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Charting the Way: Expanding the Behavioral Health Workforce - The Role of Peers

May 24, 2021

Behavioral health challenges—notably substance use and mental health—are more prevalent than ever, but the workforce needed to provide support is shrinking, even as the need for equitable services grows. How did we get here? How can we turn the tide? And how can we incorporate social justice into those efforts? We’ll address all of these questions in the Charting the Way podcast miniseries.

For many people, especially those with mental illness or substance use problems in underserved racially or ethnically diverse communities, it’s difficult to receive the support they need. In the second episode of Charting the Way, Lisanne Brown of Abt and Keris Myrick of S2i at the JED Foundation talk about the vital role peers and people with lived experience can play as we address America’s need for more behavioral health workers.

Listen to episode 1 here and episode 3 here.

    Read the Transcript

    Eric Tischler: Behavioral health challenges, notably substance use and mental health, are more prevalent than ever, but the workforce is shrinking even as the need for equitable services grows. How did we get here? How can we turn the tide? And how can we incorporate social justice into those efforts? We'll address all of these questions in this podcast miniseries.

    I'm Eric Tischler from Abt Associates, and joining me today are my colleague Lisanne Brown and our guest, Keris Myrick. For years, Keris has held some of the highest level positions in the world of mental health peer support, including chief of peer and allied mental health professions for the Los Angeles County Department of Mental health. Today, she's director of the JED Foundation and co-director of S2i, the Mental Health Strategic Impact Initiative at the JED Foundation.

    Lisanne has more than 20 years of experience in public health evaluation and research, and her areas of expertise include maternal and child health, health care access, and the integration of primary care and behavioral health. Welcome.

    Keris Myrick: Thank you.

    Lisanne Brown: Thrilled to be here, Eric.

    Eric: Keris, if you could help me set the table here: What's the role of peer and community-based leadership as part of the behavioral health workforce, and why is it important?

    Keris: This is really such a great question. A couple of things I want to do first is define the word “peer,” because it's a word that's used a lot in the behavioral health field and it can have lots of different meanings. When we're talking about peer, sometimes we're talking about what used to be called consumers, or people with lived experience who are the actual recipients of service.

    We can also be talking about capital P, Peer–I'll put it that way–where we're really talking about peer workforce, or certified peer specialists, recovery coaches. Those are folks with lived experience of a mental health condition, or a substance use condition, or both, who are actually trained to provide support to others in the workforce.

    Your question is really almost two or threefold around what is the role of peer- and community- based leadership in the behavioral health workforce? I think there are a lot of different roles. One is they can be people who are providing services as providers, or supervisors of those providers. They can also be folks who are in administrative roles in either, like me, for example, when I worked for the L.A. County Department of Mental Health, I was the chief of peer and allied health professions. And basically, what that means is that there were five different chiefs of the providers, or disciplines, if you will. We call it discipline chiefs, but that sounds like you're whipping people, which we definitely were not.

    Eric: Thanks for clarifying.

    Keris: Yeah, just to clarify. We're five different disciplines, and many of them we know already. Psychology, psychiatry, nursing, social work, and then I was the fifth discipline, just like you would think of the fifth dimension, which was for the peer workforce and allied health professionals, which are health workers, and any roles in which people do not have a license to practice, but may have some training and/or certification.

    So leadership is really important because, for those of us who were service recipients, we see those services from the, "Wow, I received that” services end. And then, when we moved into leadership positions, we see, well, “Gee, that's how the system works?” or maybe doesn't work. And so, we become a really important informant in a leadership role to help the behavioral health system actually be much more responsive to the actual people that they're serving. And to think about stuff like access, and “What is access? What does that mean?” I'm going into all sorts of stuff, and you can see why leadership is super important.

    Eric: Great. And Lisanne, you want to weigh in on that, and your take on that admittedly broad question?

    Lisanne: I think a lot of behavioral health clinical staff have a lot of challenges understanding, I think, the differences between, I think, the little P and the big P, and how to integrate those staff into their services, because I don't think they really understand either.

