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Overcoming Barriers and Recognizing the Unique Val ...
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Presentation and Q&A
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Hello, and welcome. I'm Dr. Amy Cohen, a clinical psychologist and director of SMI Advisor. I am so pleased that you're joining us today for SMI Advisor's webinar, Overcoming Barriers and Recognizing the Unique Value of Peer Support Specialists with Prior Justice Involvement. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoting 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 take care of your patients. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. Credit for participating in today's webinar will be available until May 20th, 2022. Slides from the presentation today are available in the handouts area, found in the lower portion of your control panel. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. We're going to reserve 10 to 15 minutes at the end of the presentation today to address your questions. Now I'd like to introduce you to the faculty for today's webinar, Amy Brinkley, Tony Sanchez, Justin Volpe, and Dr. Deb Pinals. Ms. Amy Brinkley is a Recovery Support Systems Coordinator at the National Association of State and Mental Health Program Directors, also known as NASHPD. Mr. Tony Sanchez is a mental health advocate at Faces and Voices of Recovery, working to enhance and develop recovery-oriented systems for care of all individuals. Mr. Justin Volpe is a Peer Support Specialist at NASHPD and has been doing peer support specialist work for the last 14 years. And lastly, Dr. Deb Pinals, she's a Clinical Professor of Psychiatry and the Director of the Program in Psychiatry, Law, and Ethics at the University of Michigan Medical School. She's also the Medical Director of Behavioral Health and Forensic Programs at the Michigan Department of Health and Human Services. So let me talk you through our learning objectives for today. Our first objective is to evaluate the value of peer support specialists with prior justice involvement to other stakeholders, including reduced recidivism rates and increased community integration. Second, we want to help you develop strategies to overcome stigma to ensure peers with prior justice involvement have an opportunity to add value to clinical services. And lastly, determine steps that can be taken to initiate changes in personnel laws and regulations, peer certification processes, and reimbursement policies. I am so pleased to welcome this panel today of my esteemed colleagues. And I'd like to hand it over first to Ms. Amy Brinkley. Thank you, Amy. Hello, everyone. It is great to be here. I want to send a special thank you to APA and SMI Advisor for allowing us to put this webinar on. I also want to give a shout out to Kristin Nalon and Ted Letterman from NRI, who helped us to coordinate and get all of our ducks in a row so that we could be here today. So the concept for this webinar originated from the Rural Peer Learning Community that NRI hosts. And that is an ongoing community that was scheduled to end, but because it was so successful, has determined that they will continue to meet. So if anyone is interested in getting involved in that, Kristin Nalon can get you that information. So next slide, please. My name is Amy Brinkley. As she said, my title is Recovery Support Systems Coordinator for NASMHPD. I've been at NASMHPD now for a couple months. Previously, I was Director of Recovery Support Services for the state of Indiana. And can we get the next slide? So I do not have any relationships or conflicts of interest related to this subject matter to note. I will say I am a person in long-term recovery, so I do have direct lived experience in mental health recovery, substance use recovery, and I've been out of the criminal justice system now for 10 years. So I have that lived experience as well. So I'm going to take a few minutes here at the top of this presentation to talk about the history of substance use and mental health care services. We're going to talk about the current state of the state for peers with felony backgrounds. And then we're going to take a slightly deeper look into what two states specifically are doing well. Next slide. So the first thing we're going to talk about here is the history of substance use peer recovery support services. And one of the things that I wanted to note here is that for more than two centuries, recovering people and their families have been at the forefront of efforts to organize or sustain addiction-related mutual aid societies, religiously and medically focused treatment institutions, and a wide variety of alcohol and drug-related advocacy groups in America. An important thing to note here is that when we talk about mutual aid societies, a lot of people automatically think of Alcoholics Anonymous, which started in the 1930s, or Narcotics Anonymous, or any of the other anonymouses that started thereafter. But it's important to note that it actually dates back. Mutual aid societies actually date back to the early 1700s with the early Native recovery circles. So there is a longstanding history here of substance use, mutual aid societies, and peer support services from the community perspective. Next slide, please. In addition to that, mental health peer support dates back as well. So consumer involvement started when groups organized. This doesn't date back as far as the substance use mutual aid societies. However, it does date back to the early 1800s. So some key issues that were addressed by the early consumer groups include people being excluded and stigmatized, stigma and discrimination, freedoms being denied by labeling and dehumanization, people being traumatized by treatment that is more aggravating on mental health than helpful. And the important thing that I want to point out here is that when we talk about freedoms being denied by labeling and dehumanization, I would say that a lot of this is still ongoing today within our criminal justice system. And I say that from direct lived experience. So I myself was incarcerated for approximately four years. And I was one of the lucky few who got to go through a therapeutic community. And I received peer support services. I was introduced to the recovery community. However, I had a sibling, my brother, who was incarcerated for a substance use disorder who was not so lucky. He did not have access to a therapeutic community. He did not receive peer support services. He did not get the mental health or the substance use treatments that he needed while he was incarcerated. And five days after release, he took his own life. So I cannot stress enough the importance of providing peer support and opportunities for people to access recovery. Next slide, please. So one of the things that I wanted to point out here on this slide is that our timeline for mental health peer support. So when we talk about change, people advocating is how we got where we are today. So when we look back at 1845's very first advocacy group, look at the title. I mean, the title says everything. When we think about how far we have come, whether it's language related or treatment related or best practice related, advocacy is what was at the forefront of all of it. So if we are ever going to make a change on our system today, it is going to