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ND Peer Support: Recovery Model
and Professional Development
(Presentation by Darrin Albert, MS, CPS, CPRP, 2013)
Serving ND in 8 convenient locations:
1.
2.
3.
4.
5.
6.
7.
8.
Fargo (701-412-1217)
Bismarck (701-255-6402)
Devil’s Lake (701-662-8424)
Dickinson (701-227-0135)
Grand Forks (701-746-4530)
Jamestown (701-251-2964)
Minot (701-852-3263)
Williston (701-577-0267)
NDDHS
Popular depictions of peer
pressure are often negative……
But can peer pressure be positive?
While nobody should be “pressured” into anything, social
interaction, teamwork, encouragement, WRAP training,
skill-building, empathy, intervention, mentoring, and
support groups can go a long way to facilitate wellness,
recovery, and positive outcomes for people with mental
health issues.
What exactly is peer support?
On peer support….
“Peer support is a system of giving and receiving help founded on key principles
of respect, shared responsibility and mutual agreement of what is helpful. Peer
support is not based on psychiatric models and diagnostic criteria. It is about
understanding another’s situation empathically through the shared experience
of emotional and psychological pain. When people identity with others who
they feel are ‘like’ them, they feel a connection.”—Mead, Hilton, & Curtis, 2001
(from Pratt, Gill, Barrett, & Roberts, 2007).
“Peer Support Services provide the opportunity for individuals in recovery from
mental illness to assist their peers with moving forward in their personal
recovery journey to lead meaningful lives in the community. Peer Support
promotes personal responsibility for recovery.”—from 2013 Peer Support ND
brochure (NDDHS)
“Certified Peer Specialists are well grounded in their own recovery and have
expertise professional training cannot replicate. They are certified by the North
Dakota Department of Human Services and employed by the Mental Health
Recovery Centers.”—from 2013 Peer Support ND brochure (NDDHS).
“In Peer Support we understand each other because we’ve ‘been there,’ shared
similar experiences and can model for each other a willingness to learn and
grow. We come together with the intention of changing unhelpful patterns,
getting out of ‘stuck’ places, and building relationships that are respectful,
mutually responsible, and, potentially, mutually transforming.”-Copeland and
Mead, 2004
Psst…….a brief history of PS
“Mental health peer support has existed for decades, both
formally and informally, in such environments as clubhouses,
drop-in-centers, and consumer/survivor networks. In this
sense, the existence of mental health peer support is not a
new concept to the mental health system. Since the 1990’s,
increased attention has been paid to the importance and
potential of expanding mental health staffing patterns to
include ‘consumers as providers’ within mental health service
settings.”- MN DHS
Peer Specialists Have Wisdom
Wisdom is a function of
experience, pain,
knowledge, and
resilience. Peer specialists
can share their wisdom
through self-disclosure in
the form of “recovery
stories.”
Peer counseling and the recovery
model
Peer support (also known as peer counseling) focuses on goal setting,
WRAP, crisis management, strength-building, and wellness. While the
term recovery is commonly used in relation to substance abuse,
recovery from many other mental health problems is also possible.
Peer support is culture informed. It respects a person’s world-view
and unique experiences.
Peer support is trauma informed. It recognizes that recovery from past
trauma is possible through understanding how the coping mechanisms
of past trauma can impede recovery in the present or future (i.e.
trauma-reenactment).
Peer support is one of the ten components of recovery along with
hope, self-direction, person-centered, empowerment, holistic, nonlinear, strengths-based, respect, and responsibility (U.S. Dept. of
Health and Human Services).
NIMH names peer support as one of ten essential elements of
supportive community integration (from Pratt, Gill, Barrett, & Roberts,
2007).
Peer support is consistent with the recovery model, psychiatric
rehabilitation, deinstitutionalization, maximum client involvement,
community integration, least restrictive environment, dignity of risk,
and normalization. A peer support program’s fidelity to the recovery
model can be assessed using the ROSI (Recovery Oriented Systems
Indicator).
The “Recovery Model” also involves
minimizing the reliance on traditional
mental health systems
“We support each other
to get out of the
hospital…stay out of the
hospital…and get the
hospital out of us.”
----2012 ND State Peer
Support Brochure
Let’s strive to cut out the
middle man!!
Random fun fact
The Recovery Model may be new in practice but not in
principle. In fact, the terminology itself has been used
as early as 1937 when psychiatrist Abraham Low
developed the self-help organization Recovery
Inc./International. Abraham’s work has also been one
of the antecedents to modern day WRAP.
