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With advanced training, peers gain credibility

March 15, 2016
by Lori Ashcraft , Kathy Bashor and Mike Franczak
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A quiet revolution is taking place across the country that we may all want to be paying attention to: The emergence of advanced training for peers who have joined the behavioral health workforce. I’m going to use a broad brush to paint a context for this development, and then we’ll take a deep dive into one project so we can learn how the moving parts fit together. Perhaps the most interesting questions is not “How is this happening” but rather, “Why is this happening?”

The recovery movement in behavioral health began to occur in force in the late 1990s, and on its heels came the emergence of the peer movement. Adding a peer to a program’s workforce soon became a symbol of a program’s willingness to take the recovery movement seriously. As a new profession, Peer Support Specialists—as they were initially regarded—faced many challenges, not the least of which were existing professionals that were confused by their presence.

As long as peers worked in peer-run organizations, their existence went unheeded by mainstream mental health programs. However, when peers began to be added to treatment teams, crisis programs, residential programs and hospitals, the resistance to their presence escalated exponentially.

“Patients” were regaining their lives through a recovery process and joining the ranks of professionals in the workforce and were called “peers” not “patients.” This was not an easy pill for other professionals to swallow in the early 2000s, and still isn’t in many places. The concept of “peers” did not fit well into the existing model of patients being patients and professionals being professionals which was the prevailing prototype.

In all fairness, existing professionals were not introduced to peers in a way that allowed for an easy integration. The peer role was not explained, and the differentiation between the peer role and the role of other professionals was not made clear.

In spite of the stigma, the resistance and the disappointment, peers have become a valuable element in the behavioral health workforce. Their contribution has been validated in all areas of service, and early research findings support and verify the significance of their contribution.

Fast forward, and we see the peer workforce rapidly growing and gaining credibility. With the integration of primary care and behavioral health, we see even more opportunities for peers to make a meaningful contribution.

Ron Manderscheid, PhD, executive director, The National Association of County Behavioral Health and Developmental Disability Directors, predicts that by 2020 peers will constitute 30% of the behavioral health workforce. Some think the figure is closer to 45%.

This is due to the fact that peers have held their ground through painful periods of resistance and have proven their worth. It is also due to the workforce shortage facing our nation in all sectors of healing arts. In most states (38) peers are required to complete a specialized training and to be certified before being hired.

Peers can do more

Within the first couple of years of peers being on the job, an unexpected fact became apparent: Peers were having a profound effect on the quality of care being provided in the organizations that employed them. The person-centered, recovery-oriented approach to care was finally taking root in many of organizations, and the mutuality offered by peers escalated the process. It was also becoming increasingly obvious that peers were capable of offering much more than their original training had prepared them to offer.

They needed more training that wasn’t clinical in nature. Peers did not need to know how to become junior case managers or inexpensive counselors. Since they weren’t doing clinical work, the next steps had nothing to do with diagnosing, medicating or managing. So what was the missing piece that could prepare them to take the next steps in the important work they were doing? Peers needed to find ways to make impact that was both deeper and wider in order expand into the potential they clearly had to offer more.

By “wider” I’m referring to the ability to apply what they already knew to a broader audience. For example, they may need further training in how to apply their skills in crisis settings or in housing programs. With further training they could be great job coaches or supported education mentors. With primary care integration, they could learn to support people with physical illnesses and chronic conditions—people who could benefit from learning the recovery and resilience skills that peers are so good at emulating.

By “deeper” I’m referring to applying peer skills with more purpose and empowerment. Peers were working effectively with people who were interested in recovery but needed more confidence and skill to work just as well with those who weren’t initially interested and lacked confidence in their own ability to recover.

This knowledge and skill set are new because they are delivered from a mutual perspective without overtones of control or attempts to manage and because the focus is on strengths instead of problems and symptoms. This is not a retreaded, dumbed-down social work or psychology curriculum that is needed. It’s human being skills that have to do with connecting, engaging, inspiring and empowering, all from a point of mutuality. These are skills that foster recovery and resilience that aren’t available in secular educational settings for people with a lived experience who may not have any other educational degrees.

