Hello and welcome, I'm Shereen Kahn, Senior Director of Workforce and Organizational Development at Thresholds, Illinois' oldest and largest provider of community mental health services and social work expert for SMI Advisor. I am pleased that you're joining us for today's SMI Advisor webinar, Using Peer Support to Empower Self-Management and Participation in Treatment for Individuals who are Difficult to Engage. 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. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians and one Continuing Education Credit for Psychologists. Content for participating in today's webinar will be available until September 19, 2021. 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 questions 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. Now I would like to introduce to you today the faculty for the 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 NCHSAC as a consultant for the National Council for Behavioral Health, the University of South Florida, SAMHSA, the National Association of State Mental Health Program Directors, among many other agencies. Patrick, thank you so much for leading today's webinar. Thank you, Shereen, and I just want to start off by saying that we have no conflicts of interest related to any of the subject matter that we're going to discuss in this presentation. So today's learning objectives are, upon completion, we think that participants will be able to identify potential obstacles to building trust between individuals in need of assistance and the formal system of care. They'll be able to determine ways in which peer support can address lack of trust and help to build therapeutic relationships. And they'll be able to compare the benefits of individuals participating in their own treatment through self-management versus consequences of providing services that are not agreed to by the individual. So we know that some people are difficult to engage in services, and there's a number of different reasons for it. Frequently, people who have experienced involuntary or coercive services or treatment resist reinvolvement with the system of care. Involuntary treatment can be very traumatic for some individuals. It certainly takes away feeling of control of one's own treatment. It affects your self-esteem, sense of autonomy, and your confidence in yourself. Individuals who feel that this control has been taken away, a lot of times they just don't trust the system that they see as coercive. Some individuals have experienced restraint, seclusion, and forced medication. And some feel that clinicians that previously received treatment from remember them as they were during their crisis time and not as they currently are. And this, again, can kind of result in a feeling of depersonalization, a feeling for the individual of inadequacy. With young people, 80% of young adults with first episode psychosis drop out within the first year. There's a number of reasons for that. Mistrust of the system and failure to establish a really good alliance with the provider is the most frequent cause. Often a young adult's first introduction to the adult system is very frightening and confusing. And people feel that they're not treated with respect, they're not supported, and they're not understood. You're brought into a system of care that is very depersonalizing. And this is really difficult when you're first going through the symptoms of your own issues, but now you have to deal with the complexity and the confusion and depersonalization of the system of care. Street homeless people frequently have a real distrust of the system based on the fact that they perceive a lack of practical assistance, finding housing, finding food, finding access to clothing, finding access to laundry and bathing, and all of the things that they need to get by on their day-to-day life. A lack of flexibility and the persistence that people come back to them over and over, or don't come back to them over and over to try and work with them in a way that's acceptable to the individual. Black Americans are 20% more likely to report serious mental health problems, and yet they're less likely to use the system of care. Lack of representation of the African-American culture among clinicians and a lack of understanding of race issues affects on overall mental health. Clinicians is another reason why people are resistant, Black Americans are resistant to participating in services within our system. Mental illness-related stigma still exists in the behavioral health care system and among practitioners. People with lived experience frequently report that they feel devalued, they feel like they're dismissed and dehumanized by health care professionals. Over the last 30 years, as we've moved, and maybe 40 years, as we've moved more away from just a really clinical approach to mental health care to what is a hybrid kind of approach based on support and clinical services and recovery-based, we have the feeling that things are getting better, and they are, but we also have, we assume sometimes that the people that we're providing services to feel the same way, and that's not always true because for each individual, it's strictly about their individual experience. The pervasiveness of reports of negative interactions suggests that the problem is not limited to a small number of providers. It's a much larger problem than we sometimes recognize. It's a problem with how the system perceives and prioritizes people living with mental health disorders. The system of care is very difficult. People with serious mental illness, only about 65% of them ever receive treatment in a given year. People with other mental health problems, only about 45% receive services within a given year. So, the system is overtaxed. It's overburdened. Providers are in the same situation, but what happens is the individual kind of takes the brunt of that. People have to fit into a system that is not always really an adequate fit for them. It doesn't help them to feel like they're being seen as an individual. This creates