Peer support promotes psychiatric
rehabilitation (i.e. recovery)
“The goal of psychiatric rehabilitation is to enable
individuals to compensate for, or eliminate the functional
deficits, interpersonal barriers and environmental
barriers created by the disability, and to restore ability for
independent living, socialization and effective life
management.”- from Pratt, Gill, Barrett, & Roberts, 2007
“Recovery is a deeply personal, unique process changing
one’s attitude, values, feelings, goals, skills, and/or roles.
It is a way of living a satisfying, hopeful, and contributing
life. Recovery involves the development of new meaning
and purpose in one’s life as one grows beyond the
catastrophic effects of psychiatric disability.”- William
Anthony, from Ashcraft, Zeeb, & Martin, 2007
“Recovery is remembering who you are and using your
strengths to become all that you were meant to be.”from Ashcraft, Zeeb, & Martin, 2007
“The task is not to become normal. The task is to take up
your journey of recovery and to become who you are
called to be.”-Patricia Deegan, from Ashcraft, Zeeb, &
Martin, 2007
Promoting Recovery Environment
“Once we’ve been assigned a diagnoses, we talk
about treatment for ‘it.’ We’ve then lost who we
are to a generic label. We begin to think about
all of our experiences in relationship to illness:
tough feelings as depression, excited feelings as
mania, etc. No matter what we are feeling, when
we talk about our feelings using this language,
the conversation can only go in one direction.
Pretty soon everything we do, think, and say
runs through the ‘mental patient’ filter.”
“Many ‘treatments’ that were administered ‘in
our best interest’ have left us with horrible long
term effects like post traumatic stress disorder,
tardives dyskinesia, loss of memory, excess
weight and diabetes. Peer Support and WRAP
focus attention on safe, free strategies that
promote health and well-being.”
----Copeland and Mead, 2004
Recovery Environment (cont.)
*Hopeful with high expectations
*Recovery is goal
*Easy access to information
*Self determination, critical thinking, and independence are valued
*People are experts in their own care
*Opportunities for community integration with choice
*Medication is one of several tools
*Peer support and self-help are valued
----Ashcraft, Zeeb, & Martin, 2007
A culture-informed peer support
model understands the top-down
impact of:
1.
2.
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4.
5.
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7.
Planetary worldview
Continental worldview
Country worldview
State worldview
City worldview
Individual worldview
Cohort/zeitgeist
It’s about phenomenology!
A trauma-informed model asks….
What happened to this person?
It does not ask….
What is wrong with this person?
“A trauma-sensitive culture is one within which it is understood that most human
behavioral pathology is related to overwhelming experiences of exposure to abusive
power, disabling losses and disrupted attachment…Therefore behavior on the part of
workers and clients, caregiver and patients, employers and employees, parents and
children, must be understood and responded to within the context of these dynamic
forces.”—from NYAPRS peer bridger training manual
Note: Remember that trauma is relative. One person’s mountain is another person’s
mole hill!
Recovery according to SAMHSA
A process of change through which individuals improve
their health and wellness, live a self-directed life, and
strive to reach their full potential.
Health: Overcoming or managing one's disease(s) as well
as living in a physically and emotionally healthy way.
Home: A stable and safe place to live.
Purpose: Meaningful daily activities, such as a job, school,
volunteerism, family caretaking, or creative endeavors, and
the independence, income, and resources to participate in
society.
Community: Relationships and social networks that
provide support, friendship, love, and hope.
Related topics: Maslow Hierarchy of Needs; Life, Liberty, &
Pursuit of Happiness
Peer Support and the StressVulnerability Model
The etiology of mental illness is a function of stress and genetic
predisposition. Some people have a biological vulnerability to the
symptoms of SMI. However, there are certain ways the symptoms or
expression of mental illness can be reduced or prevented (from
SAMHSA IMR Tool Kit, 2009):
1.
2.
3.
4.
5.
6.
Medication compliance
Avoiding drugs/alcohol
Avoiding/reducing stress
Coping skills and meaningful activity
Healthy lifestyle
Supportive relationships
Peer Support can take an active role with all these healthy activities!
Peer support, as a consumer-driven
approach, is also related to empowerment,
self-advocacy, self-help, and the ex-patient
movement.
What is empowerment?
A term frequently used in conjunction
with the psychiatric rehabilitation value of
self-determination. It is often addressed
in psychiatric rehabilitation programs via
involvement strategies such as sharing
knowledge, power, and economic
resources with consumers, and it has
been recently defined in the literature as
being composed of three elements: selfesteem and self-efficacy combined with
optimism and a sense of control over the
future; possession of actual power; and
righteous anger and community activism.- Pratt, Gill, Barrett, & Roberts, 2007
What is self-advocacy?