come through advocacy. So in 1845, the first mental health formal advocacy group was developed. And then in the 1960s, the Community Mental Health Instruction Act was started for our community mental health centers. And then by the 1990s, the Offices of Family and Consumer Affairs were developed and supported by our state mental health authorities. So we can put a pen in this, but our Offices of Consumer and Family Affairs are people with direct lived experience housed within our state division of mental health and addiction. So for example, I come from our Indiana specific Office of Consumer and Family Affairs. And those offices formed a coalition formerly known as NACSMA, but now known as the Division of Recovery Support Services. So why that is important, I will come back to that in a little bit. So from 2000 to 2010, peer support specialist roles emerged, the National Association of Peer Support, the Wellness Summit, social inclusion and peer support were added to CMHCs. Another important thing to note in the history here is that in 2007, CMS approved peer services to be reimbursed through Medicaid. There was a letter that was sent out to all the Medicaid directors from CMS allowing states to pay for peer services and to develop their own peer support certification and programs. And then that letter was updated in 2016 to include parent peer support as well. So next slide, please. So the current infrastructure for peer support services includes peer programs, peer training, peer certification initiatives, and reimbursement of peer services through Medicaid, Medicare and private managed behavioral health care entities. SAMHSA has recognized core competencies for the development of peer training and provided states with a definition for peer workers. However, each state has its own specific state endorsed peer certification training and programs. So SAMHSA provides some best practices and parameters, but each state develops its own full continuum within that. Next slide. So earlier I said, let's put a pin in the offices of Family and Consumer Affairs. So the OSTAs were formerly a coalition of all states and territories of people with lived experience working for state mental health authorities. They are now known as the Division of Recovery Support Services. So there was a survey that went out last year to all 44 states and territories within Nashville, and we had 19 states respond. And I just wanted to point out a few key things here to note that states are reporting as it relates to this topic. So 12 states reportedly have partnerships with their prison systems and their Departments of Corrections as it relates to recovery support services. Ten states reported partnerships with their jails. As far as targeted populations, 14 of the 19 states focus on criminal justice populations. 17 of the 19 focus on SUD populations, 19 of 19 mental health, and then 14 of 19 states focus on the homeless population. And then 11 of the 19 states reportedly have a forensic peer support training in place. Next slide. The next slide here, we're going to be talking about a SAMHSA-funded mental health peer technical assistance center. So Copeland Center has a SAMHSA grant to provide mental health peer support technical assistance nationally, and they have a website through their Doors to Wellbeing grant. And essentially, this is a public-facing peer certification database that offers queries and filters. So when I went to this website, what I found is that there are 54 states and territories listed on the website. And when I ran a query just looking at background checks for peer certifications, here's what we found. So eight states reportedly do not have a background check for peer support providers. Five states reported not applicable. Thirteen states indicated, yes, they have background checks with some type of a waiver process in place. Four states reported there is an employer-only background check in place. And then 18 states did not have anything in this question. Next slide. So we're going to take a deeper look into model legislation. So the two states we're going to talk about briefly here is Colorado and Georgia. So in Colorado, they passed legislation for their Health and Human Services to develop a peer-friendly language that paves the way for peer-run organizations to become Medicaid treatment providers. That is the House Bill 21. So why is that important? So in the state of Indiana, when we released contracts for our emergency rooms to provide peer support within the emergency room, what we found is that more than half of our emergency rooms were not able to hire peers due to HR restrictions around felony background. So it was a barrier. And so what we ended up doing is we turned and put money into our peer-run recovery organizations. And we currently, four years later, now have almost 30 peer-run recovery organizations across the state who can provide peer support services to their local communities, and they can now partner with those emergency rooms. So allowing our peer-run recovery organizations to become Medicaid treatment providers is one way around the felony restrictions that employers have through their HR policies because the peer-run organizations are developing their own felony-friendly policies. So that is one way around it. Georgia has a significant criminal justice reform process and bills and policies and laws, and my colleague here, Tony Sanchez, is on the call, and he's going to be talking about that as well. So we're not going to deep-dive too far into all of these bills, but we wanted to give you guys some examples if you wanted to do some research on your own. But we are going to talk a little bit about Georgia, so go to the next slide. We're just not going to talk about all of the Senate bills and the House bills. So in Georgia, they've done — there's a specific methodology that works for Georgia that other states can implement. So first thing to know is that CMS released guidance to states that certain felonies and employee backgrounds would disqualify them from billing Medicaid, and we have been hearing that on a lot of our state coordination calls with NASMHPD. A number of states are having peer-support services claims denied because the peer-support provider has a felony restriction. So important to know is that state Medicaid plans, applicability, and state laws and definitions are variable by state, so each state has its own plan and applicability and state law in addition to the federal law. So in Georgia, they developed a policy written in collaboration with their legal team. So if we have — so for all of our other states on the call, if we have state staff on the call, they could pull in your stakeholders, so your Medicaid team and your legal team, and all of the stakeholders would be part of this policy. You would need all of the stakeholders at the table to develop this policy. In Georgia, they had the governor's support for their reintegration efforts, which was a huge impact. Not every state might have the governor's support, but definitely identify your champions and pull them in to develop this policy. I can't stress enough the legal team partnership and the Medicaid partnership if you're going to move mountains with this process. So the methodology that was used specifically, they took federal CMS guidance and laid it out against Georgia's state laws and