Anthony O. Ahmed, PhD

Assistant Professor

Dept. of Psychiatry and Health Behavior

Medical College of Georgia

Georgia Regents University

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

Delivery

Disclosures

• 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

OutlinePeers 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?

Peer Specialists as Cornerstones of Recovery

Traditional interventions in the mental health field have won some battles…lost the warLittle 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 servicesNeed to maintain adjunctive interventions to traditional careNeed to maintain alternative services to traditional carePeer-led programs outnumber traditional mental health

organizations

Peer-Led Interventions

Consumer-Operated ServicesIntentional, voluntary,

reciprocal or non-reciprocal relationship with

peers in community and/orservice settings

Mutual Support/Self-HelpIntentional, voluntary,

reciprocal or non-reciprocal relationship with

peers in community and/orservice settings

Peer SupportIntentional, voluntary,

non-reciprocal relationship with peers in service settings

Classification of Peer-Led Interventions

Peer-Provider Research: An OpportunityTraditional psychiatry research has been good

for discovery and treatment innovation but suffers important limitationsSocial distance and stigma

Peer-led recovery-based research has potential to provide an important perspectiveDecrease social distanceIncrease involvementServe activist objectives

How then may peers collaborate in research?

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

Peer-Led Interventions: The Evidence

Courtesy Davidson et al., 2006

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

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 useExample: Rowe et al. (2007)--Peer support significantly

reduced alcohol, drug use, and criminal justice involvement in individuals with dual diagnosis over traditional treatment

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?

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

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

MethodMailed out packets to GMHCN CPSs that included

survey questions and psychometric measures20% completion rate for mail-outs (N = 84)Sample survey domains:

Income and sources of IncomeEmployment and work statusHousing and neighborhoodPeer professional status and responsibilities Quality of CPS professional experienceChallenges 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)

Results: Demographic Characteristics

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)

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

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

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

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%)

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%)

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%)

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%)

What steps did you take to deal with relapse?

Recruiting Positive Coping SkillsWRAP; 12 steps; recovery tools; support

network; peer support

Modifying Work ScheduleTaking time off; fewer work hours; reducing

work load;

Psychiatric ServicesMedication reevaluation; hospitalization;

psychotherapy; counseling;

Support and Accommodations Provided by Employer

Employer Provided Time OffDay off, extended time off, paid sick leave, unpaid leave etc.

Employer Provided a Lighter Work LoadFewer cases, additional help, etc.

Employer Adjusted RolesNew job, flexible schedule

Clinical SupportEAP, Onsite Intervention, Hospital Transport

NoneEmployer unaware, employer viewed relapse as

inconvenience,

What opportunities, tools, and supports could improve your experience as a peer specialist?

Professional Development/Continuing Education:Literature to assist in facilitating groupsTraining in working with peers with dual diagnosisTraining in working with peers during acute episodesTraining specific to running peer groupsOperating as a peer specialist on an ACT teamSocializing and professional networkingDealing and resolving ethical dilemmas

Vocational Resources:More job opportunities for peersCreate opportunities for vocational training

What opportunities, tools, and supports could improve your experience as a peer specialist?

Financial Compensation and Resources: Pay advancementProvide support for activities and supplies Increase range of benefitsTransportationHousing

Increase Awareness:Educate traditional providers about peers

provider competenciesEducate traditional providers about peer-led

interventionsEducate peer providers about the value of peer

specialists

In What Roles or Activities Would You like to see CPSs in the Future?

Administrative and Supervisoryadvisors 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 SystemIn police departments; more involvement in the court

system

In What Roles or Activities Would You like to see CPSs in the Future?

Academic SettingsSchools alongside guidance counselors and other

staffUniversity psychology clinics and counseling

centers Proliferation of Peer-Led Interventions

Increase the number of peer centersDevelop more peer-led interventionsProvide services in social security and DHRProvide services in private practice clinics

Other ActivitiesSpiritual counselingLife coachingPolitical activism

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

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

Recovery Attitudes Promote Community Functioning

.52*-.25*

Recovery (MARS)

Symptoms Community Functioning (SFS)-.23* (-.10)

Recovery Attitudes are Protective From Stress

.49*-.92*

Recovery (MARS)

Stressors

Index

Symptoms

-.82* (-.13)

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

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

AcknowledgementsThe Georgia Mental Health Consumer

NetworkMs. Sherry Jenkins-TuckerMr. 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

AcknowledgementsCurrent Peer

SpecialistsLinda JohnsonVanessa DuntonStacy CamilleBarry Jones

Past Peer SpecialistsSherry EvansJulie Roberts

Project GREATProject GREAT

AcknowledgementsAcknowledgements

Project GREAT Project GREAT Emeritus Peer SpecialistsEmeritus Peer Specialists

Certified Peer Specialists