    Keris: Yeah. I think a lot of times, it's like bringing in a new role into your treatment team. Let's put it that way. And if you don't understand what that person is supposed to be doing, or how they're supposed to be doing it, how do you support them really doing their role according to their scope of practice? I think this is another reason why peer and other types of leadership are really important. Because we can help our behavioral health treatment teams have a better understanding of the work that we do, how we do it. And if we do it according to our scope of practice, we can actually get the outcomes that the evidence says that we can obtain. When we do things like training, if we have people who are running the office of consumer and peer affairs, if you will, we can always help our providers in that way. Now, I'm losing my voice, so hold on.

    Lisanne: Well, here, I can chime in for a minute while you grab a sip of water.

    Eric: Hydrate.

    Lisanne: We've learned from some studies in HIV clinic settings that providers don't fully understand how best to integrate allied health staff to improve the services for their patients. There's a real opportunity to improve recovery efforts outside of the clinic setting to ensure that people [regain] their overall wellness over time outside of the clinic setting.

    Keris: Maybe to give an example, and I'll use LACDMH as one of the examples, but I can do this, support people in other realms, too, is looking at things like grand rounds. That might be even a first step of an example to train on “What is a peer? What is a community health worker? What is their scope of practice? What kind of services do they provide within the clinic setting?” And also, there may be community-based settings, there may be prevention work. And how does that intermix with the entire team, and/or with the role that you're providing, for example, as a psychiatrist?

    Sometimes when we're trying to implement new work, such as integrating technology into a space of mental health, that can include tele-health as well as using any other kind of digital therapeutics. Partnering up peers and the provider, force to figure out how are we going to actually implement this new way of providing services and supports into our system of care.

    That is another way that I will say licensed providers can have a better understanding of the role of peers, not only as the provider or supporter who may be supporting the person in understanding how to use the technology, helping them set up an email account, some very basic stuff, but they also hear how the people they're serving actually use technology, understand the services they're receiving, understand, "Well, that guy can never show up. I just think they're actually being non-compliant."

    And the peer will say, "Well, actually, I had to help that guy actually get the bus tokens. He's not showing up because he can't get on the bus to get here." But that may not come out in a natural conversation, but it may come out more naturally with the peer who's been there and done that. I think that's ways in which we can utilize the peer workforce, and not just to do the work of providing the support and service, but also to help inform how those services are actually provided within the mental health setting, and also within the community at large.

    Eric: I know we had challenges building that peer workforce. You want to address what's going on there? What we might be able to do to build that workforce?

    Keris: I think there are a couple of different things to think about within when we think of workforce at large, we think of counting widgets, and the number of-- How many psychologists do we need? Et cetera. And peer workforce is new to this equation. At least in my mind, the first thing that I would think of is first probably not counting the widgets, but looking at what kind of collaborative care and team is needed to support people. And doing that in a way that everybody is operating within their scope of practice.

    I think right now, especially when we look at public mental health, we'll see a lot of people doing things that are probably not within their scope of practice, but maybe in the scope of practice of somebody completely different. How can we count widgets, and know if those widgets are even right? I think first kind of backing up into who do we need where, and how should they be deployed is one thing to look at. And when we look at the peer workforce, I think, again, it's fairly new. There are 48 states that have met the CMS guidance for having a statewide peer certification.

    And I think understanding what is the role of the peer. Really trusting that we have enough evidence about the outcomes from peer support or peer services that are provided. There's plenty of evidence. Is it "gold standard" evidence-based practice kind of thing? In some areas yes, and in some areas no. I would say that for some things that we're doing, it is definitely an emerging practice. We don't have the funding to go get a gold standard, evidence-based kind of research.

    And I think the other issue is funding. Who's going to pay for it, and how is it going to get paid for? And the rates are variable across the country, the Medicaid reimbursement rates for peer services, they're variable. And if a person can't make a living being a peer provider at a low rate, will probably mean there's a lower wage, then it may not be something that somebody with lived experience might do. They might actually go into something completely different where they're making more money, either in the service array, or in a more supportive position.

