Hello and welcome. I'm Tristan Grindow, Deputy Medical Director and Director of Education for the American Psychiatric Association. I'm so pleased that you are joining us for today's SMI Advisor webinar, How Peer Support Complements Clinical Practices. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to today's faculty, Patrick Hendry. Patrick is Vice President for Peer Advocacy, Supports, and Services for Mental Health America. He provides national advocacy and develops new services and training for peers within the behavioral health system. Patrick has worked as an advocate and initiator of peer-run services for 27 years in a variety of leadership roles, including former director of NCSTAC as a consultant for the National Council for Behavioral Health, and the University of South Florida, SAMHSA, NASMHPD, among a list of other agencies. Patrick, thank you so much for leading today's webinar. Thank you, Tristan, and I'd just like to start off by saying how glad I am to do this webinar, because peer support is the cornerstone of my work, and it's really fulfilling to see it accepted so broadly. I'd also like to start by saying that I have no relationships or conflicts of interest related to the contents of this webinar, and just one additional thing is I'm just getting over something, so my voice is a little bit rough, and I may have to cough at some time during the webinar, but I'll do my very best to mute the audio. So our learning objectives for this webinar are to really evaluate the readiness of organizational practice for the introduction of peer support services, identify the necessary changes in the practice or organization to prepare the staff for the introduction, and then develop methods of evaluating the effectiveness of peer support in their practices. Let's start off really by, I think we need to define what we mean by the word peer. A peer is an individual with a diagnosis of a psychiatric disorder or substance use disorder that has had negative effects on their life. A peer specialist is an individual with specialized training and work experience that supplements lived experience and who helps others in a holistic manner to move towards recovery. So this brings us to a couple of questions. Can a non-clinical support service like peer support exist beneficially in a clinical environment? Can it have a lasting effect on the way services are provided, and what outcomes can peer support provide that are fundamentally different than traditional services? Peer support specialists not only can work in clinical environments, they often do. I mean, they work in inpatient settings. There's a national model called the Peer Bridger Program, where peers go into inpatient settings, meet with the individual, build a relationship, work with them on their discharge planning, and then follow them back into the community to provide connections and resources and individual support during that really critical time after discharge from hospitalization. They work in crisis care units. They work as members of mobile crisis teams and in emergency rooms. They also work as members of whole health care teams. In fact, with one of the largest HMOs in the country, peer support has been working with critical care teams where individuals are receiving services from a broad range of practitioners because these people will come in, they'll have a behavioral health diagnosis, but then they'll have another chronic, serious health disorder, perhaps diabetes, COPD, heart disease. And so peers are working, and they have to be able to work with the person as the whole person and assist them in planning out their life and self-management. They work in integrated behavioral health and primary care settings, and they work in community health centers with clinical staff. So peer support has been expanding throughout behavioral health, primarily in community mental health, I have to say. Significant progress has been made in including them in areas that have traditionally been clinical services, as I was just talking about. It's really important that inclusion in these environments does not imply that peer support staff perform clinical roles. Peer support is just what its name says. It's a support service, and it's not a clinical service. And it's very important that people understand that and that staff understand that so they don't expect peers to play a role, perhaps in medication matters or any other type of treatment services. Peer support is proving to be the primary change agent in transforming the system of care to a recovery orientation. So peer support workers have been polled over and over. We've done a number of surveys about their jobs and how they feel about it. And on the positive side, many workers feel that they're giving more than they should Many workers feel that they're giving, they're making a positive social contribution, which is very important to them. You know, when people are going through their own recovery, they're helping others in their recovery is, feels, brings back self-esteem and the concept of worth to society. They also say it increases their wellness, helps them build social networks, gives them opportunities to move ahead in their career. Now, for now, that's primarily into supervision or training work. But as more and more of health care opens up to peer support, we will see peers expanding into more management roles, program leadership roles, all kinds of roles. We've even actually had in a few agencies around the country where a peer support worker ended up as the CEO of a large organization. Peer support workers also see this kind of work as a first stepping stone back to substantial employment. Many people, when they come off of disability, and that's where most of the people in peer support come from, start off by doing part-time work, and then they work their way up to full-time work, and then hopefully to higher and higher roles. And again, as we see the maturation of peer support throughout health care, we're going to see many opportunities open up. On the negative side, there's been some challenging experiences. They've experienced negative or rejecting attitudes by non-peer staff, which is particularly common when the staff is not prepared for the introduction of peer support. They felt like they were being