Hello, and welcome. I'm Amy Cohen, a member of the Clinical Expert Team with SMI Advisor, and I'll be moderating today's event entitled Peer Support as a Profession. 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 the faculty for today's webinar, Patrick Hendry. Patrick is Vice President of 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 National Council for Behavioral Health, the University of South Florida, SAMHSA, NASHBIT, and many other agencies. Patrick, thank you for leading today's webinar. Thank you, Amy, and I'm delighted really to be here to talk about peer support as a profession. I think it's a subject that's very near to my heart. I'd like to start off by just saying that I have no relationships or conflicts of interest related to the subject matter that we're going to talk about in this presentation. So if we're going to talk about peer support as a profession, we need to make sure that we all know what we're talking about. So what do we mean when we say peer support, and what do we mean when we say a profession? In 2001, Sherry Mead, an advocate and the founder of the intentional peer support movement, one of the top trainings in the country, developed a really widely accepted definition about peer support. And the core of it is peer support is not based on psychiatric models and diagnostic criteria. It's about understanding another person's situation empathically through the shared experience of emotional and psychological pain. And she goes on to say that when people find connections with each other, affiliations with each other, they feel closer to them. And this connection or affiliation is a deep holistic understanding based on mutual experience where people are able to be together and work together without the constraints of a traditional expert-patient, doctor-patient type relationship. SAMHSA has also done a lot of work on trying to define the role of a peer support worker. And one of the things that pops up right away is that peer support workers play many roles. Among those are advocates, navigators, and linking people to resources, sharing their own lived experience, but only in a way that aids the other person. You're not really there in a peer support role to make sure you tell your whole story. You just use the parts of your story that are appropriate to the person that you're working with. Providing communities of support and helping people to connect with their communities. Building healthy relationships. You know, one of the issues that a lot of people living with SMI is that they become ill at a very young age. And so consequently, many people are not able to build those skills that they need going into adulthood like how to build healthy relationships and intimate relationships and, you know, how to, the do's and don'ts of employment and things like that. So peer support can help a lot for people who have kind of lost that section and now they're coming into a new phase of their life where they may have the opportunity to recapture that information. So then we talked about what is a profession. And essentially a profession is any type of work that needs a high level of knowledge or skills and people maintain and improve their skills through ongoing education. And they commit to behaving ethically to protect the public. So peer support involves specialized training, certified peer support, specialized training, state approved credentialing, ongoing professional development, and a commitment to a code of ethics and professional responsibility. So essentially they meet the criteria of a profession. We're going to look at a few examples of a typical code of ethics, which is for, this is from the Florida Certification Board and they certify a number of different types of positions in behavioral health and in other areas. And this is basically the kind of code of ethics that most people would have no matter what state they're in. Their first point on their code is about professional standards. So an applicant or certified professionals got to meet and comply with all terms, conditions, and limitations of any professional credential they hold. So they can't step outside the boundaries of that convention. And the second point makes that even stronger in that those same people shall not perform services outside their areas of training, expertise, competence, or scope of practice. And then it goes on and there's a total of six subheadings under professional standards. Some of the other major headings or other headings are criminal activity, and that has three subheadings, sexual misconduct, three subheadings, fraud related conduct, four headings, six subheadings, exploitation of consumers or vulnerable population with six subheadings. And then safety and welfare, and this is one many people will be familiar with. Even a peer support. When a condition of clear and imminent danger exists that a consumer may inflict serious bodily harm on another person or persons, an applicant or certified professional shall consistent with federal and state confidentiality laws take reasonable steps to warn any likely victims of the consumer's potential behavior. And then finally, there's two other headings. One is on records management and how to keep confidentiality. And then one is on cooperation with the board that has provided the certification. And the number one under that is an applicant or professional shall cooperate with a Florida Certification Board disciplinary investigation or proceeding. So these type of standards and ethical codes are utilized throughout credential professions. If you want to look at these in more detail, you can just go to floridacertificationboard.org and then you can click on their code of ethics. So peer supports come a long way. Probably ever since people have come together in groups and people have had traumatic experiences and negative events in their life that have seriously affected them, they've probably gathered to support each other really since the beginning of civilization. Individuals we know with substance use problems began organizing peer support quite early. They provided addiction recovery mutual aid societies during the 18th and 19th centuries in Native American recovery circles. And then formal peer support or the beginnings of formal peer support in mental health can be traced back to the end of the 18th century in France. The superintendent of the Bichert Hospital in Paris in 1793 decided that he would hire patients who had been discharged to come back and work as staff within the hospital. And he said that these people were better suited to this demanding work because they were usually more gentle, honest, and humane. And this was the beginning of the moral treatment era. Moral treatment developed in Europe in the 18th century, brought to America by Dr. Benjamin Rush