interpretations. Then with their legal support team, they developed their own parameters of what the CMS guidance looked like in practice for Georgia. So Georgia essentially developed a review request process for certain felony disqualifiers that Medicaid supported, which allows for an individualized assessment and determination process for peers that have felony backgrounds that allows them to qualify for peer support practitioner work that is reimbursed by Medicaid. So dissecting the federal language against the state policies is the way to go, and definitely making sure that your Medicaid team is on board with that, because per that CMS guidance and the letters to Medicaid providers that Medicaid drives this. And oftentimes the Medicaid authorities divert to the state mental health authorities, but it has to be done in collaboration. So next slide, please. So the challenge for you and the challenge for all of us is to know your state's policies and regulations on felony background restrictions. The second thing here is to advocate for felony-friendly policies and laws that support reentry into the community for people exiting the incarceration system. Step three, be the change that you want to see, because change starts with us. And we can go ahead and skip through the next couple slides. I did put some resources in here for folks if you want to do some research on your own, especially with what Georgia's done. They have done a lot. They have done a lot of work to model state, really. A lot of states are starting to model Colorado as well with their recovery community organizations being allowed to bill for Medicaid. We also found about five or six states have second-chance laws that are felony-friendly, and then only about six or seven states have peer-specific language at all in their laws. So definitely know what's available in your state and then advocate for change. And next slide. And now I'm going to pass it on to my wonderful friend and colleague, Tony Sanchez from Georgia, to take us through the next section. Thank you. Tony, it's all yours. Thank you, Amy. You did a wonderful, wonderful job. Thank you for all of that information. I also want to take the time to thank APA and SMI-VASA. I'm going to talk about my experience in Georgia. I'm going to use a two-prong approach. I'm going to talk about my lived experience and the work that I was able to participate in to change some of those policies. So my name is Tony Sanchez. I'm a certified peer specialist. I work at Faces and Voices of Recovery. I'm the director of partnerships there. Prior to joining the Faces and Voices team, I was the director for the Office of Recovery Transformation for the Department of Behavioral Health and Developmental Disability in the state of Georgia. Next slide. Disclosures. No relationships or conflicts of interest related to the subject matter of this presentation. I have to say that out loud. Next slide. Who am I? I know you all heard a brief introduction about me earlier. Typically when giving introductions, we talk about those major professional or educational highlights. But what you're seeing now is how I really identify myself. My name is Tony Sanchez. I'm a person in long-term recovery. What that means to me is it's been over 20 years since I've used any mind mood altering substance. I'm a grandfather. I'm a son. I'm a black man in America. The reason I lift those things up is because I need to be able to bring all of who I am into the space that I'm in. Everything happens within a cultural context. Next slide. How does the world perceive Tony Sanchez? When I first found recovery and was trying to get a job, there was so many barriers I faced because of my race, ethnicity, my prior convictions, and my drug record. And because I have no college education, I was turned away from so many opportunities because of my record. Next slide. So what does this all mean, right? And I wanna talk about a vicious cycle that I was in, but that it's not unique to people who have similar backgrounds just like myself. So the system makes you believe that once you're found guilty and you serve your time, that you can re-enter into society and put all that behind you. But even after you serve your time, your punishment lasts way longer from probation to parole. It lasts way longer from probation, parole, supervision, unemployment. And a lot of times you're often not able to truly re-enter society. In my case, even though I was in recovery and had not used monoxone chemicals since June of 2001, as a convicted felon with prior drug convictions, I was not able to find work. For many people with backgrounds similar to mine, it becomes a vicious cycle, like I've shown here. So you re-enter society, go back to your family and community, and you look for work. Then you're rejected by employers, sometimes by your family, friends, and people in the community. You become discouraged and struggle with finding a place to belong. Unfortunately, some people, and that's my story too, return to drugs and crime for various reasons. They may experience that loss of hope since they can't find a job or grapple with no sense of belonging. I struggled many times feeling less of a man because I can't provide for my family and because I was turned away again and again for work. And the cycle continued for me until I made that decision when I was released in December 20th, 2001, that I wouldn't be going back no matter what. I don't care what society thought of me, that I was gonna make it to the other side. Next slide. So making an impact, all right? So now I wanna talk a little bit how I became involved in creating a policy in the state of Georgia for people with a criminal background, as I mentioned. I struggled a lot with finding a job. I was often turned away from good paying jobs when they learned about my criminal record. And after working for an agency in Georgia, I suddenly became ineligible for my position due to a new state policy that was put in place. I knew that I didn't wanna be silenced or live in fear that my position, now I didn't wanna live in fear that my position was gonna be taken away, that I was gonna walk in one day to work and they were gonna say, yo, Tony, you have to report to HR, right? So the fear of not knowing, the fear of not knowing what was gonna happen day to day felt really similar to when I was using drugs, right? And I have worked so hard to come out of that that it didn't make sense that I felt like that while I was in recovery and employed, right? But nonetheless, after receiving the letter from the state that I was no longer eligible for my current job after 14 years of recovery, I decided to appeal the process. And after being persuaded by a friend to apply for the director for the Office of Recovery Transformation with the Georgia Department of Behavioral Health and Developmental Disabilities. So I knew it was time to make changes to these discriminatory processes and policies, right? Because during the interview process, I was able to tell DBHTD, the same people who sent me the letter to tell me that I was ineligible, that what they were doing was discriminating. They were discriminating against people, right? That the discriminatory policies told a story that meant that they didn't believe in recovery. See, this very agency was spending so much money in certifying peers and talking about, and using