnosis, further increasing the potential for maintaining a rigorous standard of practice in this area (Corcoran & Walsh, 2016).

Additionally, social workers’ front-line position and presence in an extremely wide range of practice settings provide an opportunity to participate in the early identification of issues such as autism spectrum disorder (Dababnah et al., 2011) and borderline personality disorder (Eckrich, 1985). A social worker’s perspective on family and financial factors can prove essential when conducting a differential diagnosis for substance abuse issues (Gropper, 1992). Furthermore, social work’s role as the largest mental health care providers to those with psychiatric disorders supports the need for diagnosis as an important component of implementing evidence-based practice.

Professional Tensions

An extension of the first theme relates to the tensions that exist for social workers related to diagnosis because of social work’s professional values and the biomedical model of psychiatric diagnosis. Several authors posited that emphasizing diagnosis in social work diminishes the psychosocial lens characterizing the profession (Carney, 2014). Social work is known for using the Person-in-Environment (PIE) perspective to assess patients and clients, which emphasizes social, environmental and cultural factors (Corcoran & Walsh, 2016). Several publications highlighted how the biomedical model, to which DSM diagnosis is inextricably linked, is known to conflict with social work ethics and values, a sentiment that was expressed strongly in a series of publications dating as far back as the 1980’s (Kirk & Kutchins, 1988; Kutchins & Kirk, 1987; Kutchins & Kirk, 1988). This apprehension amongst social workers to fully endorse diagnosis has the potential to influence practice decisions. For example, Courtenay (1991) found that a bias against diagnosis and consequent underutilization of diagnostic tools could explain the under identification of borderline personality disorder in social agencies.

More recent publications in our sample showed that some social workers are apprehensive about the lasting stigma of a DSM diagnosis and its role in pathologizing the client rather than empowering them (Corrigan, 2004; Hitchens & Becker, 2014; Newman et al., 2007). With the non-multiaxial DSM-V, social workers are also concerned how the removal of an axis to note psychosocial stressors will affect their ability to provide a comprehensive diagnosis (Corcoran & Walsh, 2016). Some publications mentioned that the lack of a social work presence in the development of the DSM might be a barrier for social workers who diagnose. For example, few groups outside of psychiatry participate in the review and development of the DSM (Frances & Jones, 2014). One publication called for social workers to have a stronger voice with diagnosis by participating in the development of the DSM (Newman et al., 2007). Of note, social workers participated in task forces informing the DSM-III, and IV (Millon, 1983; Washburn, 2013). Considerable contributions have been made by Janet Williams who utilized classification from the DSM to conduct field trials of PIE to pay attention to psychosocial and environmental functioning (NASW Foundation, 2021). The APA developed the fifth edition of DSM through wide scale collaboration including thousands of clinicians many of whom were social workers, this was thought as a crucial step to ensure the manual had real world considerations (APA, 2013b).

We found that social workers recognize diagnosis to be an inextricable part of mental health practice. The profession has not developed an exact alternative to the DSM (Frazer et al., 2009). It is notable that PIE is commonly used as an alternative to commonly implement social work expertise and philosophy, especially since it is a client-centered approach (Karls & O’Keefe, 2008). It was developed for all areas of social work practice including medical and psychiatry allowing the classifying of social functioning to better understand client difficulties, perceptions and interactions within the context of their environments including mental health (Karls & O’Keefe, 2008). The need to elevate the social work voice and perspective in this context of the DSM is essential since many social workers, particularly in the US, are required to diagnose using the DSM (Phillips, 2013). Social workers in other areas where diagnosis is not a requirement are in a position to leverage this situation and draw attention to the ecological factors involved in diagnosis.

The social work profession has long expressed concerns about the pathologizing and stigmatizing effects diagnosis may have on patients and clients. To address the stigma piece, Corrigan (2007) recommends that social workers conceptualize diagnosis as a continuum and emphasize understanding the individual over normative statements about the groups they belong to. Furthermore, Corrigan (2007) adds that focusing on models of recovery rather than poor prognosis can mitigate the stigmatizing effects of diagnosis. Another perspective we reviewed advises social workers to focus on framing diagnosis in a positive light and delivering de-stigmatizing education about diagnoses to the public (Linton, 2014).

