Hello and welcome. I am Jose Villarreal, Clinical Director of Behavioral Health at Erie Family Health Centers and Community Care Expert for SMI Advisor. I am pleased that you are joining us for today's SMI webinar. What does it take to establish mutuality and form a successful peer-to-peer specialist relationship? 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 clinical community, our efforts have been designated to help you get the answers you need for the care of your patients. Today's webinar has been designated for one AMA PRA Category 1 Credit for Physicians and one Continuing Education Credit for Psychologists. Credits for participating in today's webinar will be available until December 12th of 2021. Slides from today's presentation are available in the handout area, found in the lower portion of your control panel. Select the link to download the PDF. And please feel free to submit your questions throughout the presentation by typing them in the question area, also found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for some questioning and answers. Now, I would like to introduce you to the faculty for today's webinar, Patrick Henry and Danielle Zavala. Patrick is the Vice President of Peer Advocacy, Support, 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 different leadership roles, including the former director of NCSAC as a consultant for the National Council of Behavioral Health, the University of South Florida, SAMHSA, NASTED, among many other agencies. Danielle Zavala is the Associate Director and General Counsel at Mental Health of America, Northern California. Danielle is deeply committed to the advancement of mental health policy and mainstreaming mental health issues, especially in the workplace. As an experienced attorney at Employment Law, Danielle works to educate businesses on the importance of mental health in the workplace. Thank you both for leading such an amazing seminar today. Thank you, Jose, and I just want to start off by saying that we have no relationships or conflicts of interest related to the subject matter we'll be discussing today. So our learning objectives upon completion of this activity is to be able to state the core components of a peer support relationship, be able to summarize important elements of mutuality that are not sufficiently available in peer support services provided in the behavioral health system, and to propose changes that can be made to improve the peer-to-peer specialist relationship. Start off by just this very simple definition of mutuality. Mutuality is a positive interactive relationship between people involving reciprocity and cooperation. It is a relationship of mutual action and influence. The concept of mutuality in peer support is really complex, and when we talk about peer-to-peer relationships, we are talking about mutuality at the core of peer support relationships achieved through empathy, collaboration, equality, and equity. Mutuality is present in that both parties are of equal importance in the relationship, and equity is present in that resources and efforts are proportionately provided to assist the individual in their personal recovery. A sense of shared lived experience with behavioral health problems and treatment contributes to mutuality. That idea of shared lived experience is what we're trying to really get at today, because what we're talking about essentially is how closely do people need to be linked in order to feel mutuality? The peer supporter or peer specialist frequently has had specialized training and is paid to provide their services, so it's part of the peer specialist's role to really be open and transparent about that formal role and to try to overcome any feelings of power imbalance that are inherent in that one person is being paid and has gone through specialized training, because as you begin to form that true peer-to-peer relationship, you're trying to come together as equals. There's a real benefit for both parties in doing this. Peer support is based essentially on a very old concept, and at one point, it was even referred to as a therapy, and that's the helper principle, in that when one person helps another, the helper is also helped, and in some cases, helped more than the person receiving the support. Researchers have found that traditional approaches for conducting research in partnership with marginalized communities and the people who feel they live on the margins of society can reinforce feelings of stigma and power imbalance, even if it's not intended, so when researchers try to partner with these communities that have been really felt disaffected or marginalized by the world around them, that very partnership itself can create an additional feeling of stigma and power imbalance, and that's because, again, when those two groups come together, the researcher's coming in with a feeling of more power than the person that they're working with, and so it's inherent, incumbent, I mean, on the researchers to be able to level that playing field. Marginalized communities are groups of people who are excluded from the mainstream social, economic, cultural, and educational life of the greater community, and that's certainly true of people living with mental health issues. Our society has traditionally, I should say, it's beginning to change, but has historically pushed people with mental health problems to the edges of society, and consequently, one of the largest problems that people with a diagnosis face is that many of them end up living in poverty. Our system of social supports doesn't allow people the opportunity to live a life of at least subsistence without suffering while they're trying to overcome their own mental health problems, so these groups can include people who are excluded because of mental health diagnoses, gender identity, sexual orientation, race, age, and all other factors. Do feelings of marginalization create enough of a bond if people are matched solely on mental health factors, or do other areas of identity create a barrier to establishing a therapeutic peer-to-peer relationship? So what I mean by that is, as a person with lived experience, I have a connection to other people with lived experience, and we have something we can talk about, and we have some