The Promise of Peer Counseling

Data on high school students from the Centers for Disease Control is dark. 29 percent experience poor mental health, and 42 percent have persistent feelings of sadness or hopelessness. One in five has considered suicide. One in ten has attempted it.

In the face of such need, it should be good news that the mental health workforce is growing at a relatively rapid clip. And yet, there are not nearly enough talk therapists and psychiatrists currently specializing in the treatment of teens.

In researching the workforce problem for a soon-to-be-published book about the collapse of youth mental health, I found no clear solution for the shortage of providers. The deep deficit of specialized therapists presents a classic case wherein those most in need of help get the least. And, asking around, the case seemed hopeless. But in mental health, hopelessness is treated as a starting point. Or, to quote a talented therapist I know, “Okay, so, we’ve found the darkness. Now where’s the hope?”

One ray of hope I did come across was peer counseling: In schools and community centers, peer counseling programs are helping teens help one another move through difficult feelings. 

What these programs offer is an offset to the provider shortage rather than a direct correction to it. But once we accept that the workforce deficit in youth mental health has no straightforward solution, the promise of peer counseling grows ever brighter.

How, first, did the youth mental health provider shortage come to be?

Lockdowns didn’t help: The rising call for youth providers led to more work for them, which in turn decreased their numbers. At the height of the pandemic, many exhausted providers left their youth mental health careers behind, according to Angela Diaz, a pediatrician specializing in adolescent health and the former director of Mount Sinai’s renowned Adolescent Health Center. “The pandemic dispersed a workforce that was short to begin with,” Diaz said. 

The workforce was short to begin with because therapists tend to treat teens in institutional settings only on their way to more lucrative careers in private practice — often the preferred path for mental health professionals who, typically saddled with student debt, will scrape through a lower-paying stint at a clinic or school rite-of-passage style before moving on.

Top-down attempts to reverse this trend, like taxpayer-funded tuition incentives for pre-professional specialization in adolescent mental health, are more unrealistic than ever in the second Trump administration. But even if they weren’t a political dead end, such incentives would not make a lifelong commitment to working with adolescents a more attractive prospect for the average therapist.

Treating teens is, quite simply, too rare a calling. And for good reason: It’s really, really hard work.

Anna Freud, daughter of Sigmund, was a pioneering therapist to troubled teens. Building on her father’s work, she founded the field of adolescent psychiatry. And so Dr. Freud knew whereof she spoke when she described the treatment of adolescents as a “hazardous venture from beginning to end, a venture in which the analyst has to meet resistances of unusual strength and variety.” Or, to put it another way, a surly 17-year-old dragged to her therapist’s office by her parents can be a tougher nut to crack than a court-mandated drug-counseling client.

Today, the UK-based institute that bears Anna Freud’s name conducts public health research. Youth mental health care is in collapse across the pond as well, and to address the UK’s own provider shortage, the latest findings at Anna Freud support the development of — wouldn’t you know — peer counseling programs. 

Peer counseling is just what it sounds like: Adolescents who choose to receive training as counselors learn fundamental talk-therapy skills — like listening, without judgment, about the tough topics caring adults typically struggle to discuss with teens and vice versa.

At the core of any peer counseling program is a mental health professional teaching teens how to listen deeply and offer each other support. A key part of any program is training peer counselors to recognize when a case is beyond their help and to refer a peer, at that point, to a clinically trained therapist. Amid such a shortage, every teen who can be helped by a peer counselor without that referral means one less name on a waitlist for specialized clinical treatment — and more availability for the highest-need cases.

Sheila Balk has directed the peer-counseling program at Pomona High School in eastern Los Angeles County since the mid-1990s when conflict mediation was its primary mission. “Back then, we would break up two fights a day,” she recalled. These days, it’s anxiety: “Panic attacks—two or three [students] a class period.” Then as now, peer counselors derive a profound sense of purpose from their work: It improves their confidence, Balk said, knowing they’re part of a legacy of community support.

What these peer counselors learn about themselves in the process, they carry with them for the rest of their lives. Peer support has benefits—boosting students’ morale and confidence, combating loneliness, and edifying community bonds—beyond our capacity to quantify.

A peer counselor delivers the “talking cure” in the form of on-the-spot and in-context understanding. As opposed to weekly therapy with an expensively credentialed provider for whom every teen is a challenge in large part because of how challenging it is to be a teen.

To quote that talented therapist again: “Hard people to be around are hard people to be.” And, I would add, it’s hard for adults who survived adolescence to remember how hard it was. Or to remember how we survived at all. If we were lucky, we had someone to talk to, whom we trusted to listen. For most of us, that was a peer—or what’s more commonly called a friend.