Clinical Activities and Diagnosis

Social workers demonstrate effectively assigning diagnoses and using their clinical judgement to rely on environmental and cultural clinical judgement where appropriate, which is supported by the DSM-IV as it notes that the nuances of individual’s cultural frame are important (Barrera & Jordan, 2011). Social workers are also often consulted to test the reliability and validity of various diagnostic and assessment tools (Guest, 2000) and to assess concordance between clinical judgement and DSM criteria for certain diagnoses (Hilbrand & Hirt, 1987). Issues such as diagnostic overshadowing and misdiagnosis amongst mental health clinicians must be considered when assessing how diagnosis are being implemented (Holub et al., 2018; Kirk & Kutchins, 1988).

Several publications described how social workers add value to collaborative processes of diagnoses in interdisciplinary team settings. In one perspective, Cotrell (2007) proposes that when diagnosing dementia, social work’s knowledge of the patient’s functional losses is an important component of differential diagnosis. Furthermore, social workers are participating in consultation roles to lend their psychosocial perspective. In one example, social workers consulted with pediatricians to add a psychosocial lens to diagnosis of ADHD, depression, anxiety, eating disorders, and family communication issues amongst a pediatric population (Geist & Simon, 1999). Researchers have also demonstrated interest in how mental health professions with different theoretical orientations approach and understand the biopsychosocial component of diagnosis (McFarland et al., 2018).

Social workers employed in interprofessional settings find that DSM diagnoses provide a common language for communicating with psychiatrists and other professionals (Hitchens & Becker, 2014; Ishibashi, 2005). Many social workers view enhancing their diagnosis skills as a career advantage (Lyter & Lyter, 2016). Furthermore, social workers recognize that diagnosis helps with implementing evidence-based interventions and guides referrals for service (Barsky, 2015). Regarding addressing the dominance of the biomedical model of diagnosis, Dewees (2002) provides a comprehensive perspective on social workers re-establishing their essential role in interprofessional contexts and seeking opportunities for critical dialogue. Social workers are uniquely positioned to critically examine prevailing beliefs about the biomedical model and foster an environment where open dialogue may thrive (Dewees, 2002).

Contextual Factors and Diagnosis

Our findings show that organizational factors impact social worker’s ability to diagnose mental health conditions. This includes billing practices, workload, and on-the-job supervision and support. For example, a national survey in the US indicated that while social workers consider the DSM an important part of their clinical practice, they feel pressured to use it for insurance billing purposes (Frazer et al., 2009). Another study noted that clinicians (including social workers) are more likely to diagnose bipolar disorder when they have a low patient load, or when they have more time (Becker & Lamb, 1994). Furthermore, our review of the literature demonstrates that social workers are knowledgeable about the benefits and limitations of the DSM. For example, social workers believe that as an assessment tool, the DSM provides a common language and encourages smooth interdisciplinary communication. However, diagnosing with the DSM also incurs concerning issues such as misdiagnosis, undermining environmental or cultural factors, and the potential for diagnosis to proliferate further stigma (Kutchins & Kirk, 1988). To address some of these concerns, the DSM offers the Cultural Formulation Interview to enhance clinical understanding and decision making for the purpose of clinical diagnosis and person-centered assessments (DeSilva et al., 2015).

Our review demonstrated that barriers to diagnosis are also influenced by the organizational context social workers are practicing in. For example, a study we reviewed showed that organizational factors in child welfare such as high caseloads and high staff turnover affected social workers’ ability to identify depression in caregivers (Chuang et al., 2014). Social workers also experience pressure to diagnose due to employer demands and insurance billing policies. In one study, social workers cite insurance billing as the most common reason for providing a DSM diagnosis, with half the participants claiming they would not use the DSM if it was not a requirement for billing (Frazer et al., 2009). Hitchens and Becker (2014) also found that the social workers felt obligated to record a diagnose in order to receive reimbursement for their services and continue to work with their clients. This pragmatic and nonclinical use of diagnosis raises questions around the consequences of linking diagnostic decisions to reimbursement, such as minimizing psychosocial concerns and benefitting agency survival over client or patient welfare (Frazer et al., 2009).

