Hello and welcome. I'm Alexia Wolfe, Director of the Delaware Behavioral Health Consortium and SMI Social Determinants of Care Expert for SMI Advisor. I'm so pleased that you're joining us for today's SMI Advisor webinar, Repositioning Mental Health Service Users as Educators in the Mental Health Professions. Next slide. 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. Next slide. 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 January 16, 2024. Next slide. Slides from the presentation today are available to download in the webinar chat. Select the link to view. Next slide. Texting for today's presentation is available. Click Show Captions at the bottom of your screen to enable. Click the arrow and select View Full Transcript to open captions in a side window. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide. Now I'd like to introduce you to the faculty for today's webinar. Mr. Tony Munoz-Hilliard, Dr. Sasha Agrawal, Dr. Stephanie Lehmel, and Dr. Mira Bodek. Tony Munoz-Hilliard is a New York certified peer specialist, national certified peer specialist. He works as a PACT peer specialist and is an advisor for the Public Psychiatry Fellowship of New York State Psychiatric Institute at Columbia University Medical Center. Mr. Hilliard has no relevant financial relationships to disclose. Sasha Agrawal, MD, MSC, FRC, PC, is associate professor in the Department of Psychiatry at the University of Toronto and staff psychiatrist at the Center for Addiction and Mental Health, where he works on two assertive community treatment teams. Next slide. Stephanie Lehmel, MD, is currently the director of public psychiatry education at New York State Psychiatric Institute, Columbia University, the director of the Public Psychiatry Fellowship, and associate professor of clinical psychiatry at Columbia University Medical Center. Mira Bodek, MD, uses her interest in teaching and adult learning and the interface between healthcare and technology in her role at MIMA Needs Medical Center Residency Training Program. Mira is the director of communications for the American Association of Community Psychiatry. Thank you all for leading today's webinar. So thanks everyone for joining us today. We're super excited to be here. As you saw in the previous slide, we have no financial disclosures to make. And our objectives today are as follows. We really hope that we'll be able to outline the rationale for including people with lived experience or peers as educators in the mental health professions. We wish to describe an innovative model for training mental health professionals that pairs service users as peer advisors to psychiatric trainees. We'll be hearing with the program at Columbia. And we want to have some conversation about some of the benefits and risks for service user educators and trainees when learning with and from each other in this way. So our title is Service Users as Educators, Disrupting the Frame. And when we talk about disrupting the frame, this is the frame that we're referring to in part. So this is a painting from in part. So this is a painting from the late 19th century. And it depicts a scene from a hospital in Paris. It's still there, apparently, the St. Pizker. And it's maybe one of the more well-known paintings in the history of medicine. And there's a lot going on in this painting. And the person in the middle, the man standing with the tuxedo is a Charcot, who was an eminent neurologist at the time, one of the leading physicians in France. And because this is the late 19th century, this precedes psychiatry as a discipline, the way we would understand it now. But some of his thinking and teaching at the time led to the modern practice of psychiatry. Beside him, you can see a patient who is in a particular pose, which at the time was understood as hysterical. And the scene depicts a medical learning environment. And there's a lot going on in terms of race and gender and social class and other things into professional hierarchies. But what I want us to really focus on for our purposes today is the question of where the patient fits into this medical learning environment. And I think you can see that the main source of knowledge in this interaction is Charcot, who's the professor. And the students to his right, our left, are engaged in a kind of a lecture, maybe demonstration, lesson. And in the painting, you can quite clearly see that Charcot is the one whose knowledge counts. And it's been disseminated, essentially from him, with maybe a passing glass to the patient and then over to the students. And I think the reason I'm showing this painting is because there are many ways in which this still resonates with the way we think about the way we experience health professions education 150 years later. The patient, as you can see, is more or less an illustration. She's not quite fully conscious. Her knowledge about her situation, her experiences, her theories, her ideas about her challenges, her medical conditions, whatever they are, are really absent from this encounter altogether. And I would argue that anyone who spent any time in a, at least a medical learning environment, recognizing that the different health professions have somewhat different histories and cultures, but at least in the medical learning environment, that there are many things from this painting, which still are operating today in terms of where we position the patient in how we disseminate information to trainees. And so a few things to highlight from this are, one, we tend to construct our training so that learners get a very narrow view of patients' experiences. We see folks through a particular lens, and we may not find out a lot about certain parts of their lives because we're busy focusing on the medical story, the symptoms, the illness, the treatments. So there's a narrowness to that case. It's also highly skewed in the sense that we see people at their worst. We tend to see people in the emergency department or the inpatient units. When people are doing well, they're not coming in for medical or health services as often. And so we tend to get a very skewed view of patients. We also get a constrained view because there's a script that we have to stick to. You know, there's certain questions that doctors