How to fix the mental health workforce? WA has an underutilized resource: peer counselors

The Mental Health Project is a Seattle Times initiative focused on covering mental and behavioral…

How to fix the mental health workforce? WA has an underutilized resource: peer counselors
How to fix the mental health workforce? WA has an underutilized resource: peer counselors

The Mental Health Project is a Seattle Times initiative focused on covering mental and behavioral health issues. It is funded by Ballmer Group, a national organization focused on economic mobility for children and families. The Seattle Times maintains editorial control over work produced by this team.

Patti Shah Karam wasn’t in a healthy head space. It was the day before Thanksgiving and big holidays are hard for her, as she’s mostly estranged from her family.

But Thai Nguyen, a 31-year-old peer mental health counselor who was at Shah Karam’s Shoreline apartment for their weekly meeting, helped pull her out of bed and out of a funk, she said.

Remind yourself that you want better in life, he told Shah Karam, 55. That this negative pattern doesn’t have to continue. “I know it doesn’t feel that way, but that’s what we’re going to keep working on.” 

Shah Karam nodded. “See how he is. No matter what happens, he boosts me up,” she said. 

Nguyen’s work as a peer counselor — someone who has personal experience with mental health challenges or substance use and uses that expertise to support others — represents a growing niche in the mental health landscape. Peers build close connections by relating to people in a way clinicians don’t. And because peers don’t require the same level of schooling and licensure, they can get trained faster and start working, helping close the gaps for a behavioral health industry desperate for more staff.

Peer work takes various forms in Washington: Some peers work alongside clinicians as part of a client’s care team at community behavioral health organizations. Some run residential facilities where clients can stay for days or weeks. Others serve more as volunteers.

There are limits to their roles, though. Peers don’t replace clinical work. And as the model evolves, there are other questions among skeptics and peers themselves: How should peers set boundaries with clients when they build close relationships? How can their positions be valued and paid equitably?

“I remember when peers first arrived on the scene. There was an incredible amount of suspicion about them, particularly when they were part of a clinical team,” said state Rep. Lauren Davis, who helped found the Washington Recovery Alliance and served on King County’s Behavioral Health Advisory Board. Since that time, she said, there has been a tremendous amount of education and advocacy to support peer work.

“If the stigma were gone, there would be pay equity for peers,” she said. “That being said, I do think peers are tremendously valued.”

What is peer work?

Jonathan Forbes keeps a picture of his last jail booking on his desk. It’s from 5 1/2 years ago when he was a lean 150 pounds, he said, “completely strung out” on drugs, homeless and “completely hopeless.” Forbes, now the program manager at Peer Spokane, shows that photo to every client he works with.

“Having experienced all of that myself firsthand, it builds an immediate rapport with the members that we serve,” he said.

In Forbes’ view, peer work diverges from other mental health services, like clinical therapy, because goals are centered on the person’s preferences — not insurance requirements or counseling frameworks. Peer support can also extend beyond mental health into other areas of life, like giving someone a ride to a local food bank or helping mediate a dispute with their landlord.

“Our job is to simply greet you as a whole person,” said Joshua Wallace, the CEO and President of Peer Washington. “You may be feeling beaten and broken down, but you’re alive, and you made it through our door.”

In the eyes of the state, however, peers have been “enshrined as second-class in the health care workforce,” Rep. Davis said. Washington’s Title 18, which details descriptions for other professions in the state, doesn’t include peers.

Because peer work is not currently listed as a health profession, they cannot bill commercial insurance companies for their services. They’re instead classified as agency affiliated counselors, which means they can only get reimbursed for working with clients at community behavioral health agencies. Peers who work in primary care or emergency departments cannot bill for their services, even if their clients are on Medicaid.

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Codifying the profession “would expand locations where peers can work and bill, so it would be a real boon for our behavioral health workforce shortage,” Davis said.

Davis, who previously sponsored a bill to codify the role, said she is working with other lawmakers again on similar legislation this session. While the bill had cleared several hurdles in the state House and Senate, it ultimately didn’t pass amid questions about how best to credential peers.

At Compass Health, peers, along with care coordinators and therapists, are a “critical” part of mental health care teams, said Megan Boyle, director of children’s intensive services. 

But there are challenges to getting peers onboarded, she said.

Peers undergo training in a couple of ways: To work for a community behavioral health organization, they need to seek credentials through Washington’s Department of Health. In addition, most organizations want peers to complete a 40-hour training course through Washington’s Health Care Authority. But these trainings often have waiting lists, Boyle said.

In his 2022 State of the Union, President Joe Biden called for a plan to create a national certification program for peer specialists, to “accelerate universal adoption, recognition, and integration of the peer mental health workforce across all elements of the health care system,” according to his outline, but that has yet to be implemented.

Boyle also said pay for peers is a concern.

“There is a ton of stress and responsibility placed on them,” she said. “And I would like to see them receive pay that matches their contribution.”

Average pay rates are difficult to determine, but current job postings in Washington mostly have ranges between $18 and $24 per hour, with some going up to $34 per hour.

The mental health workforce, in Washington and nationwide, has struggled to retain clinical providers as burnout and low pay compound. But Wallace said Peer Washington has continued to attract peers.