Education and Training

Our appraisal of the literature demonstrated that social workers are considering the impact of education and training on their diagnostic capacity. For example, social workers support the mandatory inclusion of courses on diagnosis in school curricula (Dziegielewski et al., 2002; Raffoul & Holmes, 1986). We also noted a gap between education and competence in identifying certain mental health issues. In one study, authors found a lack of association between social work education and identification of substance use disorders in caregivers (Chuang et al., 2014). Social work’s increased role in developing and updating the DSM was emphasized amongst educators, who also noted that students are capable of understanding the strengths and limitations of the DSM and using it in a nuanced manner (Lyter & Lyter, 2016). While educators have expressed concern about social work values conflicting with the traditional biomedical understanding of disorders, they also appreciate the role of the DSM in diagnosis and treatment planning and believe that the profession needs a stronger voice in further DSM revisions (Newman et al., 2007).

Several authors expressed concerns about education and training programs not adequately preparing social workers to become diagnosticians (see Barrera & Jordan, 2011; McLendon, 2014; Richardson, 2007). In one notable example, Ponniah et al. (2011) reported the results of a national survey examining the inclusion of structured diagnostic assessment training in accredited social work, clinical psychology, and psychiatry residency programs in the US. The authors found that while didactic training and clinical supervision in structured diagnostic assessment were offered by the majority of programs, MSW programs were amongst those more likely to provide didactic training without a clinical supervision requirement, therefore diverging from the ‘gold standard’ of training (Ponniah et al., 2011). A lack of uniformity on training requirements for diagnosis across different states may be yielding social workers who are inadequately prepared to diagnose compared to other trained professionals (Shah et al., 2019). Barrera & Jordan (2011) also examined the quality of diagnosis training social workers are receiving. They reported that while social work graduate programs are increasingly offering courses on diagnosis, this does not reflect an improvement in the quality of the training if students are not being taught how to properly use the DSM with people of color.

In addition to education and training, our review demonstrated concerns around professional competency. One author noted that social worker diagnosis leads to higher rates of misdiagnosis, particularly when the method used is unstructured, free-style interviews (Nugent, 2005). Earlier studies also examined inconsistencies in the clinical judgement of mental health professionals (including social workers) and whether practitioners are adequately equipped to use existing diagnostic classification systems (Becker & Lamb, 1994).

Schools of social work offering diagnostic training must ensure they are offering high quality training that is keeping up with new directions in the field. This includes incorporating diagnostic content related to minorities (Barrera & Jordan, 2011) and providing opportunities for diagnostic training and field placements in integrated care such as psychopathology, diagnostic interviewing, and medication management (Belsher et al., 2014). Lyter & Lyter (2016) advise social work educators to take a more active role in promoting the development of diagnostic classification systems and also furthering the biopsychosocial perspective in the current system. There are also suggestions for further research regarding the interest from social work students and clinical directors to have courses on structured diagnostic assessment (Ponniah et al., 2011).

To address the limitations of DSM diagnosis, several authors advised how to work both with the DSM and in parallel to it, by enhancing and supplementing the diagnostic process. Bransford & Blizard (2017) for example, note the lack of significance given to trauma etiology in the DSM-V and call upon social workers to supplement traditional diagnosis with trauma-informed assessments and interventions. Social workers are also encouraged to remain on top of new developments and literature which may enhance their understanding of strengths and limitations of the dominant diagnostic system, and also provide supplemental skills in assessment techniques and theories (Ahmedani & Perron, 2012). In our review we noticed that several authors encourage the social work profession to find its own voice and niche within diagnosis (see Levine, 2000; Probst, 2013).

Discussion

This review sought to chart and synthesize the literature on social workers engaging in activities of diagnosis in Canada and the US. Characterizing the venues, methodologies, and examples of social work activities in the literature shows significant contributions of the profession in diagnostic practice. As the demand for mental health services continues to rise, it is imperative to effectively utilize social work’s contribution in diagnosis. Since the purpose of diagnosis is to direct the course of treatment, thorough and comprehensive assessment skills are necessary (Harkness, 2011). Our scoping review demonstrates the need to critically review social workers scope of practice and skills as they are crucial to addressing mental health backlog and community well-being especially with worldwide shifts in mental health overburden. Our scoping review found the term diagnosis is commonly used and the vast majority of literature uses the term in reference to clinical activity. It is concerning; however, that few articles are examining the jurisdictional variations and/or the professional scopes of practice issues that are arising in jurisdictions where diagnosis is not yet part of social work scope of practice. This is particularly problematic for places like Canada where legislated diagnosing is still in its infancy in many places.