and other health professionals are supposed to be asking patients or expecting to be asked, and we don't tend to deviate very far from that script. And then I think the painting helps us also see that in addition to the gaze being narrow, skewed, and constrained, it is fundamentally also oppressive. There is a power dynamic, a hierarchy that is operating where the doctor or the health professional is on top, maybe the learners in their various stages of training are in between, and then at the bottom is the patient. And so there's a kind of a hierarchical relationship with patients, which also constrains the way we understand people in our training. And what I would like to argue is that when we have a learning environment which creates a particular view of patients, and we have trainees who are going through years and years of training in this environment, it's really hard to create the kinds of values in a system that we all hope to achieve in a recovery person-centered system where we emphasize choice and citizenship and dignity, empowerment, hope, inclusion, meaning, respect, and rights. These are the things we're aiming for, but our system is designed to create a relationship with patients through training, which is at odds with these values. And so what are we going to do about that? Well, one idea which we're talking about today is to really restructure the learning environment so that patients aren't in this particular position as that's illustrated in the painting, but to really bring them in as educators whose knowledge counts and who can participate in the learning in a different way so that trainees learn to relate to patients in a different way. And this idea of including service users or people with lived experience, patients, peers, as educators is something which is increasingly becoming common, particularly in the UK and Australia where it's actually mandated in a number of health professions, but also becoming a bit more common in other places as well. And so, you know, we sort of imagine maybe moving the patient to the teacher's position, but it's actually not quite that simple because, of course, as you can see in this illustration, just moving the patient into the teacher's role, unless we pay attention to things like power and unless we prepare students for that change, unless we think about the hidden curriculum and we think about the ways that patients can still be subjected to those constraints and those limitations that we tend to impose on them in our medical learning environments, in our health professions, education environments, we may run into a problem where actually we're not getting as much change as we want. So I think the invitation here is to think about how to bring patients into the medical learning environment, into the health professions education environment in a different way as educators with knowledge that matters and to bring that knowledge into our training environments and giving it the respect that it deserves and creating spaces where we can relate differently to patients all through training so that at the end, graduates have a different understanding of the knowledge that people with lived experience have and a different way of relating to them. So with that, I'm going to turn things over. Thank you, Sasha. Next slide. So I'm going to be talking with you a bit about the Columbia Public Psychiatry Fellowship Program and this is a program that has tried to incorporate a lot of the concepts and views that Sasha has just discussed in our fellowship. So first, I'll just tell you a little bit about our program. It's a postgraduate program, so all of our fellows have completed their residency training as psychiatrists when they come to us. We have on average about 10 fellows each year and they actually are working, even though we call them fellows, they're actually working in as part-time attendings in different mental health programs throughout New York City and they're working as full-fledged psychiatrists in those settings. And then two days a week, they come to us for didactics and supervision and different projects that they work on and three days a week, they're working in the field. And just to give you an example of some of the jobs that our fellows have, some of them work on ACT teams, they work in the homeless outreach programs, they work in jails in the criminal legal system, in shelters, in emergency rooms, in outpatient clinics, any place that would hire a psychiatrist is a potential place for our fellows. I'm sorry, I forgot to turn on my camera. It's a potential place for is a potential place for our fellows to work. Next slide. So as we teach our fellows, we have three conceptual lenses that overlie everything that we teach. The first is recovery-oriented care and trauma-informed care and that's an umbrella through which or a lens through which we teach everything. We also have a social justice lens that we use, which includes equity and diversity principles in terms of providers and clients and a systems-based practice lens, which is understanding that people's lives are complex and that they have to navigate multiple systems of care to get their health needs met. And the one that we're going to be focusing mostly on today is the recovery lens. Next slide. So as Sasha mentioned, one of the first things that we do when the fellows first join us is we try to undo a little bit of the training that they've had through medical school and residency, which is primarily focused on the medical model, where the clinicians are sort of taught that they are the experts, that they have the knowledge, and that their job is to recognize symptoms and signs of illness, make a diagnosis, and treat the symptoms. So that's and treat the symptoms towards symptom resolution. And that there's very little emphasis on the knowledge that the individual patients bring to this dyad. And it's often very one-sided and the power differential is on the side of the provider. So that's the traditional medical model that Sasha was talking about. And that is how most of our residents are trained. Our fellows are trained during residency. So we say to them, step out of the medical model, don't throw it away entirely, but step out of it and put it aside and embrace