the word recovery and allocating dollars to support recovery, but their actions just didn't line up. They were spending all this money, but to train individuals to provide those services, but then those people couldn't find jobs because of their criminal background. So I wanted to dismantle any stigma surrounding people in recovery. I was living proof that people can get better and become productive members of society. And ultimately sharing my story gave me a sense of purpose again. One of the things that I truly believe is that everything that I go through is not even about me, right? It's so that I can use my experience to help somebody else. Next slide, please. After being hired, I wanted to use my platform to seek real change for the recovery community. So here's a list of some of those goals. You know, I had when working with the policymakers on creating new policies, right? So individuals should, you know, so there was some tenants, you know what I'm saying? In creating this policy, right? That we needed to adhere to. These were like our north star. These were our anchor, right? That individuals should be given the opportunity to tell their story. Everybody, everyone wants to be heard and believed. People living in recovery with private justice involvement should be treated as citizens. After I paid my debt to society, you know what I'm saying? I wanted to be considered and treated like a citizen of the United States, just like I was, right? Policies should support people in recovery. And by doing that, we're supporting the whole community. And then there should be contextual, conceptual, and practice alignment. That the way that we write our policies and our service definitions, right? Should align with the way that we talk about recovery and that it should also align with the practices that we act upon. So there should always be that conceptual, contextual, and practice alignment in everything we do. And it's easier said than done, but if we are intentional about it, we can accomplish that. Next slide. So out of these discussions, a committee was formed to create new policies that would put the processes in alignment with support for those in recovery. Through that process, all individuals were still required to have a fingerprint based criminal history background check. They were then notified of their status and those with criminal backgrounds are categorized based on barrier record data. And if they're determined and eligible, applicants are given the opportunity to request an individualized assessment that will overturn their status or could overturn their status with the proper supporting documentation, such as details about the crime, the amount of time since the date of offense, rehabilitation and recovery, and furthermore, absence of additional criminal charges. We also asked for character references and a written page statement, right? And the individual is able to talk about their role in the crime they committed when they were using or when they were prior to recovery, while also having an opportunity to talk about what their life is now. One of the things that we always wanna do is lift up recovery. And not that recovery should, that recovery should not only be possible, but that it should always be the expectation. And then what type of contributions they're making to the community and their families after incarceration and finding recovery. And so that's basically it. That's what I have for today. But I just wanna say, I just wanna point out that this was in collaboration. Amy talked about support from the governor's office, but also the commissioner, Judy Fitzgerald, and the executive leadership team at the Department of Behavioral Health. We had legal, we had the advocates in Georgia participating. I mean, we had people in recovery who were impacted by discriminatory practices and policies that didn't allow them to go back to work. And because of it, we were able to create something that I hold special to my heart, right? That allows people to go back to work, right? So I just wanna thank you for your time. Here's some bibliography, some of the stuff that I talked about. I also wanna thank you. And at this time, I wanna pass it to my colleague, Justin Volpe, who will continue with this conversation. Thank you so much, Tony. Oh man, I don't know if I could follow that up. Between you and Amy, we're really stacked today. My name is Justin Volpe, and I'm a peer specialist at NASHPD. I'm gonna tell you a little bit about my history as working as a peer in the criminal justice system. Can you please go to the next slide? No relationships or conflicts of interest related to the subject matter of this, okay. So before I started with NASHPD, which was just this year in January, I spent 14 years with the Miami-Dade County Jail Diversion Program as a certified recovery peer specialist in Miami, Florida. In this program, which would be a whole presentation in its own, it was meant to divert people with serious mental health issues out of jail, some on probation, but mostly pre-adjudication that had serious mental health and co-occurring issues. We dealt with people with basically all misdemeanors and low to mid-level felonies. The peer specialists, which was my role there, would work in the community with these individuals supporting their recovery and making sure that they stay compliant with treatment to close out their court case. In this field, I've worked with thousands of people and I have extensive knowledge of the way our community works. Doing that, I would provide wrap classes, wellness recovery action plan classes to the clients, as well as assisting them to appointments, providing support, peer support on the phone, going out to eat with them, taking them to court, just doing normalized things to let them know recovery is real and living that path as a person in recovery. Because 15 years ago, I was in their same shoes, in jail in Miami-Dade County. And I turned my life around. I turned my life around thanks to this program. After me will be psychiatrist Deborah Pinals, and she's a much brighter light than some psychiatrists that have played in people in recovery's lives. I remember when I was transferred out of jail and taken to a psychiatric hospital that the psychiatrist came in and bluntly told me that I had schizophrenia and I would probably never work again or live a fully functional life. Well, I can tell him and you guys 15 years later that not only have I made a career about this, I've been a national consultant and I've also trained over 2,500 police officers in Miami-Dade County in CIT, which is Crisis Intervention Team. And that allows police officers at their discretion to Baker Act in Florida or involuntarily hospitalized someone in a psychiatric crisis. And I'm speaking tomorrow at 1045, if you can join me. And the success of this program, there's been multiple articles, press and film. There was a PBS documentary in 2020 called the Definition of Insanity. It streams for free online. And I won the 2021 CIT International Award for person with lived experience or Fred Fries Award. And this June 27th and 28th, there's a film, Hiding in Plain Sight by Ken Burns on PBS at the air. Can you go to the next slide, please? What I wanna talk about is the importance of the peer supporters, what they play. Cause I was not the only peer supporter. Our program hired