things that we can identify with, but is that enough in itself for us to be able to create a really therapeutic peer-to-peer relationship, or do we need to look at the other factors that are involved in making up the identity of the individual? So it could be these issues of gender identity or sexual orientation, race, ethnicity, age, any kind of factor that tends to separate people within our society. The transgender community cites as a cause for postponing seeking mental health care as a lack of provider knowledge regarding trans health and experience. So there, it's very clear that people are not seeking mental health care because they feel that the people who are providing the care do not have sufficient understanding of their particular health and experience. Support from groups or teams who can provide a shared identity, language, and structure of accountability can enhance mental health. And when we talk about identity, we're talking about all those things we've already referred to, and even when we talk about language, we're not necessarily talking about language in the formal sense, we're talking about the language that we use to describe ourselves and to describe our experiences. A study in the Southeast indicated that seeking support from a person in a shared cultural community helps to locate information about access to services that may be hidden from the general public or dominant view in behavioral health. And so this is very, very true. Again, we can go back to the example of the transgender community, which has created supports of their own that most people are not even aware exist. So just to type a few things into the comment section, describe someone, if you can think of someone who might have difficulty finding a peer specialist who they feel is enough like them to provide the best support. So if you're familiar with our behavioral health system, and I think our entire audience is familiar, then think of somebody who would be seeking that type of support, who would find it difficult to find it within the existing system. And you can just type those in. Social work activists from marginalized communities continue to talk about the need for social change movements to be accelerated by peers with lived experience and culturally specific knowledge. If we go back to the entire peer support movement, and in fact, peer movement or consumer movement or go even further back and actually still in existence today, the survivor movement, we are looking at social change movements. The movement in mental health began primarily in this country during the times of deinstitutionalization. So we're talking about the late 60s, the 70s, and even to the early 80s, where people were being pushed out of psychiatric hospitals, state hospitals, and pushed back into the community. Now, in many ways, this was a wonderful thing. In 1955, the United States had 550,000 people in state psychiatric facilities. Currently, it's about 55,000, and even that's too many. But as they began to push people out, they turned them out into the community, but they didn't provide them with the supports. The funds that they saved by having fewer people in hospitals did not necessarily go into providing community-based services. So now you had a lot of people coming out of facilities that had had very negative experiences, and many of them came out quite angry and quite damaged and traumatized, and they wanted nothing to do with the existing system. This was the beginning of a social change movement, and it was at the same time that so many other movements were really strong. We started off with the racial equity movements of the 60s, even the 50s and 60s, and on into the 70s, and gay rights movements, and women's rights movements, and all kinds of civil rights advocacy going on, and mental health was part of that, but it was a part that didn't get talked about as much. Approaching peer support through a broader lens than the way we traditionally understand lived experience can exclude some things like race and color and ethnicity and gender identity, sexual identity, age, and other human attributes and conditions. So if you can do that, if you can look at the whole person and try to match people as closely as possible, you're going to have many more opportunities for successful peer support relationships. Peer support has turned into a very valuable tool in behavioral health. It's a very valuable tool throughout healthcare, and it exists throughout healthcare, but it's been more formalized in behavioral health and specifically more formalized in mental healthcare, and it's worked quite well. We know that people who have peer support have a lower rate of rehospitalization or perhaps emergency department usage. We also know that people report an increased quality of life and satisfaction with the services they do receive when they're getting peer support, but we're still just working on just that basic definition of shared lived experience, and that's why we need to look at it from a much broader point of view. So again, we're not going to do a group discussion right now because we've got a lot of information today and we ended up increasing it, but you might want to type in some ideas that you have. Why is it important to match peer-to-peer specialist relationships on areas beyond that shared lived experience with a diagnosis or a disorder? Community-based approaches to peer support find that peers provide support when existing systems fail to respond to marginalized groups in culturally appropriate ways, and we can see this throughout, again, the civil rights movements where certain groups were oppressed or marginalized and began to provide their own types of supports, and it was community-based. Peer support relationships built on a broad-based trust between empathetic peers effectively validates experiences, marginalization, exclusion, and oppression. So when it is truly a peer-to-peer relationship and you're able to build that trust with another person, it validates their experiences of marginalization, exclusion, and oppression, and that's extremely important to get to a point where you can begin to move towards your personal recovery. Formal systems of peer support are not always either available or appropriate to provide