When recent graduate Dr. Sandy Rao began her PhD in social work at the University of Calgary, she brought with her years of experience as both a clinician and a senior leader in Ontario's health system.
Yet, despite her deep understanding of mental health care, she found herself haunted by a question no program or policy seemed to answer: "We were doing all the right things: engaging the community, co-designing programs, listening to lived experience, so why wasn't it working?"
That question became the foundation for her doctoral research: exploring not just mental health access, but how to research access, finding ways of including people who are usually missed in traditional studies.
Before entering academia, Rao, PhD'25, was director of Mental Health and Addictions at Ontario Health. She'd led the development of a "low-barrier" access model that involved thousands of community engagements and did everything that was usually suggested for removing barriers. The only problem was it didn't work.
"It was supposed to be the gold standard," says Rao. "But, when it launched, it failed to meet people's needs. That's what drove me back to school. I wanted to understand why."
The "access paradox"
Working under the supervision of Dr. Gina Dimitropoulos, PhD, of the Faculty of Social Work and Dr. Scott Patten, PhD'94, MD, of the Cumming School of Medicine, Rao's research uncovered what she calls the access paradox: the realization that the very things required to access mental health care are often impossible for someone experiencing mental illness.
"If we were designing a system for someone with a broken leg, we would never put the clinic on the 30th floor with no elevator everyone would agree that makes no sense yet, that's exactly what we do to people with mental illness," Rao says.
"We design systems that require them to fill out dozens of forms, travel to new places, make phone calls and advocate for themselves, all the things they're least able to do when they're unwell.
"In effect, the system becomes an exclusionary structure. If you manage to do all those things, people assume you must not be that sick. It's a catch-22. That's the access paradox."
Rao's collaborators and co-researchers included young adults with lived experience trying to navigate the health-care system.
The HEARTS Study
Rao's doctoral research, the HEARTS Study (Helping Enable Access and Remove Barriers To Support for Youth and Young Adults) brought these insights together.
Designed and conducted with young people who live with mental health-related disabilities, HEARTS explored what real accessibility means in practice, and how traditional research often excludes the very individuals most affected by inaccessibility.
"The goal of HEARTS was to make sure that the research process itself didn't reproduce the same barriers we were studying," Rao says.
"We co-designed every part of it, from how we gathered data to how we shared findings, so that young people could fully participate, even when traditional methods made that hard."
The study identified the access paradox and led to the creation of Rao's Mental Health Accessibility and Policy Solutions Lab (MAPS Lab), which continues to partner with youth, families and service providers to test new, equity-informed approaches to care.
"The MAPS Lab is about moving from theory to action," she says.
"We're building evidence with communities, not for them."
A social work lens on health research
For Rao, HEARTS is also a prime example of why social work research is so essential in reimagining systems of care.
"Social work starts from values: justice, dignity and liberation," she says.
"Other disciplines try to bracket those things out, but we don't. The goal of this research was emancipation; to make research itself accessible and liberatory for young people with mental health-related disabilities."
Her approach, rooted in critical realism, challenged the biomedical model's reliance on a single "objective" truth. Instead, Rao and her co-researchers embraced multiple ways of knowing, incorporating lenses that included Indigenous and Afrocentric perspectives.
"There isn't one way to be well," Rao says. "And there isn't one way to create knowledge, either."
These multiple ways of knowing the world are, for example, reflected in her innovative dissertation which included a playlist of songs chosen by participants who struggled to express their experiences in words.
"Music became a language for people whose symptoms made it hard to communicate," Rao says.
"It let them be heard in a way that felt authentic."
Co-creating solutions
Rather than simply identifying what was broken, Rao's team co-developed a Recognition-Access Opportunity Map, a tool to help practitioners and systems reduce barriers in real time. Recommendations include offering home-based services, reducing redundant paperwork and adapting physical spaces to minimize sensory overload.
"Something as simple as dimming lights or changing the environment can make a huge difference," Rao says.
"We can't wait for structural reform before we make things more humane."
She also reframes common narratives: "We say young people fall through the cracks,' but the truth is, the system was never built for them. They're not failing, they're surviving ableist structures that were designed without them in mind."
Changing the conversation
Rao's research is already influencing teaching and practice.
Now an instructor at the University of Toronto, she integrates her findings into her social work courses.
One small, but powerful shift she promotes is moving from asking clients, "What's wrong with you?" to, "What matters to you?"
"It's a subtle change, but it transforms the encounter," Rao says. "It's about dignity, not diagnosis."
Her work has also inspired her young co-researchers to lead their own projects several have already published their first papers.
"That's what I'm most proud of," Rao says.
"Helping young people find their voice and lead their own research and then stepping out of the way."
What's next?
Rao continues to practice as a clinician while leading international collaborations on critical realism. She directs the North American Network for Critical Realism and co-leads a global fellowship that includes scholars from India, Iran and across Africa.
Her next goal is clear: to keep turning research into action.
"Research sitting on a shelf helps no one," Rao says.
"We now have an evidentiary start.
"The next step is putting it into practice - creating systems where everyone, regardless of ability, is seen, heard and valued."
The University of Calgary, Faculty of Social Work is Canada's largest school of social work and recognized as a global leader in social work research.
Dr. Gina Dimitropoulus, PhD, is a professor in the Faculty of Social Work. She is also a member of the Cumming School of Medicine's O'Brien Institute for Public Health, Hotchkiss Brain Institute (HBI) and HBI's Mathison Centre for Mental Health Research and Education. She is also a member of the CSM's Alberta Children's Hospital Research Institute.
Dr. Scott Patten, MD, PhD, is a professor in the Department of Community Health Sciences, Cumming School of Medicine (CSM). He is a member of the CSM's O'Brien Institute for Public Health, Hotchkiss Brain Institute (HBI) and HBI's Mathison Centre for Mental Health Research and Education. He is also a member of the CSM's Alberta Children's Hospital Research Institute.
