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Peers prove that recovery is possible, every day

June 27, 2012
by Alison Knopf
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Nationwide, peers and peer advocates help people with mental health concerns stay in recovery, get needed supports, and lead fuller lives
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In the addiction world, being in recovery means being substance-free. But it also means having “a better quality of life,” and that is the underlying theme of all recovery, including recovery from mental illness, says Laurence Miller, M.D., medical director for the division of behavioral health services in the Arkansas Department of Human Services, and professor of psychiatry at the University of Arkansas for Medical Sciences.

The concept of peers – people who have the same condition as the people they are helping – originated in the addiction field, because the notion of recovery started there, says Miller, who is a spokesman for the American Psychiatric Association. “When I was in training, there was no such thing as recovery,” he says. “We talked about stabilizing patients so they could leave the hospital and not come to the clinic so much, but that was it.”

What recovery really means is “having a life like everyone else,” says Miller. “With newer medications, there is the opportunity to have a full life, not just stability,” he says. “People can have jobs, go to school, have relationships.”

Health care reform

And it is this full life – wellness – that is the reason why peers are an essential part of health care reform. The Affordable Care Act emphasizes wellness promotion and prevention and, for the mental health field, that means diversion away from emergency rooms and hospitals, says Harvey Rosenthal, executive director of the New York Association of Psychiatric Rehabilitation Services (NYAPRS). This gives peer services the opportunity to develop sophisticated models around wellness coaching, crisis respite, warm-line services, peer bridging, and peer-recovery centers, he says.

State Medicaid agencies and private managed-care organizations are encouraging and expanding the use of peer services, says Rosenthal. About 17 years ago NYAPRS developed a “peer bridger” model, in which peers are trained to provide support to people who have had long stays or frequent admissions to state hospitals. The model aims at helping these people make a smooth and lasting transition to the community. “We help them get out of the hospital and stay out of the hospital,” says Rosenthal, who was hospitalized in 1969, and ended up working in a state hospital and then in a clubhouse program before joining NYAPRS.

Credibility of peers

Some people think that even psychiatrists should have experience with mental illness in order to be better clinicians, says Miller. “I have heard the argument that ‘If you don’t have schizophrenia, you can’t treat me.’ I don’t buy it. If we’re going to think of these illnesses as real and biologically based, we have to embrace the concept that it doesn’t take one to treat one.”

But Miller does think someone who is trained and has been through the experience of mental illness has tremendous power to help professionals. “One of the things peers can do is give hope,” he says. “Professionals talk to patients and treat patients, but when you have someone who has been through it, walked the walk and talked the talk, that gives hope to people that they can do the same thing.”

Having a mental illness “isn’t necessary for recovery support, but it gives you more credibility,” says Deborah Fickling, a behavioral health ombudsman and peer advocate working in New Mexico. Peers are a part of the movement to counteract the traditional paternalism of psychiatry, in which patients are told “’You’ll do whatever I say because I’m the doctor and you’re the patient,’” she says.  

‘Living examples of recovery

Peers offer a unique contribution to recovery that is unavailable without them, says Rosenthal. “They act as living examples of recovery,” he said, giving hope to people who for years were told they couldn’t do it.” Peers also provide a personal relationship – a connection to a real person – who can give them a sense of independence in a health care system that often encourages dependency. “This is an honest and reciprocal relationship,” says Rosenthal.

And the hope isn’t only regarding clinical realities of mental illness. Peers help consumers understand that they too can deal with just plain reality, which can be difficult even for people without disabilities. For example, Fickling helps people navigate the complicated Medicaid system.“I share with people who are looking for help themselves that I’ve been there,” she says.

Agencies that hire peer specialists can get reimbursed by Medicaid for comprehensive community support services that are clearly not clinical, says Fickling. These services can be as simple as learning how to take a bus or how to open a bank account, she said. When the person with the mental illness is a child, there are also family support specialists who can help parents navigate the system.

Peers don’t have to be matched by diagnosis, says Sue Bergeson, Vice President for Consumer Affairs at OptumHealth Behavioral Solutions, which contracts with peer organizations to provide services to members. “What you really want from a peer is someone who understands what it’s like to live with a mental health condition, period,” she says. “I have these symptoms, I have to take my meds. It’s not about unique patterns of symptoms. Even if two people have bipolar disorder they’ll experience it differently.”