treated as patients by staff members. They've actually been present when individuals receiving services were mocked by staff for their conditions. They feel that they're not included in staff free time activities, which to them means they're not being accepted as equals. And they also have experienced that calling in from allowed sick days are often treated as symptoms of whatever their diagnosis is, and this can be very disturbing to a person because we all are entitled to have days off from work for our health care, and it shouldn't be considered in a different way because somebody has a psychiatric history. So we're trying to figure out how this need for peer support came about, and advocates quite a while ago were examining the prejudice among mental health clinicians about the people they serve, and they promoted the idea of having certain non-clinical needs for people receiving services that they could be best addressed through peer support of others with similar experiences. Because shared lived experience is so important, peer workers can often build trust and connect with individuals who've resisted treatment and facilitate achievement of recovery goals. Now, that's an extremely important role because we all know that there are people who are very resistant to joining into treatment for a number of reasons. They may have had a bad experience previously. They may have been hospitalized involuntarily, and that's scared them away from treatment. It may just be an overall distrust of the system. But when peer support comes into the equation, people are building relationships with the peer supporters as equals. That's the basis for peer support is that it's a spirit of what we call mutuality. So people meet each other where they are, and they can share their experiences and share their thoughts on the matter. So the individual who may have been resisting might reframe their thoughts and find a way to at least start to begin to experience treatment that may help them out for the rest of their lives. Non-peer staff also have experiences, and they've been through it. So on the positive side, non-peer staff have said that they feel an increase in empathy and understanding for people in recovery because they're working alongside peer support staff. They've also reported that they've gained a belief or a stronger belief in recovery from working with people who utilize their personal experiences as a means for increasing the quality of life for others. And that's really important, and we're going to talk about that a little more, too, the fact that they're changing the attitudes of the staff. On the negative side, initially, when peer support was introduced, non-peer staff often expressed the fear or the idea that the cheap labor provided by peer support staff might lead to less non-peer staff positions. That's not been the case. Peer support, when it's added to it, is a supplement to existing services. It doesn't replace services. Staff have also expressed the concern that peer workers might experience burnout at a higher rate than other people. And again, actually, when we have pulled human resources administrators and supervisory roles, we found out that the stress of a job seems to affect people on basically an equal basis. Most people, when they go into peer support, are very strong in their own recovery, and they've learned many, many coping skills that help them get through. And they also know when to step back from the situation to make sure that they don't reach that burnout situation. Now, people who are in recovery and receiving services have experienced things from the advent of peer support. Peer support workers are seen as role models because they're people who are succeeding in moving more and more into their own personal recovery. They promote increased hope, motivation, and they help people build larger social networks, which are so critical to health in general. Social exclusion and isolation are a cause for many problems across the health spectrum. They've reported that they're able to build rapport with peer support workers more easily than with non-peer staff because of the perceived lack of professional distance. And that kind of gets into the ideas of boundaries. And boundaries are a bit different to peer support. We have all the boundaries, basically, that any credentialed professional would have in terms of having personal relationships and intimate relationships, financial transactions, all of that type of thing. But a peer support worker very frequently, because of where they may live, will be coming on to a staff where they need to work with people they already know, and particularly in rural environments. So, boundary issues are a little bit different. Organizations have said that they see a decrease in stigma when peer support workers set a positive example in their communities. So, how do you go about preparing your organization for peer support? So, when it's first introduced, a lot of times there's a clash of cultures. Peer staff are coming into a setting that's been traditionally grounded in a medical model of treatment. And, of course, the peers are coming from a recovery orientation. The medical model has historically focused on biophysical stabilization, symptom management, med management. A recovery-oriented approach looks at the person in the context of their quality of life and the variety of influences on their mental health. So, that may include issues like access to services, housing, transportation, family dynamics, a number of things that won't be as closely looked at under a medical model as it is in a recovery-oriented approach. In a recovery-oriented approach, the balance of power shifts towards the individual receiving the services. And decision-making becomes collaborative. So, providing staff with shared decision-making training can be really helpful because the whole idea is that when a person feels ownership of the decisions made in their treatment plans, they are far more likely to carry that treatment plan through to the finish because it's theirs and they own it. Now, they may need the help and probably will need the help of providers. Particularly if it comes to issues of medical treatment. But at the same time, those providers need to be able to work with the person in partnership