One morning last May, 10 students and two instructors from across California gathered on Zoom to talk about empathy.
Empathy, said instructor Elizabeth Morrison, is often undervalued. But it’s a crucial skill for any effective mental health care provider. People who find their way into this academy, she said, tend to already have a lot of empathy and be good at communicating it.
“Often that doesn’t get chalked up as a counseling skill. It’s like, ‘Oh, you have a really good heart. You’re a really good person,’” said Morrison, who speaks with the warmth of a therapist and the passion of an advocate. But in fact, she said, “You are engaging in a highly effective counseling strategy every time someone says that to you.”
The students on the screen, who nodded with interest, were not therapists or even formal students of psychology. They were workers from health clinics, public health organizations, and substance abuse treatment programs, with jobs such as case managers or community health workers. This session was part of their training in the Lay Counselor Academy, a private course co-created by Morrison in 2022 to prepare workers in community settings to provide mental health counseling even if they lack an official license to practice therapy.
As small and intimate as the session felt, it reflected a national push to circumvent the onerous requirements of licensure amid a critical shortage of mental health providers.
Mental health care in the United States is in crisis. As the need for care surges — a longstanding trend exacerbated by the Covid-19 pandemic — the demand for therapists far outstrips the supply. In national surveys, more than one in five U.S. adults suffer from mental illness, yet almost half of those in need report receiving no care. People struggling with mental health challenges often spend months on a wait list despite needing immediate care. Others simply can’t afford it. And getting care is even harder for people living in rural areas and people of color.
One solution that is gaining support is to create more pathways into the field of mental health care. The requirements of traditional licensure make it quite hard to become a therapist — harder, many advocates and scientists contend, than the evidence suggests is necessary.
This is not to say that traditional training and licensure are irrelevant. Licensure exists in part to preserve quality control and prevent charlatans from peddling bogus treatments. John C. Norcross, a professor of psychology at University of Scranton, compiled a history of disproven treatments and co-created a course on the topic titled “Psychoquackery: Discredited Treatments in Mental Health and the Addictions.”
“All I have to do is go Google [quack psychology] and I say, ‘Oh my god, this is why we have licensure,’” Norcross said.
Yet Norcross is in favor of integrating lay counselors into the mental health care system. “There are people who say once you open the floodgates, don’t be surprised when the house washes away. I’m certainly not one of those,” he said.
For one thing, he explained, “By requiring graduate degrees we are inadvertently, with good intentions of ensuring quality control, guaranteeing that many people go without service.”
Requirements for therapist licensure vary by state and by type of license, including professions such as social work, marriage and family therapy, or professional clinical counselor. But in general, candidates must earn a master’s degree, pass a standardized law and ethics exam, work thousands of hours under supervision, and then pass a standardized clinical exam to obtain licensure. Doctoral-level psychology licenses follow a similar progression. The exams typically cost hundreds of dollars per sitting; the academic degrees, tens of thousands or more.
Advocates for change contend that these barriers to entry contribute not only to the overall dearth of therapists in the U.S., but to the lack of diversity among practitioners. The American Psychological Association (APA) reports that Black psychologists comprise only 5% of all psychologists in the U.S., despite Black people making up nearly 14% of the overall population. About 8% of psychologists are Hispanic, though Hispanic people make up 19% of the population.
In the face of these issues, there’s growing interest in the use of lay counselors. One scientific journal recently announced a call for papers for a special issue on the subject. In its executive summary for a recent population health summit, the APA declared that the “exclusive reliance on trained mental health care providers when there are severe gaps in support for training of a mental health workforce has left millions untreated.” A number of recent research articles suggest addressing the gap by innovating on the traditional model of mental health treatment, including where and how it is provided and who provides it.
Lynn Bufka, associate chief of practice transformation and quality at the APA, believes that an expanded approach to providing mental health care is essential to meet the current need. “We clearly cannot meet the need for mental health services in this country with the existing workforce,” she said. “We’re going have to consider those kinds of models and options in order to get to where we need to be in this country.”