who was a signer of the Declaration of Independence, but he was also one of the founders of the American Psychiatric Association, what is now the American Psychiatric Association. So this entire movement was based on humane psychosocial care. The very modern era of peer support evolved starting in the 70s when we were really full into deinstitutionalization across the country. And in the 1950s, in the mid 1950s, there were over 550,000 people in psychiatric hospitals in the United States. And currently that's somewhere around 55,000. So incredible reduction, but even maybe reduced further. So these folks that came out of these hospitals and the moral treatment era had kind of waned at the end of the 19th century. And then in the early days of the 20th century, unfortunately, many of our institutions reverted back to rather inhumane and cruel types of treatment, punishment, and the way that people were treated. So a lot of the people who came out in deinstitutionalization were pretty upset. They felt that they had been injured severely by the system and they were being discharged into communities that didn't have access to the supports and services they needed anyway. So they began to come together. And a lot of this was on the West Coast, in Oregon, in California, the Bay Area, and also in New York. Some of the first peer organizations began to arise and they met in small groups to provide mutual support. So many people resisted further contact with mental health services and they called themselves the anti-psychiatry movement or survivors. But other people began to realize that the best way to change the system to help people was from within. So very soon, mental health consumers, as we began to call them in the 80s, began working in community mental health centers, some as volunteers and others as paid employees. In 1999, well, in the 1980s, we saw the rise of a lot of new kinds of peer-run services first. There were drop-in centers that were peer-run. So these could be social centers, but they were also places you went for advocacy, to learn about what's going on in your life, and to understand how the system works. We saw a lot of advent of peer-run services of different kinds and the beginning of really large peer organizations. And we saw peer advocacy start taking place on the local, state, and federal level. So as we moved into the 90s, it became more and more comprehensive and organized. So in 1999, the Georgia Medicaid Authority approved peer support as a reimbursable mental health service. That had not been done before. And in 2001, Georgia became the first state to create a formal certification and approved training for peer support. So this was the beginning of the certification era that really took place very rapidly after that. State after state began to create certifications. In 2007, the Center for Medicare and Medicaid Services said that peer support is an evidence-based mental health model of care, and that CMS was reaffirming its commitment to state flexibility through approval of these services. So they put the choice into the state community. And some states took up on that and began, as they created these certification models, they began to be able to be reimbursed for Medicaid services. And then some states still have not done that. And so in some places, the peer support that does exist is being paid for through state general revenue. In 2016, so this movement really began to grow quickly. So in 2016, the University of Texas and the Texas Institute for Excellence in Mental Health released a report, Peer Specialist Training and Certification, a National Overview. And in that report, they listed approximately 24,000 peer specialists who had been certified in 41 states and the District of Columbia. So this had started off from virtually zero 15 years before and then grew to this 24,000. And then it really began to grow. We've done an informal survey, and actually this was done a year ago at Mental Health America, where I work, and we now put the number of people who are certified peer specialists at over 30,000, and we think it's probably closer to 35 or 36,000 by now. And this doesn't include the over 6,000 peer specialists not certified, particularly in California, which has the largest number of people working in peer support of any state, but it has no certification. So there's now 45 states in the District of Columbia and some of the territories that are providing certification. So one of the most important things as this has grown is now peers are starting to work as an emerging workforce in behavioral health in places that they've never been before. They are now often working side by side with clinicians in a variety of healthcare settings. So they're working in inpatient rooms, they're working in emergency departments, they're working in community mental health centers, they're working in peer-run organizations, they're working with mobile crisis units, some even work in crisis units, run respite facilities, and the list goes on. Working in clinical settings carries up a real concern for the peer support community, and that's that we're afraid that peer specialists who are working in a minority within a clinical environment may begin to shift to a more clinical focus. And we believe that, and this was stated by Pat Deegan, and I'll speak more about him in a minute, but Pat said that it's imperative that peer support provided by peer specialists remains strictly a non-clinical service, and it's focused on the commonality of being a peer. And so we frequently refer to that as keeping our peerness, no matter what type of service we're performing. This is part of a chart that Pat Deegan developed, and Pat's a really interesting person, and she has a PhD in clinical psychology, and she is a peer. She's an advocate, and a researcher, and a human rights advocate also. She's done extensive work in the use of shared decision making, and she's created a program called Common Ground that provides tools for peers and clinical staff to create real partnerships in treatment. This is extremely important. So in this chart, like I said, it's a much larger chart, but she shows how the peer's perspective and the clinical perspective are different, but where they overlap. For instance, a peer would work, their work is guided by the principle of mutuality. In other words, from our point of view, meeting somebody as an equal, that there is no power imbalance in that relationship. And it's defined as a focus on the connection between the peer specialist and the peer, wherein there is reciprocity. In other words, the peer specialist learns from the person they're providing services to, sometimes even more than the other person does, but there's a mutuality involved. If you look at it from the clinical side, clinicians are in a role of