support to marginalized communities. Social systems can fail to ensure equitable access to support. This happens all the time. You can look at the equitable access to support, you can almost look at it by zip code and understand where the lack of access and where the increases of access exist. Informal or volunteer peer support has a lot of benefits. So this would be peer support that's not coming through that formal system. It's not part of your behavioral health service. When you have an informal or volunteer peer support system, and this is where most peer support started, in fact, all but two states now have a certification for some type of peer support specialist in the District of Columbia, and virtually every state requires prior experience before you can get that certification. Now most peer support is paid for through Medicaid these days. Some is paid for through general revenue and grants, but the primary source of payment is through Medicaid. So if you're not certified, you can't get reimbursed for your services through Medicaid. Where do you get your experience? Most of it comes in as volunteer experience. People may work in a drop-in center or a clubhouse, or they may work on a warm line or in any other type of helping position to aid other people living with similar experiences to them. One of the things about informal or volunteer peer support is that it's low or no cost to already underfunded and improperly funded services. So when volunteers come into the mix, what we've done is we've increased the availability of peer support without increasing the cost. Let's talk a little bit about community initiative care. Generally a community initiative is when individuals and partner organizations come together to improve the health and welfare of a community, and this is a growing idea. People are beginning to see the benefit of people, individuals who care about a particular subject, coming together with partner organizations to improve care, not as a formal program and not necessarily even seeking separate funding. They seek to reduce the effects of social problems in order to improve the quality of community members' lives. Community-based initiatives focus on self-organization of public services. Think about that. It's a radical concept, the idea of self-organization of public services. Peer support in general is a public service. It comes through our public health system, generally our public behavioral health system. Community-based initiatives come from outside of that formal system, and yet they add to the strength of that system. Community-based initiatives can include both formal and informal initiatives, so you can combine the two. The initiatives rely primarily on volunteer work. Professionalized nonprofits generally use a paid workforce, so when you have those two groups coming together, a professionalized nonprofit that may be a peer-run organization that's providing peer support for the programs they run, and they're funded either through grants or state funding or some other source of funding, and then they join together with a volunteer workforce, you've multiplied the strength of the system of care. Just think about that idea of what we mean when we talk about community-based initiatives, this whole idea of a public approach to public services, a community approach to public services. Informal or community-initiated peer support is a good way to engage people who have historically distrusted or felt alienated from the formal system, and that is not unusual in behavioral health. We have hundreds of thousands of people in this country who have either never engaged with the formal system of care in behavioral health, or they've engaged and withdrawn because of feelings of abuse or neglect, lack of access, and sometimes even traumatic experiences. Informal peer relationships with individuals who've shared cultural backgrounds or values are really helpful in navigating systems that already continue to perpetuate stereotypes. So when you bring in people who have a shared background, a shared system of values, it's really helpful to navigate the system that's putting things out in stereotypes where we, for instance, when people are categorized by diagnosis or they're categorized by the language they speak, and we tend to put people in these boxes, which isolates them from the full range of support that they could get. In one study, black college students prefer informal over formal services because it was more culturally specific. Trans Lifeline developed a crisis line through a trans community by the trans community with no police involvement. And this affirms that idea of preserving the right to self-determination for the trans community by the trans community. And this was a way for people to feel safe, to feel that they were in charge of their own support, and they created their own crisis line because they felt like no one else could speak to the issues that needed to be dealt with. So again, you can start to think about how community-based initiatives can help provide a broader range of choices for people seeking peer support. So it's that idea, as we bring in a volunteer public workforce into our formal system and we add those two together, we create a broader range of choices for people seeking support. So if peer support already works, why would we even talk about changing it? Because it does work in general. Well, as I said before, from people's own reports, it increases quality of life as defined by the individual. It increases satisfaction with mental health services in surveys that are done, people receiving peer support. And it lowers re-hospitalization rates and ER usage. Now, all of those things are tremendously positive. Anytime we can improve quality of life, we're doing something right. When we're not improving quality of life, we're not doing the right thing. Satisfaction with services means that more people will choose to access the services available to them. And that doesn't necessarily mean clinical services or non-clinical services. It's whatever they choose to access because they're satisfied with the way it's being provided. And when you lower re-hospitalization rates and ER usage, one thing you're increasing people's quality of life tremendously, but you're