Miguel Rodriguez experienced his first episode of psychosis at 18, and it forced him to drop out of college and move back home with his parents. Now, seven years later, he takes a seat in a convention hall in Concord, California, wearing a blue cap and gown that matches those of his classmates.
It’s graduation day for a group of nearly 50 people who have completed a 9-unit course called SPIRIT – Service Provider Individualized Recovery Intensive Training – and have become certified peer support providers. The graduates aim to be part of the solution to a problem that keeps growing bigger: More and more people need mental health support and services, but there are far too few clinicians available to meet their needs.
Peer support providers have the potential to play an important role in the mental health field, not only because they can help fill the gap in the workforce, but also because they have something unique to offer. Their lived experience working to recover from mental health or substance use challenges gives them insights they can offer to others in similar situations.
“I’ve been able to turn a lot of corners within my own recovery and progress as a human being,” Rodriguez said as he walked in from the parking lot, moments before the ceremony began. “I want to use what I’ve experienced to help others.”
The years after his illness struck were difficult ones for Rodriguez. But he eventually found the right combination of medication and community support services and learned to manage his condition. Now, as a graduate of the SPIRIT program – taught in partnership with Contra Costa College and Contra Costa Behavioral Health – he seems poised to begin transforming his disability into an asset, perhaps even a career.
In the past couple of years, spurred by the police killing of George Floyd and the shootings of numerous people with mental illness, communities across the country have been working to create new ways of responding to mental health by dispatching mental health workers to assist people in crisis instead of summoning law enforcement.
The nationwide rollout of 988 – the mental health emergency phone number – has intensified the need to hire crisis counselors in call centers. And with sky-high rates of depression and anxiety among children and young people exploding into public view, school districts and youth service agencies are scrambling to hire mental health professionals.
All of these initiatives, long sought by mental health advocates, are increasing the need for mental health first responders and counselors. The catch is there aren’t anywhere near enough people willing or qualified to do this type of work, at any level of skill and training.
Amy Watson, a mental health researcher and professor in the Social Work Department at the University of Wisconsin-Milwaukee, worries that if the workforce doesn’t rapidly expand to fill in the gaps, the effort to create a more community-oriented mental health system may be subverted.
“We finally have a window of opportunity to actually develop a better service system, but it won’t work if we don’t have the people,” Watson said.
Many experts, Watson included, think that training and hiring large numbers of peer providers like Rodriguez and his classmates will be a key to expanding the mental health workforce – along with increasing the number of traditional clinical professionals.
A new way to address mental health
Over the last few years, the number of local governments operating or paying for mobile crisis teams that can quickly respond to people experiencing mental health emergencies has dramatically increased from a handful of programs to dozens across the country, with more expected to come.
The makeup of these programs varies from place to place but the underlying aim is the same: to provide an immediate response to people experiencing a mental health emergency. That means they must be prepared to assist with a broad range of events including full-blown psychotic episodes, disturbances related to drug and alcohol use and people experiencing homelessness.
The goal for these responders is to de-escalate crisis situations, figure out what people need, and connect them to services while diverting them from jails and emergency rooms.
While community responder programs are often intended as an alternative to law enforcement, some municipalities rely on co-responder models that provide training to both crisis responders and police officers and send them out together. In many such programs, the mental health worker takes the lead and the officer is there to provide back-up.
Watson calls this the “stick-a-clinician-in-a-cop-car” model. She argues that the very presence of an armed law enforcement officer changes the nature of the response, creates additional stress for the person in crisis and poses the same concerns – the risk of arrest and shooting – as the old model. Clinicians placed in this model, she says, often take on the behaviors and traits of the police and “start dressing like police officers. They start buying tactical pants,” she said.
Community responder programs that don’t include law enforcement deploy teams using some combination of social workers, nurses, emergency medical technicians (EMTs), peer providers or crisis workers.
The stimulus package narrowly passed by Congress last year enabled the Biden Administration to allocate $1.1 billion for the training and hiring of community health workers as part of a $12 billion investment aimed at shoring up the country’s health workforce.
