Housing Options Made Easy. Inc.

ROLE OF PEERS SUBCOMMITTEE WHITE PAPER

JANUARY, 2005

TABLE OF CONTENTS

I) Executive Summary

The Partnership Committee of Erie County formed in 1997. Peer workers were being increasingly recognized for their benefit to persons served by the mental health system in the Western New York area. A small group approached Charlie Sabbatino, Chairman of the Community Services Board to discuss the need to bring peers and non-peer providers together to develop working relationships. A committee of eight persons has grown to the current attendance of 25- 30 people. This committee is unique in its inclusiveness of providers, peers, customers of services and governmental agencies.

In the fall of 2003, the Partnership held a one-day retreat to discuss the needs and possible solutions to improving the delivery of mental health services in Erie County which more than 50 people attended, representing all stakeholders. The retreat developed into three sub-committees for prolonged discussion and problem solving: Education Committee, Inpatient Committee, and the Role of Peers Committee. All committees are led by peer and non-peer representatives.

The Role of Peers sub-committee was established to discuss the evolving roles of peer workers, peer volunteers, and mental health providers within Erie County. The sub-committee was comprised of non-peer mental health providers, peer workers, volunteers, and customers of mental health services.

The interaction between peer and non-peer providers needs to be periodically examined to provide an atmosphere of continual growth and improvement for the mental health community as a whole. The peer experience has created a dynamic environment for personal empowerment in individual and group mental health recovery. Often, peer support is the only source of support available to an individual living with a diagnosis of mental illness. Peer support is frequently instrumental in assisting a person to access treatment and community services. Through mutual sharing, peers are able to assist one another in utilizing services effectively. This mutuality fosters individual growth for both the recipient and the provider of the peer service. For these reasons, the committee recommends that close association, inclusive of cross training, be encouraged between peer and non-peer providers.

The sub-committee determined that the involvement of peer workers in mental health services ranged from volunteer to that of individual practitioner, as well as, executive leadership roles. Some peers find the term “peer,” in itself, stigmatizing. Agencies have sometimes found it better to use different job titles to suit the type of service provided. However, all agreed, though the term “peer” may or may not be used, the work provided by this group of workers embodies consistent purpose and practice.

The committee evolved into an interactive, thoughtful discussion surpassing the question of “who is a peer?” to frank conversation about the changing dynamics and parameters of peer work. The outcome of our work is intended to provide a set of standards for peer and non-peer provider agencies to utilize as a benchmark to encourage uniformity of the expectations, responsibilities and employment needs of the peer advocate worker.

The goal of this paper is to promote trust and understanding between peer workers and non-peer providers to clearly understand the roles and responsibilities of participants to achieve a proactive, respectful, and mutually agreeable working relationship. Therefore, a set of guidelines are recommended to understand the role of the peer, ethical standards, support, community involvement, and dialogue between non-peer providers and peer workers.

The group identified common purpose for the development of the committee’s work:

•  To identify complimentary and unique roles
•  To incorporate multiple perspectives
•  To foster communication between peers and providers
•  Develop and promote partnering strategies between providers and peer services
•  To explore our future, and changing roles

The committee struggled with terminology, as befalls all committees of this type. We agreed to use the term “customer” for the commonly used word “customer.” We deleted the word “advocate” because all peers did not think it applied to their work. Finally we replaced the term “traditional provider” with “non-peer provider” for the purposes of this paper.

II) Values Statement

The Partnership Role of Peers Committee embodies the stated values the Partnership as a whole embraces: choice, collaboration, mutual respect, and the promotion of change and growth among people who regard each other as equals.

We extend this to the shared belief of our work: “A life’s struggle with mental illness does not take away an individual’s right to self determination or his ability to make decisions and to live (inter)independently.”

We recognize that unique talents and perspectives combined with common values and shared beliefs define our respective roles to promote health, hope, and improved quality of life for our customers through the use of complementary services.

