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Grasstops, Grassroots and Transforming Mental Healthcare with an Inclusive Workforce

Grassroots and grasstops

Workforce shortages in mental health and substance use disorder services and supports aren’t new, says Jessica Wolf, Ph.D., principal of Decision Solutions Consulting and assistant clinical professor at the Yale School of Medicine Department of Psychiatry. She’s been working on behavioral health workforce challenges in Connecticut since the ‘70s. “We were trying to figure out how to get people out of the hospital and into community-based services,” she says. However, while Wolf and her colleagues believed that people would be better off in the community with adequate supports, there wasn’t a ready-made workforce. “We wanted to develop crisis services, case management, and vocational and social rehabilitation, but we didn’t have trained people to work in communities.” 

At the same time, the disability rights and mental health consumer advocacy movements were heating up and emphasizing, “Nothing about us, without us.” “People with a history of mental health issues were saying, ‘We ought to be part of the workforce,’” says Wolf. In response, she helped develop a peer mental health certificate program at the nearby community college. Wolf and her colleagues welcomed people who’d navigated mental health challenges to join the program. Then they studied the outcomes. 

The program founders presumed people in crisis would benefit from having a guide and mentor who’d been through a similar experience. They also recognized that peer support contributes to increased hope. When a person is diagnosed with a mental illness, there’s often the assumption, even from mental health professionals, that they might as well give up, says Wolf. “Versus, I’m a person with a condition, and everybody has some kind of condition. I can get better, and here are some people who have gotten better.” 

Peers became role models and partners in a new mental health framework of relationship, hope, recovery, and change. Wolf points out the approach was divergent from the” life sentence” mental health experts had been told went along with chronic mental illness (and, in turn, what they told the people they treated). “Instead, people were saying, I have bipolar disorder, schizophrenia, serious depression—you name it, and I’ve found a way to get better.” “We are human beings, not conditions.”

Wolf and her colleagues focused on increasing workforce capacity in Connecticut while listening to the mental health and recovery community. “We were pioneers in this long before the words peer support specialist existed,” she says. Because of her own mental health challenges, her career’s work has meant a great deal to her professionally and personally. “I define myself as a person with lived experience, although I didn’t reveal that for many years when I worked as an administrator and educator for the Connecticut mental health system. I didn’t feel safe doing so.”

Her work in behavioral health pulls from a climate change effort tenet: grasstops and grassroots. According to Wolf, organizational change is only feasible with leaders, influential people, and those on the ground committing to it. “There also needs to be inclusion—not integration—of peers at the top.” She prickles at the word integration. “We shouldn’t integrate people into society but instead create an inclusive society where we treat everybody with respect and dignity.” Wolf points out that peer inclusion pushes the behavioral health field toward transformation. “As Pat Deegan says, peer workers are ‘disruptive innovators.’ They bring a different headset to how we view mental illness and mental health.” 

“People professionally trained, like therapists—their job is to help a person get better, while a peer is an equal, a mentor, and a partner.” Together, they create well-rounded services and supports. “They can complement each other and, consequently, help the person more effectively.” While cultural barriers and stigma within organizations and agencies can deter peer inclusion, Wolf says civil discourse, mutual respect, cultural competency, and shared learning can help. “We need to treat each other with mutual respect and dignity,” she says. 

Many barriers impede peer workforce effectiveness, including unclear roles, lack of career advancement, insufficient pay, and policies that hinder employment. There’s a growing understanding that peer support services are critical; however, there’s also a nationwide misunderstanding of the peer role and the function they serve, said Jess Stohlmann-Rainey, former director of Program Development at Rocky Mountain Crisis Partners. 

“…everyone seems to know peer support is good, but they haven’t spent the time to learn what peer support is.” 

Wolf believes inclusive workforce development is critical to mental health transformation. In Connecticut, state leaders and Yale University’s School of Medicine began by convening a workforce workgroup that comprised people with lived experience, family members, advocates, educators, state administrators, and workforce experts. In 2015, she and her colleagues published a paper in Community Mental Health Journal highlighting that, as part of their workforce assessment, the workgroup conducted more than 40 focus groups with people in recovery throughout the state, led by a person with lived experience. 

A central focus of Connecticut’s workforce redesign was strengthening workforce roles for people in recovery and their families. The approach included peer-run employment services (the Connecticut Recovery Employment Consultation Service), an intervention designed to promote competitive employment and the full inclusion of people in recovery within behavioral health provider agencies. Also, the state developed parent leadership training, a 15-hour, 6-module curriculum, to support and empower parents and primary caregivers of youth navigating mental health and substance use challenges. After completing the training, the state recruited caregivers to help other families and serve on boards and committees. Connecticut also funded the peer-run organization Advocacy Unlimited to develop a peer training and certification program. Recovery University is a pipeline for hiring recovery support specialists.

As state and local leaders redesign their crisis and overall behavioral healthcare systems, Wolf points out they also must examine pay and employment policies that are at odds with the intent of 988. Insufficient pay devalues the role, she says. According to a College for Behavioral Health Leadership survey published in 2016, certified peer support specialists make an average of only $15.42 per hour. Also, many people in recovery are barred from employment because they were previously incarcerated. We tell people recovery is possible while policies make it harder for people in recovery to find employment, said Tony Sanchez, director of Partnerships at Faces and Voices of Recovery. “Recovery is a mindset and paradigm shift…the belief of ‘once an addict, always an addict’ and ‘once a criminal, always a criminal,’ isn’t true.” 

Wolf notes that 988 systems should be developed and implemented with inclusion from the onset, ensuring a diversity of lenses and perspectives at the table. The entire behavioral health system needs to revisit and reconfigure itself to have a more respectful and partnering relationship with people who are in crisis, who have mental health difficulties, or are in recovery, she says. “They aren’t ‘the other.’” “We are often afraid of people experiencing mental health challenges because of fears within ourselves that we may not fully acknowledge or accept.”