The package includes grants totaling $225 million to universities, public health departments and nonprofit agencies to train more than 13,000 community health workers and $180 million to support call centers and mobile crisis response teams linked to the rollout of the 988 Suicide & Crisis Lifeline. Additionally, Biden had made $15 million in grants available for state Medicaid agencies to launch mobile crisis units.
The Biden administration also included $700 million in its 2023 budget proposal to help encourage people to enter the mental health field by supporting training through scholarships and loan forgiveness.
But at a time when the behavioral health field is experiencing a major shortage of qualified clinicians and workers, staffing these emerging programs with qualified, competent and diverse workers is proving to be a challenge. How this workforce can be created, and what it should look like is still up for debate.
Watson is one of the lead researchers exploring ways to rapidly expand the workforce. Her work, funded by a grant from NAMI, the National Alliance on Mental Illness, aims to identify the essential skills and core competencies required to do community responder work, without the need of a college degree.
The granddaddy of community responder programs is CAHOOTS – Crisis Assistance Helping Out On The Streets – which started in Eugene, Oregon; its model has recently been picked up in other major cities. The CAHOOTS team is made up of a crisis intervention worker trained by CAHOOTS and a nurse or emergency medical technician (EMT). (MindSite News published an in-depth look at this program last year.)
One variation of this approach that is gaining traction — including in cities in Ohio, Utah and the San Francisco Bay Area — is combining EMT and behavioral health skills into a single position — a behavioral EMT or psych-EMT. Another is to include a trained peer support specialist as a member of the team.
The coming of this new workforce has parallels in a piece of little-known history that led to the creation of the nation’s first paramedic program in Pittsburgh in the late 1960s. The program, which became known as Freedom House, trained Black community workers to provide emergency services while transporting people to the hospital in racially segregated Pittsburgh.
“Freedom House provided state-of-the-art first-responder training to young, purportedly ‘unemployable,’ Black community members, who were not only successfully hired, trained, and paid, but often performed at higher levels than their professional peers,” wrote psychiatrist Eric Rafla-Yuan and colleagues in an article last year in The New England Journal of Medicine. The Freedom House team was also among the first to offer service 24 hours a day, to treat cardiac arrest on-site with CPR and intubation and to use medications and electrocardiography machines in the field, according to the article.
More than 50 years later, Alameda County in California is continuing a two-decades-old EMT training program for young people 18 to 26, including youth coming out of the juvenile justice system. The program – EMS Corps – doesn’t include mental health crisis training for mobile responders yet, but Executive Director Michael Gibson said some graduates are working for the region’s mental health mobile crisis teams.
One problem with these models is the low wages that are typically paid to people who work on mobile teams, often a little better than the local minimum wage, and below the levels paid to unionized firefighters or health care workers.
Rachel Bromberg, executive director of the International Crisis Response Association, sees the shortage of mental health workers as a reflection of values that prioritize the safety and security services provided by police or firefighters over social and psychological services that can be provided by these new kinds of workers.
“In any community, there are people who can be trained to do this work,” Bromberg said. “They might not all have fancy degrees, but if you have good training and good benefits you usually can find enough people to do this.”
Clinicians, the bottleneck
The backbone of many community responder programs is a mental health clinician, often a licensed clinical social worker (LCSW). But there is growing concern among industry experts that relying on master-level professionals to power community response is unsustainable at a time when the demand for these professionals is exploding – and the shortage widening.
There are other problems with relying on licensed clinicians to do the bulk of this work, Watson says. The pool of social workers is not racially diverse. Many master’s level clinicians are looking for better-paying jobs that don’t require them to go out on calls at night. And according to Watson, social workers on community responder teams are often the first to say they don’t feel safe going out in the field without police.
“Our master’s level clinician workforce is predominantly white suburban females who may not be as comfortable going into the South Side of Chicago,” Watson said. “They’re just not as familiar with the communities that they may be serving.”
Efforts are underway to increase the capacity and diversity of the pipeline for social workers incentives like paying their tuition and providing scholarships or loan forgiveness for those willing to work in mental health.