    Is there stigma? Yes. Is there discrimination? Yes. And I think those are things that we also have to address. And I like to think of it this way, so let's take a very large system. Let's say there are 8,000 people working in a large mental health system. Just looking at our mental health system. If there are 8,000 people, and they know that one in five or one in four people are affected by a mental health condition sometimes in their life, I ask people just to do the math. And just by the mere fact of the math, do not count your peers, take them out of the equation, you probably already have people who are working within the system who have a mental health and/or behavioral health condition, they're just not out about it. More than likely they're using it, thinking about what happened with them, to them while they were receiving services. And so, how they may address someone, how they may answer the phone, how they may look at a resume may be impacted by that very lived experience that they have, though they're not out about it.

    Keris: If we do the math and recognize that we probably already have people working with us who have a mental health and/or a substance use condition, the idea of there being some kind of stigma or discrimination about increasing that number doesn't really make any sense to me. I like to back into it that way so that people can see this is not an oddity. This isn't like, "Oh, we've never had them before." Had people with lived experience working with you all along.

    Lisanne: Yeah. I think this is a real opportunity to, in addition to thinking about expanding the role of peers, is training for clinicians and providers to become more familiar with social disparities that impact the population, and really understand that there may be staff within their existing practice and their existing system, just as Keris was mentioning, that they already have the assets internally and just may not be aware of them. But I think some internal education may also, and training may also help the situation.

    Keris: Yeah. I think there's actually some new work being done in many of the professions around adding a competency of structural competencies. A lot of times we hear about cultural competency, but we don't hear much about structural competency. And structural competency gets right at some of those issues you're talking about, which is really understanding, and then addressing some of the structures that inhibits people being able to fully move forward in their wellness. We can make people feel better. We can provide people all sorts of medications, tools, resources, and supports, but if they're continuing to struggle with the very structures that are causing the trauma and/or distress, then it's like this cycle.

    And I like the work, for example, that Dr. Stephanie Lamelle is doing in New York, which is in her residential program she has her residents, these are psychiatrists, she's a psychiatrist, she has her psych residents actually pair up with a peer and spend a day with them. So that, number one, they could see the role of the peer, and see exactly what they're doing and how they're doing it. They can also spend the day with the peer providing support to a person who's receiving services, and the resident walks the walk of alongside that person. If the person has to take the bus to get somewhere or public transportation, so does the resident. If the person only has two bucks a week to spend on food, so does the resident. It becomes a really powerful in vivo kind of real life experience for the residents to have a better understanding of the role of the peer, and also the life of the people that they're serving.

    I think Yale has a similar program, and I would love to see in the peer workforce, we look at issues of structural competencies. One of our competencies is to be advocates. There is a self-advocacy and system advocacy, but we think a lot of times the system advocacy is on the system itself versus on the multitudes of systems that impact a person's life if you think of social determinants of health, and the different systems that are there.

    The other thing that is done, a lot of us do this, is we'll do trainings at the national conventions of the different license providers, American Psychiatric Association, American Psychological Association. Point being is that we will join up with psychiatrists, psychologists, nurses, and social workers, and provide training at these national conferences where a lot of the professions get their CEUs or CMEs. We become a part of that training force right where people are entering in, and trying to get more information about the services they provide to their CME and CEU obligations.

    Eric: Great. Lisanne, do you have anything to add to that?

    Lisanne: Well, I think the social determinants of health framework is very relevant here coming from public health perspective. A lot of public health professionals don't fully understand the scope of what people or individuals are facing, and how important it is to have peers to help navigate all of the different challenges in their lives, whether it's from transportation, food access. And there's so many different factors, and different needs that people may have that someone with a lived experience can really help inform from a structural level.

    Keris: I think there's one other thing when you say that that I'd love to bring up, and that's this: I think also there's a disconnect between mental illness and serious mental illness, which used to be serious and persistent mental illness. And so, when people say, and people still say serious and persistent mental illness, and then talk about recovery, which is always interesting to me. It feels a little oxymoronic, unless you're persistently recovering, which we want, but this idea of persistent illness as in somebody is always ill, meaning always symptomatic.