up to eight peer supporters and we had three different funding sources, none of which build Medicaid. So when we talk about getting around some of these laws and the way things are, yes, we need to change. And everything that was previously stated before me is absolutely correct, but we need to get creative too. And to make peers work, focus on what we're supposed to focus on. And that's the participant. Remember, we're clinical. We add to clinical support. We are not clinical support. The relationship peers have and that lived experience, whether it's in the justice system or in any facet of life, we're here to support them and it should be made so that we can strive at that and not have to spend hours doing notes. When I went from having an open felony to becoming a Miami-Dade County employee, that transition happened in eight months. And I had only closed out my court case two months before I was hired by Miami-Dade County. That's because despite the record that a judge wrote off and granted me time to work there. And it's things like that that we can get around to do. There's all sorts of different funding and grants that we can approach and hire full-time peer specialists. When I began the field, there was barely enough work for a peer. And now there's, at least in my area, there's a lot of jobs. So the program was so successful because of the peers engagement. When the program first started, they would literally get people out of jail, send them in a taxi to their recovery houses or ALFs, assisted living facilities. And they say, you have a doctor's appointment on Tuesday. You have court in four weeks. We'll see you then. And somebody will call you. And we'd never hear from the participant again. And when they started to incorporate peers around 2006 or 2007, we saw much more retention. Just alone, our misdemeanor program received approximately 300 referrals a year and recidivism rates dropped from about 75% to 20% annually. And we measured that number by, not if you participated, but if you participated in the program and completed treatment successfully. So if you completed treatment successfully, only 20% were rearrested eventually. And in our felony program, which was much more serious cases, we went down the recidivism rate of 6%. We've saved the county over 15,000 jail days in more than 84 years of people's sentences. And that's a whole team. But the peer is a big part of that team. And the peer with that lived experience that can walk those shoes with the person that's been in that same jumpsuit and ate the same lunch they did before they went to court and to help guide them. And that's really the power of peer support. And what I wanna promote is that we need to find a way around these laws and get more people in the lived experience in these positions. And it makes the community safer. It provides fulfillment, employment and families. Because of the result of this, I went from having no hope to a beautiful home, married, two kids, and I got the American dream. So with that, I wanna pass it over to Dr. Debra Pinals, because I know she's worked a lot with peers as a psychiatrist, and I wanna hear her experience with them. So thank you so much. Thanks, Justin, and to my other colleagues on this panel and to the SMI clinical advisor for bringing in this important presentation, I think, to the audience. I really appreciated Justin's kind words about me, but I am just a psychiatrist who has learned through my own personal professional experience about what it's like to work with peers. And by taking that leap and working with peers, I have realized what a great asset they can be and what a critical asset they can be in doing things that I, as a psychiatrist, really am not able to do in terms of how I speak to people and some of the things that I need to pay attention to. So you already heard a little bit about my background. I will say that I have been working in the field of peer support now for probably over 15 years, starting with the time when I was working in a program where we had a peer worker hired to work with justice-involved clients. And interestingly enough, some of the issues that you heard about before about hiring practices really came to light because we had deliberately hired somebody with a criminal background. There was a lot of questions about whether that was acceptable or not. And we have come such a long way to understanding how that can work and how that can work for the benefit of others, but there's lots of details to think about. We can go to the next slide. I have no relationships or conflicts of interest related to this presentation, but I do want to talk a little bit about a model that my colleague, Dr. David Smelson, and I co-developed along with several other colleagues that supported this work. And this has been largely funded through grants from the Substance Abuse and Mental Health Services Administration and has been tested in other grants funded by the Bureau of Justice Assistance. And essentially, this is a model of support that started as somewhat of a wraparound support model for veterans facing homelessness and working with them around transitions so that they can be housed. We modified that model to address the needs of people with co-occurring mental health and substance use disorders who are in criminal justice context. And the model called MISSION uses an integrated approach. It combines many different evidence-based practices. There are other SMI advisor talks I've given on this model if you're interested in that. But essentially, what we do with this is we have a case manager and a peer who work together as a team during times of transition, whether an individual with mental illness is in a specialty court, like a mental health court, a drug court, or facing reentry after a period of incarceration, or even just working with probation as an alternative to incarceration. And through years of working with that model, I have come to see firsthand accounts over and over and over again of the value of the peers as a critical member of the team. And also some of the things, some of the lessons learned that I needed to learn as a psychiatrist in helping peers have success in their roles. So we can go to the next slide. So first of all, for the perspective of a psychiatrist or other treating professional who might be listening to this, and of course, as a psychiatrist, I can only speak to that, but I think this applies to other mental health professionals. Many mental health professionals are not familiar with working with peers. It is not something that we typically learn about in training programs, although I think this is changing. And so when you first think about working with a peer, there may be some discomfort. We're taught very much about boundaries and about making sure that we're seen as the professional and that we're not there to be friends with our patients, we're there to help treat our patients. And as such, when we think about the peer role, which essentially uses one's personal story to help inspire and provide hope to the individual, to help be that beacon, to help them walk the walk of their own personal recovery, it can be disquieting for a professional who wouldn't be revealing our personal stories, and we're trained very much not to reveal our personal stories. And so I think that's an important thing to recognize is that