Making Peer Counseling Radically Accessible

Tim Desmond, LMFT
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After years of dreaming, planning, and researching, Peer Collective (peercollective.org), an online platform for low-cost peer counseling is now officially up and running.

This launch happens at a time in which countless people in the world are suffering and don’t have enough access to emotional support. Suicide and mental health disability are growing worldwide, and many of the leading figures in the mental health profession believe the system is badly broken.

The Dream

In 2015, about a week after I published my first book, Self-Compassion in Psychotherapy: Mindfulness-Based Practices for Healing and Transformation, a colleague asked me a challenging question. She asked if I believed that the field as a whole would be more effective if every clinician would read my book. Based on my understanding that training doesn’t tend to improve therapist outcomes, I said no. She responded, “Then what would it take for the field to be more effective?”

I lost some sleep on this question, but eventually started imagining a world in which anyone could hit a button on their phone and be connected with a compassionate and empathetic listener. I imagined it would either be free or affordable enough that cost wouldn’t be a barrier.

At the time, I was living at a meditation retreat center in the woods of New Hampshire and caring for my wife who was dying of cancer. Founding a new ambitious project like this didn’t seem likely.

In the Belly of the Beast

A few years later, I was invited to give an author talk at the Google campus in Mountain View, CA. After my talk, I met David Yu Chen, a Google software engineer with a passionate interest in mental health. He approached me and said he wanted to develop a mental health project. I’d never met a software engineer before, and I felt like this was probably my only chance to try building my vision.

Eventually, the two of us developed and ran a peer-counseling project at Google for eight months. As a former Occupy Wall Street protester, showing up at the Google offices everyday felt gross to me.  However, I learned a lot during that time. We did research on how to screen and predict which peer counselors would be effective, and how to make peer counseling approachable to a broad range of people. It was also during that time that some of the therapy researchers I most idealize joined the project, including psychologist Bruce Wampold, an expert on what makes therapy effective. However, it became clear that Google would never sponsor something radical or aimed at underserved communities. They were more interested in how our project could be used to sell Google Cloud to employers.

So in the summer of 2019, I left Google and founded Peer Collective. As of this writing, there are 30 peer counselors on the platform offering 30-minute counseling sessions for just $14. People can connect with a peer counselor who’s been through whatever issue that person is facing. They can find peer counselors who are available at nearly any hour, and talk over Zoom (which offers phone or video calls). Nearly one thousand more have applied to be peer counselors, and we’re growing slowly and carefully.

Could Online Peer Counseling Transform the Mental Health Field?

Absolutely!

Let’s look at some of the biggest obstacles to people getting quality mental health care.

First, research shows that talk therapy is effective, but it’s too difficult to access. The average price of a therapy session in the US is $150, and in areas like New York and San Francisco, it’s closer to $250. Further, almost a third of Americans live in areas with a shortage of mental health providers. People who need care often can’t afford it, can’t find a practitioner, or have to wait months before they can get an appointment.

Peer counseling, on the other hand, is generally either free or low-cost. By creating an online platform for peer counselors, support can be available to anyone with an internet connection at whatever time works for them. I believe the biggest contribution that online peer counseling can offer is improving access.

A second major obstacle to quality mental health care is choice. Research shows that a poor match between “client” and practitioner is one of the biggest factors in people leaving mental health treatment. At Peer Collective, users can browse through our peer counselors and book a session with anyone they believe might be helpful. They can try sessions with several peer counselors until they find someone they like. They can stick with a single person for consistency, or maintain relationships with multiple peer counselors.

A final major obstacle is stigma. Our research at Google indicated that some people who are turned off by the medical paradigm of clinical mental health are much more open to peer counseling. In professional psychotherapy, the basis of the relationship is diagnosis and treatment, whereas in peer counseling, it is based on shared experience. I believe that battling stigma is complicated. However, peer-based services can be one way to counter stigma by normalizing human suffering.

Other Benefits of Online Peer Counseling

 When I first spoke with Bruce Wampold, whose work in promoting the common factors model of therapy I’d admired for years, I asked him, “If you had to hire 100,000 therapists and you wanted them all to be good, how would you go about it?” He responded that he knew exactly what he would do.