Through this collaboration we articulated values common to peers and non-peer providers as well as our common responsibilities to:

•  Respect each other’s unique and/or diverse role
•  Regard differences and issues as opportunities for growth on both sides
•  Maintain open communication
•  Adhere to a described standard of ethics both at a corporate and individual level
•  Regularly increase our understanding of the differing aspects of our work through mutual exchange in training and educational seminars

III) Ethics

The committee discussed ethics in broad areas and shared specific ethical concerns that surround peer work. The prevalent ethical concern rested in the relationship between the peer worker and the customer. Noting that the mental health recovering community is interconnected, the group acknowledged that fraternization commonly occurs but is not in violation of ethics when fraternization is with supervisory knowledge, for the well being of the person served, not contrary to and in support of the service plan, and that the peer is responsible to disclose prior relationships. This issue is addressed further in the peer training guidelines. In summation, the group adheres to the following ethical principles:

In working with our customers peers and non-peer providers alike subscribe to and function within a code of ethics that prohibits conduct which improperly favors or disfavors any individual or group of customers. Universal ethical beliefs include:

•  That all customers are treated with dignity and respect
•  That abuse/neglect/coercion whether physical, sexual, financial or emotional of any customer or group of customers in any form is always ethically wrong
•  That all personal, civil and human rights are respected and protected
•  That practitioners and providers understand and respond appropriately to individual and cultural preferences in all service activities
•  That information regarding each customer is held confidential until the individual gives informed consent for information and participates in the development of the response
•  That socialization with customers is governed by reasonable employer policy, and
•  That all activities facilitate, and do not impede personal growth or the individual’s recovery objectives

IV) Characteristics of the Peer Worker

Group discussion ensued around the definition of “peer.” Members had differing views of “who is a peer” and “the work of peers.” The committee recognized that, although the work of peers is different in varied settings, there are commonalities in training and services in all peer run agencies. This produced the term “peer characteristics” to encompass the many backgrounds and skills found in peer workers and for the recommendation of common standards.

The relationship between peers and their customers is founded upon the principal of equality. Peers, in order to be effective, are in equal relationship to persons served. All recognized that duties are guided by agency policy and at times services need to be withdrawn or reduced due to choices an individual makes. Recognizing that these may be difficult issues to convey in the casual settings of some peer work and could have an adverse effect on the peer and customer relationship, consensus is that these issues need to be addressed in conjoint sessions with the appropriate administrator. Thus, the peer remains in the role of a support person.

The following common characteristics are adapted from the work of Darby Penny and a committee formed to set standards for job descriptions within the New York State Office of Mental Health:

•  A peer is a past or current recipient of mental health services
•  A peer has experienced a major interruption in his/her ability to lead a fulfilling life
•  A peer is dedicated to promoting empowerment and self-determination in the service of recovery
•  A peer is objective and strives to have no control or authority over a person’s life
•  A peer is willing to share/disclose life experiences related to mental health systems

V) Diversity of Peer Roles in the Community

A) Peer Provider Role

Through their work in the community, the peer role has a positive effect on reducing the stigma of the diagnosis of mental illness and the accompanying issues. Peers are active on many levels and in many segments of the community.

In Erie County, peers are on the public payroll, providing services to others with mental health issues and helping themselves at the same time. They have been instrumental in initiating changes in the delivery of mental health services, choose their governing board members and bring customer voices into their policy-making process.

Peers make presentations in schools at every grade level, helping students and teachers understand mental illness better.

Peers regularly talk to the news media about their illnesses and recovery, using their stories to spread compassion and understanding for all customers of mental health services. Peers host their own radio programs and appear on television.

Peers work with local churches to organize special educational events for members of congregations who want to understand mental health issues better and often volunteer their own services. Peers are often directly involved in individual services to other peers and customers. They run self help groups and warm lines for one another, consistently supporting an individuals’ ability to achieve their recovery.

Finally, the process of recovery often evolves to a leadership role for the peer. With respect to the diversity of the customers within the mental health system who partake of services it is important to consider that a segment of that group have had full leadership/professional careers before receiving a diagnosis. Consideration should be given to include this population by creating opportunities commensurate with their background and ability.

B) Peer Volunteer Roles

Volunteers are a large part of the wellness program in the mental health system. As part of individual recovery efforts, people attend peer seminars on wellness and take part in trainings to understand the issues of empowerment, wellness, and recovery. Programs cover many areas including facilitator training, system advocacy, job training, peer advocacy and leadership training. Individuals who receive training may pursue a role as a peer provider, but many take that information and use it in the community by actively volunteering to help others and to enhance their chosen roles in the community.

1) Support Groups

The evolution for peer support began as several recipients of services gathered to share and discuss their experiences, resources and needs. Facilitating self-help groups became a common experience for many peers before they ventured into employment. Many prefer to continue their service on a voluntary basis.

Self help groups lend a vital role in the recovery processes. Self help groups are frequently run by peer facilitators who volunteer their time to share their personal learning about recovery and empowerment. They commonly provide information on services within a given area. Many people have accessed mental health and community services for the first time, or have found services fitted to particular situations through the guidance of these groups.