to move towards mutually identified goals. So some of the things you can do to get ready is work with your staff to make sure that they understand what the role of the peers will be when they come into the organization and be very clear about what peer specialists do and what they do not do. Frequent questions that come up all the time, how do peers manage boundaries with the people they serve? I mentioned that before. What is the role of self-disclosure and peer support and how is it used? Are peer specialists strong enough to avoid empathy for them? So there's, you know, I could go through these, but there's two really excellent links here, and these slides will be on the website, SMI Advisor. And they really do go into these in great depth. The idea of a difference of boundaries, but still maintaining a professional relationship, the importance of the ability to self-disclose. You know, one of the things that has happened in community mental health to a large degree, not everywhere, but, you know, in the past, if you were a clinician and you were working with somebody to help them with their mental health issues, and you also had a diagnosis, perhaps anxiety or depression, you were not allowed to utilize that in your relationship with the individual. You couldn't self-disclose. Since peer support staff have been coming into many community mental health centers, those attitudes have changed. And some places it is now acceptable. In fact, it's considered to be an added value that their clinicians can also use their experience in their relationship with the people they're serving. Peer support workers, like I said before, frequently work as members of whole healthcare teams that are made up of clinical and support staff. So you'll have, you know, you'll have doctors, you'll have nurses, you'll have therapists. You'll have social workers, maybe case managers. It's important that peer support staff be accepted as a full member of the staff and that their contribution to the individual's health be recognized. And sometimes that doesn't happen. As I mentioned, there's a large HMO that's now using peer support really broadly with critical care teams. But when that project first started, there was a standoffishness of the professional staff that weren't used to working with peers. And so for, you know, their morning meetings or they would get together and very often they wouldn't invite the peer who was working with the individuals also on a unit in an inpatient setting or outpatient, but they wouldn't invite them to the full meeting. They would just have them come and report. And we found out since they've opened up and seen the value of peer support in their work with the people they're serving, they've become much more open to the ideas of the peer supporter as a full member of a staff or team. So some of the key functions of peer support in clinical settings, assistance in daily management, such as working out specific plans for achieving goals, and how they develop between the individual being served in the care team. One of the skills that are taught to peer specialists is how to help people to identify goals that are so important to them that they're willing to make changes in their life. And that's not an easy thing to do, particularly when you have somebody who has come out of a long inpatient stay and frequently when you talk to them, to stay on their meds, to stay out of the hospital would be about as far as they can see. And it's the role of the peer support worker to make sure they see a much broader horizon of opportunities in the world and the things that they can hope to achieve in their life. They provide social and emotional support for self-management, which is really critical, and coping with stress and negative emotions. Excuse me. You know, the negative emotions, a lot of it comes out in negative self-talk. Excuse me, I'm gonna take a quick drink of water. Comes out in negative self-talk, and there are some classes that peer support can provide to people about how to curb negative self-talk, and therefore control negative self-thoughts. They provide a linkage to care and community resources. So they help people, particularly coming out, again, out of inpatient settings or coming out of crisis, to connect with the services that they need, make sure that they make it to the appointments that they've made, and also connect them to other community resources like support groups or drop-in centers or club houses, and then to more basic things like housing needs, food stamps, and other things. And they can provide ongoing support for prevention and health management. La Raza and the Alivio Medical Center and Peers for Progress use an inpatient-centered medical home as a focus for peer support, serving predominantly Latinos in Chicago. Individuals that were receiving treatment for diabetes were offered peer support based on physical health criteria and depression or psychosocial distress or a physician referral. And at the close of it, this was a fairly large survey or research project, and at the close of it, the overall improvement in the test group was small, but it was significant when compared to the group that was offered group education and support. So that individual focus has a very positive effect. Some of the other benefits of peer support is it really helps alleviate some of the pressure on what we know is an overtaxed behavioral health system because it reduces re-hospitalization rates. There have been reports, particularly from some of the managed care organizations doing Medicaid managed care, that in programs that they've run on a statewide basis, they have seen drops in re-hospitalization rates in those critical 90 days post-discharge as high as 60% or even higher. And it lessens emotional stress on individuals receiving services because they have somebody they can relate to and talk to in an open way. Again, it helps individuals activate self-management and work in partnership with their providers. And it lowers overall costs because if you can lower re-hospitalization rates or lower emergency room visits or crisis stays, you have made a huge financial change in overall budgets for a region. And so those funds are able to provide access to services for a greater number of people. Sound supervision is really