also lowering costs in a system that is already strapped for funding. Now, we only are able to provide services in this country for about 45% of the people who need services. But the system struggles to tend to the psychosocial needs of frontline communities. So we're not reaching some of those communities that are still feeling on the edges of society. Community-initiated peer support is a better position to address limited access to cultural and responsive mental health care. Insufficient academic research is available on these subjects. And so this is something that we're, the academic world is just starting to really look at and try to understand the dynamics behind it. Even though community-initiated support is generally a volunteer workforce, there's still some aspects that would greatly benefit from funding. Communities will continue to grow in the margins in order to respond to systems that have failed them. So this is where, like the Trans Line, Lifeline, where a group comes in and provides their own supports and services because the system has failed. By doing it, this will determine what works best for their particular culture. Peer support is an agent of change, not the status quo. And this has been fundamental since it began. And for many, many years, it was very difficult for our community health, mental health system to really recognize the validity of peer support. I know in the introduction, it said I've been working in this field for 27 years. It's now up to 31 years, I think. In my first jobs in peer support, working in community mental health, I was put in very menial roles, working with day treatment groups just to help them as they made popcorn and went around the community mental health center to sell it to the staff. And that was considered peer support, consumer support at the time. Individuals with lived experience are not only worthy of dignity, care, and healing, but they are also worthy of being valued. They're also paramount in driving innovation and leading movements towards liberation. If we had not come in as peers, and if we had not come in from our own movement, that survivor movement, that ex-patient movement of people coming out of the institutions, if we had not done that, we would not have changed the system as much as we have. There's a nationwide conversation about the need to provide greater access to community-relevant peer support for marginalized and oppressed identities. This last two years has been a time of discussion of equity, equality, fairness, and opportunity throughout our culture, throughout our society. And it certainly exists in peer support too. And we're beginning to understand that peer support, while it's a very positive thing and it's had tremendous effects on moving us away from a purely clinical approach to mental health, or largely clinical approach to mental health, to looking at the whole person and understanding that recovery is only possible when you deal with people as the whole person. Peer support, as I said, is an agent of change. It adds a focus on supports and recovery to traditional treatment. So again, you're looking at the supports beyond the services. Peer support is able to build trust with members of these communities when the support worker is most closely matched to the experience of the individual receiving support. Peer support workers can be models of recovery and self-management. And that's probably beyond the idea of shared lived experience. Being a model of self-management, being a model of possibility of recovery is one of the most powerful things about peer support. Peer support can be provided through community-based initiatives and it can break down barriers for people who frequently felt that the larger society is ignoring them. And in fact, it has been ignored. So as we begin to really kind of go back to our roots and go back to this idea of people coming in and serving in volunteer roles to enhance the workforce, we're creating something far more powerful. One of the things we've learned from the past two years as we've experienced COVID pandemic is that the needs of the mental health system, behavioral health system have increased tremendously. And if anything, our workforce has decreased. You can't ramp up a clinical workforce rapidly to meet an emergency need, which is what we're facing now. We have a system built that is functioning as best it can, but the need has increased so much over the last few years, anxiety and depression. And then the things that those trigger, so people with any type of mental health issues may be feeling exacerbated symptoms or their life may be spinning out of control. They may feel lost. They may feel that society is not on their side. The one group of people you can ramp up is a volunteer force of peer support. And we can provide degrees of training, but a lot of it is just those people to people skills. Strategies for increasing the peer workforce should include recruiting and engaging peers from underserved communities and also those who speak multiple languages. So when we want to increase the formal peer workforce, we've got to go out and actually recruit and engage people from these communities. Same thing on the side of the volunteer workforce. We need to go out and recruit people to come in and work in that capacity. And then if they want to, the opportunity exists to then move into the formal system and go through state certification and all of the things that will allow them to get paid jobs and hopefully to build careers. Peer support is a critical part of the treatment continuum. And it helps keep people engaged in their communities and it reduces the high cost of crisis services. So if you can do those things with a partially volunteer workforce, you are multiplying the power of peer support. Expanding the peer workforce and better serving these communities that are pushed to the edges can result in lower costs across healthcare. What that means, it's not a savings. It's not that somebody is making money off the system. It means that there's funds available to provide more services and better access to services. So how do we fund building a diverse formal peer support system? We want to increase education, training and certification opportunities. We need better