An individual’s efforts to defend his or her own personal or
civil rights, including the right to receive quality treatment and
rehabilitation services. This term also refers to efforts by an
organized group of consumers to rally support for a common
cause.--Pratt, Gill, Barrett, & Roberts, 2007
What is self-help?
Involvement in nonprofessional activities
that provide support
and information for
oneself and others
who share a similar
illness or problem.-Pratt, Gill, Barrett, &
Roberts, 2007
What is the ex-patient movement?
Organized efforts by
persons with a history
of psychiatric illness to
advocate for civil rights
and humane treatment
approaches. The
movement has also
provided access to a
variety of self-help and
alternative treatment
approaches.--Pratt,
Gill, Barrett, & Roberts,
2007
Random fun fact
“Mental Health America is the country’s oldest and largest non-profit
organization addressing all aspects of mental health and mental illness.”
“Mental Health America was Established in 1909 by former psychiatric patient
Clifford W. Beers.”
The description on the bell reads: “Cast from shackles which bound them, this
bell shall ring out hope for the mentally ill and victory over mental illness.”
--mentalhealthamerica.net
Peer support and
humanistic psychology
The similarities between peer
support and client-centered
humanistic therapy can hardly
be ignored.
Like humanistic or client-centered
theories…….
• In general, peer support focuses more on listening than giving
advice, psychoanalyses, psychodynamic, or medical-model
interventions.
• Peer Support respects the experiences and phenomenological
interpretations of the individual through unconditional positive
regard, empathy, and congruency (see Copeland and Mead, 2004).
Client-centered theory (cont.)
• Support always comes from an individual with an actual DSM-4 TR
diagnoses. He or she self-identifies as a person with first-hand experience
with mental illness and models how recovery is possible.
• Peer Support theory asserts that a more efficacious or robust form of
empathy can be achieved through a consumer-driven support system by
consumers and for consumers.
• Peer Support therapeutic processes are also influenced by social learning
theory (Bandura, 1977), social comparison theory (Festinger, 1954),
experiential knowledge (Borkman, 1999), helper-therapy principle
(Reissman, 1965; Skovholt, 1974), and social support theory (Sarason,
Levine, Basham, & Sarason, 1983).—Salzer et al., 2002 and Solomon, 2004
(from Pratt, Gill, Barrett, & Roberts, 2007).
The Peer Support Approach
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Listen, listen, listen!
Use empathy
Focus on strengths
Reflect feelings/thoughts
Roll with resistance
Ask open-ended questions
----Ashcraft, Zeeb, & Martin,
2007
Recovery Pathways
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Spirituality
Hope
Recovery environment
Empowerment
Choice
----Ashcraft, Zeeb, &
Martin, 2007
Random fun fact
Alcoholics Anonymous (AA), an early version of peer
support and self-help, was a joint contribution between
a NY stockbroker and Ohio surgeon in 1935.
--(from Pratt, Gill, Barrett, & Roberts, 2007)
A jury of one’s “peers”
There is a reason people on trial want a jury of peers.
Why?
People tend to feel more understood and supported
in the presence of similar or like-minded people.
While this assumption may partly involve in-group
bias, it also assumes mutual understanding based on
common ground, experiences, and congruent life
histories.
SMI clients may feel more “at home” with a certified
peer specialist for similar reasons. This can expedite
the length of time necessary to establish a trusting
relationship between the helper and helpee.
Recovery and Community Integration
“The availability and use of skillfully delivered psychiatric rehabilitation
supports (e.g. supported housing, supported employment, supported
education, peer support), especially those using effective models,
increase opportunities for people to fully participate in various critical
social roles and activities.”-Mark Salzer, 2006.
Community Integration Framework
Community Presence and Participation
Psychiatric Rehabilitation
Community Integration
Well-Being and Recovery
It takes a village…….
“For those who have been removed from their
community as a result of hospitalization, incarceration,
or placement in programs outside their home
communities, the ability to feel ‘a part of the
community’ is weakened. It also weakens their chances
for recovery.”--Peggy Swarbrick, 2006
Peer operated initiatives are comprised of three types
(Clay, 2005):
1)
2)
3)
drop-in/self-help centers
peer support and mentoring
education and advocacy
----from Psychiatric Rehabilitation Skills in Practice ,
2006
Recovery is also about eliminating barriers to facilitate
maximum community involvement. Key legislation
includes:
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1988 Fair Housing Amendments Act
1973 Rehabilitation Act (including section 504)
1990 Americans with Disabilities Act
1963 Community Mental Health Centers
Construction Act
1973 Comprehensive Mental Health Services Act
Ticket to Work and Work Incentive Improvement
Act
Workforce Investment Act (WIA)
1999 Olmstead Decision
1986 Protection and Advocacy for Mentally Ill
Individuals Act (PAMI)
Individuals with Disabilities Education Act (IDEA)
1977 NIMH Community Support Program (CSP)
The 4 kinds of peer support
1.
