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. 3. 4. 5. 6. 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 • • • • • • Listen, listen, listen! Use empathy Focus on strengths Reflect feelings/thoughts Roll with resistance Ask open-ended questions ----Ashcraft, Zeeb, & Martin, 2007 Recovery Pathways • • • • • 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: • • • • • • • • • • • 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 • • • • • • • • • • • • • • • • • 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): • • • • • • • • • • • • • • 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: • • • • • • • • • • • 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 • • • • • • • • • • • • • • • • • • • • • • 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 • • • • • • • • • • • Tammy Falk Dawn Pearson Ed Larson Beth Gravalin Karen Beard Laura Westerholm Brian Powers Susan Helgeland Sherry Shadley Cari Jehlik Etc.