problems for individuals seeking help, and then they discontinue services, let's say, and they have increased adverse outcomes. Really the quality of the therapeutic relationship is probably the most important part in determining success of engagement. Recovery-oriented services reinforce empowerment and a sense of autonomy and respect and can improve engagement, and this is both on a clinical level and on a peer support level. While research has tried to find ways to improve treatment and engagement, peers have noted that our system of care doesn't treat users often with empathy, dignity, and the respect that people want and need in their lives. Peer support workers share their lived experience when appropriate, and this helps them to build trusting relationships through the common bonds of shared experience and understanding. Peer support is based on a very simple concept of mutuality, the idea that we come together as a peer supporter and a person receiving support as equals. We both bring something to that relationship, and in peer support, we frequently say that the person providing the support gets as much out of the relationship as the individual receiving support. It really goes back to a very old premise, which is the helper principle, the idea that when we help others, we are helped ourselves, and some research even shows that the person in the helper position may actually receive more benefit out of the relationship than the person who is being helped. Acceptance of a patient's expertise concerning their own life and their own condition and the openness and joint discussions concerning knowledge are important. So when we approach people, we have to recognize that while we may be an expert in whatever service it is that we're providing, the individual is an expert on themselves, and trust is closely connected to feelings of autonomy and power. When there's an imbalance in power, and it's kind of innate in a mental health clinical relationship that there is, because one person comes in and they have the weight of a system behind them, and the other person is an individual, and so there's a feeling that one person has power and the other one doesn't. Peer specialists are faced with the task of trying to eliminate as much as possible that imbalance of power and try to create really a relationship of equals. In that case, power is not owned by just one person. Mutual understanding between the person being supported and the supporter is important. The goals of the individual are the most important goals of all, and it's up to the supporter to understand what those goals are and then to support the individual in achieving their personal goals. People want to be treated as individuals, as people. They don't want to be just one of many, and so when you're in a clinical role and you're seeing a lot of different people in any given day, it's very difficult to step back each time and remember that that person who just walked in the door has that need and that desire to be seen and recognized as an individual and to know that the services they're receiving are specifically for them and not just a formula for treatment. Depersonalization, when people are treated as just part of a system of care, it results in mistrust, and this again creates a problem for people to either engage at all or to re-engage if they feel that they've been pushed away from services that they want and need and desire. So building trust and a good sense of rapport is a first step in establishing a peer relationship and really probably in any kind of helpful relationship. This gives you a solid base for working together to identify and accomplish the person's own personal goals and work towards the life that they want. In peer support work, the fundamental element is the idea that we come together in that we're considered peers and that we both have kind of a shared lived experience, and that doesn't mean that my experiences in the system are exactly identical to another person. It doesn't necessarily mean that we have the same diagnosis. It doesn't mean that we received exactly the same services, but it does mean that we have been in that system of care, and we know how complex it is. We have experienced the effects and social effects of having a diagnosis and receiving services, perhaps being hospitalized, perhaps being taken in involuntarily, and each of those elements gives us another way to connect with people and to build trust. Trust also increases the likelihood that the individual is going to feel safe in asking for help. When peer supporters share their own personal stories, and they only share the amount of their story that's necessary to relate to the individual, they reveal their personal strengths and their vulnerabilities, and this reinforces their identity as peers, and again, that sense of peerness, which is kind of nebulous, but it's a real force when people come together and begin to be able to relate to each other's experience and understand that they share feelings about how it is to go through these experiences, and it helps build bridges across the differences that might initially divide them. Having been there, as we say in peer support, and having shared experience with behavioral health and other disruptive life issues, there's less fear of stigma and being judged when individuals have access to peer support, so when I, as a peer specialist, go to meet with a person for the first time, and we begin to just kind of feel each other out and understand who we are as individuals, the person may not initially understand what peer support is, and even if they do, they may not initially want it, so it's up to me, as the peer specialist, to kind of explain what's available to people and who I am as an individual and a little bit about my own personal experience in order to build that sense of peerness or camaraderie so that we can come together and begin to build a trusting relationship. In reviews comparing peer support and clinical practice, peer support does better in areas related to the recovery process, and