instead a recovery model. And in the recovery model, it really is about teamwork and engagement and that the key component to the team is the person that you're providing the care for, the patient, and that the patient has expertise that they're bringing to the team, and that their knowledge and their goals and their decisions about their well-being are just as important as all the other team members and are center to how the team functions. And in this process, you get the diversity of the multidisciplinary team's knowledge, but all of it is driven by the actual patient's knowledge and the patient's goal in a recovery-oriented setting. Next slide. So then we were trying to figure out how do we actually do this? Because again, as Sasha said, it's difficult to sort of undo the training that a lot of psychiatrists have. So in our fellowship, we were trying to think about ways to teach recovery-oriented care that's person-centered and person-driven in the context of a training program. And after meeting Sasha and looking at his work, we decided to create the Peer Advisor Program. So the Peer Advisor Program is a collaboration that took place originally between Howie the Harp, which is a peer specialist training program in New York City, and several other advisors who helped us to design the Peer Advisor Program and help us come up with the model that we have now. And key to the principle of this program is that the people with lived experience, the peers, are the advisors to the fellows. Next slide. And so this is our ninth year of having the program. And it's really an upside-down model where we've totally flipped the power dynamic, where the people with lived experience are the teachers and the experts, and our psychiatry fellows are the learners. And this really allows a role reversal, which gives the fellows and the peers a unique opportunity to see each other in a very different way. And to do this, we hire one peer for each fellow. So we have 10 fellows, we have 10 peers. And all of our peers have worked as peer counselors, so they've had experience in clinical settings and in teaching. These are all paid positions because we believe that we pay everybody for the expertise that they're bringing to the group, that the fellows and the peers meet for one hour, either in peer pairs, where it's a peer and a fellow paired, or in small groups where they do small group activities. We designed it with the small group activities because we realized even in having the peer-fellow pair, you really are only getting the perspective of that dyad. And because we want diversity of thought, we have the small group activities, which allows both the peers and the fellows to experience an interaction with the rest of the larger group. And after the peers and the fellows meet, then there's an opportunity for a group discussion with all of the peer advisors and the faculty. And we use this time to really touch base with the peer advisors to get a sense of how the fellows are doing. But it also serves as an opportunity for the peers to actually speak with each other, because as is often the case in any clinical setting, there may be one or two peers, and they often don't get an opportunity to interact with each other. So this one hour after the peer-fellow interaction also gives the peers an opportunity to talk about their various jobs, to exchange information, to collaborate around presentations that they often do together. And it's just an opportunity for all of us to learn from each other. And then we also encourage the peers and the fellows to try to meet in the community. So not just meeting in this structured setting of the fellowship, but to actually meet in the community, either at the peers' job or at the fellows' job or any other place that they choose to sort of further their exploration of each other as just individual people. Next slide. So at the end of the at the end of the year, we also have a reflections, where we ask all of the peers and we asked the fellows to think about what the experience of the year has meant to them. And, and they anonymously read each other's reflections during the celebration. And every year, it's always fascinating to sort of hear the thoughts, because we don't know we don't know which reflections are from a peer or which reflections are from a fellow. It's always fascinating to hear people's experience of the transition over the year's time of what they've learned from each other, the knowledge they've gained the things that they've implemented into their practices that they've learned during the experience. We also now because we're in our ninth year have had ongoing collaborations between peers and faculty and peers and fellows in various presentations, locally and nationally. Next slide. This is just an example of some of the questions that we pose to the fellows and the peers when they're meeting. And these are these topics are meant primarily as icebreakers to get conversations going. And and the real emphasis is on being curious about each other, trying to learn from each other and be curious about each other's perspectives. So, and so this gives the peer and the fellow an opportunity to both hear to share their own perspective, but to hear the perspective of their partner. So for example, self injury and suicidal thoughts. So you know, the question we pose is why is this so hard to talk about? And and who is responsible for an individual person's safety? So you can see that these are very intense questions. And we try to have a safe environment and a brave environment where both the peers and the fellows feel comfortable sharing ideas around these topic areas. One of the fun group activities that that the peers that they do in small groups is taking an average psychiatric recovery, a psychiatric process note, and rewriting it from sort of the medical ease, the medical language that we typically use in our documentation of people's medical health, and rewriting it from a recovery oriented perspective. And with the idea and the respect that patients should be allowed to also see their notes and read their notes, and that it should be a useful thing for them. And this is always an interesting thing to do, because it really challenges the fellows ideas of what how