2.
3.
4.
Emotional: Demonstrate empathy, caring, or concern to bolster person’s selfesteem and confidence.
Informational: Share knowledge and information and/or provide life or
vocational skills training.
Instrumental: Provide concrete assistance to help others accomplish tasks.
Affiliational: Facilitate contacts with other people to promote learning of social
and recreational skills, create community, and acquire a sense of belonging.
----------Cobb, 1976 and Salzer, 2002 (from SAMHSA, 2009)
The four tasks of peer support (Mead, 2008):
Task 1: Connection. This is when empathy is established
and we realize we are not alone.
Task 2: Worldview. This task is accomplished when peers
and peer providers acknowledge that our experiences,
culture, and family affect/influence our current
personalities. It is also about knowing that there are no
bad people….only bad situations.
Task 3: Mutuality. Peer support relationships are mutual,
reciprocal, and involve give/take. The hard line between
client and provider is more blurred. This task values the
human need to help and be helped. “It is healing to learn
that one needs and is needed, cares and is cared for, and
can receive as well as give” (Deegan, 2005).
Task 4: Moving towards. This task involves three
fundamental questions: where am I now? where do I want
to be? how do I get there? This task is less about what isn’t
working and more about focusing on our strengths.
Peer support tools
Peer support professionals can utilize various tools
to aid them in their work with clients:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Readiness assessment
Functional assessment
Resource assessment
WRAP (Wellness Recovery Action Plan)
Self-disclosure and recovery stories
Interest or values assessment
Motivational interviews
Goal assessment
Psychoeducation
Skills-training exercises
Odds and/or ends….
“The capacity for hope is the most significant fact
of life. It provides human beings with a sense of
destination and the energy to get started.”–
Norman Cousins
“Recovery does not refer to an end product or
result. It does not mean one is ‘cured.’ In fact,
recovery is marked by an ever deepening
acceptance of our limitations. Recovery is a
process. It is a way of life. Like a plant, recovery
has its seasons, its downward growth into
darkness to secure new roots and then the times
of breaking into the sunlight. But most of the
time, recovery is a slow, deliberate process that
occurs by poking through one little grain of sand
at a time.”—Patricia Deegan
Random fun fact
The ND peer support program has its roots in 2003
when Western Sunrise Inc. received a grant from the
ND Olmstead Commission. It was patterned after the
New York Association of Psychiatric Rehabilitation
Services Peer Bridger Project.
Some key Figures of Recovery Model
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Patricia Deegan
William Anthony
Shery Mead
Mary Copeland
Abraham Low
Wolf Wolfensberger
Marc Gould
Paul Liberman
Robert Drake
Mark Salzer
Lori Ashcraft
Gary Bond
James Prochaska
Carl Rogers
Rollnick & Miller
Abraham Maslow
Victor Frankl
Peer support involves a unique kind of listening (Mead,
2008):
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Understanding how each of us has learned to see the world.
Remembering that people are complex, unique, and forever
changing.
Listening from a position of “not knowing.”
Listening for the “untold story.” How does conformity, blind
obedience, culture, and role-acting influence our narratives?
Providing validation (avoid premature problem solving)
Reflection of feelings.
Asking clarifying questions.
Building connection.
Listening with an ear for role.
Direct honest respectful communication (including
assertiveness).
Negotiating reality. This skill respects phenomenology,
worldview, personality, and moral relativism.
Sitting comfortably with silence.
Thinking and talking differently about diagnosis.
Sharing relevant personal change stories.
Additional tips in effective
communication
• Use I statements
• Don’t intentionally dig up past abuse
• Believe people, even if their reality is
different from your reality
• Share some of the things you’ve done to
get through
• Create hope and develop trust
• Getting “unstuck” may mean learning to
sit with discomfort
• Learn to tolerate difficult situations
• Stay present
----Copeland & Mead, 2004
Peer support and “big feelings”
“We are not a culture that has a lot of
tolerance for intensity or ‘big feelings.’ We
tend to want to calm people down or make
it stop because we are uncomfortable. In
peer support we can recognize that people
have a lot of big feelings and they aren’t all
dangerous, they are in fact, rich with
information.”----Copeland and Mead, 2004
“Now the classic approach to dealing with
suicide and self-harm issues is to ask the
person to make a ‘contract’ or agreement
with you not to engage in any suicidal or
self-harm activities. We don’t think this
approach is helpful. It is mostly a way of
controlling our discomfort with the
conversation.”----Ashcraft, Zeeb, & Martin,
2007
Peer support is about limits….not
boundaries
“In mental health, clinicians are taught that boundaries keep people in “appropriate”
roles: the patient is the patient and the clinician is not. In peer support we don’t have
fixed roles with each other. Sometimes we are the listener, sometimes the listened to,
and sometimes that even changes in one conversation!”