2) Volunteerism

Perhaps one of the more successful avenues leading to fulfilling lives is that of volunteering and community involvement. Peer work is not for everyone who lives with diagnosis. However, becoming involved in the community in any capacity promotes wellness, empowerment, and self-esteem. The committee encourages all peer and non-peer providers to develop and extend opportunities for volunteering to individuals living with a diagnosis of psychiatric disability.

VI) Training Guidelines

The Role of Peers Subcommittee recognizes that training is a necessary element in the preparation of individuals for peer work. It was thought that such training should be both instructional and experiential and should be provided by a peer-based group. Wherever possible, training should be tailored to the specific peer role the individual is assuming. It is recommended that training be provided both prior to an individual’s embarking on peer work and also on an ongoing basis during an individual’s work as a peer. It was felt that peer workers must understand and identify with the peer role. When peers are working within a non-peer agency, all agency training provided to employees must be made available to peers.

While it was not the intent of the subcommittee to prescribe a specific training curriculum, certain training elements were identified as necessary and desirable. These elements include but are not limited to the following:

A) Advocacy

These are essential skills for a peer worker requiring that he/she can offer customers assistance in the areas of:

•  Advanced directives
•  Self advocacy
•  Systems advocacy
•  Patients’ rights
•  Use of community resources
•  Goal setting
•  Facilitator training

B) Empowerment

The skill of empowering is a primary focus of the peer worker. The term “empowerment” is often brandished in a perfunctory manner with little attention paid to the skills of “empowering.” Empowerment is allowing others the tools needed for self-care and promotion with the understanding that people are held responsible for their decisions and have the right to support respectfully used.

C) Boundaries

Peer workers form relationships based on the sharing of personal experiences. This sharing should be “other-directed” and may best be described as “sharing with a purpose.” While an integral part of peer work, self-disclosure should always be used cautiously and for the benefit of the person served.

D) Communication Skills

The ability to effectively communicate with others is a primary skill for the peer worker. Learning to accept and use feedback regarding their communication skills and style is a primary focus in peer education. Peers may be called upon to work with a diverse group of customers and their communication skills must therefore be versatile and flexible. Key among these are:

•  Networking skills
•  Advocacy
•  Written (case notes)
•  Interpersonal
•  Acceptance
•  Conflict management / mediation / negotiation
•  Problem solving
•  Coaching / mentoring
•  Support group facilitation

E) Knowledge of the History of the Peer Movement

•  Peer models
•  Medical model
•  Stigma awareness
•  Recovery movement

F) Values and Ethics

•  Code of ethics
•  Privacy/confidentiality
•  Values including personal, corporate, and peer principles

G) Utilizing Supervision and Support

VII) Working Together

A) History

Employers have, in the past, engaged peers without clear guidelines related to their role as a peer. By establishing policies, procedures and job descriptions that address the unique role of the peer the agency protects the peer role, enhancing personal and professional growth for mutual benefit.

Some employers believe that these are not separate issues – that all employees have the same needs and policies set should apply to all equally. Because a peer is assigned duties different from that of the clinical staff, care must be taken to assign policies that protect the peer role. An example may be a peer accompanying an individual to a support meeting after clinic hours. These are individual circumstances to the type of workplace setting and licensing.

B) Guidelines for Working Together

The Role of Peers Subcommittee discussed the roles that peers can play in providing services within non-peer organizations and clearly recognized the value of peer services in assisting customers in their recovery efforts.

The Subcommittee formulated a number of ideas as to how peers and non-peer providers can work successfully together. They include the following:

•  Non-peer providers recognize the value of the peer role and work actively to incorporate peers into their services to customers
•  Non-peer providers create opportunities for peer workers to have contact with other peers so they can receive consistent support and education
•  Education as to the roles and responsibilities that each worker assumes increased worker satisfaction and productivity
•  Peers and non-peer providers should work to understand and appreciate their respective roles in the provision of rehabilitation and recovery services
•  The unique skill sets a peer brings to the delivery of services should be treated as equal and relevant to the customer’s need
•  Recognition and encouragement of the unique identification peers have with one another can help people derive the most benefit from their treatment
•  Peers should be provided with an appropriate level of supervision from both the non-peer agency and a peer supervisor
•  Issues or problems that arise as peers and providers work together are opportunities for growth and can be positive
•  Effective working relationships evolve over time and require patience and open communication in order for growth to occur
•  Fees paid to peers by non-peer providers must be fair and equitable
•  Peers and non-peer providers alike should respect the diversity that exists within the peer community
•  Peers strive to offer each other options and choices and should respect each others personal program of recovery
•  Peers serve to proactively reduce the harm that may result from prior treatment experiences
•  Agency policy should define and describe the role that peers can or should play in providing services
•  Provider organizations should work actively to create a welcoming, supportive and collegial environment for peer workers

