Asian health center tries unconventional approach to counseling

KFF Health NewsOct 9 2024

In her first months as a community health worker, Jee Hyo Kim helped violent crime survivors access supportive services and resources. When a client with post-traumatic stress disorder sought a therapist, she linked him to one that fit his needs. She helped clients afraid to leave their homes obtain food delivery vouchers. As one client described her, Kim was a "connector."

Then, Kim learned to go further. Through a training program, she gained the know-how and confidence to provide emotional support. She learned evidence-based mental health counseling skills such as asking open-ended questions. She also discovered that some things she was already doing, such as listening attentively and restating what she hears, are core to communicating empathy — a vital component of a successful relationship between a client and their mental health provider.

"It was very refreshing to see that it's named and to realize those are skills," she said.

Asian Health Services, where Kim works, is a part of a fledgling movement trying to address a dire shortage of therapists by training community health workers and other nonlicensed professionals who have trusted relationships with their communities to add mental health counseling to their roles. This approach, already implemented abroad and proven to help address some common mental health conditions, is called lay counseling.

The Oakland, California-based community health center serves mostly low-income Asian immigrants who speak limited English. As a community health worker, Kim now also practices lay counseling under a licensed therapist's supervision. She does not have a license, but as a Korean immigrant and strong-arm robbery survivor, she shares lived experiences with many of the people she serves, enabling her to build trust.

Research suggests Asian Americans see mental health providers at lower rates than people of other races, and up to half of some subgroups report difficulty accessing mental health care. Figures like these may be only the tip of the iceberg, as Asian Americans can be reluctant even to seek help. Cultural stigma against mental illness and feeling like one’s problems pale in comparison to the trauma faced by earlier generations are among the reasons, said Connie Tan, senior research analyst at AAPI Data, a think tank.

Asian Health Services introduced lay counseling during the covid-19 pandemic. Violence against Asian Americans was spiking, and therapists fluent in any of the 14 languages spoken by the communities the health center cares for were in short supply. Six percent of people in the U.S. identify as Asian, Native Hawaiian, or Pacific Islander, but these groups account for only 3% of psychologists.

Concerned that people were falling through the cracks, the health center in 2021 launched a grant-funded initiative to support victims of violence. In addition to lay counseling and therapy by licensed providers, available in several languages, the program, known as the Community Healing Unit, provides services such as helping clients access crime victim funds.

The program has sent 43 community health workers, case managers, and other employees to a lay counseling training program, said Ben Wang, the health center's director of special initiatives. Trainees learn through formal instruction, observing teachers providing counseling, and practicing counseling with one another, along with feedback from instructors.

Thu Nguyen, a domestic violence survivor, was struggling with anxiety and self-blame. "My inside talk eats me up," she explained. Worried that sharing with family members would burden them, she was unsure where else to turn for support after meeting with a therapist she didn't click with. Through the program, Nguyen was assigned to Kim, who connected her to a compatible therapist.

Nguyen also leaned on Kim for emotional support. When she confided feeling guilty and inadequate as a single mother, Kim responded without judgment and affirmed Nguyen's dedication.

"She validates my feeling," said Nguyen, a Vietnamese immigrant. "She would say, 'I understand that it's hard. You're doing the best.'"

Asian Americans can struggle to find therapists who understand their culture, speak their language, or come from similar communities. Licensed therapists typically must complete an advanced degree, pass professional exams, and work at least two years under supervision. Requirements vary by state and by type of license. It has long been held that the process ensures high-quality care.

Lay counseling proponents contend this path is costly and time-consuming, limiting the field's diversity and exacerbating the therapist shortage. They also point to favorable research. Lay counseling has been implemented in several countries, where mounting evidence has shown it can improve symptoms of depression, anxiety, and a few other mental health conditions.

"The idea that someone without a license could not [communicate empathy] skillfully is ridiculous," said Elizabeth Morrison, a psychologist and co-founder of Lay Counselor Academy, which has trained 420 people, including Kim, to add lay counseling to their roles since launching two years ago. Trainees hail from a variety of jobs, including faith leaders and first responders.

The 65-hour primarily virtual course teaches topics such as supporting people who have experienced trauma, counseling methods such as cognitive behavioral therapy and motivational interviewing, first-line strategies for treating depression and anxiety, and setting boundaries. The course does not teach how to diagnose mental health conditions. Instead, trainees learn to affirm strengths, acknowledge feelings, avoid giving advice, and otherwise listen empathically.

Asian Health Services staff members who provide lay counseling receive ongoing support and guidance after the training from a program manager and a licensed therapist, Wang said.

Raquel Halfond, a senior director at the American Psychological Association, said she believes it's important for lay counselors to receive training and to practice under the supervision of a licensed mental health professional, but the group has no formal model or standards for the use of lay counselors.

The course not only upskills but also recognizes what many trainees already do or have learned that may not be acknowledged as counseling. "It's like this invisible, unpaid work, and people chalk it up as someone being nice," Morrison said.

Lay counseling is still nascent, and it often takes years for a new field to become established — and for insurers to get on board. Morrison and Laura Bond, a research fellow at Harvard Medical School's Mental Health For All Lab, another lay counseling training initiative, said they are not aware of any organizations that can bill public or private insurers for lay counseling.

In an email, Leah Myers, a spokesperson for the California Department of Health Care Services, which oversees Medi-Cal, the state's Medicaid program, acknowledged there is no billing code for lay counseling or certification for lay counselors. She said Medi-Cal reimburses certain nonlicensed providers for services that "may include what would be considered 'lay counseling'-like activities" but would need more details to make a determination.

The Community Healing Unit's largest grant, from the state of California to support victims of hate crimes, ends in 2026. The program has served over 300 people and is developing a survey to gather feedback, Wang said.

Nguyen knew Kim wasn't a licensed therapist but didn't care, she said; she appreciated that Kim, a fellow Asian woman, made her feel safe to process her feelings. Kim was also easily accessible through biweekly check-ins, and responded promptly if Nguyen called at other times.

Now, Nguyen said, telling herself "you're doing good" comes more easily.

Supplemental support comes from the Asian American Journalists Association-Los Angeles through The California Endowment.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.