this is changing to a degree, but I think it will always probably be true to some degree because each of us working in the peer support role has gone through that process of trying to identify what recovery is for each of us as individuals, and then how do we achieve it in working our way through a very complicated system of care and all of the social issues that are attached to the idea that we have a diagnosis, so peer support tends to build greater levels of self-efficacy, empowerment, and engagement, and by sharing stories, individuals receiving peer support value the sense of belonging to a group. One of the most common things that you hear when somebody has their first encounter with the mental health system of care and then comes in contact with peer support is that they are just so amazed and relieved to know that they aren't the only one, that they're not alone, that other people have experienced similar things, and we know that, but it doesn't feel that way, and for so many of us when we're first diagnosed and our first introduction to the system, we receive a very negative message. We receive a message of you have a mental illness. You'll always have a mental illness. You have to take medication probably, and you'll probably have to always take medication. When it's a serious diagnosis and you've gone through a lot of traumatic events and a lot of negative experiences based on your illness, you also are frequently told you'll probably never work again, or if you do, it's going to have to be something very low stress and simple, so what that is is a message of hopelessness. Basically, you're being told that your life is over. The peer support message is this isn't true. There is life beyond diagnosis. There is life through treatment. There is life through the accepting of support and figuring out what directions we want to go forward with. Peer support affects many important outcomes for youth, and peer support is a very difficult topic when we come to providing support for youth, particularly when we're talking about people below the age of 18, and this is because the formal peer support system is in almost every state, 48 states, is based on a formal certification that you are a certified peer specialist and therefore your services are billable through state's Medicaid services or other types of payment, and in the other two states that don't yet have certification, they are also recognizing your support through some type of formalized training. In the youth system, it's difficult to really say that you're a peer when there's a significant age difference, so for most peer supporters working with youth, the age is maybe 18 to 24 where it still is kind of a viable relationship. There's a lot of work being done all around the country, though, to begin to teach the skills of support to people younger than 18, not that they're going to be employed, not that they have that kind of formal responsibility, and also the system doesn't have the liability involved in that, but that they're able to support their friends. They're able to support other people going through similar experiences. When my oldest son was first in the system of care, he was 12 years old, and his first hospitalization came at 13, and he was scared, and he didn't know what to expect. He didn't know what was going to happen to him, and then some other people in the group, in the support group he was in, started talking about their experience, and for him, that was his safety line, just knowing that there was somebody else there who'd gone through something similar, who understood, and who were willing to listen to him and take him seriously. Adolescents report receiving greater emotional support, who report receiving greater emotional support, are less likely to feelings of depression, emotional distress, and loneliness. So, in my son's case, that was what happened for him. He was strengthened just by the idea that there was somebody there who gave him the emotional support he needed in that moment, beyond his family. Racial identity is also important to social identity at this time of life. So, individuals with a higher level of ethnic or racial identity are likely to receive higher levels of peer support because they're more open to it. They have a greater sense of self and how they fit into their community, and therefore, they're open to receiving the support of others around them who have similar ideas. So, then we need to talk about what happens when a person who has disengaged or never engaged in the system begins to work with a peer support individual. Motivation and activation are the two catchphrases that we use. Motivation and activation towards self-management is related to service engagement. Motivation and activation are related, but they're distinct concepts. So, individuals with high internal motivation, which you can have either external or internal motivation, so individuals with high internal motivation, like, I want to participate in my treatment because it will help me. I know this about myself, and individuals with high external motivation, my doctor and my family think that treatment will help me. Those are the most likely people to adhere to their treatment, and they're followed only by people with high internal motivation, so the second group with the most likelihood of adhering to treatment, the people who have that own sense of self that I want to participate because I know it's going to help me. Individuals with high external motivation only are the ones who are the least likely to adhere to it, so researchers are beginning to look at social environmental factors such as the presence of peers who support that sense of autonomy and competence and believe in people's ability to recover and are able to convey that message to a person in a way that they can take it in and make it part of their own life. Engagement and activation are frequently used synonymously, but they are likely two completely separate aspects of health and well-being. Engagement is when individuals and systems establish a bond