funding for existing peer specialists across conditions and substance use and co-occurring disorders. With a focus on recruiting from diverse populations and that can include any type of situation. The LGBTQ plus community, youth, BIPOC communities, the criminal justice system involved individuals, non-English speaking or people with multiple languages in their background. We need to invest in peer training that includes a focus on measuring quality and barriers to employment, including an effort to re-engage trained and certified peer specialists who are not working. So we need to make sure that we, as we train people and we get them certified that we actually have jobs that they can step into. And that's where beginning to build this community initiative, which will eventually lead to a funded source of services is a great beginning to use this huge wealth of peer support that we have out there that's still untapped. We need to invest in higher levels of certification and reimbursement for peer specialists who demonstrate significant experience and knowledge in the field. In other words, the more, the better you are at what you do, there should be opportunities for advancement in peer support. People should have the opportunity to actually build careers that pay them a living wage. We need to designate funding to provide continuing education to existing peers so that they can continue to adapt to current changes and to utilize broader resources. We need to include peer support specialist workforce development in any federal workforce development initiatives that we have to address unemployment. And I know the Department of Labor is looking specifically at peer support as a workforce that needs further development. Again, so how do we fund it? The behavioral health workforce is not representative of the racial, ethnic, cultural, and linguistic diversity of the United States. Marginalized communities are disproportionately affected by the health and socioeconomic effects of COVID-19. While Medicaid is the primary funder for peer support, efforts should be made to secure specific funding through private donors, local, state, and federal sources to expand that workforce for these diverse communities. And priority should be given for funding of peer support services in underrepresented communities. These four issues are ones that are extremely important that we begin to think in these terms if we're going to meet this expanded need for support with really a system that has suffered its own losses going through the pandemic. Community initiative peer support programs, as I have said, primarily or frequently rely on volunteers. Expenses can be paid through a variety of means. Local private sector sponsors through grants and federal and local money. We can issue specific support groups. Issue-specific support groups can be an example of community-initiated peer support. So sometimes, say a bipolar support group, sometimes the members will contribute themselves to pay for refreshment or minimal supplies that they might need, educational materials. Local organizations can contribute the use of space in their facilities. This is all the ways that we began, and we need to continue to do it this way, but we need to actually expand it. Local health organizations can provide funding based on cost savings that are a result of the availability of peer support. As peer support is successful in supporting people in the community and helping them move towards recovery, we have cost savings that need to be put back into the system to increase the availability of services for all of them. And then we can talk about what are some of these alternative ways to fund peer support. So I'd like you all to be thinking about that. Now I'd like to turn it over to Donyell, and, Donyell, please talk to people. I'll be happy to switch slides for you. All right. Thank you so much, Patrick. So I'm Donyell Zavala. I'm the Associate Director and General Counsel here at Cal Voices. We were previously known as Mental Health America of Northern California, and we're a peer-run organization. We've been operating since 1941, so we're 75 years old. And so I'm here, my portion here is mostly to talk about how to operationalize the expansion or the diversity in the peer support workforce to promote mutuality. Next slide, please. So diversity in the peer workforce promotes mutuality. I feel like Patrick touched on a lot of this, but mutuality really requires meeting people where they're at, right? Having that shared lived experience with them, not expecting others to come to you or adapt to your way of doing things, understanding and respecting others' needs, concerns, barriers, and challenges, and sometimes modifying your approach to achieve better individual and overall results. So shared lived experience is really essential to meeting people where they're at, because peers, you know, with that shared lived experience, know where people are at, because that's where they're from too. Peers have been there, done that, so they really do understand. And peers reflective of the diverse populations that they're serving are better equipped to recognize the specific needs, concerns, barriers, and challenges of these communities, and are able to identify the most effective solutions to address them. Next slide, please. So diversity in the peer workforce promotes mutuality, because it's essential to understand why peer support works to begin with. So as Patrick mentioned, peers model resilience, self-care, wellness, and recovery, sharing insights and tools that have worked for them specifically. Those receiving services from the peer supporter see and believe that change is possible. That's key. Peers dispel myths and reduce stigma related to seeking services. Peers help individuals identify their personal needs, develop strategies to achieve them, and support them in implementing these strategies. And peers advocate on behalf of the people that they serve and teach them to advocate for themselves, which in turn helps to increase engagement in services, and also make services more appropriate and effective for marginalized populations. And the work peers perform also reinforces their own wellness and recovery based on that helper principle. So credibility and