He told me about the Facilitative Interpersonal Skills (FIS) assessment, which is the only type of metric that’s been shown to predict therapist effectiveness. Our team ended up creating our own process—based on FIS—to assess people who were applying to be peer counselors. In our assessment, applicants watch seven videos of highly emotionally challenging interactions while their responses are video recorded. The prompts include situations such as someone saying, “You’re acting really nice, but you’re paid to be nice, so it feels phony.” The applicants are then rated on the eight qualities that make up FIS: verbal fluency, hope & positive expectation, persuasiveness, emotional expression, warmth & understanding, empathy, alliance capacity, and alliance rupture repair. Only about 10% of peer counselor applicants pass the assessment.

When we tested this method at Google, we found that we had a high degree of agreement between different raters, and (more importantly) we could quickly predict which peer counselors were going to be good. Many researchers have suggested that if the least effective 25% of professional therapists could be removed from the field, overall outcome would improve dramatically. I believe the reason that so many professional therapists have such bad outcomes is that they never need to pass an assessment that actually predicts effectiveness.

Finally, we believe that making emotional support accessible is an issue of social justice. We’re focused on balancing affordable and accessible care with making sure that our peer counselors are paid a living wage (currently $20/hr).

Currently, we’re reaching out to underserved communities through doctors and community mental health centers so we can bring support to the people who need it most. We hope that in 5-10 years, everyone in the world will have easy access to compassionate and skillful peer counselors at the push of a button.

30 COMMENTS

  1. Wow Tim,
    I find this so encouraging. I am fascinated by the therapist testing.
    I was wondering where psychiatry would stand if testing like this was
    used to include or exclude.

    There is nothing but positive in your plan and I hope your vision of global access is
    going to happen.
    I am wondering, do you see fundraising in the future for this program? Keeping
    in mind that funny things can happen with going bigger etc, but not if
    one holds the vision.
    I hope you always keep the vision and standards.

  2. “They were more interested in how our project could be used to sell Google Cloud to employers.” ???

    May we say Google seems to have a disconnect in it’s society improving goals?

    “In professional psychotherapy, the basis of the relationship is diagnosis and treatment, whereas in peer counseling, it is based on shared experience. I believe that battling stigma is complicated. However, peer-based services can be one way to counter stigma by normalizing human suffering.” I agree normalizing the reality that humans suffer from real life problems, is a much wiser and more logical way to help people, than diagnosing/stigmatizing and treating/neurotoxic poisoning people.

    “He told me about the Facilitative Interpersonal Skills (FIS) assessment, which is the only type of metric that’s been shown to predict therapist effectiveness.” “The analysis with age, FIS, and SSI as predictors indicated that only FIS accounted for variance in outcomes suggesting that a portion of the variance in outcome between therapists is due to their ability to handle interpersonally challenging encounters with clients.”

    Since NO mainstream, DSM billing, “mental health” worker today, may EVER bill ANY insurance company for EVER helping ANY child abuse survivor EVER, without first misdiagnosing ALL child abuse survivors.

    https://www.psychologytoday.com/us/blog/your-child-does-not-have-bipolar-disorder/201402/dsm-5-and-child-neglect-and-abuse-1

    And since discussing child abuse and rape are “interpersonally challenging encounters,” especially for those mainstream, DSM believing and billing, “mental health” workers, who can’t bill to EVER help people dealing with such crimes. I’m quite certain peers, who may discuss such shared real life issues, would be a needed and beneficial addition to the “mental health” industry.

    “I believe the reason that so many professional therapists have such bad outcomes is that they never need to pass an assessment that actually predicts effectiveness.” I personally believe their failure results from psychiatric DSM design, and the psychologists’ complicit, historic, systemic child abuse and rape covering up crimes/goals.

    https://www.indybay.org/newsitems/2019/01/23/18820633.php?fbclid=IwAR2-cgZPcEvbz7yFqMuUwneIuaqGleGiOzackY4N2sPeVXolwmEga5iKxdo

    https://www.madinamerica.com/2016/04/heal-for-life/

    And the fact that the majority of “professional mental health” workers may not actually EVER bill to help the majority of their legitimately distressed clients. So they misdiagnose them, resulting in lots and lots of psychiatric, psychological, and therapist malpractice. But all this “mental health” industry malpractice is largely due to intentionally, systemically covering up child abuse and rape for the men, wealthy, and religions of our society.