important in peer support. And whenever, in my work, that we introduce peer support into a new environment, we make sure that someone on the staff has been trained in peer support supervision. And if you're thinking of bringing peer support into your organization, that's a very good idea and a great place to start. Clinical supervision is essential for all staff working in the clinical environment. Peer support also benefits greatly, though, from face-to-face personal supervision by other behavioral health peers trained in peer support. At the very least, the supervisor needs to be very familiar with what peer support is, what it can be expected to do. And supervision includes checking in with peer specialists, sometimes about their own recovery, just as a way to open a conversation, about additional training, such as documentation and client updates. So any position needs supervision. In a four-state study on the emerging roles of peer providers, a number of human resource interviewees reported that peer support staff required no more accommodation than any other staff. Peer support supervision credentials are offered by many training organizations. One of the largest employer outside of the VA, the largest employer of peers, is a company called RI International in Phoenix, Arizona. And they offer supervision training. The Peer Leadership Center does. Appalachian Consulting, which is run by a man named Larry Fricks, who is considered to be really the father of modern peer support, and created the first peer support certification credential in Georgia. Consequently, Georgia has been at the lead in introducing peer support across the spectrum. Via Hope in Texas provides supervision training. Mental Health America of Northern California does. And many, many other training organizations. I think DBSA does, and quite a few others. And it's really important that someone be trained in those special supervision skills for peer support. There's been an ongoing series of meetings at the Carter Center in Atlanta called the Pillars of Peer Support. And they did a whole session, a couple of sessions on peer support specialist supervision. And nationally recognized experts and stakeholders came together from all over the country to identify and create a consensus about the use of peer support, and also about the proper use of peer support supervision. The concepts identified by them laid the groundwork for the creation of peer supervision training and credentialing around the country. So they created the outline, the template for doing peer support supervision. And one of the things that came out of this whole series meetings that took place over about five years was that peer specialists are in, but not of the system. And that's a little confusing when you hear it. But they work within the system, but they're not really a part of that clinical system. It's a very unique position that peer support occupies in the treatment world. Establishing effective supervision, as I said before, critical first step for employment of persons in recovery. Providing supervision for peer support workers is, as that one survey said, really almost exactly like supporting people without disabilities. And after recruiting, hiring, orienting new employees, any ongoing issues can be addressed in supervision, such as job and job role clarification, expectations and performance, confidentiality, disclosures, and working as a team member. Oddly enough, one issue that comes up very frequently when peer support is first introduced into a new environment is people are worried that they will not maintain confidentiality. And from the peer community, we've always thought that that was a very strange idea, because if anybody's gonna be concerned about confidentiality, it's gonna be people who receive services. And peer support specialists are people who receive or have received services, and they're very aware of the importance of confidentiality. Supervisors are responsible for establishing an environment for growth and learning. So they're constantly helping the people that they're supervising to reach a new level of knowledge, to reach out, to find new techniques that might be helpful in their job, to participate in webinars and workshops and attend conferences. Supervision is frequently provided in two ways, the administrative and the clinical. And so clinicians providing clinical supervision should also be very familiar with the peer support model so that they understand how it fits with theirs. And then administrative supervision is frequently provided by an individual with lived experience. Supervision is not support on its own, but it can be supportive. The role of peer support in mental health has been focused on supporting the recovery model of care. And a series of eight case studies were conducted in California to examine how peer support approaches vary within different organizational cultures. And their findings were pretty interesting. They found that overall, they saw that peer support improved quality of life as decided by the individual receiving the service, improved satisfaction of services and supports, improved engagement with people who've been reluctant to enter treatment, improved whole health, including chronic conditions like diabetes, decreased high blood pressure, decreased anxiety, like diabetes, decreased hospitalization days and overall inpatient days per year, and reduced overall cost of services. And not because they're cheap, but because what they do keeps people out of that deep end, the most expensive type of services, thereby increasing access to services. They also saw, though, that when peer support was introduced into a very, very strictly controlled kind of medical environment, it took it longer to be part of the system and start to produce its full range of positive effects. And so there's a variation, really a continuum of how you will be affected by the culture of the organization you're going into. The interesting thing, though, is that peers change that culture. So I want to say thank you and turn this back over to Tristan. And again, thank you very much for listening.

peer support

mental health

clinical practices

peer support specialists

re-hospitalization rates

supervision for peer support workers

organizational culture