The how

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The number one reason that some professional mental health care workers may not work well with peers is that professionals do not want to admit that about 80% of people diagnosed with a mental health diagnosis are the victims of iatrogenic harm. Peers are aware of the often harmful and dark side of psychiatry which routinely robs people of hope by telling them they have a permanent brain disorder because of bad genes or a 'chemical imbalance' without any scientific proof. And no, I'm not a scientologist, just a mother of a beautiful daughter, an adult trauma survivor who has been deeply harmed and stigmatized by those to whom I naively entrusted her care when she experienced a break from reality.

In the military, before the rules were changed due to grassroots organizing, victims of MST (military sexual trauma) had to report a sexual assault to their commanding officer, even if the CO was the purpetrator. Of course, if you are an advocate for rape victims we think this is a barbaric way of handling rape reporting but in mental hospitals psychiatric rape is common.

When you hold down a terrified trauma survivor and forcibly inject him/her with Haldol, a routine practice in involuntary clinics and hospitals, this practice is politely ignored or dismissed as necessary and 'evidence-based' even by psychologists who are trauma informed. When you are stripped of your clothes and put in a metal cell, institutionalized, restrained, forcibly shocked, medicated with mindnumbing drugs that make you more psychotic (disorganized or incoherent), more hostile or agitated (akathesia) or suicidal, who are you going to tell, your prescriber or the clinician who routinely approves of or ignores or discounts such practices? It's time we call needle rape for what it is, especially on the eve of the expansion of such barbarity if the Murphy Bill passes in the Senate.

Most psychiatrists don't listen; they aren't trained to listen plus they don't think they are capable of harming their patients, which makes them very dangerous people. Most psychiatrists don't have a clue as to what their patients are afraid of; they tell their patients routinely that they lack insight if they are non-compliant with their treatment order or if they do not identify with their diagnosis and that this is further proof of their illness!

The most powerful peer advocates are those who were deemed hopeless by their treatment providers and because they received effective support in their recovery from extreme states, often from non-traditional sources outside the system, without system funding, had the courage and compassion to come back to tell their truth and in the process, create hope and plant seeds of recovery, helping to shepherd others out of the insane mental health system so that, they too, can recover.

I think the article is a useful overview of the peer support profession. However, the headline of this article doesn't help the (vastly important) need to expand the peer workforce and for 'traditional' providers and the public to understand what we do ( I work as a peer supporter in MA).

The headline sends the message that peers are effective and valuable, but ONLY with 'advanced' training. Unfortunately, many in the 'traditional' mental health world are leery of peers' credibility to begin with, as the bias is usually skewed toward clinical roles. Training is of course very important, but perhaps the most important part of peer supporters' education is their OWN lived experience, their recovery and their inner wisdom. The headline seems to send the message that 'advanced' training regimen is the only thing that makes a qualified peer supporter.

The second half of the headline, "peers gain credibility," is also quite off-putting. In my experience, every peer supporter has credibility...actually, taken as a whole, peer supporters regardless of formal training have more credibility, sometimes vastly more, than many clinicians and psychiatrists. The term 'credibility' is highly judgmental, and suggesting that peers have to work harder to gain it is insulting. I don't know if the authors of this article were involved with the creation of this headline, but it continues a rather long and tiring trend in the media of putting down people with lived experience of mental health issues. I hope Behavioral Healthcare will exercise better judgment in the future when assigning headlines!

As another commenter has pointed out, the lived experience is one of the key aspects of peer support. And equally important is the ability to temper that lived experience in a way that helps a peer rather than distracts a peer from their own recovery and access to their inner wisdom. This "tempering" typically only comes with training. Our natural tendency is to overload a peer with stories from our own experience. At various points in the peer interaction, these stories might be helpful, but timing, willingness to listen, and ability to discuss alternative pathways is essential.

there is no information in the article that I could find that says how to become registered for this.

Long before peers were able to play a significant role in the mental health system, school-based peer programs were active in engaging peers to help their teen counterparts with multiple issues and concerns. The peer helping movement in schools was also resisted at first by professionals who scoffed at using teens to help each other. What's important is that teen peer helpers provided a variety of non-clinical, supportive, and practical assistance to those in their peer group starting as early as the 1970's. The principles of peer recovery work had their origins in the work of these youth, and the similarity between what children, youth, college students, and senior citizens do today as peer helpers (peer mentors or peer counsellors) is almost identical to what peer support workers do in the mental health system.

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