this is another piece that it may be unfamiliar to the treating professional, but that's why peers are able to do something that the treating professional isn't really able to fully take on. And it can be an augmentation and an asset to the entire treatment array that is being offered. So it's very important that mental health professionals become familiar with the work of peer support specialists. And I think you heard examples of this from my colleagues on this webinar today, some really fantastic examples of their work and how they overcame obstacles and became very much recognized professionals both helping establish policy and practices and on the ground helping people in need. And each of those people that they were helping likely had some kind of treating professionals that were working with them as well. But because we're often unfamiliar with it, as we learn more about the role, we can also learn to leverage the role to assist patients that we are treating with adherence to treatments, with understanding why the doctor is prescribing certain medications, engagement strategies to help people who may have challenges with engagement, and then also understanding barriers to that engagement where the peer might have information about things that the patient may not have felt comfortable talking about. For example, if a patient doesn't feel comfortable talking about a particular side effect, they may feel comfortable talking to the peer. Or they may not feel comfortable or feel like I as a treating psychiatrist can really relate to some of the challenges they're facing with hunger and joblessness and all of those things. They may feel traumatized. We know that patients with trauma histories often when they get to the doctor's office have a very hard time articulating fully what's going on for them. And so that peer can be kind of an interpreter to help both the patient feel more empowered to speak to their treating professionals, and also to help communicate to the treating professional about what may be difficult for that person. And to do that in a way that's really proactive and also not sort of telling on, but done in a way that helps support that person's recovery. Next slide. It's also important for treating professionals to recognize that the peer support workforce, as you heard about from Amy in the very beginning, has really evolved. It is actually a professional workforce. So it is not just random people just talking about their stories, which by the way can be helpful in other ways, but it is really a professional role that we have learned more and more about in terms of what should be the contours of the role, what should be the responsibilities of the peer support specialist, and how we can work with them so that they actually function as professionals on the treatment team. Now having worked in state hospitals when peers were first brought in, there was a lot of discomfort and lack of understanding and really some growing pains in terms of figuring out how to make the peer not feel like an add-on to the treatment team or like an outsider to the treatment team, but really feeling like somebody that was part of the treatment team as well-respected and integral as the licensed professionals. And to that end, there are certifications now for peer specialists, as you heard about before. And the national and state standards continue to evolve. This becomes, again, a very important piece of the work, and it helps ensure that when their services are provided that they can be billed through entities like Medicaid and even private insurance, because the more they are recognized as professional elements in the treatment provision, the more that billable service can be recognized. Next slide. So what can you do as a licensed clinician in working to support the peers in the workplace or to encourage peers to be brought into the workplace? One is ask questions. When there is a peer support specialist that is brought in, it's really important that you ask that peer to understand how they got there, to understand some of their story, and to understand how they think that they can utilize that story to help the patients that you're seeing in their recovery. Also answer questions. I've done several sessions with the peer support specialists that I've worked with to help answer questions that they have. For example, they're often asked questions by the people they're serving about medications, about what happens if I have a medical condition and I'm prescribed this, but I'm also taking these psychiatric medications. You're there not to make the peer a licensed prescriber, but to help answer questions in lay terms so that they can help translate those answers and be sure for themselves about how they can help support an individual in their recovery. For example, when medications were being, early on, we've been promoting medications for opioid use disorder and alcohol use disorder for a long time, but in the beginning of my work with peers, there were a lot of questions that the peers had because of some of the stigma related to those medications. Educating the peers and being able to answer their questions about how I do my book of business and what I need to know so that when I go into the appointment with the patient, I'm getting the answers that I need to help adjust medications or recognize the symptoms better that the person I'm treating might be facing. So both asking questions and answering questions really fosters a dialogue as you would, frankly, with any colleague. Just like I might reach out to the social worker on my team, I need to equally reach out to the peer and vice versa. Listening to their stories not only can be incredibly heartwarming and incredibly inspiring and remind us why we're in this business to begin with, it can really help you understand how their story can be a tool to helping the patients that you're treating. Also have them listen a little bit to your story. Of course, again, since we're trained in boundaries and our own sense of often keeping our stories to ourselves, it can be a little bit intimidating to open up, frankly, but it's important that they understand a little bit about where you're coming from to the extent that you're comfortable sharing it so that they can feel like you're a real person that they can talk to and not just some distant MD or some distant PhD or social worker or some other person with a degree. Again, really feeling like you're equal colleagues. It's also important to reach out. If you have concerns about a patient you're seeing, reach out to the peer. Have you seen this? When Johnny came into my office, I don't know, he just didn't look like he was feeling the same. I don't know, maybe he was hearing voices again. I'm not sure what's going on. I'm a little worried about him. Talking to a peer support specialist can help you gain perspective and they can say, you know what, that's so funny, doc, that you mentioned that because I was noticing that he was a little bit more disorganized and seemed a little bit more agitated when I was talking to him. You can bring that information together to bring it into the treatment. Also take their calls. Again, very important. They may have that inside baseball information that can be critical. We heard about the story, the tragic story of Amy's brother, and I'm so sorry to hear about that. There