    I do believe judging peer helpers based upon “verbal fluency, hope & positive expectation, persuasiveness, emotional expression, warmth & understanding, empathy, and alliance capacity” is wise. But I do not agree, judging them based upon their ability to get the religious institutions and the “mental health” industries out of their, systemic, multibillion dollar, primarily child abuse and rape covering up industry, is wise. That’s too much to ask of a peer survivor. I tried, and the systemic, religion’s and “mental health industry’s,” primarily child abuse cover uppers and profiteers, don’t want to get out of that business.

    I do agree, “making emotional support accessible is an issue of social justice. We’re focused on balancing affordable and accessible care with making sure that our peer counselors are paid a living wage (currently $20/hr).” I’m quite certain the child abuse acknowledging within the “mental health” industry, should be paid as much as, if not more than, the child abuse denying DSM “bible” believing and billing “mental health workers.”

    I too hope “that in 5-10 years, everyone in the world will have easy access to compassionate and skillful peer counselors at the push of a button.” Maybe I’ll look into working for your organization, so long as the peer support movement is not a child abuse covering up organization, like all the DSM “mental health” industries.

  3. I have a little problem with this idea that the receipt of “mental health” trickment should serve as a gateway to a career in the provision of “mental health” trickment. What was madness again? Wasn’t it something like not learning from experience, and repeating your folly ad nauseum?

  4. Hi Tim,
    I think this is amazing work that you have done. I’m based in New Zealand and have 2 questions for you
    1. What ideas do you have around taking this to a global level. I would be very interested in how we could get this running here and I think through my networks could possibly get this happening.
    2. How do you get hold of so you can use the Facilitative Interpersonal Skills (FIS) assessment
    Thanks

  5. A friend of mine is in a self supporting peer group. And the subject of “medication” is a very sensitive point within this group.

    My friend said that it was very important NOT to advise anyone on this subject, BUT that a person could always relate their own experience of what worked for them (and what didn’t) in their own Recovery.

  6. We need a good strong business model to expand what is effective. We need the new paradigm to make the old system obsolete. $28 per hour to the client, $20 per hour for the peer, and $8 per hour to make a scalable business model might work.

    However, I am concerned that only 10% of peers pass the test. The test sounds more about what makes therapy effective instead of what makes PEER SUPPORT effective. Those might be two different things. In fact, Dr. Jean Campbell’s COSP studies looked quite clearly at what makes peer support effective.

    And also, the test sounds quite discriminatory against autistic people.

    • Don’t you think this is all pretty crazy? It reminds me of the Universal Life Church — send in your fee and become a “minister.” Why not just pick names out of a phone book and offer them money to talk to you?

      (This is not a response to your comments per se. But you do seem to grasp some of the inherent contradictions so I thought you might agree.)

      A “peer” is someone who shares your basic social status (Merriam-Webster: One that is of equal standing with another). There is no “test.”

    • In honesty would Tich Nhat Hanh pass the test, or Eckhart Tolle, or any of the other heavy weights? Would Elanour Longden?

      “…The applicants are then rated on the eight qualities that make up FIS: verbal fluency, hope & positive expectation, persuasiveness, emotional expression, warmth & understanding, empathy, alliance capacity, and alliance rupture repair. Only about 10% of peer counselor applicants pass the assessment….”

  7. “stigma”, can ever only be dealt with by abolishing psychiatry. It is simply them that stands in the way of “normalyzing”
    Let’s not participate by advertising within and reaching out to “mental” services.
    If any “service” is not about weakening the BS MI, then ultimately it is not an empowering alternative.
    People need to take power back, not be caught in another system. It is really about brainwashing. If we were brainwashed to believe, even partially in the MI system, we need debriefing.
    Psychiatry cannot be debriefed. They, like jimmy, would rather die for their beliefs, even if it means taking their believers with them.