    I think sometimes what happens is language is super duper important. And so, when we talk about serious mental illness, there's this othering that happens. It's like, "No, you don't have that mental illness over there. That's the okay guy. You have this over here, and well, that's just ridiculously serious. We really got to double down on that sucker." And so, the way that I think that then turns around into the belief about people being able to recover fully, meaning when you look at social determinants of health, for example, or living full lives in the community, there's a limit. And it's like there's a belief that there's this limit, because you have a serious mental illness, and people treat to that limit.

    And so, when people are treating to that limit, then actually folks who are receiving some of those services actually meet that expectation. It's like a Pygmalion effect kind of thing. And so, if you're treating to the limit, and people only reach that limit, it's like, "Well see, that's serious mental illness." It's really hard for us to think about people going beyond that.

    And so, I like to reframe it. I know I can't get rid of serious mental illness. It's a concept to help with understanding who's going to be in public health and not, and who's going to pay for things. And I understand that as a construct. I think when we're thinking about public health approaches, and the roles of our providers, and peers, and community health workers, thinking about what do we do when someone's mental health condition is at its most serious? That's the continuum. And that it's not always there, but at times it can be there.

    What are we doing when it's not there? What are we doing, again, in a prevention, so it doesn't get there? And that's all sorts of different ways of thinking and reconceptualizing serious mental illness is this continuum of waxing and waning, and providing people the supports that they need, the treatment that they need, no matter where they are in that continuum, as well as I say holding the expectations the sky is the limit, and people get to tell us where their sky is, and then we need to support them to reach that sky.

    Eric: Well, that seems like a good segue to ask you about your comment that “Access is about too many people in this system without a way out.”

    Keris: Yeah. Very interesting about access. This is another one of those when you're in the system, and you see how the system treats you from the "consumer peer lived experience” lens. Access starts to be very different when you then start to work from the system end, and that does have a lot to do with this idea of, well, is access really about getting in the system or is access about helping people move through and out of, especially, the public mental health system?

    This does not mean that people are not still getting treatment and support as they need, but not to the expectation such that when you have a serious mental illness, you must be in public mental health forever and a day. “You will always be on medication. You will never live a life fully. You won't go to work.” I'm sorry, those are all the things that I, and many of my peers were told, especially when given a diagnosis of a serious mental health condition. I was definitely told, "Well, you won't go to work. You won't finish school. You'll always live in some kind of congregate care or with your family." And it was this weird death sentence.

    And even when we talk a lot about recovery now, a lot of people are still getting that same message. And it starts off, "Well, you have a serious mental illness." People are shaking their heads, their eyes are squinting, and they're making that serious face like, "Oh my gosh." And so, when we treat people that way, we hold people in the system, and the system can only hold but so many people. How are people going to get in if we don't have the belief that people can flourish, and come out of the system, and move on in their lives? And again, some people may need longer care than others. We can't predict that I don't think.

    Yeah, I think how do we help people move in, and through, and out? And if they need to come back into the public system, making that easy. It's not easy. It's just not easy to get in. If you're trying to get things like to get on disability and things like that. It's not an easy thing for people, especially if you're not doing well.

    I think there are two points of it: What can we be doing more on the prevention end on the community end? There's a lot more that we could be doing to support people in the community where they are. How they might receive services. If they're afraid even to access. There are things like barbershop projects, especially in communities of color where barbers are actually trained almost like peers. Some of them do have lived experience, some of them don't. But definitely their community workers who can support the person who's coming to the barbershop or the beauty salon. If you're an African-American, you just don't go get your hair done and you're gone. That is an all day, serious affair. You're hanging out there, you're talking to people, you're talking to the beautician, you're talking to the barber. And usually, you're telling them or talking to them about your life. Like imagine Cheers, no alcohol, but a bunch of barber chairs, hair sinks, and shampoo. That's what's happening there, and it's just a super way to ... And you're hearing that they're struggling, but as a barber, you might not know what to do.