In addition, the strengths of the profession have been highlighted, especially in improving the health of families, individuals and communities, particularly in key roles and functions across systems of care (de Saxe Zerden et al., 2019). Although the DSM along with International Classification of Diseases (ICD-11) is the dominant diagnosis tool, it is only one tool. Our review emphasized how social work brings an even more robust lens that can provide a greater understanding of strengths and contexts, which are often neglected if only using the DSM (Turner, 1984, 2005). Several sources used diagnosis plus other terms like strengths-based assessment to illustrate that social work’s role includes yet extends beyond DSM, in fact social work has a role in conceptualizing what diagnosis is within their scope.

It can be argued given the strong influence of the biopsychosocial paradigm in clinical social work practice, that social workers can make critical contributions to the diagnostic process in the field of mental health. It is important to note that the goal of information gathering in the diagnostic process for any professional is to reduce diagnostic uncertainty enough to make optimal decisions about care (National Academies of Sciences, Engineering, and Medicine, 2015). Accuracy of a diagnosis is predicated on the ability to have a comprehensive picture of the client’s story that integrates the biological, psychological, and social world of the client. Social workers as independent practitioners or as members of the mental health team contribute biopsychosocial formulation, generate hypotheses about the origin, and causes of a patient’s symptoms, which are inclusive of biological, psychological, and social factors. This unique contribution is particularly important in an era where funders for mental health services are placing more emphasis on changing behavior, not people, in environments with complex psychosocial histories, and there has been little attention to the impact of the social environment or to biology on individuals (Berzoff & Drisko, 2015).

Professional Positioning

Social workers understand and utilize their professional responsibilities to ensure ethical and competent practice. As one of the largest providers of mental health services, social workers utilize comprehensive assessments to enhance well-being. Assessing client strengths is central to the relationship formed for accurate assessment and treatment. Social workers are also well positioned to understand the intersections of culture, gender and race and the need for ongoing review of environmental and social factors influencing outcomes. The process of diagnosis provides the framework within which many systems of access operate. Through this, intervention is often determined; social workers are critical to understanding the influence of social determinants on prognosis of quality of life. Diagnosis certainly organizes a clinical picture, deciphers intervention and subsequently a frame for pathways to care, social workers not only contribute to this frame but also understands the underpinning relationships between client and environment. The contextual person in environment approach is employed by social workers in a variety of settings, including vulnerable, impoverished, and disadvantaged populations. The profession is well suited to facilitate DSM diagnosis with a comprehensive biopsychosocial assessment by enabling a suitable intervention plan. Given the historical collaborative involvement of the social work profession in the development of diagnostic systems within the field of mental health such as the DSM, and The Psychodynamic Diagnostic Manual, the profession is well positioned to advocate for the controlled act of communicating a diagnosis pertaining to an individual’s full range of psychosocial functioning (Lingiardi & McWilliams, 2015). Advancing and supporting legislation to extend diagnostic privileges to social workers signals an opportunity to capture the complexity of human life and the critical perspective social workers offer to client interactions.

Despite there being some research that includes social work, very little research is being conducted to specifically advance our knowledge around diagnosing specific to the profession. This is problematic because the knowledge domain of diagnosis is rapidly evolving (Turner, 1984, 2005). In the absence of advancement of knowledge related to diagnosis, the profession of social work will remain inhibited in this domain. In addition, there are varying opinions and perspectives related to diagnosis in social work. There needs to be more research to provide social work with professional guidance (Turner, 2005).