“Sometimes traditional mental health boundary policies become pretty tempting
because they allow us to set an arbitrary line and not have to set individual, situational
limits. For example we start telling people that workers don’t ever give out their home
number or we say that workers can’t be recipients or guests. We start using boundaries
to separate ourselves and then fall into the same power dynamics as a traditional
helping relationship.”
----Copeland and Mead, 2004
Peer support and trauma
reenactment!
“Trauma re-enactment means that when a current situation triggers
feelings from an old traumatic event, we fall into behaviors and
responses that were relevant to the original event, but are probably
not relevant to what is currently happening.”
“We challenge each other when we find ourselves in old roles and we
name the power dynamics for what they are.”
----Copeland and Mead, 2004
Remember….
Peer support specialists are professionals AND consumers. Not
only do they carry first-hand experiences with mental illnesses,
but they are also credentialed through the ND Dept. of Human
Services and are required to acquire annual CEU’s (continuing
education units).
Power-informed peer support: The 7
power dynamics (Mead, 2008)
1. Who’s got the keys
2. Provider discomfort vs.
client safety
3. Rules vs. negotiation
4. Power reactions to
“learned helplessness”
5. I’m staff and “more
recovered” than you
6. Seeing the client as the
problem
7. Provider privilege and bias
Random fun fact
Did you know that peer support specialists have
their own set of ethical guidelines just like any
other professional human service?
Peer support can include individual or
group settings
One-on-one matches: Individuals will be matched with
a trained Certified Peer Specialist. They will meet
weekly to provide development of natural supports,
education, advocacy, emotional support, skills training,
problem solving skills, goal setting, and referrals to
other community supports.—NDDHS (from Peer
Support ND 2012 brochure)
Group meetings: Peer led group meetings provide the
opportunity for: sharing life experiences, wellness and
recovery education, social support, a decrease in
feelings of loneliness, reducing isolation, increasing
leadership skills and developing coping skills.--NDDHS
(from Peer Support ND 2012 brochure)
Peer support is not…..
• An expert telling you what your experience
means.
• Telling someone what to do.
• Superficial power-down relationships.
• Telling you you’re sick and socially
unacceptable.
• Protecting people from taking risks that are
“too stressful.”
----------From Copeland & Mead, 2004
Related concepts: dignity of risk, person-centered
Random fun fact
Prosumer: A term used to describe identified consumers of mental health
services who are also mental health professionals (Pratt, Gill, Barrett, &
Roberts).
“Prosumers are former mental patients, graduates of various forms of living
hell, transformed into consumers and now activated towards a wide variety of
work roles to help others who are still in the first stages of defining their
selves and their beings.”-Manos, from Pratt, Gill, Barrett, & Roberts, 2007
Benefits of peer support
1.
2.
3.
4.
5.
6.
7.
Increased independence
Reduced symptoms of SMI
Reduced stress and improved mental health
Increase in self-awareness, insight, and coping
skills
Increased life satisfaction
Community cost-effectiveness
Reduced hospital stays
-----------------See Pratt, Gill, Barrett, & Roberts, 2007
Peer Support and EBP
Besides the plethora of evidence supporting the benefits of
traditional client-centered approaches, there is also a growing body
of evidence showing the benefits of peer support in relation to
wellness, recovery, and mental health (see Pratt, Gill, Barrett, &
Roberts, 2007; see U.S. Dept. of Human Services, 2009).
Peer support can produce outcomes equal or greater than cognitive
behavioral therapy (see Psych Central News, 2011).
The benefits of peer support has been recognized by the federal
government in Mental Health: A Report of the Surgeon General
(1999), and the 2003 President’s New Freedom Commission on
Mental Health Report (see Pratt, Gill, Barrett, & Roberts, 2007).
Current research suggests peer support as a promising best practice
(see Pratt, Gill, Barrett, & Roberts, 2007).
Peer support specialists can also offer potentially valuable services
through high fidelity to established EBP’s such as: medication
management, assertive community treatment (ACT), supported
employment (SE), illness management & recovery education (IMR),
family education, and integrated Dual Diagnoses treatment (IDDT).