that links health, illness, and well-being to a system of care, so you're engaging an individual in a system of care in a variety of types of care and treatment. Activation is the important step of taking on the role of self-care in the promotion of your own health. A person is engaged when they see a provider who recommends a course of action, and they are activated when they choose to pursue that action, so when a provider recommends a course of action and the person begins to accept that idea and they're engaged in that conversation and begin to hear what treatment is, that's engagement, but when they decide to pursue it on their own, to take ownership of it, to begin that process of self-management is when they are truly activated. Activated individuals are able to self-manage symptoms. They're able to engage in activities that reduce health problems and maintain functioning. There's a type of peer support training called WHAM, whole health action management, where peer specialists are trained to help people to not only manage their behavioral health, their mental health, issues with addictions and or substance use, but also other health care issues and particularly chronic issues like diabetes or COPD, issues of extreme weight gain and possibly heart disease, so when people begin to become activated, they begin to look at that broader picture of themselves and they begin to engage in activities that can address themselves as an entire person and not just a series of symptoms. They begin to be involved in treatment choices. When we develop treatment plans, 30 years ago when I first was coming into the system of care, when we talked about treatment plans, basically I was presented, I would have a discussion with my caregiver and then I would be presented with a treatment plan, but it wasn't something that I had developed on my own. Now, we believe in person-centered treatments and it's much better, but it's still not completely there until the individual buys into it. When people begin to activate, they collaborate with their providers. They work as partners in creating a treatment plan, in carrying out a treatment plan, in doing all of the other things in their life that will benefit them in their own health and well-being. They make choices about providers based on performance and or quality, and so this is one thing that unfortunately in our system of care we don't have enough of and that's choice. Our system, as I said before, is frequently overburdened, so not everyone has the ability to say, well, I don't get along with this particular person. I'd like to see someone else. When we can do that, it can be very beneficial, but unfortunately because of the way our system is developed and the way it's funded, we don't always have that ability to make those choices, and then also when you're activated, people begin to navigate the health care system on their own, and this is where peer support can be really valuable. Case management has been the traditional way of learning to navigate the health care system, and it's been incredibly good, but peer support comes at it from a different point of view. You're learning to navigate the system through the eyes of somebody who's already been there, who's done that and can talk about it from a first-person point of view. Again, with motivation and activation, activated individuals have a role in self-managing. They collaborate with their providers. Activation is linked to improved outcomes and reduced service utilization caused by poor health, and when I say that, reduced service utilization is not always the goal. In fact, when people receive peer support, and begin to activate self-management, frequently they utilize more services, but it's aimed towards improved health conditions. It's not because of crises. It's because they're making really thought-out judgments about what they can do to increasingly improve their situation and achieve their own goals in treatment. The other thing about activation is that you can modify it. People can begin to make other choices. They can begin. Some people, when they first start to activate in the idea of self-management, they think this means that I am the only one who will make decisions in treatment. Now, we know when, for people who perhaps choose to take medication and they see a physician for those medications, the physician is the expert on medication. Individual is an expert perhaps on how certain medications work for them or don't work for them or their reaction to side effects. They're an expert on themselves, but it's not a one-way street. That partnership, that collaboration is really important, so activation is something that you can modify in ways that are, just move you forward into your own, achieving your own goals as an individual. The patient activation measure by Insignia Health breaks it down into four steps, four levels, so people are disengaged and overwhelmed, and they say my doctor is in charge of my health, and these are people that at that point, they lack confidence in their own knowledge. They can be passive. Their adherence to treatment may be poor. They may have very high emergency department usage, very high utilization of any type of crisis-type services, and a very high risk of readmission. Then, the next step up is becoming aware but still kind of struggling. I could be doing more for my health, and that's that pre-decision-making but beginning to become aware of it. Individuals who have some knowledge but still not enough to fully govern or fully self-manage, they begin to believe, they still believe that their care is largely out of their control, but they also feel that they can set some goals, and so they may still have high emergency use and high risk of readmission, but they are starting to make more decisions on their own and move in the direction of self-management. When people begin to take action and gain control and realize that they're part of their own health care team, these people have the key issues, the key understandings about building self-management skills, and