trust are really key to this model, and shared lived experience builds that credibility and trust. So when we talk about marginalized communities, and we're talking about, you know, what types of lived experience, shared lived experience are important, I think that it's important that we focus on what those salient identities are when you have intersecting identities. And so there's intersectionality of lived experience across various factors, which include age, race, culture, ethnicity, sexual orientation, gender identity, criminal or juvenile justice involvement, foster care, homelessness, immigration, military service occupations, socioeconomic status, region, whether you live in an urban environment or a rural environment, education, trauma, dual disability, religion, and spirituality, et cetera. So all of these aspects can really contribute to an individual's most salient portions of their identity. And so it's really critical that we have peer support workers who are able to match these characteristics. So peers with intersecting lived experience and identities can address the needs, concerns, barriers, and challenges that drive disparities for these populations. As Patrick also mentioned, mistrust of the system, you know, based on historical challenges, their legal status or past experiences, cultural definitions and contexts, language barriers, overcoming a one-size-fits-all approach, and lack of services integration and cross-system collaboration. Peers can help with all of these aspects of services. So I'm kind of a visual person myself, so this model here helps me really understand why peer support works. Shared lived experience builds credibility and trust, increases engagement and services, enhances effectiveness of services and improves overall outcomes. Next slide, please. So I wanted to share some real life examples from our organization. About how we have used peers with intersecting identities to provide more effective services to specific populations. So youth with past juvenile justice experience host weekly anger management groups for youth currently involved in the juvenile justice system. Spanish speaking parents host Spanish support groups for parents of children and youth experiencing behavioral health challenges. LGBTQ peers in rural communities provide services to LGBTQ individuals and host regular support groups for parents of LGBTQ children and youth. Hmong peers adapted WRAP materials, Wellness Recovery Action Plan materials, and hosted a picture-based WRAP group in the Hmong language. And African-American peers have served on local alternatives to 911 advisory bodies to help develop non-law enforcement responses for individuals from BIPOC communities experiencing crisis. Next slide, please. I wanted to give a snapshot also of how diversity in the peer workforce is achievable. So we did a survey of our staff as of August 31st of 2021, we had 78 total employees, and all of them identify as peers, primarily as individuals who have experienced a mental health or behavioral health challenge, and then also individuals who identify as family members. So 77% of our staff identify from one or more traditionally underserved group, 49% are from BIPOC communities, 22% identify as LGBTQ, 15% have lived experience with a criminal or juvenile justice system, 15% have lived experience with being unhoused, and 14% have a dual disability, so they have a physical disability as well as a mental health condition, 14% identify as older adults, 12% have had lived experience of a co-occurring disorder, 10% identify as immigrants or refugees, and 4% as military veterans. We also have a diverse language capacity, 11 of our staff speak Spanish fluently, and we have one staff that speaks each of the following languages, Russian, Hmong, Tagalog, Visayas, Vietnamese, Urdu, and Cantonese, so it is possible to hire a diverse peer workforce. Next slide, thank you. So I wanted to talk a little bit about how to do that, how to operationalize that, because in our opinion as a peer-run organization, mutuality begins between the employer and the peer support worker. So some issues for organizations to explore include hiring criteria, criminal justice, education, work history, credit history, housing, driver's license, personal transportation, professional references, all of these can be potential barriers to employment or potential barriers to increasing the diversity of the peer workforce. The hiring process itself, thinking about the response time between the application and candidate contact, multiple rounds of interviews can be intimidating and exhausting, along with a number of interviewers, if you have a lot of people in the room, complexity of the questions that are asked and the post-interview follow-up all can contribute to or undermine the ability to hire a peer workforce. The working conditions within the organization itself, pay, benefits, time off, schedules, flexibility, the number of peers working on a team, it's always very important to have at least two peers working together, the supervision structure, are there peer supervisors supervising peer staff, training, performance measures, professional development and career advancement opportunities are also critical. And then organizational culture, respect and appreciation for peer team members, clear expectations and standards, fairness, open communication and advocacy. Essentially, we wanna look at what would make a peer from a traditionally underserved community or marginalized community want to work at this organization and what would make them want to stay. Next slide, please. Other things to consider include scopes of work and practice guidelines. So allowing peers to focus on meeting people where they're at, conducting outreach, engagement, advocacy, alternative services delivery approaches to ensure that you're reaching out to those marginalized communities, developing specific measurable, achievable outcomes for peer performance, developing core competencies, activities and job duties that are directly tied to these specific outcomes. Developing job descriptions, lived experience should be a requirement and the lived experience that is necessary should align with the target population or the desired outcomes of the program. And the job