we speak to people and how we document medical health and mental health. Next slide. So the primary goals are really to recognize the diverse recovery journeys that people have. We want fellows to critically examine their own biases and judgments of each other. We also want them to identify the social and structural determinants of health and recovery, including some of the deleterious effects of prejudice, discrimination, poverty, and social inclusion, exclusion, and the impact that that has on people who are seeking mental health care. To help the fellows integrate these integrate natural community and peer supports into their treatment and understanding spirituality, cultural practices of the folks that they're working with, and to critically examine to what extent mental health and addiction services impact and are actually providing hopeful environments and preserving people's dignity and empowering people, and not traumatizing people. Next slide. So in summary, the peer advisor program is a reversal of the typical hierarchy between psychiatrists and peers that allows for curiosity in both directions for people to just see each other as people and learn from each other. It provides a safe and brave space for sharing of ideas and discussion of often difficult topics and to facilitate collaborations and looking for opportunities for peers and psychiatrists to work together in clinical settings and also in other advocacy. And that both peers and fellows to become better providers of services because of this experience. Thank you. And now I'll pass it on to Tony. Thank you, Stephanie. So I use this image, you know, in this role as, you know, sometimes we can switch our roles as recipient or provider of services, right? Who is requesting and who are providing these services. And so this speaks to my role as recipient and as provider of peer services. Next slide, please. So one of the ways that I have been trained to, you know, to be able to work with somebody and provide these services is through this model of intentional peer support, you know, which provides me with the language and the tools to work with somebody. And in this process of learning about each other and our experiences, much like this program, right, we're all co-producing new ways of learning, new ways of moving through a crisis or whatever we might be going through. So this was important to me, and this is the way that I bring my teachings, if you will, into this program of advisor. Next slide, please. And as we heard Stephanie talk about some of the topics that we discussed throughout the year, you know, these are things that I may have had personal experience with or in my role as a provider of peer services that I, you know, that I might be working with somebody. So I can use my lived experience, you know, to talk about some of the things that we come together to talk about, right? I think one of the things that I, you know, that I like to talk about is stepping out of the medical model. And so, you know, we may have a conversation of what that might, you know, be and look like, right? Some of the questions are, are some alternative treatment services that can be used in mental health? Should these treatments be prescribed, supported by psychiatrists? Is there, is peer counseling and support treatment? And what is the meaning of a diagnosis and how is it used in the system? So, you know, I share a lot of my experience, you know, with all these topics. And the other thing that I like to, that I like to do and I'll bring is, you know, some of the things that I'm reading about mental health, how peer services are being used in different settings. You know, I might talk about an article that was shared on Talk Crisis now, right? About the importance of peers in a crisis care team. You know, I think sometimes our roles might be underestimated. You know, and I think it's important to, you know, to talk about all these things, right? Just so that we, you know, the fellow has, you know, gets an understanding of how we might work in different settings. Or, you know, there's, you know, I think both Sasha and Stephanie shared about, you know, social determinants, right? When I was going through a difficult time, you know, that was important, right? Losing my housing, losing my work and going through all these things. Where am I going into the community to look for resources and help, right? So these are the things that I might be talking to the fellows, but also to the people that I may be providing support and services. And I think one of the things that I like about this program is that the fellows come, I think, with, you know, this curiosity of, you know, wanting to know how do I connect with somebody? You know, how do I help somebody that needs help? And so, you know, I might share my experiences, but I might also bring this article in the New York Times about a Boston doctor that, you know, how he was able to build that connection with the people that he was working, right? I mean, you know, for him, it was, you know, learning to listen to his staff and to the people, right? And, you know, maybe rubbing that person's foot to, you know, to help him build that connection. And these are all things that, you know, that are thought-provoking and new ways of listening, right? New ways of being with people in need of services, in need of care. You know, I might post, you know, an article, a research article that, you know, asks the questions, you know, what would, you know, a psychiatrist do when their patient, their person is asking, what would you do in regards to taking medications, right? So sometimes it's not the same, the response isn't the same as what they are prescribing and telling their providers. Again, this is another way of having these other conversations with the fellows. You know, are our diagnoses or, you know, what we're going through crisis, are they really all having to do with mental illness? Or is there a medical condition that might be affecting our mental wellness? And so, you know, there's articles about, you know, in the Washington Post about a catatonic woman who awoken from 20, after 20 years, you know, and it was determined that, you know, there was an autoimmune disease that, you know, was causing a