Current evidence-based practices of the recovery
model
Medication Management (MedMAP)
Assertive Community Treatment (ACT)
Supported Employment (SE)
Illness Management and Recovery Education (IMR)
Family Education
Integrated Dual Diagnoses Treatment (IDDT)
Promising best practices:
Supported Education
Peer Support
Supported Housing
What might a peer support fidelity
scale look like?
A SAMHSA project called the Consumer Operated Service Program Research
Initiative (COSP) identified 6 central components of consumer-operated
programs. They were used to create the COSP Fidelity Assessment Common
Ingredients Tool (FACIT). The 6 domains include (Pratt, Gill, Barrett, & Roberts,
2007) :
1.
2.
3.
4.
5.
6.
Program structure around consumer choice
Safe environment
Recovery-oriented philosophy
Formal and informal peer support strategies
Education (including skill-building)
Advocacy
Did you know?
Fear of job displacement is the
main reason many mental health
professionals are resistant to
embrace peer support.—Ashcraft,
George, and Martin, 2010.
Remember: Mental health workers
must strive to role-model
teamwork and social skills by
learning to work together with the
clients’ best interests in mind. Peer
support specialists are assets to any
team of fellow mental health
professionals.
Through role modeling, peer support
specialists also dispel common myths
of mental illness
Myth: People with SMI are
dangerous
Myth: People with SMI are
irrational
Myth: People with SMI lack
intelligence
Myth: People with SMI lack
common sense
Peer Support is More than People-first
Language
It’s about people-first action!
(Work first) + (Education first) + (Housing first) + (Health first)=
(People first)
Related topics: continuity of care, basic needs, choose-get-keep
There are no bad people, only bad
situations
While this mantra can reduce blame and pointing fingers, it
does precious little to explain/improve negative situations
SMI consumers may face.
Human behavior doesn’t occur in a vacuum. It must be
understood in the context of space, time, environment, and
other variables.
Systemic barriers can prove challenging for consumers and
peer specialists. Some of these challenges include but are not
limited to:
1.
2.
3.
4.
5.
6.
The job/experience vicious cycle
Criminal background checks after people have “done
their time” (i.e. bowling rules)
The “disclosure gamble” of SMI during job or housing
interviews
Reasonable accommodation of DSM-IV TR diagnoses
The downside of deinstitutionalization (i.e. substance
abuse and homelessness)
“Triple or quadruple diagnoses” (i.e. the addition of
poverty and/or a criminal record)
Not-So Fun Fact:
Behavioral health service providers have been
found to harbor some of the strongest prejudice
towards people with SMI (see Ashcraft, George,
& Martin, 2010).
What roles do peer specialists play?
•
Coach/mentor: Peer specialists have been there. They have done that. As fellow
consumers themselves, they tend to have street-smarts regarding the ins and outs
of the mental health system and can help peer-matches navigate accordingly. Peer
specialists can also assist with general life skills, job skills, or other areas currently
diminished by mental illness.
•
Advocate/role-model: Peer specialists write their own WRAPs and role-model the
idea that recovery is possible. They have primary experience with mental illness
because they have an actual DSM-4 diagnoses themselves. This kind of experience
and empathy cannot be obtained through a text-book or second-hand learning.
Peer specialists can assist their matches with setting goals, writing WRAP’s, and
identifying positive behaviors that promote wellness/recovery.
Note: The service categories for peer specialists
in ND include recreation, skill teaching, socialemotional support, advocacy, support groups,
linking to supports, etc.
Peer specialists take on aspects of
various roles:
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Role model
Fellow traveler
Case manager
Counselor/therapist
Resource coordinator
Coach
Mentor
Supporter
Advocate
Friend
Teacher
Due to stigma, there are misconceptions
regarding peer support. Some of this is
due to some people underestimating the
professional abilities of peer specialists.
Myth: Peer support is not therapy.
Fact: Peer support is based on various
forms of therapy.
In addition to the therapeutic processes already mentioned on slide 25, peer
support is also influenced by components of various therapies including but
not limited to client-centered therapy (Carl Rogers), motivational interviewing
(Miller & Rollnick), milieu therapy, reality therapy (William Glasser), rational
emotive behavioral therapy (REBT, Albert Ellis), cognitive/behavioral therapy
(CBT), recreational therapy, and occupational therapy.
Syllogism
Major premise: All therapeutic
outcomes are a result of therapeutic
processes
Minor premise: Peer support
produces therapeutic outcomes
Conclusion: Therefore, peer support
is based on therapy!