description should also define requirements broadly and tie specific job duties and outcomes to bonafide occupational qualifications. So for instance, if you're serving diverse communities, you wanna ensure that the peers that you're hiring have language capacity and that they have a history of engagement with that specific community, that they're able to establish trust and credibility with a specific population or a variety of populations, that they have experience with specific systems or overcoming certain barriers or challenges that are common to certain marginalized communities or populations. And one thing also is to avoid the parent trap, I call it the parent trap. It's when we're hiring family members who have lived experience of supporting their loved one with a behavioral health challenge, but they themselves do not have experience of recovery from a behavioral health challenge. A family member's lived experience is not the same as someone who has received services and to build that credibility and trust, it is really key to have that shared lived experience. Next slide, please. Oh, I'm done. Lucky me, no, I'm just kidding. Personally, I'm really inspired to see your dedication and to witness the advancements in peer support services. So thank you so much for such a valuable presentation. Before we shift into Q&A, I wanna take a quick moment and let you know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access resources, education, upcoming events, and even submit your questions directly to our SMI experts. Download the app now at smiadvisor.org or slash app. Okay, so let's get into some questions here. So one of the questions that came up is, how do you actually match a peer with a peer? Do you have specific ways of going about that? Tanya, do you wanna take that? Sure, so I think it starts with hiring, right? So we're very cognizant of the populations that we're serving in the various areas where we operate peer programs. So we wanna ensure that we're hiring peers who reflect the lived experience of those communities in that area. And then, it's ensuring that when a peer is matched with a client, that they have enough shared experience or enough intersecting identities that the clients will feel confident and comfortable working with that peer support worker. It's not always a perfect match. We don't match based on somebody's diagnosis or specific mental illness that they've gone through. We really try to match based on whether we believe that the peer will have credibility with that client. It's not always perfect. The client can request or the peer can say that I think that this relationship is not a match, but we do our best. I would add to that too, that Cal Voices is really amazing because they have such a diverse workforce that they're able to match people in many ways that most organizations can't do. Frequently, community mental health centers or smaller organizations will only have a few peer support workers, so it's very difficult. But even when you're able to match on all these kind of marginal community-based basis, you also have to match based on personality. And in some ways, that's probably the most important part. If two people can't communicate well together, if they don't feel an empathetic relationship, then it's gonna be difficult for that peer support relationship to work sufficiently. Yeah, that's so fascinating. And I have a follow-up question to that. So do you have specialized or do you require specialized training for individuals working with youth and young adults, someone experiencing a first episode of psychosis, substance abuse, and so forth and so on? I'll start on that one, Damian, and then you can follow up with it. Okay, sounds good. Some states have different trainings and different certifications. There are states that have youth certifications and specific trainings for dealing with youth who've come through perhaps a therapeutic foster care program and then suddenly find themselves lost in the adult system. There's people who work with youth below the age of 18, which is very difficult to do because of the ability to identify with the person. There's peer support groups that are based upon race and ethnicity now beginning to form and trainings around the country. There's forensic or criminal justice involvement certifications and training. It exists, it just doesn't all exist in one place. Yes, I agree. And I think that we ensure that all of our peers have a core training that's 77 hours in the provision of peer support services. And then in the hiring process, I keep going back to that, but to me that's where it all begins. In the hiring process, we ensure that for instance, if somebody is working with a transition age youth, they identify as a transition age youth themselves or have recently been a transition age youth because that credibility is key. California is just implementing peer certification program now, and it has not launched yet. It'll be launching in the next year. And some areas of specialization where once someone receives a peer support specialist certification, they can then apply for an area of specialization. And those areas of specialization will be with family members, with transition age youth, veterans, LGBTQ, forensic, and unhoused. And so all of those specialization certifications will be available in the next several years. So that's certainly something that our state is working on. This is so fascinating. Danielle, can you speak a little more about the general requirements when you speak about the 77 hours of training, like the specific core components? Sure. Okay, so we developed our, so we deliver the training. We've been delivering a peer personnel training and placement program for about five or six years here at Cal Voices. And so we don't just train our own peers. We train peers from around the state. And those core components were developed prior to the certification standards that came out from the state just this year. So what we currently train our peers in is Recovery 101. So really foundations of recovery. What is the recovery model? What was the recovery movement and the consumer movement that it grew out of? What does it mean to provide recovery-oriented services and practices delivery? And then we have