Clinicians have a powerful skillset, but it’s not always the right match for a community responder team, said Anne Larsen, a project manager at Council of State Governments (CSG) Justice Center, a research nonprofit. Larsen was hired in 2018 by the police department in Olympia, Washington to implement a mobile crisis team based on the CAHOOTS model.
In her experience, the best person might be someone with lived experience who can be a navigator, support the person in crisis at the moment, and direct them to services.
Larsen paints a picture of a team responding to a person who is unhoused, barefoot and in the throes of a psychotic break. “The clinician isn’t going to be sitting down and doing a counseling session on the corner of the street,” she said, and that’s not what they need first, anyway.
“The person needs shoes first of all and then the clinician needs to figure out if the person has a place to sleep for the night,” Larsen explained. “Sometimes, we can overcomplicate things, especially folks that have an education.”
For these reasons, Larsen thinks peer providers or peer navigators should be the backbone of mobile crisis units, with as few barriers as possible to entry.
Calling all peer providers
The peer support movement as we know it dates back to the 1970s after the Community Mental Health Center Act expelled people with mental illnesses from institutions and into the community. Today, peer providers are part of a fast-growing profession of community health workers that is projected to grow by 12% over the next decade, according to the U.S. Bureau of Labor Statistics.
Mental Health America estimated in 2018 that there were about 30,000 peer specialists working in the U.S. but that is likely a significant underestimate, said Jillian Hughes, the group’s communications director.
Peer providers work in various public health and behavioral health settings, from crisis centers to mental health wards to drug and alcohol counselors to community-based services. People who train to become peer providers do so because they have a passion for helping others. They’re also more likely to live in and be a part of the communities they serve.
Peer providers are a solution, but experts caution they aren’t the silver bullet to workforce challenges. Many community responder programs, like the one in Contra Costa County, already employ peer providers in some capacity. Peers have a long history of effectively supporting people in behavioral health, but they typically have some of the lowest salaries on the team.
Dani Jimenez, 32, another 2022 SPIRIT graduate, joined Contra Costa Health Services mobile crisis team in late August as a Mental Health Community Support Worker. She’ll earn the base salary – about $40,000, a bit lower than the national median of $46,590 for a community health worker, according to the BLS.
“It’s definitely not a career that you go into for the money,” she said. Even so, it’s still more money than she was making at Starbucks, and there’s room to grow in the position. “I’m a single woman who doesn’t have any kids, so for me getting a position and the salary that I was offered, it was like, ‘Okay, this is great!’” Jimenez said.
Lived experiences are the peer provider’s foundational asset, but some in the field worry it can also be a liability. Certain types of situations in the field may trigger or retraumatize peer providers. The value of lived experience is also not necessarily relevant to every call.
Peer providers are also a limited resource. Besides seeking more money for training programs to increase peer hiring, Larsen said she would like to see workforce efforts focused on people formerly and currently incarcerated.
“We have an untapped workforce of folks reentering our communities from incarceration,” she said.
Her ideal is to have a pathway for formerly incarcerated individuals to get into community responder work. Prisons have all types of career development programs, so why not have one for community responders?
To get such a program up and running in prison would require significant philanthropic funding. Philanthropists have shown they are willing to support reentry. The Chan Zuckerberg Initiative provided $450 million last year to efforts to reform criminal justice. The biggest barrier, she noted, will be pushback from corrections and public safety unions.
“The start of something super promising”
After Rodriguez collected his certificate on stage, he walked back to his family and got hugs and a bouquet of flowers. They planned to take the lunch back to his parents’ home.
Pre-pandemic, the SPIRIT graduation was known for its large dance parties and impressive lunch spread. This year, with the highly infectious Omicron variant surging, the annual dance party was canceled. Lunch was still served – BBQ chicken, sausage, beans, and a cupcake – but it was to-go only and handed out at the end of the ceremony.
Before attending SPIRIT, Rodriguez had worked various jobs – Trader Joe’s, his parents’ bike shop, a local coffee spot – but none seemed like a career. Today, he has options – including a job offer from the Contra Costa Health Services community responder team.
“It feels like the start to something super promising and tangible,” he said. “Something exciting to look forward to for sure.”