they try to make their life the best it can be in their goal arena. They have a lower usage of emergency services, a lower risk of readmission, good use of preventative care and screening, and then this level four is maintaining that place that you've achieved in level three. This is where you realize that you're your own health care advocate. This is true activation, and this is where we want people to come to. People have adopted new behaviors, and now they need to be able to find ways to maintain those behaviors that are helpful to them, and that's the most successful state that we can hope for. Peer support can assist individuals in learning how to ask questions, and it gives them the support to do so. When we first start working together in a peer support relationship, support or in person being supported, the first part of the process is to understand where the individual is in their own life and what their needs are and what their goals are and how they think about themselves and how they think about their future, and then the peer supporter's role is to help them then begin to establish goals that will get them where they want to go and then help them to figure out what are the steps that they can take to achieve those goals, and these aren't the goals of the peer support person. They're the goals of the individual, so you truly are there in just a support role. This increases the individual's participation in their own care, and it increases activation and self-management. One-to-one peer support focuses on the individual, and peer support can be provided in a number of ways. We do it through one-to-one peer support where one peer specialist works with one individual at a time on their own individual goals. We can also provide peer support through support groups. We can provide peer support during times of crisis, even in mobile crisis teams. Peer support is now being provided in inpatient care and even in prisons and jails, so peer support is extremely flexible and can be utilized in almost any aspect of the system of care, so part of it, again, is to help the individual, wherever they are in that system of care, to set goals and begin to make choices of their own and move forward. We did a webinar a few months back on the use of peer support in mobile crisis, and so in mobile crisis, in most places, crisis calls are first responded to by law enforcement, but a number of places have mobile crisis teams where a clinician or a clinical person who has the legal ability to enact a hold on a person, if that's deemed necessary, goes along on the call. In some states and in some local areas, they're including peer support on that. What they found by including peer support in that role on a mobile crisis team is that they become the interpreter for the individual who's in crisis in that moment, and they're confronted by people showing up, and law enforcement is probably there in some capacity, hopefully in the background, while the individual, the clinician, or whoever talks to the individual, and the peer supporter is there to support the individual and help them to understand what's going on, what the possibilities are, and what they can do to influence those possibilities to achieve what they most need in their time of crisis, and for some people, that might be they need a place to stay for the night, and the resolution is finding them shelter. In some other cases, it might be that they need their family to come and to help them and take them home and make them feel safe in that way, and that alleviates the crisis. In other cases, it might be a voluntary or an involuntary hold where a person is taken in for assessment, which in most states is a 72-hour period of time where a person is assessed, and then a decision is made about what type of treatment they need from there on. Peer support plays a role in all of this, and once people understand how that system can work, then it brings down that tension and that feeling of trauma that almost all of us who've been through these type of situations, and I've been through it. One of my first involvements in the mental health system was being taken to a crisis center in the back of a police car with my hands handcuffed behind my back. I was in crisis, and that was extremely traumatic to have as my introduction to care, so when there's an interpreter there who can explain to you what's going to happen and what influence you can have over that situation, it really lowers that feeling of trauma and fear. In a 2013 study on the perceived impact of certified peer specialist services, this was done in Pennsylvania. It was reported that CPS focus on service engagement results in greater individual activation and services, so when the CPS, when the certified peer specialist focuses on engagement, then people are far more likely to be activated to participate in that engagement. Almost three times as many reported an increase in their use of outpatient therapy as those who reported a decrease, and this goes back to what I was saying before. Three times more people who've been engaged through peer support are likely to increase their use of outpatient therapy compared to people who don't receive those services and report a decrease or even receive those services and report a decrease in use of outpatient therapy. This is the way we like to see people make those decisions. These are choices being made by people, and they're seeing treatment in their own particular case just for them, not as a generality, as a benefit for them, and so they choose to further engage in it, and there were similar increases in the overall usage of outpatient services, so while we may see a decrease in crisis services or we may see a decrease in readmission or admissions to hospitalization, we may see an increase in outpatient services and outpatient therapy, and this is to the benefit of the individual, and it's the system working at its best. Openness to accepting an individual's personal experience about their health creates trust on both sides, so when you listen to the