His organization, which is mostly volunteer-based, pays peers $20 to $25 per successful meeting, he said. It’s mostly a stipend to offset costs for travel, coffee or any activities pairs might have done.

“What they’re getting out of peer work is validation of their own recovery,” he said.

Expanding the model

As the peer model continues to grow in Washington, a new facility that finished construction this month in Tacoma aims to extend peer work to 24/7 support. SafetyNet, Washington state’s first respite facility run entirely by peer counselors, will offer a voluntary place “to go seek refuge and engage in activities that enhance our wellness,” said Greg Jones, the administrator and clinical supervisor of peer services at SafetyNet. 

In the one-story, five-bedroom home’s living room you may see groups practicing yoga or having therapy sessions. Turn a corner and you’ll walk into a sauna room with a Himalayan salt wall. Outside, residents could be drinking coffee, chatting and connecting.

Operators don’t do room checks. There are no restraints or forced medication. Therapy is optional.

A resident that would fit SafetyNet’s criteria is someone who is stressed and looking for a place to decompress. Someone who has a serious mental illness and is in crisis should go to a hospital, Jones said. 

Jones said the Washington Department of Health licensed SafetyNet as a behavioral health agency and home health agency. The program will accept Medicaid and private insurance. It’s unclear how much a stay would cost; rates are still being negotiated.

Residents can come to the house for up to seven days per month, on a rolling basis. They must go through pre-admission screening with certified peer counselors to determine eligibility criteria and “invest their spirit into the experience.” (Jones said the faith-based program is about “honoring divinity” but not tied to any specific religion.)

“You’re in the driver’s seat of your own recovery process. I’m just the co-pilot,” he said. “We’re just about understanding what your goals are and doing whatever we can to assist.”

Boundaries

The peer model often relies on close relationships and extensive availability, even outside of traditional business hours, which can raise questions about setting professional boundaries to protect the peers’ time and well-being.

Shah Karam and Nguyen talk a few times per week to check in. If she’s having trouble with family or another issue, he’ll get a long text.

“I almost see him as a friend now,” she said.

Nguyen said he sets boundaries by taking a different role depending on his client. “Sometimes, I’m just their peer or their friend, helping them push them along the way. Other times I take the harsher role and someone else can be the friend.”

Davis rejects the idea that peers are any less professional than clinicians, despite the lack of university training.

Peer services are important before, during and after mental health treatment, she said. “People who have peers stay in treatment longer,” and have better results afterward.

Pierce County reduced involuntary hospitalization by 32% by using certified peer specialists offering respite services, according to an internal analysis from OptumHealth.

Limitations

Most peers said they view themselves as a valuable addition to someone’s overall growth, and just one of many people assisting their mental wellness.

“My concern about peers is that they can be misused,” said Jerri Clark, founder of Mothers of the Mentally Ill. “They need to be understood for their important role and not used to replace the roles that are just starkly missing in our current systems of care,” she said, referring to physicians and other medical providers. 

Clark’s son, Calvin, had bipolar disorder and became homeless as his condition grew more severe. He died in 2019.

There’s a view in the mental health field that most people just need somebody to talk to, who sees them for who they are, she said. People with severe mental illnesses, however, need sophisticated medical interventions.

And it’s the fact that peers could be, and sometimes are, exploited, undervalued and underpaid that concerns Evelyn Clark. A change consultant and racial equity trainer at a health consulting business, she said she’s worked for various behavioral health organizations throughout Washington for nearly 15 years.

In her experience, agencies often don’t understand the role of a peer, “so they put us out there to figure it out with no support.”

Even when she was a supervisor and part of a management team, she said she was not making as much money as people in clinical roles.

People in leadership would tell her, “Well, if you want more money, go back to school,” she said. But, she argues, “part of the peer role is that you don’t need a degree; it’s your lived experience,” and the educational debt many clinicians carry can be financially debilitating, a 2022 report from the Behavioral Health Workforce Advisory Committee found.

Mental health resources from The Seattle Times

Peers need to work for organizations that have peers at the top of leadership and support the diversity of their staff, Evelyn Clark said. Peers tend to be more racially and ethnically representative of the clientele they’re serving, compared to clinicians, the report found.

Muhamed Selavic, 25, said he struggled to get hours and fair pay while working for SPARK, Students Providing and Receiving Knowledge, a Washington peer organization.

Management at the organization cut his hours down from 40 to 25 due to budgetary constraints, and “shut down” peers when they pushed for raises, he said. He wasn’t receiving health care benefits and didn’t get reimbursed for gas even though he often drove across the state.

Carolyn Cox, the program director for SPARK, said her organization receives positive feedback from the vast majority of peers they work with. The peers, who make between $22.50 and $30 an hour depending on experience and where they live, are contractors, not employees. They work on an as-needed basis, without benefits, and are told upon starting that some contracts have slower periods where they may not have hours, she said. Cox said reimbursements for travel were part of some but not all contracts.

Selavic ultimately stopped working with the group. “I have my own nonprofit that I just recently started” called General Purpose, “and we’ve been in programming for a month now,” he said in December.

Still, peers say there are reasons they stay in this work, despite the challenges.

“For me, it’s the opportunity to give them something that I didn’t have — a space full of promises, opportunity, growth and learning and a healthy environment,” Selavic said. “Just seeing that smile.”