In Washington, an innovative statewide peer support program connects counselors who combine their personal experience of recovery from mental illness or addiction with skills learned in formal training to deliver behavioral health services that support recovery. Since 2007, when the Centers for Medicare & Medicaid Services released Medicaid reimbursement guidelines for peer providers, many states have adopted similar programs. Despite its notable shortage of mental health professionals, California is not one of them. I recently visited Olympia, Washington, to learn how the peer support program works there. I met with Pattie Marshall, the peer support program administrator for the Washington Health Care Authority’s behavioral health and recovery division, and Mike Wimberley, a certified peer counselor for the last five years. Our conversation has been edited for length and clarity.
Q: What is a peer counselor, and what training do they need to work in the state of Washington and be reimbursed by the Medicaid program?
Pattie Marshall: A certified peer counselor is someone who identifies as having a significant life-altering mental health challenge and has been in recovery for at least a year. Our training and certification program has four steps. The first step is an online course, and then peers apply for approval to take the training. Once approved, students complete a 36-hour in-person training and must pass an exam.
Mike Wimberley: We believe that people are experts in their own recovery. We support them in the choices they make, and we believe people learn from having the ability to make choices.
Q: What special approaches or skills do peer supporters bring to the people they support?
Pattie: Peer support is about modeling hope and recovery, and not being perfect. There are many paths to recovery. There is no single right or wrong decision. It is individualized and about choice.
Mike: We meet solely in the community. That could be at people’s homes or at the Social Security office to apply for benefits, or maybe at an intake into mental health services, which people find stressful since they might be grilled on their life story. Someone I work with might say, “I’m struggling with hearing voices.” I’m able to relate, having had that experience, and share tools and coping skills I’ve used. “Does music help with the voices? Or what does?”
Q: How did you find your way to peer counseling?
Pattie: My life was a cycle of trauma through childhood. As I got into my teenage years, I was already drinking and using drugs — trying to work full time and go to school and just always feeling like I was the one making poor choices.
Pattie first went to drug treatment in her early 20s. While it was very helpful, she says no one addressed the trauma or anxiety she had long experienced. Soon she was using drugs again. Over time, she realized she also needed mental health treatment. She said she signed up for every support group at her community mental health center.
So when I took the peer training I didn’t even know what I was getting into. It was a decade ago and nobody knew what peer support was. I really thought I was just taking a training to maybe work at a helpline or a compassion center or something. But this was an opportunity to give back in a way that I hadn’t really seen before. It was also the first time I was in a room with people who had similar stories to me. I was hearing all these stories of resilience and recovery and hope, and I honestly had never heard of peer support before that. Eventually I decided that I wanted to support people throughout the state and really build the training program. So I went back to school and got a bachelor’s degree to work in administration at the state.
Mike: I started realizing that I’m hearing voices. I didn’t know how to make sense of the experience — and it seemed really major. I had a diagnosis of schizophrenia, and my life was over as I had once known it. When you’re given a label like schizophrenia, bipolar, even major depression, any label can be kind of daunting. We break down stigma by normalizing experiences that have been deemed abnormal. I wish at some point along the way someone had been there that had been like, “Hey, I’ve been through similar things and you can get through this because I’m a lot of these labels and diagnoses and stuff can be daunting.” It would have been nice to have someone to normalize my experiences.
Q: How is what you do different from, say, a sponsor in Alcoholics Anonymous (AA)?
Pattie: I’ve been in AA, and I get the sponsor thing, but when you look at peer support and AA, there are a couple of very significant differences. Your sponsor is an accountability person, not a person for you to just talk to. It has an intentional power imbalance. They’re holding you accountable to following the 12 steps. But if we’re talking about peers, they’re working with your clinical team, they’re meeting you where you’re at, modeling hope.
Q: On the flip side, how is your support different from what a smart, compassionate friend would offer?
Mike: There’s a spectrum. At one end might be a therapist, in the middle is a peer counselor, and on the other end is a friend. I feel like people respond differently when you meet with them as equals.
Pattie: I don’t want my friends to know all the things I would tell a peer counselor. I don’t tell my friends what medication I’m on or what my diagnosis is. I would just want to have a friend. Unlike friends, there is a power imbalance no matter how mutual we want to be as peer support specialists. We are a provider type, we are a service, and there are goals and things that we need to do to be in that relationship.
Mike: We try to empower people to advocate for themselves within the systems they’re in, and a lot of times they’re really frustrated.
Pattie: And that’s very different from a case manager or liaison that might speak on behalf of someone. We try to encourage and support people to speak on behalf of themselves. And we’re careful to have great boundaries and say, “It’s great that you want to hang out, but really what this says is that you’re ready to hang out with other people.”
Q: In California we have a workforce problem. There aren’t enough health care workers to serve everyone with mental health issues or substance use disorders. How are peer supporters helping fill that workforce gap in Washington?
Pattie: Peers are boots on the ground. When you add peers to a clinical care team, you’ve got another person. But just adding a person who didn’t have that specific role wouldn’t give people the same benefit. If it was just a greeter who didn’t have the lived experience, it wouldn’t be the same. A peer helps people engage, do their orientation and their assessments. A peer talks them through the process and says, “Hey, this is going to be really challenging. I know it was when I did mine.” That’s the value peers add to the broader care team.
Q: How significant is Medicaid reimbursement to the success of the peer support program here?
Pattie: Medicaid is the basis of the program here in Washington — it’s where we get our funding. Ninety percent of the peer counselors in a community mental health setting are reimbursed by Medicaid.
Q: Do you think of yourselves as success stories?
Pattie: We are patients who have a success story, yes, but we’re not unique. There are lots and lots of people who are doing really well. Telling our story helps break down stigma. I’m bringing that lived experience voice.
Mike: A lot of people have asked me, “What does recovery mean anyway?” A lot of times I just say it’s about being at a place where you can work toward your dreams.
Lisa Aliferis is the senior communications officer for CHCF’s High-Value Care team, which supports policies and care models that align with patient preferences, are proven effective, and are affordable.
Lisa came to the foundation after working as a health journalist for 25 years, most recently at KQED News in San Francisco, where she was founding editor of State of Health, a daily blog focusing on health policy and public health in California. She conceptualized and wrote KQED’s popular consumer resource Obamacare Explained: A Guide for Californians. Lisa’s work has also been published by NPR’s Shots, Kaiser Health News, and JAMA Internal Medicine. She has produced television news health stories for many outlets, including Dateline NBC. Lisa holds a bachelor’s degree in economics from Brown University. As part of her year as a Kaiser Family Foundation Media Fellow in Health, she completed graduate courses at the University of California, Berkeley, School of Public Health.