are ways that we can help put a circle of support around people by taking the calls of the peers that are supporting them who may know best about the distress our patients are in. I would say bi-directional communication is really important. Next slide. We've given you a lot of resources in this webinar to think about, to learn about the peer work that can be done. There is a lot more available. I'm just really honored to be part of this great panel and to be speaking about something that I think has become such an integral part of the work that I do. I couldn't see ever turning backwards from all the things that we've done with the work with peers and how we can work synergistically together to better the lives of the people that we're all serving. With that, I think I'll stop. Thank you so much, Dr. Pinals. Thank you to the whole panel today who shared with us such interesting information that I hope will help us move together as a community, mental health community, to include peers just in more meaningful ways. Before we move into the questions and answers, and please add your questions in the panel, I want to tell you, take a moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access all of our resources, our education opportunities similar to the one today and upcoming events. You can also use it to complete mental health rating scales and submit questions directly to our SMI team of experts. We have a consultation service and we answer questions within 24 hours during the workweek, so please feel free to enter consultations there. You can download the app now at smiadvisor.org forward slash app. So let's move into questions. I'll ask our panelists to join me on screen again so that we can address some of the questions. So I'll ask this, actually, let me ask this first one to Amy. Where would someone go to find out how many peer specialists are in Colorado and how they are trained? So can you hear me? Yes. It's perfect. So your state mental health authority would likely have that information. Not every state has a public-facing database, so some states do, and I'm not that familiar with Colorado's, so you would look for your, I would just a quick Google search, just look for the Division of Mental Health and Addiction or Peer Support Certifications for Colorado and find somebody who works with the state mental health authority and send them an email and say, hey, is there a public-facing database or just ask them directly how many peers are certified in that state. That would be the quickest way and or go through the credentialing providers. So a lot of states have multiple certifications slash credentialing providers. So you could go through them and say, hey, just trying to find out how many people are certified. Wonderful. And the person already wrote back and said, super. Thank you so much. So that's wonderful. And someone added in the chat that if you're in North Carolina, for example, you could go to pss.unc.edu to find out about some training. So look around, states have some information. So one of the things that I often hear from peers is, maybe Justin can take this question first and then others can join in. How do you think about the training that's required by your state versus national certification? How do you think about that? That's a great question. I would love everybody else to chime in. For myself, I was not certified for a year while I did the job. And there's a lot of people doing the work. And especially people that cannot do the work because of criminal background screenings should be able to be paid and awarded for that role they play in the community. I'm working with my state to update some of the training requirements right now. But what I can share my experience is that despite what training is, when you get out there in the field, it's a whole different story. And I think it's like that in a lot of fields. And I just want to keep that as a reminder that you may be, you know, filling in circles on paper. But when you get out there, especially in the criminal justice field, you have to be very flexible. And I'll open it up to anybody else that would like to share on that. Anything about certification and the importance of that? I mean, I guess I would just add, not all states for Medicaid, not all states have that as a billable service, as I think Amy mentioned. I think the more there's certification, the more it gets recognized, again, as a profession and not just some, you know, random idea where, you know, some prevention strategies are not billable services. And this isn't really just a prevention strategy, it's actually part of a treatment strategy. So I would just say that certification can be important for those reasons. Another question actually directly to Amy that came into the chat was, can you speak? I don't know if you can, can you speak as to why Indiana is not certifying forensic peers? Do you have any ideas about that? Yes. So we do have a training for forensic peer certification, but the Division of Mental Health and Addiction has a purview related to mental health and addiction. And so we certify mental health peers, substance use peers, and youth peers with a accreditation for forensics. So if somebody who also has a mental health, a substance use, or a youth lived experience happens to also have forensics, they can get trained. It's just not a standalone certification. And I think Tony was going to say something too, I'm sorry. Yeah, Tony. No, I'm good. I was actually going to respond to the previous question, and from my vantage point with Faces and Voices, we get to do a national scan, and each state is different. And what may work in Georgia may not fit for New Jersey. So I think the most important thing is that each state gets together and come to some consensus of what actually works for them and what they're trying to do. I know that in the state of Georgia, because it's a Medicaid-biddable service, there was a certain path that we took with certification, and it actually works. I think the most important thing, right, because being a person in recovery and knowing that peer support changes lives, I mean, the whole service delivery system in tandem, working together creates opportunities for people to get better, that there are some core competencies that each state should have, you know what I mean, across the board, but how they provide that training should be, in my opinion, left to the state, if that makes sense. Yeah. And if I could just add one more thing, Amy, I know we're almost out of time, but it is, I think it's like people said, but also remember the laws in each state and the processes, for example, forensic processes are different in each state. So for each state to have their own knowledge of how law and mental health and legal regulation of psychiatric practice unfolds is important for those forensic peers. And then also it's important to realize that besides billing, when you are working with criminal systems, for example, you want your peers to go into the prison system to do visits or to go into the jail sometimes, or to work with somebody who's on parole. And you have to work with those correctional authorities to make sure that they know that this is a professional. And so those roles can be very different across jurisdictions as well. So this question, and I know we're almost done, but this is like the