Clinical Activities

Social workers have a professional responsibility to maintain proficiency in theory and practice regardless of occupying a wide range of practice settings and roles. Similar to other care related professionals social workers must demonstrate a commitment to continuing education (Ontario College of Social Workers and Social Service Workers, 2021). This includes ensuring they have the necessary skills and knowledge to assess, document and plan for treatment plan as well as respecting informed consent (CASW, 2005). Many jurisdictions are struggling to meet growing demand for mental health services. The Mental Health Commission of Canada (2016) notes service, treatment, and supports need to be delivered in culturally safe and competent ways. This cultural safety is grounded in the recognition of cultural diversity but also acknowledges the imbalances of power that impact relationships between providers and service users. Formal social work training focuses intensely on cultural sensitivity and humility can enhance the quality of assessment and treatment as it extends to diagnosis. Given the large and widespread presence of the profession, many of these service gaps can be addressed with increased social work scope of practice.

Policy makers, professional associations, and regulatory bodies of social work should promote, in the best interest of the public, the expansion of diagnostic privileges to a qualified group of social workers. Current challenges accessing mental health and addictions services include long wait times, lack of understanding of services, uneven service quality between regions, and fragmentation (Government of Ontario, 2020). The profession of social work is not relegated to a particular practice setting but instead, is a role that spans across health and mental health. Social work holds the ability to evolve rapidly in the context of the future of health services including trauma approaches and integrated models. Providing social workers the environment and context to use the DSM appropriately in clinical work would help to significantly address barriers to access.

Contextual Factors

Since the emergence of the profession, social work has been intimately involved in the care of communities. The profession continues to connect social and environmental conditions to mental and physical outcomes and enhanced quality of life. Enabling social workers to reliably diagnose certain mental health conditions can alleviate barriers to access and lengthy wait times (Ratnasingham et al., 2012). Social workers are well-positioned to make a timely contribution to a more specialized diagnostic role in their practice settings. Uniquely, social workers are also positioned to not only diagnose, but provide comprehensive treatment including connections to community-based programs and services such as substance abuse treatment, shelters, and outreach programs. The US has clearly embedded diagnosis in the social work role and as such the profession scope is widely recognized to include this. We require more Canadian content as Canada is lagging behind in addressing the full scope of practice (Austin, 2017; Turner, 2005).

Mental health conditions can not only be diagnosed but also individuals, families and couples can be provided treatment for anxiety, depression, trauma, addiction, and many other mental health issues. This requires the comprehensive exploration of the capacity to create legislation that formalizes the contribution of social workers to the diagnostic process.

Education & Training

As part of a larger system, use of the DSM allows interprofessional and cross discipline colleagues to converse in common language, as such formal and professional training programs will require accurate learning of diagnostic categories (Newfoundland and Labrador College of Social Workers, 2020). Diagnosing using the DSM requires training, experience, and supervision. Training and educational prerequisite considerations ought to be a combination of academic, clinical experience, and specialization. Formalized training for social workers already includes and aligns with some aspects of mental health recognition as noted in the DSM. Further aligning academic requirements with clinical social work scope of practice will ensure appropriate levels of expertise are matched with high quality competencies. The strengthening of curriculum to not only include the recognition of symptoms but the ability to include differential diagnosis could be enhanced with schools of social work in Canada. In a study of social work educators and the use of the DSM classification system, Lyter & Lyter (2016) noted over 90% of respondents reported DSM content being included in the curriculum. Literature examined in this review noted the significant support from social workers to ensuring advanced preparation for any increase in scope of practice, including the legal authority to submit a DSM diagnosis for social workers amongst other professions (Lyter & Lyter, 2016).

Limitations

Given the broad nature of the research question, the findings may be similarly broad. Similarly, scoping reviews do not appraise quality (Arksey & O’Malley, 2005). Scoping review methodologies provide an overview of topic areas, as opposed to assessing for methodological quality. This scoping review examined the nature of the literature on the practice of diagnosing mental health disorders in Canada and the US and excluded other international literature.

Conclusions

In many jurisdictions social workers are integrated fully in a mental health system of care. Mental heath is a rapid growing concern requiring trained professionals to provide timely information about assessment, treatment approaches, and diagnosis information. This includes the recognition of symptoms and supporting recovery. Diagnosis is an essential and logical integration in social work scope of practice, especially since social workers bring extensive expertise and knowledge in their client interventions.