    There are projects like The Confess Project in which barbers are trained to be able to have these conversations in the ways that culturally align to support people either in the moment, or help refer them. I have a peer here in Los Angeles, and he's come up with this great ... He's a barber, so he's like, "Yeah, they come here all the time, and they send the person who's talking on the street, they send them to me as I'm cutting hair." And what he really wants to do is take that Confess Project idea, and move it up a notch. What would happen if we had a social worker or a psychologist available right there? Don't make them go to the mental health center. They're already there. They're live and ready to go, right? You've talked to them about what it means to live with a mental health issue, to get treatment and supports. And they want to know more and they really want to engage, why do we have to send them away to wait for an appointment? How cool of an idea to have somebody there either adjacent to the barbershop, in the barbershop, in an appropriate setting. Again, I don't know how the going of all of that would work, but I think it's a fabulous idea of being able to meet people where they are, and create new access points that are not just, "This is the door in, and this is the door out."

    Lisanne: This is such an important point about trying to meet people where they are. And we've had success in other types of programs with HIV using barbershops for condom distribution, and different information about other public health programs. And this absolutely needs to be extended to overall wellness. Inviting people in the community such as barbers or others. Could think of beauty salons also. We could think of other venues where we could really bring information. Churches also. There's just a lot of opportunity for this kind of community-based prevention. And as Keris was saying, really meet people where they are, and not wait until they're in crisis.

    Keris: Things that I could just state there, especially as we look at the headlines around COVID, and this expected tsunami of mental health, as people are saying, and understanding that also from a trauma lens, and ensuring people understand trauma, and trauma-informed care. And that sometimes, and I look at Japan and what happened in the tsunami, and their understanding of the needs of what would happen during, after, post, having such a traumatic event happen in March of 2011 with the tsunami, and the support that they're providing people throughout this entire time.

    And they never talk about it from a mental health perspective, meaning mental illness, but they do talk about it from a trauma perspective, and the various community supports that are available to people. I think sometimes we can look at what's happening as far as when you say, "Well, who's the workforce?" Or, "Where are the supports going to be?" I think we do need to think about all of the various community supports for people. I'm thinking about all the grocery store folks who have had to remain open. And during this entire time, that was considered essential. And so, what kind of emotional health and wellbeing are we providing, or what kind of support are we providing to maintain their emotional health and wellbeing during this time of the pandemic, when they and other essential workers have been available to us? Is it where and how they can receive it?

    I think it's not only about who is the workforce and who are these community members, but how is that being provided? Of course, we know teletherapy. We have a gazillion apps out there. There are more than 10,000 "wellness apps," or apps that focus on mental illness during the pandemic. We don't know how many are out there. A lot of them are not regulated, so you have to be a little bit careful about that. But I think when we think about things like phone lines, texts lines. What can be available to people in the grocery store at the grocery store? And it might be a group of grocery store workers.

    I think we can be very creative, and this is where funding is probably going to be really essential. And why I like the job that I'm doing now with the mental health strategic impact initiative is we're looking at what is the role of philanthropy? And how can philanthropy help us in looking at some of these? And I would say most of them are pretty intractable mental health system issues in which we do get stuck with, well, Medicaid might not be able to do it. So-and-so might not be able to do it. But how can we start to build up some resources using philanthropy, such that we can augment the things that happen in our "systems of care"?

    Eric: I was going to ask, we've discussed a lot of great ideas. How do we start honing ... Maybe we pursue all of them. How do we develop the evidence base that this is where we need to go? This is what we need to do. How do we develop that strategy? Including the financing that you just talked about, Keris. Do you want to talk about that?

    Keris: Yeah. I think there's a lot of evidence, of course, for the peer support workforce. On the SAMHSA  site, for example, there are some infographics that actually make it easier, have made it a lot easier for people to be able to get a very small lit review by using an infographic. What is a peer, what do they do, how do they do it, and what's the evidence behind it? And I think that starts to help people see where the evidence is. (See SAMHSA’s Peer Support infographic and Peers Supporting Recovery infographic.)