lot of her illness and symptoms. And so, you know, these are some of the things, sharing my own personal lived experience, but also sharing what, you know, I am reading. And I think through my work, providing peer services, right, I hear a lot of people. I hear a lot of people about, you know, using the internet to, you know, to get information. And sometimes it's, you know, I think these articles and this, you know, what is being put out there is significant and might help some of the people that I work with, you know, to maybe shift the way that they see themselves, right. If you want to go back to the previous slide, Sasha, you know, so in working this way, right, instead of going, instead of saying that I'm helping somebody, is that I'm learning with somebody, right, just like I do it with the fellows, right, is that we're all learning new ways, right. And this happens to when, you know, we go back into the peer meetings after meeting with the fellows, right. It's a new learning. I mean, I'm always learning from my peers about, you know, their own ways of moving through their crisis, you know, and this is about connecting, right, how are we connecting, you know, how do we learn, how do I learn to see myself in the world and, you know, what is coming back at me. And, you know, I think we're all peers, right, we all talk about it. You know, I'm always impressed also about, you know, sometimes the fellows are able to share some of their experiences, personal or familial experiences. So, you know, I really love this program, because it allows us to co-create and, you know, hold these professions together, that no one has the answers, but together, you know, we can find new meaning and new learnings. And with that, I will pass it on to Mira. Thank you, Tony, and thank you everyone who's been listening so far. Alexei, it's okay with you. We're going to stop sharing the slides, and I'm just going to talk a little bit about the lessons that we learned through this process, and then open it up for discussion, and we would love to see questions from the audience. So, anything and everything that you're curious about, that you would like to learn, you can put your questions in the Q&A, and we would love to take those. But I'll just take just a couple of minutes. I think we're doing well on time. I'll take just a couple of minutes to talk about some of the lessons learned from our program. And I'll say, so I'm part of the faculty at Columbia, and I am lucky enough to share an extra hour with a group of peers with Stephanie every month after they have met with the fellows in this group debriefing, and it's been such an enriching and humbling experience for me to hear from all of the peers and have a chance to meet with all of them as a group every month. And then more recently, because this debriefing, this group supervision had been so helpful, in the last couple of years, we started doing the same for the fellows. In the past, we would just check in with the fellows kind of in individual one-on-one supervision about how their interactions with the peers has been, but now we formalized it into an open discussion the week after they meet with their peers to give them a chance to share in a group as well and learn from each other. So I think that's the first kind of lessons learned that the one-on-one interactions between the peers and the fellows have been truly transformative. The small groups interactions where we have two or three pairs meeting together, so the fellow peer pairs grouped together and having a topic for discussion or an exercise like rewriting a progress note or writing a wellness and recovery action plan together, those have been truly meaningful in the sense of providing a more diverse experience and opinion and range of thoughts, not just from the peer that the fellow has gotten to meet with, but from the other ones as well. Those have been really meaningful and we now have a split in terms of all of the sessions throughout the years. And then the last one is having the whole group together, peers separately and fellows separately, has really added to the richness of the program and to so many insights that maybe didn't necessarily come up in the one-on-one or in the group conversation. So that was the first thing that I wanted to share. The second thing that I wanted to share was that pretty early on we realized that flipping the power dynamics and changing and disrupting the hierarchy in this way can be uncomfortable and can be quite uncomfortable on both sides. And specifically as a psychiatrist, I'll speak from the fellow's perspective, we represent a discipline that has had a terrible history. Many, many situations in which our profession has taken advantage of patients and mistreated them and abused them. And we carry that responsibility while we as clinicians might practice in a completely different way. This is unfortunately the reality and the history of psychiatry. So being put in this situation of being an ambassador for a discipline with this history can be truly uncomfortable. So one of the peers and one of the fellows early on have come up with a document called rules of engagement or a statement that they've wanted to put together just to make sure that everybody feels comfortable and heard and respected. And I wanted to read it to you very quickly because I think it's very meaningful. This is a meeting of peer counselors and psychiatry fellows. We meet because we share a common goal, better mental health for ourselves, for the people we work with and for our community. We recognize that each group brings specialized training and the distinct perspective to this meeting. Each person, regardless of their group, has a rich collection of lived experiences. The views expressed come from our training and our lived experience and as a result might be passionately expressed. It is natural to feel defensive sometimes about one's own group identity, personal experience or training background. In the spirit of collaboration and out of respect for all perspectives, we aim to keep our tone always respectful, to listen with genuine curiosity, to speak from our own experience and to give each other the benefit of the doubt. Ultimately, we aim to create a safe environment where