individual and you understand what they think about their personal health and situation and you acknowledge that they have that degree of expertise about themselves that no one else can ever have, it creates more trust, and building an alliance in a therapeutic relationship of any kind is important when working with individuals with serious mental health problems. It's important in working with all people. When you build an alliance, a feeling of trust between the two people, a degree of equality, a lessening of the power imbalance, and the idea that this is a partnership and we can move forward together to the benefit of the individual. Social modeling theory states that other people in similar circumstances might have the most influence on behavior change, in other words, peer support, so other people in similar experience and circumstances being a peer supporter who has gone through a system of care, has gone through that experience of being diagnosed, has gone through some of the things that happen to us socially frequently, loss of jobs, loss of financial stability, sometimes ending up living below the poverty line if you end up on SSI, loss of housing frequently, so when somebody else who's been through that and understands what that's like for them, they're likely to have the most benefit in creating change for the person or helping the person to create their own change. The ability of peer support to regain and or build trust with an individual who's been reluctant to engage in services results in increased activation and self-management, so we go back to the beginning of this. People frequently withdraw from the system or never engage in the first place for a number of reasons, and the primary one is a lack of trust. Lack of trust is built on a lot of things. It can be built on bad experiences. It can be built on inaccurate knowledge of what's going to happen for the individual. This is where that navigator role becomes so helpful, and it can also be, it can also happen because they have heard from other people that their experiences were negative. The peer support role came out of the deinstitutionalization movement of the 70s, the late 60s, the 70s, and even into the early 80s, when states in the late 50s, there were 550,000 people in state psychiatric hospitals. There are currently about 50,000 in state psychiatric hospitals. In the late 60s, 70s, and in the early 80s, states began to realize that this was not beneficial to the state and it was not beneficial to the individuals. There were huge problems with warehousing people being held under really inhumane conditions, and so they began to release people into the community. Now, the people they were releasing were frequently people who had been damaged by the system of care and were frequently very angry, and so they began to come together, and also the money that was saved in the system by releasing them from hospitalization did not go into community services, so you had people who were out there that didn't have beneficials, community support, and what they did is they began to come together and support each other. This was the beginning of the self-help movement for mental health, where people met together in support groups, and it was the foundations for peer support, which began right at that time, and it has continued to build, to be redefined, and evolved throughout all that time, so it's, you know, peer support is all about that sense of why can you trust me? How can you trust me? What can I do to help you achieve what you want to do? And now we've built this very formal system where people go through training. They go through certification processes. They go through a number of different types of processes that allow them to be hired and paid for with state funds, through Medicaid funds. We don't yet have peer support supported by Medicare, but we're moving towards it, and we're also moving towards peer support being paid for in the private health care system. People are seeing the benefit of peer support. There's been a tremendous upsurge in research over recent years, and we know that peer support is something that can and does work for many people, and that it has results of increasing engagement, reducing re-hospitalization rates, reducing crisis rates, greater sense of quality of life for individuals receiving peer support, greater satisfaction in services. In a randomized, controlled trial of peer support for intervention for individuals with serious mental health problems, a study found it provided evidence in support of emerging research and theories that identify peers as playing a unique role in connecting individuals. Emerging research and theories that identify peers as playing a unique role in connecting individuals who have been less likely to engage. Shared experience, trust, alliance-building, reduction in power differential, openness to the individual's self-knowledge, support without being directive, and mutuality make peer support a very highly effective service for creating a safe and potentially productive treatment environment. And with that, I thank you, and hopefully we will move on to some questions. Thank you, Patrick, for such an interesting presentation. Before we shift into the Q&A, I want to take a moment and let you know that SMI Advisor is accessible from your mobile device. 