Peer Support 101, which is really the foundations of peer support, which is actually, we go over SAMHSA's core competencies for peer support workers and behavioral health settings. And we talk about how to operationalize those core concepts. We have recovery planning training, which is what it says on the tin, teaching peers how to engage clients in recovery planning for themselves, really focusing on the four major dimensions of recovery and the guiding principles of recovery, again, from SAMHSA. We also do ethics, boundaries, and confidentiality, which covers HIPAA, but also just really ethical boundaries in the peer support field. We do group facilitation training. We do a training called Surviving and Thriving, which is really about how to get your first job in the peer support field, what to expect, how to develop job skills and employment skills. And then we also do a training called Managing Up, which is nonviolent communication skills, how to communicate with your coworkers and your managers and conflict resolution. And the last training we do is mental health first aid. So all of that adds up to 77 hours. All of our peers that we hire must go through that core training curriculum within the first three months that they're hired. Many peers have already gone through that training, so it acts sort of as a hiring funnel for our organization. And as I mentioned, we also train other peers throughout the state, so they're able to come to us from other organizations to receive that core training curriculum. Thank you. That sounds fascinating. I'm sure they're getting a lot of bang for their buck. So I have another question here. What suggestions do you have to successfully integrate a peer within the clinical group? Want me to start, Vanya? Go for it. You know, this is a big topic. And part of the reason why it is such a big topic is there's been this belief among many people in the peer community for years that if peers work in a clinical environment, they're gonna become co-opted. In other words, their goals in working with people will be the clinical goals for that person. And that's not the case, but an organization has to make sure that they don't put that type of pressure on people. And people need to also have sufficient training of their own and confidence in their own abilities to do that. When you introduce peer support into a clinical environment, one of the most important things is really to educate the people working on the clinical side about what this means. They need to understand what we mean when we talk about a recovery-oriented system of care, what it means to be a peer specialist, for instance, what type of training you go through, what type of certification, ongoing education. Need to be able to understand why it is that peer support has this special way of people relating to each other, that peer-to-peer shared experience, shared cultural background, whatever the areas that we are able to have as touch points between us. So they need to understand those things because frequently I've seen peers hired to work, say in a hospital environment or a clinical environment of some sort, where the staff really didn't feel that they were full members of that staff, that they somehow were not professionals in their own way. Peer support is a profession. And some people don't like to think of it as a profession because of the connotation that means you've changed it, you've watered it down and you've taken away some of the purity. That's not what it means at all. It means that people are capable of doing their job, that they're well-educated in the techniques that help them to do that job. And they continue to grow just like any professional and they work by a code of ethics and responsibility. And I would just add to that, I think that the number one quality for clinical teams who are looking to integrate peers, what you really need to have is openness and secondly, flexibility. It's very, very difficult for peers to come into an established structure that is not necessarily understanding of what their capabilities are, what their competencies are and what they're able to provide. And so I think that the team or the organization just really needs to be open and flexible and recognize as Patrick mentioned in his presentation that peers are a change agent, they're intended to be a change agent, they're intended to make services more effective for the individuals who are receiving services. And so the team really needs to be open to that and they need to be willing to take a look at their current practices and be willing to update them as necessary. Thank you so much. So this is our time in regards to answering questions. I appreciate the presentation and the information you shared. So if anyone on the call has any follow-up questions about this topic or any topic related to SMI, our clinical access are available for online consultations. Any mental health clinician can submit a question or receive a response from one of our SMI advisors. Consultations are free and completely confidential. SMI is just one of many SAMHSA initiatives that are designated to help clinicians implement evidence-based care. We encourage you to explore the resources available on the Mental Health Addiction and Prevention TTS, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad band of topics from school-based mental health to the opioid epidemic. To claim credit for today's participation in this webinar, you'll need to have met the required attendance thresholds for your profession. Verification of attendance can 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 finally, please join us next week on November 18, 2021, as Dr. Matthew Goldman with University of California, San Francisco presents on Expanding the Evidence-Based for the Crisis Care Continuum. We'll also be presenting on the Call Centers, Mobile Team, and Stabilizing Units. Again, this free webinar will be November 18, 2021 from 3 p.m. to 4 p.m. Eastern Standard Time. Thank you for joining us and until next time, take care.

diversity

mutuality

peer-to-peer specialist relationships

serious mental illness

peer support

marginalized communities

integration into clinical settings

training and certification

recovery

disparities in mental health care