On the ground, the need for novel approaches feels urgent. Gaurav Mishra, chief behavioral health officer at San Ysidro Health, a network of federally qualified health centers that serve a diverse population of about 140,000 in San Diego County, feels it acutely. With 300 to 400 referrals coming into his department each month, he said, “There is no way to hire enough people that we can meet the community needs.”
Mishra, a psychiatrist, adhered to the traditional vision of therapy as practiced only by licensed clinicians until a crisis in 2021 expanded his view. That year, his team was tasked with providing mental health care for 3,500 unaccompanied minors who had arrived from Mexico and Central America without their parents. He first assigned licensed clinicians to provide group therapy to meet that massive need, but quickly recognized that even that would not be sufficient.
Within a matter of days, his team trained community health workers, who began leading group sessions at a pace of four groups per day, with 30 kids per group, seven days a week. It was a success. And Mishra realized that these group leaders were providing exactly what the kids needed — emotional support, not advanced diagnosis and treatment.
“Then I started thinking backwards,” said Mishra. “Why are we not doing this in our health centers?”
Mishra has now sent about a half-dozen staff to the Lay Counselor Academy, and he intends to eventually send all 20-plus community health workers on his team. In addition to therapy groups run in English, he is piloting groups in Spanish and Arabic — languages in which he couldn’t possibly serve all the people in need through one-on-one care. Rather than spend months on a wait list for therapy, San Ysidro Health patients with mild to moderate symptoms of mental health issues can now divert directly into group therapy led by a lay counselor.
These groups cover how to manage anxiety and depression. “I’ve had patients tell me directly that it’s been really impactful,” said Mishra. “They’ve avoided hospitalization from the skill sets they’re learning.”
Many end up never needing to see a therapist, he added. “And then the people who do need that higher level of specialty care can get in quicker.”
Mishra sees this service not as an imitation of traditional therapy, but as an option that’s different and valuable in its own right. Because community health workers often hail from the same communities and cultures as patients, he said, “They speak the language of the community … and so in that way they do connect to the patient in a different way than a clinician would.”
Most of the experts and practitioners interviewed for this article agreed that licensed therapists play an important role in research, training and supervision, diagnosis and long-term treatment of mental-health issues, ensuring the safety of patients, and providing specialty care for patients with severe or complex mental illness.
But research also demonstrates that, given the right structures, lay counselors can be just as effective as licensed therapists for many kinds of patients.
One 2015 meta-analysis of peer counseling models for treating depression symptoms found that across 23 studies, peer-administered interventions were as effective as those administered by professionals and more effective than no treatment. A 2021 meta-analysis of 44 trials, meanwhile, found that interventions from non-specialists in mental health — including nurses, midwives, lay counselors, and teachers — were more effective in treating and preventing symptoms of perinatal depression and anxiety compared to control groups that continued to receive treatment as usual. (The 2021 paper also notes that there was a lot of variation in the trials included in the meta-analysis.)
“This is not a debate or a question anymore. There’s been over 100 randomized controlled trials conducted by now” showing the effectiveness of counselors without formal licenses or degrees, said Daisy Singla, senior scientist at the Center for Addiction and Mental Health in Toronto and associate professor of psychiatry at University of Toronto, who co-authored the 2021 meta-analysis. “I don’t think it’s a matter of whether these providers are effective … for a large number of people. It’s how can we implement these in a scalable way.”
The use of lay counselors to expand and extend the reach of services has been tried and studied extensively in developing countries. Singla began years ago developing mental health treatments that community members could provide in rural Bangladesh, Ethiopia, India, and Uganda. Then, as more and more North American friends and family called her to ask how to find a therapist themselves, she said, “I realized that maybe some of these lessons could be applied locally at home.”
Norcross also cites examples of alternative forms of counseling in the U.S. starting from the 1960s, with the most well known program being Alcoholics Anonymous. “This is a magnificent way to diversify the workforce,” he said. “It does mean loosening some of the traditional licensure and training requirements. But in a crisis, that’s what you do.”
To be effective, researchers say, lay counselors need training in ethics, screening patients for mental health issues, and referring them to appropriate specialists, along with a handful of evidence-based methods such as cognitive-behavioral therapy. They need ongoing supervision by a licensed practitioner. And they need the core social skills to build trust and rapport with patients.