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"If we’re going to think of these illnesses as real and biologically based.." Yet are these illnesses really biologically based? Substantial evidence points other-where.
“Currently, the diagnosis of mental disorders is based on clinical observation—identifying symptoms that tend to cluster together, determining when the symptoms appear, and determining whether the symptoms resolve, recur, or become chronic. However, the way that mental disorders are defined in the present diagnostic system does not incorporate current information from integrative neuroscience research, and thus is not optimal for making scientific gains through neuroscience approaches." (National Institute of Mental Health Strategic Plan 2008 (pg. 8))
Trauma exposure has been linked to later substance abuse, mental illness, increased risk of suicide, obesity, heart disease, and early death.” (Leading Change: A Plan for SAMHSA’s Roles and Actions 2011–2014 – pg. 8)
“One consequence of trauma is the compulsion which can develop to repeat the circumstances of the original trauma. This can result in an individual placing him/ herself (or others) in harm’s way due to an unconscious effort to achieve a better outcome of the traumatic circumstances.”( Healing Trauma by Peter Levine Ph.D. (pgs. 20-25) ©2005)
According to the medical model there are four causes of brain dysfunction: (Biology and Human Behavior Professor Robert Sapolsky, Stanford University, The Teaching Company)

1. Anatomical abnormalities or damage
2. Lack of oxygen or glucose
3. Electrolyte imbalance
4. Neurotransmitter deregulation; the imbalance of brain chemistry.
While outside the scope of this paper, research indicates other factors, including imbalances in the body’s electromagnetic field [Vibrational Medicine for the 21st Century , Richard Gerber, M.D., 2000 (pgs. 292-306)] also exist which can contribute to brain dysfunction.
"Psychosis, characterized by hallucinations, delusions, and/or a general loss of contact with reality, can be generated by many conditions that impact cerebral function. Brain injuries or growths, neurological infections, drug reactions, and severe endocrine disorders are just some of the medical issues that may be indicated." [Complementary and Alternative Medicine Treatments in Psychiatry 2012 Edition by Dan Stradford, Garry Vickar, Christine Berger, Hyla Cass (pgs. 26-27)]

“As a cost-effective measure to reduce these diagnostic errors, Koran and his associates developed an algorithm—a step-by-step procedure—to efficiently narrow down the likelihood of medical disease in psychiatric patients.” [Complementary and Alternative Medicine Treatments in Psychiatry 2012 Edition (pg. 32)]

More than twenty years after its development, it is still little used- or known. “…the lag between discovering effective forms of treatments and incorporating them into routine care is unnecessarily long, lasting about 15 to 20 years” [Achieving the Promise: Transforming Mental health Care in America, July 2003 (pg.2) Apparently it is more convenient, or profitable, - at least for some -just to drug people without adequately screening them.

I appreciate and celebrate Dr. Miller's recognition, personally and on behalf of the APA, that peer practice has brought an invaluable component to traditional mental health services. The presence of people with lived experience who are in recovery are, as he states, proving the reality of recovery to people using services.

It's equally important to stress that this message is now getting to people who provide services, create policies for services, and fund services. The indisputable proof of recovery in the form of real live people has finally achieved what years of rigorous research has attempted to do. Studies from the 1800's on, and the seminal work of Harding and the international community in the 1970's attempted to demonstrate that people can and do recover. This research, however, was routinely rejected as somehow flawed because everyone "knew" from their professional experience that mental illnesses are biologically based brain conditions that are chronic and life long, hence today, we still refer to people as having "SPMI" - Severe and Persistent Mental Illness.

I anticipate that peer practice will also demonstrate the facts summarized in Mr. Bennett's response above. As someone who experienced severe emotional distress and was diagnosed with schizophrenia and bipolar disorder, both biological illnesses within the DSM-IV and V structure, I can now look back and see 30 years of "traditional" treatment approaches that devastated my life. It wasn't until my mid-40's that other possibilities, such as trauma and recovery, were introduced. It wasn't until my mid-40's that I saw that people actually do recover through the eyes of another further on the recovery journey.

The ACA gives us the opportunity to not only widen the role and value of peer practitioners within the mental health system, but also challenges us to acknowledge the depth of what we don't know, open the doors to more possibilities, and recognize that the human spirit is a greater healer than compliance with any medication or treatment regiment.

Lyn Legere, Boston

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