helping and supporting participants with a focus on diagnosis, identification of strengths and treatment, and there's no expectation of reciprocity in clinical participant relationships. In other words, it's not anticipated, and this is probably not always true, but it's not anticipated, that's not a point that we try to make, that the clinician is going to learn as much or more from the person they treat. The overlap is that they both have unconditional positive regard for the person being served. Peer support focuses on learning together rather than assessing or prescribing help, and clinical focuses on assessing and helping. They overlap in a desire to support recovery and the person's achievement of their potential. So, as I said, in the back of this presentation or the citations under Deegan 2017, you can access this full report and this full chart, and it's really quite interesting because we do begin to see how complementary peer support and clinical work can be. So, peer support has really expanded throughout publicly provided behavioral health. It's available all over the country in many, many community mental health centers and other publicly funded behavioral health services. It's not available in every community, but it is growing extremely quickly, and so most people working in the public system are familiar to some degree with peer support, but very little progress has been made in providing peer support in the private sector. And one major reason for this is that there's a huge variability of standards from state to state in their certification requirements. And so it's really difficult for large health organizations or large funders like Commercial Insurance or even Medicare to contemplate using peer support where they're paying at a set rate and they're expecting that if they use peer support in Washington state and they use it in Florida, they're gonna get the same quality and standards and knowledge as they should in both states. Right now, as I said before, 45 states have peer support training and certification, and three of the remaining five are currently developing, so pretty soon it's gonna be 48 states. At this time, there's very little reciprocity between states. And so we've looked for a solution to this problem, and we realized that national certifications can provide the needed continuity across state lines. And currently there's two really major national type certifications. One is the National Certified Peer Recovery Support Specialist, and that's put out by the Association for Addiction Professionals, and their acronym is NADAC, and I don't understand how those two things go together, but anyway, and this is primarily for individuals in recovery from substance use and then maybe with co-occurring mental health disorders. The other national model is done by Mental Health America, and it's the first and only advanced level national certification that's called National Certified Peer Specialist, NCCS. And it's for peers in recovery from mental health disorders, but they may also have co-occurring substance use disorders. So in that way, they kind of overlap. This credential is not intended to replace state credentials. It's an advanced level certification that demonstrates high levels of experience and knowledge. So in fact, in order to get this certification, and you're working in a state like Florida that has a certification since 2006, one of the requirements is that you already be certified in your state. And if you're working in a state that does not have certification, there are certain training goals that you have to meet before you can apply for this. It also requires that you already have 3,000 hours of supervised experience. So it is very much more advanced than most of the state credentials. And all of these things are evolving and changing constantly. So consistent high standards make it possible for healthcare companies, insurance companies, and Medicare to know that they're gonna get those same standards from state to state. And you can look up the Mental Health America one at nationalspeerspecialist.org. And you can look at the Substance Use one at nadac.org-ncprss. And again, these things will be available. These slides will be posted to the CSS, our SMI advisor website. The peer support community is really dedicated to expanding peer support beyond behavioral health. We're dedicated to expanding it across healthcare because essentially the skills that are utilized in peer support are universal. I mean, it's the ability to listen, to help people problem solve, and goal set, and access services in their community, and learn how to build trusted relationships with people in circles of support and all this stuff. So we want our goal, and Mental Health America has brought together most of the major training organizations and some of the largest employers of peer support in the country to begin to look at how we can achieve this goal. Because we want peer support to be available to anyone who can benefit from, no matter what their health challenge it is. I grew up, my mother in the 1960s had breast cancer and she had a double mastectomy. And for the rest of my life living at home, and well beyond that, my mother held peer support groups in our living room. I didn't know exactly what that could mean to somebody until I started going to support groups 30 some years later. So peer support as a profession is constantly evolving. It's adopting a whole health approach to wellness. So even within behavioral health, we still look at, there's a lot of integration happening into primary care, and people are working with people who have other chronic health conditions. And that's very common among the peer community. I mean, we know that in reports that came out in late 2000s that people with serious mental health problems tend to die far younger than people without those types of issues. And so we take a whole health approach so that you can not only have support to try to maintain and learn the skills to work through your own journey to recovery in mental health, but that you can also develop plans and new habits and a new way of life to support what you need to manage your overall health, whether it's diabetes or heart disease or any other kind of chronic condition. Peers can now be found working on integrated healthcare teams. And they're very good at activating self-management in people who face a multitude of complex health problems. We worked with one of the largest HMOs in the country, putting peers directly into their complex medical needs teams. So this was the first time that they had brought peer support in, working with cardiologists and pulmonologists and every kind of specialty because these teams were centered around people who had multiple severe health challenges. And it has flourished and has