Bruce Wampold, emeritus professor of counseling psychology at the University of Wisconsin-Madison, has spent years studying the essential ingredients of therapy. Wampold points to a robust set of research indicating that more than the particulars of any method of treatment, it’s the relationship between therapist and patient that predicts outcomes. A significant underpinning of that relationship (or “alliance,” as it’s technically termed) is the therapist’s interpersonal skills. “Many people will find having an empathic person there to listen to and understand your issues is tremendously therapeutic,” Wampold said.
Some people naturally possess more of these skills than others, and lay counselors should be screened and selected for those aptitudes, Wampold said. But he emphasized that all counselors, regardless of their inherent abilities, need those skills refined by training and practice.
Thus trained and supervised, lay counselors are best suited to perform certain functions, the researchers and practitioners interviewed for this article said. They can counsel people with mild to moderate symptoms, who are a majority of the people needing mental health care. They can meet with people in non-clinical settings, such as community centers or churches or parenting classes. And they can be particularly effective at delivering time-limited support focused on a particular symptom or behavior.
Through this division of labor, different roles in mental health care can be performed by people with different levels of training and certification, instead of relying on licensed clinicians to do it all.
Lay counselors cannot, however, call themselves therapists, social workers, or psychologists. They cannot diagnose specific mental illnesses. And they cannot bill insurance for their services — an obstacle that limits the ways in which lay counseling programs can be scaled and funded. (At San Ysidro Health, Mishra laments that he cannot pay trained lay counselors more for the new work they’re doing.)
What do organizations that represent mental-health professions think about these calls for change? Bufka of the APA cautioned that anyone providing mental health care must have training appropriate to the services they’re providing, along with ongoing supervision by a licensed psychologist and mechanisms to refer patients who need more advanced specialty care. Ideally, she said, these caregivers would work within an integrated health care system where physicians and specialists collaboratively monitor a patient’s needs and progress.
As the use of lay counselors grows, she added, “We have to look at this from the point of view of equity. I don’t want to create a system in which some members of our society get access to one level of care and other members of our society do not.” In other words, Bufka explained, we mustn’t create a system — or even the perception of a system — in which affluent communities get therapists with advanced training and under-resourced communities get therapists who are less prepared.
At the National Association of Social Workers (NASW), Steven Pharris, executive director of the Oklahoma chapter, said that licensure is valuable, but the current system is so restrictive that it squeezes all but a narrow set of people out of the profession.
“For you as a consumer, you have a right to know, if you’re going to a physician or a social worker, that they meet a minimum standard,” he said. The problem is using a one-size-fits-all system to gatekeep a profession that needs diverse people to fill a huge array of roles. A lawyer, he pointed out, doesn’t take the same exam as a paralegal.
Pharris, who grew up in Appalachia and saw the need for greater access to care there, wants a credentialing system that provides an array of pathways into counseling that match the array of genuine needs in the field. People suffering domestic violence should have access to care from domestic violence specialists. Recent immigrants or members of the LGBTQ community might need to talk with someone who understands their particular traumas. The Native American practitioners he works with in Oklahoma, he said, should have their cultural wisdom and practice recognized as part of their expertise.
When all the jobs in social work funnel through the same licensure requirements, he added, “We’re all sitting at a four-way stop, and the state needs to put in a roundabout.”
Researchers’ suggested protocols for training and deploying lay counselors are largely in keeping with the practices at the Lay Counselor Academy. A few weeks after the session on empathy last spring, the same group assembled online to practice what Morrison calls “the home stance” — using core practices such as non-judgment, mindful listening, acknowledging feelings, and expressing empathy. “This is 80% of what we do as a therapist,” she told the students.
From there, the group moved into basic instruction in cognitive behavioral therapy, one of the most common and best-studied therapeutic methods. Then students broke into pairs to practice counseling each other.
The Lay Counselor Academy launched in September 2022, inspired in part by Morrison’s close connection with isolated communities. She was born and raised in Alaska and now lives in Modesto, a small city in California’s agricultural Central Valley, where mental health services are scarce. Much of the Stanislaus County population lives in a designated Mental Health Care Health Professional Shortage Area — as does more than half the U.S. population. Morrison’s own teenage son had to wait 11 weeks for mental health care during the pandemic, despite having severe needs and a mother with the expertise to advocate for him.