perfect question for us to end on. It's a little bit big, but also inspiring. So the person said here in Illinois, we're working on developing a peer program with the Department of Corrections and Reentry. So that's wonderful. We're aware that there is going to be issues that arise due to the criminal background component. Is there any advice you would give state agencies just beginning to implement this idea and or what is the very first step you would suggest we take? We're talking about six-month peer support while the individual is in the Department of Corrections and then six months after. So Deb, I was wondering if you could start and help us with this. Oh, yeah. I have tripped on some problems in this area, so for sure, I think it's really great that you're doing it. I would say you start with transparency and you start with working with your correctional authorities. Your correctional authorities do have the right to figure out who's allowed in the facility and not. And we had to do a lot of work to help people walk into the facility in the same way as a staff person walked into the facility. Because sometimes when you walk into a prison, well, pretty typically you have to check a box to say whether you've been convicted of a felony or not. And sometimes you might be precluded. And the prisons do have the right to decide who can come in or not. So as soon as they know that they're working with an agency, it gives them the ability to potentially make some provisions to allow that person to do that in-reach. And so I would say that's a really important step is work with your correctional professionals. They don't have to follow the Medicaid rules. They follow the correctional rules. And so you got to work with them to allow it to happen. I would add too, it's really important that going back to a recovery philosophy of nothing about us without us, it needs to be driven by people in recovery. So it's no different for the forensic system. So utilize those people who have already been inside and have transitioned successfully back into the community. Because they're going to be the ones that tell you what works, what doesn't work, how to get around things. And they're going to be able to provide the training and the actual help and peer support that's going to drive the program. I am just overwhelmed by the comments in the chat. Someone just wrote in that Mississippi is also trying to make movements in this area. So I think there is like a groundswell of states that are realizing that this is an expertise that they need. Both peers in general, but also specifically with criminal justice background expertise. If we really want to take a recovery lens, this is something that we have been missing out on. And so I really am just kind of overwhelmed by the comments and how thrilled people are and how many just deep thank yous for people sharing their stories today. And again, we at SMI Advisor are so appreciative to our connections with NASMHPD, with Amy and Justin through NASMHPD and NRI, with Tony through our rural learning community, and Deb Pinals, who's offered so much to SMI Advisor to really stretch our minds and help us move forward around the use of those with criminal justice involvement. I wanted to share with our audience that if they have any follow-up questions, and I know there were some that we weren't able to answer, please go to our website and enter a consultation. So go into the clinician side and it'll say enter consult and enter a consult and we will make sure that we get your question answered or directed to one of the folks on this panel who might be able to help you out. So if you have any follow-up questions on this or any other topic related to evidence-based care for SMI, our clinical experts are now available for online consultations. Any clinicians can submit a question, receive a response from one of our experts. Consultations are free and confidential. On behalf of SMI Advisor, I'd also like to invite our audience to learn more about APA's annual meeting. The in-person conference takes place May 21 through 25 in New Orleans, and it will be in-person, we're thrilled to say. During the live conference, clinical experts from SMI Advisor are leading a variety of sessions on how to improve care for individuals who have SMI. These topics include digital navigators, how to make technology work, improving physical health, Clozapine, and a lot more. Lastly, to claim credit for participating in today's webinar, and again, we're so happy you joined us, you'll need to meet the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes after we end today. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. Please join us next week on March 31st, 2022, as Dr. Timothy Ongst presents, Utilizing Next Generation Digital Health Technology to Improve Care for People with SMI. Again, thank you so much to our panel today, and happy spring to everyone. See you next week, and thank you for joining us today. Goodbye. Thank you. Thank you. Thank you.
Video Summary
The webinar discussed the unique value of peer support specialists with prior justice involvement. It was hosted by SMI Advisor, the Clinical Support System for Serious Mental Illness, which aims to help clinicians implement evidence-based care for those living with serious mental illness. The webinar offered one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. The presenters included Amy Brinkley, Tony Sanchez, Justin Volpe, and Dr. Deb Pinals. They discussed the value of peer support specialists with justice involvement, strategies to overcome stigma, and steps to initiate changes in laws, regulations, certification processes, and reimbursement policies. They emphasized the importance of advocacy and the need for felony-friendly policies to support reentry into the community. Amy Brinkley shared the history of substance use and mental health care services, highlighting the longstanding role of mutual aid societies and consumer involvement. She also discussed the current infrastructure for peer support services, including peer programs, training, certification initiatives, and reimbursement through Medicaid and private managed behavioral healthcare entities. Tony Sanchez shared his personal experience in overcoming the challenges faced by individuals with justice involvement and stressed the importance of providing employment opportunities for them. Justin Volpe highlighted the vital role of peer support specialists in the criminal justice system and the positive impact they have on reducing recidivism rates. Dr. Deb Pinals emphasized the need for mental health professionals to become familiar with working with peers and to recognize their value in supporting treatment outcomes. The webinar provided insights and resources for states and agencies looking to implement and support peer programs, especially within the criminal justice system. Overall, it aimed to promote the recognition and integration of peer support specialists with prior justice involvement in mental health care delivery.
Keywords
peer support specialists
prior justice involvement
evidence-based care
AMA PRA Category 1 credit
continuing education credit
advocacy
felony-friendly policies
criminal justice system
recidivism rates
mental health care delivery
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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