bridges can be built, learning can happen and the field of mental health care can grow in new and healthy ways. I just thought this was so thoughtful and beautifully written and this is the spirit with which we start this peer group interactions. Just a couple of other quick points I want to make about lessons learned. We thought that this would be quite impactful for the fellows during their fellowship year because they are in these meetings and they get to learn from the peers, but what we've learned is that it has a lasting impact way after they finish training. To this day, we keep in touch with with alumni and we hear, oh you know, I remember when this person told me naming their peer by name and then this happened in my practice or this happened in my life or this happened with a patient and how meaningful that was. I also think that it's interesting to talk about how these interactions have put us in a situation where we can develop trust and we can develop a mutual relationships as humans, not as doctor and patient or provider to provider, because the situation is completely different. And this level of honesty and shared experience has led to talking about a lot of, we call it myth, dispelling myths of psychiatry or of mental health that wouldn't have come up in a doctor patient relationship. For example, one of the ones that has been shocking to us, but then again, kind of mind blowing expected was the fact that a lot of our peers did not know that there are pressures in the mental health care system that make us have to see patients for only 15 minutes or 20 minutes, depending on the health care system that we're part of every month or sometimes every other month or sometimes every three months, that there are these situations in the system that make us be like that. We were very surprised when we were having this conversation and we heard from the peers that their impression was that this is all my doctor wants to give me or this is all my doctor cares about. And that's why they have this limited interaction with me. Another big one was about diagnosis. As some of you might be aware, there's now a federal law called the Cures Act in the United States, which allows every service user to have access to all of their medical documentation in real time and free of charge, usually through an app or an online patient portal. And while this has existed for certain medical centers and health care organizations, it's now mandatory for everyone, including any mental health care notes, therapy notes, medication management notes, inpatient hospitalization notes, etc. So now that this access has expanded, it's very interesting to see how the patient's perspective is on diagnosis. And it was also a very interesting myth to dispel and to have an open discussion about the fact that we as providers are obligated to put a diagnosis on a note. Otherwise, for medical legal purposes and billing purposes, that note is considered incomplete. So while we absolutely understand that people don't fit neatly in the boxes of specific diagnosis or that specific diagnosis could be problematic, indeed, we are obligated to use diagnosis because of the way our system goes. So that's another important lesson that we learned through this, which is that if you don't talk about a particular topic because it just doesn't come up in the doctor-patient relationship, many things can be misunderstood. And unfortunately, many feelings can be hurt and relationships can be damaged because of this lack of communication and understanding. So I'll stop here just so we have a good 15 minutes for questions, but happy to talk more about other aspects of the program as they come up through questions. Well, thank you all for such an interesting presentation. And before we shift into Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. You can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. And you can download the app now at smiadvisor.org. And we had some great questions coming in during the presentation. One of them is if there is a copy of the rules of engagement that you read, Mira, at the top of your presentation, our participants are interested in referencing that document. Yes, absolutely. And I was actually trying to figure out if there's a way I can attach it in the chat, but I do not see that. Okay. Well, we can work on that behind the scenes, but that's great to know. I know people will absolutely share it. It's not proprietary information. It's just something that our peers and fellows have put together that they truly wanted to express how they want this space to be. No, terrific. And another question is how do these relationships affect other members of the treatment team? So I'll jump in on that one. You know, I think one of the things that we really emphasize with the fellows is that as a psychiatrist, you can't really provide all of the care for any individual person on your own, that you really have to reach out and expand your team. And the team, when we think of team, we think about family members, we think about friends, we think about other physicians, somebody's primary care doctor, their dentist, the social service folks, the housing folks. So we really think about the team members broadly. And one of the things that I think happens is that as our fellows begin to incorporate recovery-oriented principles in the way they interact with clients, they convey that then to the rest of the team members. And I think that, you know, we have seen that in organizational settings where our fellows work, when we have one or two fellows who have gone through our program and gone through the peer advisor program, working collaboratively in a program, that there is over time a change in the way people see each other as team members, in the way that they interact as team members, in the way that they incorporate peer recovery-oriented principles. So even though we haven't formally studied this in terms of the impact on other team members, I think just from sort of the feedback that we get and our experience of doing this for many years now, in New York City, we have seen changes in programs in terms of how recovery-oriented they are, once the fellows have bring this knowledge to the teams. Excellent, thank you. And