The shortage gets even more severe when it comes to therapists who hail from a particular culture or speak a particular language. Morrison, who also runs an employee assistance program, said that local agencies find it hard to recruit therapists who don’t hail from Modesto, and those who live locally in this low-income, heavily Hispanic community often face barriers to licensure. Between the time and money a license requires, she said, “in large part you’re looking at barriers that disproportionately affect people of color.” She calls these hurdles “opportunity hoarding.”
Morrison, who is a licensed social worker and holds a Ph.D. in social psychology and a master’s in addiction counseling, co-created the academy with a lay counselor, Alli Moreno. Around 160 people have now undergone the training, including about 25 case workers sent by Morrison’s home county, Stanislaus. Sessions throughout the 65-hour course cover topics including ethics, identifying and addressing implicit bias within oneself, motivational interviewing, basics of addressing addictive disorders, responding to clients with trauma, and safety practices such as setting boundaries and responding to suicidality. Organizations that send staff to the academy commit to providing their graduates ongoing supervision by licensed clinicians.
Morrison also employs lay counselors in her employee assistance program and assesses their work through client responses. When she compares client responses to lay counselors and those with licenses, she said, “it’s the same.”
Beyond the use of lay counselors, experts point to a number of other solutions to the shortage of care. One involves changing the licensing exams themselves.
These exams rely on multiple-choice questions that assess book learning. Pass/fail rates are proprietary information, most of which is not shared publicly. But breaking with tradition, the Association of Social Worker Boards in 2022 released its pass/fail rates by demographic groups and revealed stark inequities. While 85% of white candidates passed the social work clinical exam on the first try, only 75% of Asian candidates, 66% of Hispanic candidates, 59% of Native American and Indigenous candidates, and 46% of Black candidates did.
The exam results also reflected disparities by age and language, with younger candidates and those whose primary language is English passing at much higher rates. Among Black test takers ages 50 and older, just 22% passed on the first try.
Experts and advocates point to numerous possible reasons for this inequity, ranging from culturally biased exam content to systemic disinvestment in communities of color. As for remedies, the NASW opposes the exam and advocates for the development of stronger competency measures. What the current exams do not cover is what many researchers argue counts most of all: real-world skill with patients, which might be better measured through role playing and observation.
With no standardized system for observing and assessing counselors in action, Holly Hughes, a social worker who runs a group practice in Santa Cruz, Calif., is working to create her own ways to provide observation and feedback for the therapists she supervises. “We’re the only field where we go behind a closed door with a Kleenex box and a lamp,” she said, with little opportunity for professional peers to assess therapists’ work and help them improve. “That’s bananas. That’s a problem.”
Additional solutions to the mental health care shortage are cropping up widely. Peer Collective, an online counseling platform, offers peer counseling with selectively chosen and trained laypeople for $25 an hour. Oregon temporarily waived social work exam fees starting last year in an effort to lower barriers to entry, while the University of the District of Columbia is launching a free master’s of social work program. The NASW and partner organizations are working to create an interstate licensure compact that would spare therapists who move between states from having to apply for licensure again.
Seasoned observer Alan Kazdin, professor emeritus of psychology at Yale University and past president of the APA, says such efforts are beneficial. But to bring about the magnitude of change that’s needed, he says, there need to be massive policy and funding overhauls to make mental health the urgent national priority it should be.
England, for example, has made a start with its National Health Service Talking Therapies program. Begun in 2008, this program provides therapy for adults suffering from anxiety or depression, either online or in-person at local settings such as health clinics or community centers. It has grown to reach 1.2 million people per year, with a goal to expand to 1.9 million.
In the U.S., Kazdin said, there’s sufficient evidence of what’s needed to improve mental health care, with lay counselors being one part of a broader solution.”“Now we’re at the point where we really do need policy and will,” he said. “We don’t want demonstration projects, we want a change.”
This story is the latest in a series on the U.S. mental health system, supported by a grant from the NIHCM Foundation. Our financial supporters are not involved in any decisions about our journalism.