Myth: Peer specialists can only work with clients
in the maintenance phase of recovery.
Fact: Peer specialists can tailor
their approach to work with
clients in any of Prochaska’s five
stages of change:
precontemplative,
contemplative, preparation,
action, or maintenance (see
Ashcraft, Zeeb, & Martin, 2007).
Myth: Peer specialists can only work with “high
functioning” clients scoring in the 4th level of care in
the ND level system (based on the DLA-20 functional
assessment).
Fact: Peer support is relevant/appropriate to all 4
levels of care in the ND level system (see Recovery
Management Manual: Services for Adults with SMI
850-10)
Myth: Peer specialists shouldn’t work with
clients when they are “symptomatic”
Fact: The peer approach can be tailored to work
with clients experiencing a variety of challenges,
including suicidal thoughts, hearing voices, selfinjury, and panic attacks/anxiety (see Ashcraft,
Zeeb, & Martin, 2007; Mead, 2008).
Peer Support and Career Advancement
Job requirements for peer specialists should not
be so stringent as to keep people from applying.
Peer specialists have something many other
mental health workers lack, and that’s actual
first-hand experience with SMI and recovery. But
why stop there?
The best-practice of Supported Education
reminds us that people with SMI can succeed in
the spheres of post-secondary education with
the proper supports. Not only would further
education enhance the professional skills of peer
specialists, but it would also role-model to
clients that education is not an impossible feat.
CPRP licensure of peer specialists is also
encouraged (Certified Psychiatric Rehabilitation
Practitioner). The CPRP credential ensures a firm
knowledge base in the Recovery Model and
evidence-based or best practices (including peer
support). The CPRP is sponsored by the U.S.
Psychiatric Rehabilitation Association. The CPRP
certification involves a challenging exam and
human service field experience.
CPRP credentialing
The Certified Psychiatric Rehabilitation Practitioner (CPRP) is perhaps
the best license available for mastering the Recovery Model and
evidence-based practice (EBP). The CPRP involves work experience,
continuing education, and a challenging three hour exam.
“The Certified Psychiatric Rehabilitation Practitioner credential (CPRP)
is a test-based certification that fosters the growth of a qualified,
ethical, and culturally diverse psychiatric rehabilitation workforce
through enforcement of a practitioner code of ethics. Currently there
are CPRP’s with PhDs to GEDs, occupational therapists to peer
specialists, social workers to case workers—they all share a
commitment to the fundamental principle that recovery from serious
mental illness is possible.”—USPRA.org
Supervision: The “co-supervision”
model (Mead, 2008)
“Supervision is considered essential in order to ensure
quality, improve skills and to provide accountability. We also
believe that this is important in peer support, and engaging
in co-supervision can bring the best of these principles into
our relationship in a way that models what we are trying to
practice.”
“Co-supervision is a process that we can use to help each
other reflect on our practice (how we’re doing what we say
we want to be doing). It is about us creating expertise
together through a process of learn, practice, reflection.”
“Once we’ve been practicing IPS (intentional peer support)
for a while it’s useful for us to check in with one another
about how we think we’re doing. Giving and receiving
reflective feedback will be an important part of a successful
co-supervision relationship.”
Supervision (cont.)
What hurts (Magellan Health Services, Inc., 2008)
1. Making peer specialists do work that no one else wants to do.
2. Seeing peer specialists as “less than” other staff
3. Feeling frightened of, or threatened by, peer specialists
4. Expecting or allowing incomplete or unsatisfactory work from peer specialists
5. Marginalizing peer specialists as not quite “real staff”
What helps (Magellan Health Services, Inc., 2008)
1. See peer specialists as a vital part of the team.
2. Setting up clear, written job descriptions and expectations for peer specialists.
3. Asking yourself “How would I address this situation with any other staff member?”
if you have a question about how to treat a peer specialist.
4. Understanding the special relationship peer specialists have with other peers.
5. Using the peer specialist’s lived experience with mental illness and recovery to
educate other non-peer staff members.