another great question is, how does the program recruit the peers for the program? Have they been in treatment for some time or are they screened in some way? So we actually, the criteria that we have for peers is that they have to have had at least five years of lived experience in mental health care, and that they have worked as peer counselors for two years. And if they were trained through Howie the Harp, which is one of our favorite programs, if they were trained through Howie the Harp, then they only need to have one additional year of experience working as a peer counselor. And then we ask everyone, we have essay questions that we ask people to answer, and we interview them. And in the interview, we're looking for people who are open-minded and willing, you know, who've had teaching experience and who are willing to be teachers and learners. We don't know anything about people's diagnosis. We don't know anything about whether they were hospitalized or not. We don't ask anything about their treatment unless they want to share that information with us. We don't ask that. That's not relevant to the work that they're doing with us. If I can add, we also ask in the interview if they're interested in teaching and if they have a curiosity about mutual learning, because I think a lot of this relationship ends up teaching the fellows and learning from the fellows and learning from the other peers. So it's really important that this is something that they've had experience with and that they're curious and open to. Right, that it's bi-directional. And to build on this topic, Tony, could you share with us what it's like collaborating with other peers in this setting? Yes. You know, like I said earlier, it's, you know, having these new learnings, right, because our experiences and recovery and how we work is different, right? Trainings are different. And so it provides, you know, I want to say that it provides everybody with more resources and more ways of holding people in crisis or when they're not well, or even when they're well, right? It's like, I think that's one of the things that I like to talk about, right, is how do we talk about the things when we are doing well, right? We don't always have to be in crisis. So I think working with my fellow peers, and some of them I've known for a while, and I think, you know, having these new youth peers is also, you know, helps me to learn new things from them, right? Because, you know, I'm older in years, and things change, and we have new ways of doing things. So that's, you know, that's always helpful for me, right, especially now that I'm working at this other organization where we do have a lot of younger individuals. So it's, you know, it's a win-win for everybody, I think. Terrific. And what is it like for program participants or for the fellows to unlearn some of their medical training through the partnership with peer advisors? You had touched on that at the beginning of the presentation and would love to delve into that in more depth. I can take that and try to answer, but I would also be curious to hear from Sasha, since the people that he's working with are at a different level. As Stephanie mentioned at the beginning of the presentation, our fellows are already fully licensed practicing psychiatrists, meaning they have gone through medical school, and they have gone through residency, and they're now in a fellowship. So that means a lot of ingrained medical model beliefs and thoughts. So the later you come into this process, the harder it is to unlearn. The great thing about our group is that they're somehow self-selected because they already kind of felt this way and thought this way and thought there was something wrong with the medical model, and they wanted to learn a different way of doing things. But sometimes they cannot help it because they've been trained in this way for so long. So it's very interesting when we meet with them, especially in the last couple of years when we formalize this group debriefing, how sometimes it's literally a light bulb going off in their head saying, why have we always been taught that we cannot disclose anything about ourselves? You know, actually, I learned from my peer that self-disclosure for the purposes of helping the person I'm working with could be beneficial, and it makes us human, and it makes us more relatable and more able to trust each other. This is just a small example, but it's really been a hard process, and I'm very proud of the fellows for engaging in this hard process of challenging what they've been taught and really trying to think critically, is that the best way of doing things? And a lot of them say they wish they would have been exposed to this in residency. A lot of them say they wish they had been exposed to this in medical school. So I think the earlier you address these issues, the better. So I would like to hear from Sasha as well, since he works with residents. So they're a little bit earlier in the process than our fellows. Yeah, and maybe I can start with my own experience being advised in this way, which is where I started thinking about this. So I was a fellow and had the good fortune of working with Maria Edwards at the Connecticut Mental Health Center as my service user advisor. And I would echo what Mira said, that it was hard to become aware of the fact that I had a very particular way of thinking about my role in my work, which wasn't working in some ways, and wasn't really meeting the needs as I was understanding them from Maria. And so that unlearning and becoming aware of the biases that one holds, which I've argued earlier, is baked into how we train people. Becoming aware of that is uncomfortable and a little disconcerting. In terms of the residents, I think, yeah, I think when we ran this program at the University of Toronto, we did not have a self-selected group the way the Columbia fellows might be. And the experiences are pretty variable. Some people immediately understood the value of this and were highly engaged and found it really helpful and informative. And other people did not. And, you know, why is that exactly? Is that an attitudinal difference? Is it that the, you know, program like this by nature is going to be highly variable? You know, each