By Liora Engel-Smith
In a state marked by a mental health care workforce shortage so severe that more than a quarter of all counties have no psychologists at all, another type of provider group is quietly growing.
These professionals didn’t get their training in college or graduate school and they can’t prescribe drugs. What they do offer is first-hand experience in mental health or substance use disorders. And with that insight, they can support others having similar challenges.
“I don’t know how to describe people in recovery because it’s almost like a wink and a nod and we all know each other and we understand even if we have different zip codes,” said Calvin Harvel, a peer support specialist in Charlotte.
There are more certified peer support specialists in North Carolina than there were seven years ago, data from the University of North Carolina shows. As of Nov. 1, just under 4,000 people had received a peer support specialist certification across the state, up from 765 in January 2012.
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Peer support has been around in the state for a long time, but it became an established profession in 2006 when the North Carolina Department of Health and Human Services made it a service that providers could bill for under Medicaid. With these changes, the state contracted the University of North Carolina to oversee certifications, training courses and curriculums, among other roles.
But the growth of the peer support workforce isn’t just about Medicaid billing, Tara Bohley, who heads UNC’s Behavioral Health Springboard, said. It mirrors a national trend toward accepting and involving people with mental illness and substance misuse in the behavioral health field.
“We’re getting closer to being able to see [the] faces of recovery and not faces of illness,” she said.
Growing pains
But that growth is not without its challenges.
“On paper, what it looks like is that North Carolina has a very large pool of peer support specialists,” said Cherene Caraco, CEO of the peer-run Promise Resource Network, an agency that supports uninsured people with mental health needs in Mecklenburg County.
“When you start digging into that … you start realizing that success is a little bit misleading.”
It’s an issue of supply and demand, Caraco said.
Only about a third of the 3,913 peer support specialists who are certified in North Carolina work in their field, according to the University of North Carolina. Roughly 2 percent volunteer as peer support specialists, and another 10 percent work in a related field. And more than 20 percent are seeking employment.
Then there’s the distribution of peer support specialists across the state.
Like other behavioral health professionals, peer support specialists tend to concentrate in urban counties, according to the data. At more than 400 specialists, urban Mecklenburg County has the highest number, while rural counties such as Bertie and Tyrrell have none, the data shows. The actual distribution of peer support services in the state may be different, Bohley said, as some specialists may live in one county and serve several other counties.
Certified peer support specialists in North Carolina by county of residence
Map source: University of North Carolina
Regardless of where they live, Caraco said, there aren’t enough jobs out there for all peer support specialists. And employers that are interested in peer support have told Caraco that they struggle to find the right specialist for their organization.
Bohley acknowledged that challenge. A large number of peer support specialists, she said, aren’t ready to work in some settings, such as a clinical environment. And UNC is working on ways to better equip peer support specialists.
“I really think we’ve paved the way,” she said. “So now it’s about refining [and] just doing better.”
Healing relationships
In the midst of a mental health crisis, the hurdles to wellness — finding help, navigating a complex system of providers and facilities, and complying with treatment — may appear impossible. The struggle itself can feel isolating, but trained peers can ease the burden. With a shared language, empathy and a relationship built on shared experiences, they can steer people to recovery.
“What the peer brings is a realness about what’s going on in a person’s life,” said Allison Wolfe, director of behavioral health services at Atrium Health Behavioral Health Charlotte. “ … They are able to talk to a patient in a really kind of one-to-one, no intimidation, [and] no feelings of judgment.”
Atrium’s psychiatric hospital added peer support services in 2015, with the goal of emphasizing recovery, wellness and focusing on the whole person, she said. The hospital has six full-time peers. It took a while to find the right candidates, even though staff focused their search on certified peer support specialists, Wolfe said.
Staff learned they had to ask prospective peer employees questions that don’t usually come up in a job interview: about their illness, recovery and coping skills.
“They need to be able to stay away from the mess of what happened when they were sick and really carry the message of hope, recovery and stability,” she said.
A peer who can use their story to build positive relationships with people in crisis can play an important role in a patient’s recovery. Something about that shared anguish can speed the relationship-building phase, said Harvel, the peer support specialist at Charlotte’s Atrium Health psychiatric emergency room. Harvel, himself in recovery from mental illness and substance use disorders, understands crisis on a visceral level.
“We all come from different places, but we’re all in recovery together,” he said.
An urban-rural divide
Full-time positions like Harvel’s aren’t always the norm for North Carolina’s peer support specialists, said Caraco, from Promise Resource Network in Charlotte. Many positions are either voluntary or part-time, with trained peers working at several part-time positions.
That’s the case for James “JD” Rea, peer support specialist at the Hyde County Health Department. Rea is the only peer support specialist in the county, according to UNC’s data. He began volunteering at the health department once a month in February, offering group and one-on-one support.
“The main thing I learned so far is just having love for the individual themselves,” he said. “No matter what I’m doing or where I’m at, I always constantly remember that the thing that helped push me along was people who stopped what they were doing and loved me as an individual.”
It isn’t that the Hyde County Health Department isn’t willing to pay Rea for his services, it just didn’t have the funds, said Caroline Gurganus, human services and substance awareness coordinator.
That is about to change as the department secured a three-year grant from the U.S. Department of Justice for a multi-county partnership that would bring a peer support coordinator to oversee the growth of peer support in the region.
Part of the new grant money is earmarked for the county to begin paying Rea, Gurganus said.
“Everything takes money to operate,” she said. “And when we have limited funds, there’s limited things that we can do with that.”
‘Nothing about us without us’
Things may soon be changing at the state level too. In March, Promise Resource Network received a three-year federal grant from the Substance Abuse and Mental Health Services Administration to develop a state-wide consumer-led organization that will guide peer support training and advocacy as well as help local peer-run organizations, among other roles.
Caraco, who oversees the creation of the new umbrella organization, dubbed Peer VOICE North Carolina, said it will be an important step to making sure peer support specialists can guide mental health policy and the future of the profession in the state.
“You know the old saying ‘nothing about us without us?’” she asked.“That’s really what it comes down to whether we’re talking about peer support, whether we’re talking about recovery, whether we’re talking about issues that impact people living with mental health and substance use experiences.”
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