Supervision (cont.): 20 pillars of
success for peer specialists (Magellan
Health Services, Inc., 2008)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Clear job description
Job-related competencies
Skills-based training program
Competencies-based testing process
Employment-related certification
Ongoing continuing education
Professional advancement opportunities
Multiple training sessions commitment
Local train-the-trainer program
Local sustainable funding
Unifying symbols and celebrations
Networking and information exchange
Expanded employment opportunities
Research and evaluation component
Multiple disciplines partnerships
Strong consumer movement
Multilevel system support
Equal treatment as employees
Non-peer staff training
Media and technology
Peer Support and Illness Management
& Recovery (IMR)
IMR is an evidence-based practice that teaches empowerment through
psychoeducation, coping skills training, problem solving , and social skills
training. Client handouts are informative and easy to understand. Not only
can peer specialists take an active role in teaching the concepts of IMR, but
they can also role-model their own recovery in the process. The topic areas
of IMR include the following ten modules:
Topic 1: Recovery Strategies
Topic 2: Practical Facts About Mental Illness
Topic 3: The Stress-Vulnerability Model and Treatment Strategies
Topic 4: Building Social Supports
Topic 5: Using Medication Effectively
Topic 6: Drug and Alcohol Use
Topic 7: Reducing Relapses
Topic 8: Coping with Stress
Topic 9: Coping with problems and Persistent Symptoms
Topic 10: Getting Your Needs Met by the Mental Health System
That’s a WRAP!
So is that the end of this slide show? Not quite. In the
context of peer support, a WRAP is a Wellness
Recovery Action Plan. WRAP is a practical way to
apply the concepts of IMR into daily life.
According to Mary Copeland (2004):
“WRAP is a planning process that involves accessing the self help tools and
resources that we have, and then using those tools and resources to develop
plans for keeping ourselves well, and for helping ourselves feel better in difficult
times. It includes a daily maintenance list, triggers and an action plan, early
warning signs and an action plan, when things have gotten much worse and an
action plan, crisis planning and post crisis planning.”
Examples of wellness tools include relaxation exercises, leisure time, peer
support, proper diet, and proper rest. Examples of triggers or warning signs
include anniversary of trauma, fatigue, financial problems, lack of motivation,
irritability, forgetfulness, stress, and substance abuse.
The appendices contain detailed information and instructions regarding coping
skills like deep breathing, progressive muscle relaxation, guided imagery,
exchange listening, etc.
The Future of Peer Support
Peer support specialists are increasingly using their
skills on IMR, IDDT, and ACT teams.
Remember: Peer specialists are professionals and
should be treated as equal team members.
Remember….
Peer support is also about coming up with
creative solutions to difficult situations
It doesn’t hurt to ask……
WWMD?
References
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Ashcraft, Zeeb, & Martin, 2007. Peer Employment Training Workbook (3rd edition).
Ashcraft, George, & Martin, 2010. Recovery Practices in Leading and Coaching : Developing and Sustaining a Peer
Support Work Force (2nd edition).
Substance Abuse and Mental Health Services Administration (SAMHSA) and U.S. Dept. of Health and Human Services.
National Consensus Statement On Mental Health Recovery.
Substance Abuse and Mental Health Services Administration (SAMHSA) and U.S. Dept. of Health and Human Services,
2009. What are Peer Recovery Support Services?
Substance Abuse and Mental Health Services Administration (SAMHSA), 2011. SAMHSA Announces a Working Definition
of “Recovery” from Mental Disorders and Substance Use Disorders (press release).
Pratt, Gill, Barrett, & Roberts, 2007. Psychiatric Rehabilitation (2 nd edition).
Psych Central News, 2011. Peer Support Helps Reduce Depression Symptoms.
Copeland & Mead, 2004. Wellness Recovery Action Plan & Peer Support: Personal, Group, and Program Development.
Mead, 2008. Intentional Peer Support: An Alternative Approach.
Dumont, Ridgway, Onken, Dornan, & Ralph. Recovery Oriented Systems Indicators Measure (ROSI). Measuring the
Promise: A Compendium of Recovery Measures (Volume II).
Recovery International, 2012. History of Recovery International. lowselfhelpsystems.org.
Salzer, 2006. Psychiatric Rehabilitation Skills in Practice: A CPRP Preparation and Skills Workbook.
Bazelon Center for Mental Health Law, 2006. What “Fair Housing Means for People with Disabilities.”
Mentalhealthamerica.net/go/history
Mentalhealthamerica.net/go/bell
Substance Abuse and Mental Health Services Administration (SAMHSA) and U.S. Dept. of Health and Human Services,
2009. Illness Management and Recovery (Evidence-Based Practices Kit).
ND Department of Human Services. Peer Support North Dakota (2012 brochure)
ND Department of Human Services. Peer Support Services (2013 brochure)
USPRA.org
ND DHS, 2013. Recovery management manual: Services for adults with SMI
Magellan health services Inc., 2008. Effective supervision of peer specialists
Images courtesy of Google Image Search
Acknowledgements
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Tammy Falk
Dawn Pearson
Ed Larson
Beth Gravalin
Karen Beard
Laura Westerholm
Brian Powers
Susan Helgeland
Sherry Shadley
Cari Jehlik
Etc.