Funnel Vision

March is the start of many things. Spring, obviously, but also two other seasons marked by analysis paralysis and a whole lot of talking without much action: the NFL Draft and the spring professional conference seasons.

For fans of NFL teams, this means spending far too much time scrolling the feeds of self-proclaimed NFL film gurus who devote an inordinate amount of time, seemingly for free, breaking down tape of draft prospects to see who might best meet their team’s needs.

For people in the mental health field, spring brings a rotating series of conferences where we talk about parity, best practices, policy developments, and system reforms. Invariably, the conversations almost always come back to the same topic: workforce.

There’s no mental health care without mental health professionals. The product of mental health care is the time and talent of those people, and there simply isn’t enough of it to meet the need.

So, any serious conversation about improving access to care eventually lands on the same question: how do we expand the workforce?

Right on cue for conference season this year, the advocacy group Inseparable released a thorough and comprehensive report on the mental health workforce. It’s exactly what you’d expect from Inseparable: extraordinarily well done, thoughtful, accessible, and actionable. If you’re interested in the issue, it’s well worth your time.

I don’t have much to add to the report itself other than to encourage people to read it.

Every time the workforce conversation comes up, I’m reminded of something from the other season happening right now: NFL Draft season.

Years ago, Malcolm Gladwell wrote about the remarkably poor track record of NFL teams drafting quarterbacks. His argument was that the problem isn’t simply bad scouting. Instead, playing NFL quarterback is a role where you don’t really know how someone will perform until they’re actually doing tasks on the job. It is very hard to project how someone will process chaos and make decisions under enormous pressure, or how they will command a huddle full of other grown men with money on the line.

Gladwell used that observation as an analogy for teaching, arguing that instead of trying to perfectly predict who will be a great teacher through credentials and testing, we should widen the field, let more people try the work in structured environments, and then evaluate them based on how they actually perform.

As a non-clinician who has spent a lot of time around clinicians, I’ve often wondered whether something similar might apply to mental health.

When you look closely at what makes someone effective as a mental health professional, the most important skills tend to be things like listening, rapport-building, emotional intelligence, reading people, and projecting empathy.

These are the qualities patients actually experience, but they’re also the qualities that licensing exams and credentialing processes struggle the most to measure.

Which brings us back to the Inseparable report.

One of the most promising sections of the report focuses on expanding who we consider part of the behavioral health workforce, recognizing the growing role of paraprofessionals, peers, and other non-traditional providers. The report calls for better reimbursement along with clearer certification and licensure structures to support these roles and ensure appropriate oversight.

That instinct is exactly right, but there’s an important design question hiding inside that recommendation.

During my time in state government, I spent a lot of time with the growing community of peer support professionals. They were legitimately heroes of mine. I often remarked that if it were me, my instinct would be to run as far away from my past struggles as possible and try not to think about them again. The fact that peers are willing to do the opposite always struck me as something close to miraculous.

In Indiana, like many states, the peer support ecosystem started out relatively informal, with relatively low barriers to entry for motivated people.

With each passing year, there was a steady push to formalize the system. A vendor operating under state contract developed a more structured certification process, which mirrored an emerging national curriculum for peer support. Eventually this process was codified and made more robust.1

None of that evolution was malicious. In many ways it was the natural result of success. As peer services became more embedded in Medicaid reimbursement and within provider networks, the pressure to professionalize grew stronger.

Many peers themselves were hungry for that kind of legitimacy. After years of being treated as peripheral to the system, they understandably wanted the same signals of professional standing that clinicians had. It always made me uneasy, though, that we were just recreating the pathologies of the system we were trying to change.

Just like systems flowing towards disorder is a law of physics, credential creep is a law of professional licensing systems. Left to their own devices, credentialing regimes almost always grow more complex and restrictive over time.

In the case of peers and paraprofessionals, that dynamic carries a particular risk: the tighter the funnel becomes and the more barriers the system erects, the more likely we are to filter out the very people whose life experience and community credibility make them ideal for the work.2

Is this actually happening today? I’ve heard anecdotes for years, but I don’t have hard data to point to. It doesn’t really matter, though, because we aren’t talking about maintaining the the current status quo, right? What we’re talking about is a dramatic increase of the number of people delivering behavioral health support, and there’s another institutional law that tends to emerge alongside credential creep, which is that these systems are inherently allergic to any consideration of opportunity costs or trade-offs.

If a regulation says a building must have fifteen sprinklers, then fifteen sprinklers it must have, even if no such buildings exist locally or the facility is otherwise perfect for the purpose. If a statute requires a full-time addiction psychiatrist for a rural recovery residence, then the requirement remains even if no such psychiatrist exists within a hundred miles. Both of those examples are real arguments from my time at the state.3

The point is that the these systems are often structurally resistant to the kinds of trade-offs that large-scale expansion requires. A certification process that just barely works for a few hundred people will become a serious constraint if the goal is thousands. If we’re serious about scaling behavioral health support to meet the need that exists, we have to be honest about how those systems tend to behave.

This all brings us to the main question: what if we intentionally designed the system to work the other way?

What if we took a different approach, something closer to the Gladwell model of widening the field and evaluating people based on how they actually perform in the work? Can our systems reflect the idea that peers and other paraprofessionals derive their legitimacy, first and foremost, from the communities they serve?4

That question may matter even more in the years ahead.

As automation continues to disrupt other sectors, the potential pool of people who could contribute to mental health and other caring professions may actually be larger than we think. In a world where more and more work can be automated, the value of human skills — and the quantity of humans available to deploy them — may only grow.

We will never discover those people, however, if we insist on forcing everyone through the same narrow credential pipeline. If we want a larger mental health workforce, the goal shouldn’t just be to expand the pipeline. It should be to widen the funnel.5

At the risk of putting it a little too simply: if you’re a human being who wants to help, can pass a basic safety screen, and are willing to be trained and supervised, shouldn’t the system at least give you a chance to try?

As legendary NFL coach Bill Parcells once put it, “you are what your record says you are.” Our current record on mental health care suggests it’s long past time to try something dramatically different.