      • “Stigma” – is for people who can’t cope with life, regardless of the label you give it.
        In the old days it was “nervous breakdown” or “alcoholic” or “those who frequented opium dens.”
        Until relatively recently, nobody would have even considered trying to help these people – they were despised and cast out.
        Whatever we think about how much “help” psychiatry offers, they didn’t create stigma. Maybe they redefined it as biological or whatever.
        Peer support sounds like a nice idea until you examine it more closely. My impression was that if therapy (of any kind including peer support) is successful, it’s because of the relationship built up between the 2. That takes time, and I really doubt it can be done over the phone. It also takes an open mind, which many peers won’t have – not those who believe in meds, and not those who want to abolish psychiatry either.

        • Does it matter who created stigma?
          It has always existed. We see our own family members in a certain way, we ascribe negative views upon them and often see them in that light.
          It is not uncommon to kind of like a person and then find out something we don’t like, and see them through that lens.
          BUT, it does not contribute to the person being seen that way on a legal, social level.

          If psychiatry does not have responsibility of stigma, why then does a medical community deliver second rate care to those branded?
          Why does someone with a label never become unlabeled?
          What is the benefit to psychiatry to keep those labels forever etched on the person’s files?
          It obviously means nothing to the shrink who did it, so why would he not remove it?
          People choose to go to psychiatrists because they recognize they need help. The drugs are not “asked for”. Most go because they have a vision that a psychiatrist does talk therapy, that he can help them figure stuff out.
          Most never go to get that label.
          Psychiatry does despise and cast out, by branding people.
          Why else would a label have so much impact on every human right?

  8. Hi Tim
    Glad to see your post and your commitment to peer help. I share your passion for bringing peer support to people everywhere and so I started http://www.SupportGroupsCentral.com over 10 years ago (now part of http://www.PeerSupportSolutions.com). We have had the privilege of helping tens of thousands of individuals from over 130 countries and we now provide peer support for Behavioral Health, Chronic Illnesses and Rare Diseases. There are about 250 monthly meetings on our site. They are hosted by a broad array of organizations – largely nonprofits. For groups that we staff, we used Certified Peer Specialists and Certified Recovery Coaches to facilitate them. There are over 30,000 of these folks in the US alone, many of whom are underemployed and like you, we offer them an above average hourly wage. One significant difference between what you are starting to do, and what we do, is that we are not trying to provide a more accessible form of peer “counseling.” We are simply bringing people together who have similar life challenges so they can help each other in a safe meeting place. Our meetings are very highly rated (e.g. 95% of particpants in one service would recommend it to others) and we have a strong outcomes (a 69% reduction in hospital readmissions for people in our Depression Recovery Groups). If we can be of help to you please feel free to send me a note at [email protected]. Keep up the good work!
    Best wishes,
    Vince Caimano
    Co-Founder & CEO, Peer Support Solutions

  9. Thank You for the work Tim,
    I volunteered at Occupy Bostons’s Medical tent after losing a job as a disability examiner with Massachusetts Rehabilitation Commission due to my dyslexia & ADHD that caused me to be slow learning a case management software program in training. Then I begged my way back into employment and became a CPS at a homeless shelter.
    Having worked in a PACT with a “billable” degree as a Rehabilitation Counselor using my own recovery has been rewarding.
    I am not sure how the nuts and bolts of online Peer service works. I enjoy sitting one on one or in groups but there is a large group of people suffering and isolation can be a contributing factor in the course of a mental health issue and interfere with recovery.
    In my work I have run into situations where supervision helps a great deal. There are some folks who have problems that are just to complicated for me to help to resolve based on my personal experience. In such situations being a resource of information on getting someone support is a role I could see myself helping with.
    My own experience is that I have received good and poor treatment from professionals. Also, through self help groups I have had good support and advice and some that was not healthy. Online Peer Support can lead to ethical concerns and I think being clear about what a person in distress can expect and what a CPS can provide in terms of support should be agreed upon by both parties and documented.There is also my concern of preventing someone from hurting themselves or others. So, just being experienced in recovering from a psychological condition does not exclude me from running into the issues “clinical” mental health counselor.
    This is something I hope to learn more about. SCS, M.Ed.,CPS

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