New state legislation proposed last week could broaden the roster of mental health workers throughout California, but it may face an uphill battle after back-to-back vetoes by two governors.
SB 803, authored by state Sen. Jim Beall (D-San Jose), would create a certification program for peer support specialists in California. Described as people with a life experience recovering from mental illness and addiction, in recent years peer support workers have gained acceptance across the country as a valuable part of the mental health care system.
Though lacking in clinical experience, peers are "experientially credentialed" and can help patients through the recovery process, providing a unique service that is linked to reduced hospitalizations and lower health care costs, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). Santa Clara County's behavioral health system has budgeted for 62 such positions, 51 of which are full-time.
Yet peer support workers are left in a weird place in California. There is no statewide certification process to set standards for the job, leading to a patchwork of different training requirements set by individual counties. It also makes it difficult for providers to get reimbursed by Medicaid, which could pay for 50% of the costs. Across the entire country, only South Dakota and California lack a certification program, according to the Steinberg Institute, a mental health advocacy group.
Beall told the Voice he's been trying to get California on board with the rest of the country, starting in 2018 with SB 906. The bill would have created a certificate program for peer workers and underscored the value of the work they do, whether in emergency departments, homeless shelters or doctor's offices.
"The peer support specialist bill is a cornerstone of a good mental health program because we have people with lived experiences through mental health challenges, specially trained to provide services in mental health settings," Beall said.
Former Gov. Jerry Brown vetoed the bill, calling it a "costly new program" that could shut out current peer support specialists who don't meet the new qualifications.
Beall said he thought he'd have better luck with Gov. Gavin Newsom, who explicitly called for peer providers to play an "expanded role" in mental health care while on the campaign trail in 2018. He authored a successor bill, SB 10, which won unanimous support in both the state Assembly and Senate last year.
"I said, 'Hell, the governor already said he supports it. This should be a slam dunk,'" Beall said.
Newsom rejected SB 10 in October, writing in his veto message that the proposal would cost too much and would be better suited for the budget process. The governor's proposed budget for 2020-21, released last week, doesn't include any funds to create a certification program, Beall said.
A missing piece
Peer support has been part of the mental health treatment model for decades, in some ways mirroring Alcoholics Anonymous and other 12-step support groups, said Kelly Davis, director of peer advocacy at Mental Health America. They act as a guide through the treatment process and tag along for doctor's appointments, listening to the patient's story and sharing their own experiences -- always with an eye toward empowerment and learning to live a life of normalcy.
While it's a common criticism that peers are not clinical staff and lack the professional experience of a psychiatrist and psychologist, Davis said that doesn't take away from the value they bring to patients who have to consider life beyond clinical treatment and psychiatric assessments. Patients could very well be miserable, lonely and confused while still showing improvements in depression screenings, she said.
Davis, who herself was diagnosed with bipolar disorder, believes she could have benefited from a peer supporter following her first suicide attempt and foray into mental health care at age 10. Instead, the message she was given throughout inpatient and outpatient care was to drop out of school and avoid stress, and that her "best hope" was to simply manage her illness. With little in the way of positive encouragement, she turned to support via online communities, which she credits for saving her life.
On its face, Davis said she received all the mental health care that advocates say are sorely needed in the U.S., yet it was still missing something important -- peer support.
"I think for a lot of people it seems 'fluffy' but it's actually extremely powerful," she said. "People want to live a life outside of disease management, and that's why I think it's so important."
As someone who works on national advocacy, Davis said California is a quirky outlier in the world of mental health. Places like Los Angeles, San Francisco and Sacramento are the testing grounds for the some of the most ambitious mental health initiatives in the country, yet something as basic as peer support is implemented in "unbelievably" different ways from one county to the next. Qualifications to become a peer supporter, for example, can range from a speedy 48-hour training to a rigorous nine-month class.
Santa Clara County has yet to take an official position on the latest incarnation of Beall's bill, but said in a statement that behavioral health staff believed SB 10 would have created the framework for high-quality peer and family support across the state. Like many counties, Santa Clara hasn't waited for the state to create its own certification program, and is currently looking to hire more mental health peer support staff.
"Qualified peer support specialists can benefit clients by reducing hospitalizations, improving functioning, alleviating depression and other symptoms, and enhancing self-advocacy," according to the statement.
El Camino Hospital also offers its own version of peer support to mental health patients in a partnership with the nonprofit National Alliance on Mental Illness (NAMI) of Santa Clara County. Over 60 patients each year opt into the program and get paired with a peer support worker -- trained and hand-picked by the nonprofit -- who visits the hospital and shares experiences and useful advice learned along the way to recovery, said Michael Fitzgerald, the hospital's behavioral health services director.
"Everyone talks down to (patients) -- therapists and doctors saying, 'Take your meds' -- and here you've got someone who really understands. They've been through it," Fitzgerald said. "There's a real value in that."
Reading through Beall's legislation, Fitzgerald said he supports the integration of peer support workers but was uneasy about the possibility that they could be seen as life coaches and counselors. He said he wants to avoid a situation where peers are seen as the primary caregivers.
Beall hailed organizations like El Camino Hospital and Santa Clara County for being proactive about mental health care and making it a high priority, but he said the same can't be said of legislators in Sacramento. Finance- and policy-minded politicians and staff, he said, don't want to deal with mental health and consider it low on the list of priorities, forcing him to try passing the same bills again and again. Much of his mental health legislation in the last six years has either been shelved, died in committee or vetoed.
"It's certainly an ingrained backwardness in Sacramento, and you have to realize that and fight against it," he said.