now into its fourth or fifth year and has quadrupled in size as a project. The advent of services has produced profound changes in behavioral health. Big part of it is that we've changed attitudes about what it means to have a mental health problem. People looked at mental health in certain ways. And despite prevalent misconceptions about the relationship between mental health and violent crime, those of us who live with serious mental health disorders are coming out of the shadows by the millions. And we're making sure that our voice is heard. And we're seeing entertainers, major sports figures using their celebrity to bring the message of recovery to the world. And it's working. And I think people are now, families maybe 40 years ago didn't wanna talk about a member of the family who might have mental health issues. And now it's becoming a mainstream subject. And we see it dealt with in popular entertainment. We also see it talked about a lot more in faith groups, in community service groups, in schools, every kind of area. And much of this has occurred because of the unconditional support that we've provided each other through this evolving process. So when somebody is ready to, they want to kind of come out and announce the fact that they're living with mental health challenges. We provide each other with the support that we need to feel safe to do that. One of the models that's become perhaps the best known in peer support is referred to as the Bridger model. And it was created in 1994 by the New York Association for Psychosocial Rehabilitation, Psychiatric Rehabilitation Association, yeah. Niacras, anyway, these are all a mouthful. But anyway, they created this model where the peers went into long-term hospitals and began to work with people in the hospital. In the hospital, they began to build trusting relationships and get to know people very closely. And then to help them plan what was gonna happen when they were discharged. And then the unique thing about the Bridger model was those same peer support workers then followed the people back into the community and continued to provide support as the individual tries to re-engage with their families, friends, employers, and community. Because those of us who have gone through this process, and I have, I have some first-hand experience, that when you go in the hospital and there's been all kinds of chaos, perhaps going on in your life, and you find a place of evenness while you're there and you begin to feel stronger, when you come back out into the community, those same things that affected you before are still there and need to be dealt with. And peer support is a tremendous asset to that. So this model also has proven to be extremely successful at reducing readmissions, particularly in that very important 30, 60, 90 days after discharge. Peer support is beneficial to people as they try to follow their own personal journey to recovery. That's how we usually refer to it as a journey. Recovery is not a destination. You don't come to a point where you are recovered. Some people may be lucky enough to experience this in their life, but that's not what we mean when we say recovery. We hope to successfully engage individuals who are reluctant to receive services. Peer workers are very good at that because they're not there to try to talk people into psychiatric services. They're there to try and help people get really informed consent about what's available to them and what the potential benefits might be so that they can make good and valid choices. They're effective at helping people manage their own health, and they're also effective at working in partnership with providers. And actually, the people that peer support works with become much more successful in working with their providers. And so again, shared decision-making being one of those tools that we use, but what we really try to foster is that when a person is in treatment, that it's being addressed equally by the treatment team and the individual receiving the service. Peer support has also been effective in increasing access to services because there's more people working, reducing long waits for engagement. Sometimes when you move to a new community and you try to get connected with treatment, you might have a four- to six-month waiting time. But if peer support's available in that community, you probably can start meeting with a peer specialist prior to those first appointments with the clinicians. And then as I said before, it's really good at reducing re-hospitalization rates and also emergency room and emergency department usage, another very high-cost type of service. So if you can reduce hospitalization rates and emergency room usage, you bring down the cost of services tremendously, which means then there's additional funds to provide even greater access to services for the greater community. As people with lived experience have worked together with clinicians and other professionals, attitudes within the behavioral health system have changed. In some instances, and I had somebody talking about this on a webinar that was on the other day, licensed clinicians have discovered the value of their own experiences with mental health problems and have been able to use it to enhance their practices. Now, many agencies don't permit that. If you're an individual providing a clinical service, but you're also an individual who has lived with depression for a long time, you don't talk about your experiences with depression. But if you can and you find out how to use it correctly, it's a powerful way to build an even stronger relationship with people you serve. And as I said, peers are being credentialed as professionals in 45 states and the District of Columbia. And just the state of California alone, I think I misstated, has over 6,000 employed peer specialists, despite the fact that they have no state certification. One of the things that we also know is, just before I say thank you and hand this back over to Amy, one of the things we know is Dr. Ron Manderscheid, who's the Executive Director of the National Association of County Behavioral Health and Developmental Disability Directors. He's also an adjunct professor at the Department of Mental Health, Bloomberg School of Public Health at Johns Hopkins University. And he's estimated in the next 10 years, five to 10 years, peer support will make up 20 to 25% of the behavioral health workforce. So we've moved on significantly from our beginnings as friends and volunteers providing support to each other to become trained professionals providing a unique and extremely important role in behavioral health.

Peer support profession

Patrick Hendry

Emphatic understanding

Advocacy in peer support

History of peer support

Certification programs

Importance of peerness in clinical settings