The Peer-Provider Collaboration as a Platform for Research and Service Delivery

1. The Peer-Provider Collaboration as a Platform for Research and Service Delivery Anthony O. Ahmed, PhD Assistant Professor Dept. of Psychiatry and Health Behavior Medical College of Georgia Georgia Regents University

2. Disclosures Contract/Grant Support • Educational grant from U.S. Department of Health Resources and Service Administration (HRSA) Bureau of Health Professions (BHPr) 2012 Award for Creativity in Psychiatric Education from the American College of Psychiatrists

3. Outline • Peers and peer-led interventions: clinical research update • The GMHCN-Project GREAT collaborative study of recovery in certified peer specialists • Peer-led interventions, services, and research in the state of Georgia: whither are we bound?

4. Peer Specialists as Cornerstones of Recovery • Traditional interventions in the mental health field have won some battles…lost the war • Little has been gained in promoting wellness, personal growth, quality of life, personhood… • There is some increasing recognition of the importance of recovery among traditional providers but psychiatry and psychology are still lagging behind • The consequence is high rates of treatment disengagement • Peer-led interventions are necessary to sustain the gains of the recovery movement • Need to give voices to individuals receiving services • Need to maintain adjunctive interventions to traditional care • Need to maintain alternative services to traditional care • Peer-led programs outnumber traditional mental health organizations

5. Peer-Led Interventions Mutual Support/Self-Help Intentional, voluntary, reciprocal or non-reciprocal relationship with peers in community and/or service settings Peer Support Intentional, voluntary, non-reciprocal relationship with peers in service settings Consumer-Operated Services Intentional, voluntary, reciprocal or non-reciprocal relationship with peers in community and/or service settings Classification of Peer-Led Interventions

6. Peer-Provider Research: An Opportunity • Traditional psychiatry research has been good for discovery and treatment innovation but suffers important limitations • Social distance and stigma • Peer-led recovery-based research has potential to provide an important perspective • Decrease social distance • Increase involvement • Serve activist objectives • How then may peers collaborate in research?

7. Peer-Led Interventions: Feasibility • Feasibility studies demonstrated that it is possible to train peers to provide mental health services • Four seminal studies conducted in the 1990s

8. Peer-Led Interventions: The Evidence Courtesy Davidson et al., 2006

9. Peer-Led Interventions: The Evidence • Peers are able to deliver services that are at least as effective as services delivered by traditional providers • In some cases slightly better outcomes

10. Peer Staff Versus Non-Peer Staff • Since year 2000, there has been an increased focus on comparing peers to non-peers—are peers really better at case management? • Comparison trials have consistently shown that peers do better at engaging “difficult-to-treat” clients, reduce hospitalization rates, duration of hospitalization, and decreasing substance use • Example: Rowe et al. (2007)--Peer support significantly reduced alcohol, drug use, and criminal justice involvement in individuals with dual diagnosis over traditional treatment

11. Future Research Into Peer-led Interventions • New third generation research interest is to— • Identify the ways peer-led interventions are different and outperform tradition treatment • Identify the interventions that only peers are uniquely qualified to provide • Distill the active ingredients of peer-led interventions • What are the experiences of peers providing interventions? In what ways does the Peer Specialist role influence peers’ lives?

12. Third Generation Studies • NIMH-funded studies by Larry Davidson’s team: • Tondora et al. (2010): 290 adults with SMI randomly assigned to a) usual care plus IMR; b) usual care plus IMR plus a peer-facilitated person-centered planning process (PCP); and c) usual care plus IMR and PCP with the addition of the peer-run community connector program. • Peer-facilitated care planning increased the sense that treatment was responsive and inclusive of outcomes that mattered to peers • The peer-run community connector program increased hope, belongingness, treatment engagement, and decreased psychotic symptoms • Sledge et al. (2011): 74 participants who had been hospitalized at least twice in the last 18 months randomly assigned to usual care versus usual care plus peer recovery mentor • The inclusion of peer mentorship decreased the number of hospitalizations (Cohen’s d = 0.41) and the duration of hospitalization (Cohen’ d = 0.44) • There was also a significant decrease in substance use and depression with peer mentorship

13. The GMHCN-Project GREAT Collaborative Study of Recovery among CPSs • Objectives: • Study the professional experiences of CPSs trained through the GMHCN • Identify the correlates of recovery among CPSs that may inform experiential aspects of recovery