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. Download the app now at smiadvisor.org slash app. Okay, so Patrick, the first question that we have is, how do peer specialists generally encounter individuals who have been disengaged from services? Yeah, and that can be a real problem, because once people have disengaged from the system, how do they show up on the radar for peer specialists? It usually happens in a number of different ways. One, they can be directly referred to contact a person if that person is open to that contact, but it usually comes about through some sort of referral through either friends or perhaps they're participating in support groups or attending social activities at a drop-in center or recovery center. It can be through family organizations like NAMI. It can be through organizations like Mental Health America. Places where people might go to get information about their own situation is a rich place for people to find out about the availability of peer support and then seek it out for themselves, but referrals are the primary way that we encounter people, because once they've withdrawn from formalized services, they fall off the radar of the formal system, and so they have to come in through another door. So, I have another question, then, about disengagement. It's not the same, but when there's, you know, engagement, is that a one-time thing or is it more of a process, and then if there is some type of disruption or fracture in the relationship, are there some peer-specific strategies that can be used to re-engage an individual? Yeah, engagement is very much a process. It's not something that just happens, and it can, and it can flow, so you can have times where that relationship becomes endangered or fractured, say, or fragmented, but it can also be repaired in most cases, and the way that it's done is through transparency and honesty, so if a peer specialist is working with an individual and they're working towards a goal and perhaps the individual has doesn't still quite trust the support of the peer specialist and maybe starts to pull away, the peer specialist can open the conversation about that. What's going on? What can we do to help? And if necessary, they can even refer the individual to another peer specialist, because, you know, when we talk about peer support, the key is that word peer, and in general in behavioral health, we use peer to refer to people with the shared experience or lived experience of having a diagnosis, of having received services in a system of care, but there's way more to being a peer, and so, you know, the VA is a perfect example of this, where people need to be referred on frequently. In the VA, I helped to write some training with the VA on homeless outreach peer specialists for individuals with behavioral health problems, and when I first went in to do the research to begin to write this, I was working with a VA peer specialist, and they had to vouch for me, because I'm not a veteran, and I could not be a peer to a person receiving services through the VA, because I'm not a veteran, and for many people, like I went out to these homeless camps, these veterans homeless camps, if you weren't a combat veteran, you were not a peer. If that person was a combat veteran and you were not, you could not be their peer, and frequently, I found that for women vets, if you weren't a woman vet, you could not be a peer, so peer is really in the eyes of the person who's receiving the support, so sometimes that relationship just doesn't work quite right, and maybe it's time to try and help them find peer support through somebody else who fits their idea of who is their peer better. Great, thank you, so I know you mentioned that the trust is basically the foundation to engagement, so how can somebody, a peer specialist, develop trusting relationship with individuals? Probably the number one answer is being extremely transparent, you know, when you, a good example where this comes into play very rapidly is when you provide peer support to people in crisis units, crisis hospitalizations, so you're kind of thrust upon the person. You're the peer specialist and there's this individual. You might go over to them the first day they're there and just strike up a conversation and start to feel each other out about how you feel about a person, but the main thing is you cannot be there cannot be a feeling that there's any kind of hidden agenda or that services are being forced upon the person. The peer has to be very, very open and honest. This is my job. I work as a peer support specialist, but here's why I do it, and then tell a little bit of your own story and then say, you know, if there's anything that you think that we can work on together or that I can help you with, I'm here to do what you want, and so you begin to build trust because you do what you say you're going to do, and you're consistent moving forward to always making sure that it's the individual's goals that are being pursued, not the goals of a system, not the goals of the individual peer specialist, so that's trust-building, and then the other part is you also come into that relationship, even as a peer specialist, with a power imbalance, because I've got the job. I'm working as a peer specialist. You're here as an individual receiving services, maybe even involuntarily, so there's a power imbalance, and you have to start to break that down. You have to start talking to the person to find out what parts of that imbalance cause a problem for the person, and then what can we do to lessen that, and that frequently is by just total honesty, and sometimes it comes about by telling a little more of your own story. Sometimes it's necessary to tell some of the things that didn't work for you or some of the experiences that were not beneficial or were scary or perhaps even traumatic. I mean, we're not there to tell our stories, but we're there to use our experience to help that person to trust us and to understand that we are there on their behalf, but we understand what they're talking about. So, Patrick, you brought up sharing your story, so are there guidelines for peers on how to share their story or anything that you can reference or any tips on that, you know, how to share to inspire hope and to relate to the person but to also be, you know, mindful of maybe boundaries? Are there any tips or resources on sharing stories as a peer? Well, first, every peer specialist training that I know of has a whole section on how to tell your story, how to use your story to the benefit of the individual you're providing support to. What, you know, kind of a rule of thumb is that we use the least amount of our own personal story that is necessary in order to get the person to open up to us. I mean, I'm not there to compare