    And then, we can look at things that are happening, for example, in South Africa with the Friendship Bench Project, which does have evidence behind it, and is being extrapolated here I believe to the U.S. in several places. I think there's probably a lot of evidence that's existing. And remember, some things had evidence behind them that we certainly wouldn't do today in mental health. So, for example, lobotomy. I'm sorry, that probably had some evidence back in the day. Not something we would do today. Which means that we always have to continually build the evidence, and not sit on the evidence of the day. And so, a lot of times when people say, "Well, that's not really evidence-based," I remind them, "That's okay. Then, we need to build the evidence."

    I think technology and integrating technology, we are still building the evidence. And that's going to be really important. And the most important is to bring along, co-design, co-leads, collaborate with the people with lived experience, and their family members, and parents, if it's young children, to help in that co-design as well. I think there are lots of ways to do it that can be within systems. They can also be within community. And looking also at other maybe legislative efforts that are happening, like Peers and Medicare Act, and the number of other new legislation. I won't get all deep into that. But I think this is the time. I have never seen so much activity around mental health legislatively, policy-wise, at the community level, at the state level. I haven't seen it in a very long time.

    Lisanne: I would just echo this is a really exciting time. And the American Rescue Plan Act, for example, has a lot of funding. It hasn't been fully fleshed out into how that funding is going to be distributed, but I think there's a real opportunity to conduct some more community-based participatory research and evaluation to design programs, and test the effectiveness of different approaches. For example, we're really interested in the role of recovery coaches for parents with substance abuse disorder, and examining the role that these peer recovery coaches can have to support parents.

    Keris: She says something, and I'm like, "Oh my God, I really want to bring up something." I want to make sure that we understand the role of families supporting families who have loved ones with lived experience, and parents who support other parents who have children or young adults who also have lived experience of mental health and substance use conditions. A lot of times we use the word “peers,” and it feels as if the families are excluded, but it is the families that also need support along with the person who is experiencing mental health challenge.

    Keris: There's going to be another thing that I think is going to be really critical for us to look at, and that is the racial inequities. And again, we're seeing a lot of movement addressing racial inequities. Of course, we're seeing a lot in the criminal justice world, et cetera, and I think the intersection of racial equity, lived experience, mental illness, mental health, and behavioral health is, again, this is a critical, critical time to really recognize that intersection, and bring in, again, that lived experience of people of color. Because sometimes where and how we need to get stuff may look very, very different than how it's being offered now.

    When I was first diagnosed, and in the public mental health system, I was seeing a lot of people in the audience of recovery conferences and things that looked like me, but I didn't see a lot of ... Oh yeah, this is a podcast. I am black, by the way. In case you didn't know. You'll see a picture of me. But point being I didn't see a lot of people who looked like me up on stage, but I saw a lot of people, people with lived experience, in the audience year, after year, after year. And my belief actually as a black person was, “Well, recovery must not be for me because we're still sitting here while everybody who doesn't look like me is moving forward, and up on stage, and doing great work, and has these jobs, Office of Consumer Affair director, yada yada yada, and I'm just sitting here with everybody else.”

    And so, I think that was a horrible feeling. And I don't want anybody to ever have that feeling because of the color of skin they walk in, because they may be LGBTQ,  et cetera, that recovery isn't for them because they're not seeing people like them as examples of what recovery can look like.

    And again, during this time, a focus on mental health, trauma, racial equity, this is such an important time to bring in folks who may not look like you, who may not have the same gender expression as you, et cetera, into these conversations to do that co-design, co-development. And even developing some legislation, some policy so that, again, we can see better outcomes for folks.

    Eric: Well, you guys are talking about a lot of possible solutions, and it's exciting to think that maybe you'll get to work on them with some of our listeners in the future. Thank you both for joining me.

    Lisanne: Thank you, Eric. Was a pleasure.

    Keris: Thank you so much.

    Lisanne: Thank you, Keris.

    Eric: And thank you for listening to this Abt podcast.

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