14. Method • Mailed out packets to GMHCN CPSs that included survey questions and psychometric measures • 20% completion rate for mail-outs (N = 84) • Sample survey domains: • Income and sources of Income • Employment and work status • Housing and neighborhood • Peer professional status and responsibilities • Quality of CPS professional experience • Challenges of the CPS role • Psychometric measures: • Maryland Assessment of Recovery for SMI (MARS); Connors-Davidson Resilience Scale (CD-RISC); Brief-COPE; Social Functioning Scale (SFS); Social Support Questionnaire (SSQ); Internalized Stigma of Mental Illness (ISMI); Brief Symptom Inventory (BSI); the NEO Five Factors Inventory (NEO-FFI-3)

15. Results: Demographic Characteristics

16. Vocational and Financial Status of CPSs • Approximately 85% of CPSs have at least some college education/post-high school and over 40% have a bachelors degree • Most CPSs earn between $10,000 to $20,000 per year • The unemployment rate of CPSs is high at 38.30% • 49.40% reported that they were “Mostly Dissatisfied” or “Very Dissatisfied” with their financial status and 37.50% for their employment situation • There was an association between income satisfaction and employment satisfaction (r = .54, p < .0001)

17. CPS Professional Role • Only a minority of peer specialists are working for pay in that role • Peer specialists reported working 18.47 hours a week on average (range = 0-85 hrs) • The majority of peer specialists feel included as part of the treatment team • The majority of respondents are at least “Mostly Satisfied” with their role as a CPS

18. Peer Specialist Employment Benefits • 72.4%% of peer specialist received no employment benefit • The benefits for CPS positions are low compared to other professions of similar levels of education

19. Housing and Living Situation • Most respondents own their own apartment • Most peer specialists reported being at least “Mostly Satisfied” with their housing • Most respondents were at least “Mostly Satisfied” with their neighborhoods

20. What are some things you do to help peers? • Peer Mentoring and Support (60%) • Goal setting, leading recovery groups; sharing recovery stories; providing support services; hospital visits, etc. • Teaching or Leading Treatment Groups (51.11%) • E.g., skill-based groups and wellness activities such as WRAP, IMR, social skills, etc. • Case Management (29%) • Housing assistance; employment; transportation; entitlements; legal support; community resources etc. • Advocacy (11.11%) • Consultation Services to Treatment Teams (6.7%)

21. What do you find rewarding about being a CPS? • The Helping Role: Assisting others to embark on the recovery journey, empowering peers, instilling hope, etc. (71.18%) • The Power of the Narrative: Sharing recovery stories and positive experiences (15.25%) • Personal Growth: Better insight, knowledge through education/training, growing with peers, etc. (12.00%) • The Reciprocity: Developing friendships and partnerships with other peers and other providers (20%)

22. What are the most difficult challenges of the CPS role? • Limited Compensation/Resources (25.45%) • Conflicts and Misunderstandings with Traditional Providers (25.45%) • Paperwork (21.81%) • Peer Difficulties (21.82%) • Maintaining Personal Wellness (10.91%) • Limited Peer Specialist Positions (7.27%)

23. Current Problems in Place of Employment • Limited compensation and benefits (32%) • Stressful work environments/millieu (22.03%) • Untenable productivity standards; difficult co-workers; problematic shifts; too much paperwork • Underemployment (15.25%) • Issues of appreciation and respect (13.56%) • Limited workplace resources for optimal service delivery (8.47%) • Inadequate supervision; office space; equipment issues • Poorly defined roles and responsibilities (4%)

24. What steps did you take to deal with relapse? • Recruiting Positive Coping Skills • WRAP; 12 steps; recovery tools; support network; peer support • Modifying Work Schedule • Taking time off; fewer work hours; reducing work load; • Psychiatric Services • Medication reevaluation; hospitalization; psychotherapy; counseling;

25. Support and Accommodations Provided by Employer • Employer Provided Time Off • Day off, extended time off, paid sick leave, unpaid leave etc. • Employer Provided a Lighter Work Load • Fewer cases, additional help, etc. • Employer Adjusted Roles • New job, flexible schedule • Clinical Support • EAP, Onsite Intervention, Hospital Transport • None • Employer unaware, employer viewed relapse as inconvenience,