notes with a person. I'm not there to say, oh, yeah, I've been through, you've been through that, listen to what I went through. You know, we're not there to compare or to say who's had the hardest time or anything. I just want to tell the smallest amount of my story that is necessary for the person to begin to see benefit in having a relationship with me and to build trust. Now, sometimes parts of my story may be to give the person ideas about ways they could proceed, so I may tell a part of the story about a process I went through to decide how I was going to go forward and what worked best for me. You're never wanting to say, hey, here's what worked for me, so it's going to work for you, because that's not true. We're all different, but you can say, here's the process I went through to make those decisions. Medication is a primary one. Peer specialists do not advocate for medication. They do not advocate against medication. They don't recommend any specific medications. They don't go against any specific medications. What they can do, though, is they can help people figure out how to make the best decision for themselves. How do they get enough information about medications so that they can make a really reasonable decision if they want to try it or not or what they might want to try? There's a lot of information out there, but not everybody knows how to find it, so part of the role of a peer specialist is to help people to use the tools that are available, the internet, through support groups where people frequently talk about these issues, but again, you never want to feel like you're in a position where the person's going to do something because you said you did. You just want to give them the idea that they have options and give them some examples of what those options might be and then ways to find answers to their own questions. Thanks. We have another question from the audience about disengagement again. Are there any strategies that you can suggest, Patrick, for somebody who might be mandated to treatment because of a community treatment order or something like that? If they're not even interested in really speaking to the peer support worker, are there any strategies for people who are mandated to some type of treatment and how to engage with them? Yeah, that is particularly tricky. It comes up more and more for peer specialists where they're put in a position of trying to provide support to somebody who is feeling that they're being forced into treatment, mandated, and perhaps even coerced, and all I can really say is that it's very slow. You have to take that relationship building very, very slowly. You just start off by having a pleasant conversation with the person. You may, in that conversation or maybe in the next conversation, have an opportunity to talk a little bit about what it is that you do as a peer specialist. You also may have the opportunity to say a little bit about what your own experience has been, why you do what you do, what that's based on, what your knowledge is based on, and begin to really slowly build up the trust, because when you first come in contact in mandated services, you're part of that. You're part of that service that's being forced upon the individual, and there's immediately a kind of a reticence to open up to you, and I've had people tell me, I don't want peer support. I don't like it. Go away, and my only thing was to go away and then maybe very gently at another time try to make some sort of really gentle contact again and just, you know, through a conversation through something else that maybe we share an interest in. You know, I've worked with people in inpatient settings. We're mandated services involuntary, and they may be watching sports on television, and so you have a conversation about sports. That may be the opening you need. You know, people come into services through mental health courts. Or they come, you know, in through what involuntary outpatient services where, you know, they are told by a judge you have to participate in services. There's a distrust, and that's going to extend to the peer specialist, too, so that trust-building is a much slower process, but it's still possible, but it's only possible if you're very transparent. You know, I have this job. I have this role, and, you know, my desire is to help you as best I can. Thank you so much, Patrick, for that very knowledgeable and informative presentation and then Q&A. I think it's time for us to wrap up. So, if you do have any follow-up questions about this topic or other evidence-based care for serious mental illness, our clinical experts are now available for online consultations. So any mental health clinicians can submit a question and receive a response from one of our SMI experts. These consultations are free and confidential. SMI Advisor is proud to partner with the American Psychiatric Association on the Mental Health Services Conference, which takes place on October 14th and 15th of this year. The keynote address at this conference features Dr. Miriam Delfin-Rittman, the newly appointed Assistant Secretary of Mental Health and Substance Use for HHS and the Administrator of SAMHSA. The conference agenda features topics such as climate change and mental health, socio-political determinants, structural racism, mental health in rural and indigenous populations, and much more. I encourage you to learn more and register now at psychiatry.org mhsc. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession, verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. And lastly, please join us next week on August 27, 2021, as Dr. Paul Margulies presents IPS-Supported Employment, Impact of the COVID-19 Pandemic on Implementation and Outcomes and Implications for the Post-COVID Era. Again, this free webinar will be August 27, 2021 from 12 to 1 Eastern Standard Time. Thank you so much for joining us. Until next time, take care.

Peer Support

Self-Management

Engagement

Serious Mental Illness

Trust

Lived Experiences

Activation

Treatment

Peer Specialists

Mental Health