peer doing this work is going to bring something different to that equation, their own approach. It's not something you can easily standardize or you don't even want to standardize. And so there's a lot of variation in the way people experience it. I think one of the interesting questions is who benefits the most? You know, is it the choir who, you know, already is committed to these ideas and sees the value and can run with the model? Or is it the folks who maybe don't get that right off the bat, but maybe can get some new ideas and some change happening, even if it's not obvious to the peer, to the program in that moment. Maybe, maybe you're, I mean, one of our fellows described it as like, sorry, not fellows. One of the advisors described it as like farming, planting seeds. And so maybe you don't see it right off the bat in the meetings that the person's very open to this, but maybe something is happening inside and over time, or maybe down the road, those ideas really start to germinate. So I think we don't know yet the question, the answer to the question of who benefits the most, or if it's even connected to how someone may see themselves in this model at the beginning. Can I just add to that also that I think in our experience that it is really truly bi-directional. So it's not just the fellows learning about recovery-oriented care, it's also peers understanding about the limitations or the restrictions of mental health care. And just an example, I remember, and Tony, maybe you remember this as well, when some of the peers were asking the fellows why doctors, why the psychiatrist only comes in for 15 minutes and walks out, and that they really felt that it was because the psychiatrist didn't care about them, that they were coming in so quickly and leaving. But after discussion in this bi-directional learning, the peers learned that the psychiatrists were just as frustrated with these 15 minute med checks, and that this was a systems issue and not a personal feeling, that the psychiatrists would love to be able to have more time to talk with people and sit down with people and interact with people, but because of the constraints of the way we do mental health care in the United States, unfortunately, there are these time limitations that are forced on people. And so I think that knowledge in both directions was super helpful for the peers and for the fellows to be able to talk about. Thank you. And part of the peers' role is to challenge the status quo. What are some ways that you support advocacy, and what are some ways that your program encourages the fellows to hold space for that advocacy in their practice? I'm happy to take that question. I think from the beginning of this I think from the beginning of this program, both the fellows and the peers, or a lot of the fellows and the peers felt that this is something that we would want to tell the whole world about because of how impactful it was for both parties. And advocating for similar programs and similar kind of flipped power dynamic relationships became something that we were very focused on. So this presentation, I don't even know the number of, I have not been keeping track, but it's maybe the ninth or 10th time that we present to a national audience together with one of our peer advisors on the benefits of this program. And we are happy to talk maybe separately if anybody's interested about implementing such programs in your institution or organization, because advocating for these types of relationships and for including people with lived experience in medical education is extremely important. And we've tried at national, we presented at national meetings of the Psychiatric Association of the Mental Health Services Conference. Next step would be to present to an education conference to challenge the way the curriculums are designed to include people with lived experience. And we've encouraged the fellows to advocate at their work sites. Not all of them work with peers, unfortunately, and the ones that do have peers in their organizations is usually just one. So we've encouraged them to spend time with their peers to develop a non-clinical relationship, just human to human trust and respect to make space for the peers opinions and input, which is so invaluable. Well, again, thank you for such a robust dialogue in the Q&A. And we'll shift now into the housekeeping in our final minutes as we're at the top of the hour. And if there are any topics covered in this webinar that you would like to discuss with colleagues in the mental health field, you can post a question or comment on SMI Advisors Discussion Board. And this is an easy way to network and share ideas with other clinicians who participate in this webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI Advisors' national experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It is a completely free and confidential service. SMI Advisor offers more evidence-based guidance on peer specialists, such as windows.org, such as Windows of Wisdom, Shape Your Own Journey with Insights from Experienced Peers. These videos share valuable first-hand advice from peer specialists who have many years of combined experience in the field. Access the videos by clicking on the link in the chat or by downloading the slides. To claim credit for participating in today's webinar, you need to meet the requisite attendance threshold for your profession. After the webinar ends, please click continue to complete the program evaluation. The system then verifies your attendance for credit claim. This may take up to one hour and can vary based on local, regional, and national web traffic and usage of the Zoom platform. Please join us next week on November 20th as Dr. Yara Zisman-Alani presents Two Decades of Shared Decision-Making in Mental Health, Achievements, Challenges, and Path Forward. Again, this free webinar will be November 30th from 3 to 4 p.m. Eastern time on Friday. And again, the date for that is November 30th. Thank you for joining us and until next time, take care.

peer advisors

mental health education programs

Columbia University

lived experience

recovery-oriented care

social determinants of health

mutual learning

disrupting power dynamics

safe space

training programs