26. What opportunities, tools, and supports could improve your experience as a peer specialist? • Professional Development/Continuing Education: • Literature to assist in facilitating groups • Training in working with peers with dual diagnosis • Training in working with peers during acute episodes • Training specific to running peer groups • Operating as a peer specialist on an ACT team • Socializing and professional networking • Dealing and resolving ethical dilemmas • Vocational Resources: • More job opportunities for peers • Create opportunities for vocational training

27. What opportunities, tools, and supports could improve your experience as a peer specialist? • Financial Compensation and Resources: • Pay advancement • Provide support for activities and supplies • Increase range of benefits • Transportation • Housing • Increase Awareness: • Educate traditional providers about peers provider competencies • Educate traditional providers about peer-led interventions • Educate peer providers about the value of peer specialists

28. In What Roles or Activities Would You like to see CPSs in the Future? • Administrative and Supervisory • advisors to regional offices and hospital administrators, program directors, decision-making teams, etc. • Education and Training • Staff training, family psychoeducation, anti-stigma etc. • Hospital/Clinical Roles • Nursing, counseling, case management, treatment planning, crises intervention, physical health training, etc • Judicial System • In police departments; more involvement in the court system

29. In What Roles or Activities Would You like to see CPSs in the Future? • Academic Settings • Schools alongside guidance counselors and other staff • University psychology clinics and counseling centers • Proliferation of Peer-Led Interventions • Increase the number of peer centers • Develop more peer-led interventions • Provide services in social security and DHR • Provide services in private practice clinics • Other Activities • Spiritual counseling • Life coaching • Political activism

30. The Peer Specialist Position Confers Clinical Benefits • Psychiatric diagnosis does not impact CPS status • Low past year hospitalization rate among CPSs • Over 40% of CPSs reported relapse while functioning as CPS but almost all took effective steps to manage relapse

31. Summary of the Correlates of Recovery in Peers Specialists • Measured recovery with the Maryland Assessment of Recovery in Severe Mental Illness (MARS) • Factor analysis distills recovery into—Hope/holistic, Empowerment, Self-Direction, and Strengths • Recovery predicted: • Positive coping • Resilience—control, commitment, action-orientation, faith, and tolerance • Community living—social engagement, communication, recreation, independence • Frequency and satisfaction with social support • Internalized Stigma—positive association with stigma resistance and inverse association with alienation, stereotype endorsement, withdrawal • Recovery attitudes as a Cognitive Antidote.. • Recovery does not depend on personality organization

32. Recovery (MARS) .52* -.25* Symptoms Community Functioning (SFS) -.23* (-.10) Recovery Attitudes Promote Community Functioning

33. Recovery (MARS) .49* -.92* Stressors Index Symptoms -.82* (-.13) Recovery Attitudes are Protective From Stress

34. What do Peer Specialists in Recovery Do to Cope? • Religion • Use of Emotional Support • Active Coping • Positive Reframing • Use of Instrumental Support • Planning • Venting • Humor • Acceptance

35. Strategies for Proliferating Peer Services • Involve people in recovery and non-peer stakeholders in the process of creating peer positions • A clear job description and role clarification • Identifying and valuing the unique contributions that peers can make to the programs and settings where they will work • Providing CPS jobs that reflect the diversity of strengths and educational background of peers • Provide compensation commensurate with background and experience • Sponsored education and training for peers to enhance the quality of their services • Senior administrator take on the role of peer staff “champion” who can address issues and problems (Davidson et al., 2012) • Providing training and education for non-peer staff that covers relevant disability and discrimination legislation and its implications (Davidson et al., 2012) • Providing supervision for peer staff that concentrates on job skills, performance, and support • Disseminate success stories of the impact of peer-led interventions

36. Acknowledgements • The Georgia Mental Health Consumer Network • Ms. Sherry Jenkins-Tucker • Mr. Charles Willis • All Certified Peer Specialists of the Georgia Mental Health Consumer Network • “Thank you for being missionaries of hope” • Mr. Mark Baker~ Center for Recovery Transformation

37. Acknowledgements • Current Peer Specialists • Linda Johnson • Vanessa Dunton • Stacy Camille • Barry Jones • Past Peer Specialists • Sherry Evans • Julie Roberts

38. Acknowledgements Project GREAT

39. Project GREAT Emeritus Peer Specialists Certified Peer Specialists