VIII) Supervision and Support

A) Supervision

The group discussed peer responsibility in the workplace along with the guidelines of generally accepted performance standards, noting the relevance of unique life experience issues to the definitions and standards of the peer role. This subject opened a lengthy discussion regarding supervision, styles of supervision and the peer knowledge of supervision. The group agreed on fundamental processes common to supervision in human service agencies:

•  All workers have supervision meetings on a regular basis
•  Supervision needs to focus on successful completion of the job
•  Supervision recognizes that all employees have unique needs
•  Supervision is a negotiable process
•  Contracted peer workers benefit from joint supervision
•  All workers are supervised at the site of assignment as well as the primary employer
•  Peer life experience provides equitable skills that are relevant to the supervision process
•  Supervision begins with the orientation process

It is often too easy for peers who have long been in one form of therapy or other to view and treat the supervisory relationship as a counseling exercise. Education on self disclosure and boundary issues is important for the peer worker to maintain a level of personal detachment in supervisory situations. Likewise, supervisors of peers need education in the dynamics of peer work that differ from the typical counseling relationship.

Most human service programs are developed around a supervision model. This formula of supervision geared to the needs of the agency, is at times, difficult for the worker who may perceive his or her role based solely on the need of the recipient of services. However, if a peer elects to work in an organized environment he or she must realize that the needs of the agency are relevant to the supervision process, in both the structured peer agency as well as in licensed agencies and other community service agencies. Three dynamics of the supervisory process are often difficult for the peer worker:

1) Dual Roles

Within any human services agency, the supervisory process is oriented to the performance of a given job within the context of agency values, performance standards, outcome expectations, and regulatory compliance. Thus, the supervisor partners with the worker to provide training and orientation as well as ongoing performance appraisal and improvement efforts in order to assist the worker to perform the job as specified by agency purposes, philosophy and policies. Often, the peer worker experiences conflicts between adapting to the human service agency’s performance expectations and personal values for recovery, empowerment and choice - especially when agency approaches appear to be in dissonance with recovery approaches. Thus, the peer worker often perceives him/herself to be in a significant struggle between agency approaches/beliefs and the peer focus on the felt needs of the customer. While it is recognized that all workers must perform to the employer’s standards as a term of employment, supervision must readily elicit peer and non-peer worker concerns with the intent to resolve conflicts and assist the worker to perform against agency standards, as well as assisting the worker to evaluate his/her “fit” with a given job and/or employer, if conflict resolution cannot be achieved.

The sub-committee addressed the dual role of peers working within agencies where they receive services. It was recognized that the benefits and drawbacks of this type of working relationship depends upon the type of service offered. The sub-committee recommends that this be addressed in the policies of each agency.

2) Power

The innate factor of power in supervision models is often the elephant in the room nobody wants to acknowledge. Because of their experience, peers may have learned to be compliant or resistant to persons in authority. The supervisor is generally the person responsible for routine employee performance evaluations which lead to wage and promotion decisions. Misunderstanding of this power on the part of the peer can hinder the objective of professional growth for the worker. When authority is exercised in combination with the abilities to listen, empathize, and employ objective creativity in decision making, it is invaluable to the peer-supervisor relationship. There will always be decisions made that workers do not like or want to adhere to. All employees, including peers are obligated to adhere to agency policy and procedure. The onus is then on the supervisory relationship to enable the peer to utilize the peer skills of honesty, shared experience, creativity and objectivity to fulfill the supervisory expectations.

3) Role Strain

Patricia Deegan introduced the term “role strain” in her writings for peers and supervisors. This is an important dynamic in human service work that is appropriate to the supervision process. The term “role strain” focuses on the role in the workplace, not on the individual. In this context people are able to address work conflicts in a non-personal manner. It allows for solution of problems between workers and leads to establishing boundaries in individual work settings. This can also be interpreted to include “role confusion.” The ideal supervisory process for the peer advocate establishes and supports the clear difference between the counseling role and that of the complimentary role of peer.

B) Support

The group recognized support as both a part of and distinct from non-peer supervision practices. All recognized that support is an integral component of supervision. In addition, the group agrees that the work of the peer based on shared concepts of recovery often, in itself, requires additional support from peer workers or those who are privy to unique circumstances a peer may encounter. The following standards regarding support were agreed to:

•  Support is individualized and provided according to individual needs
•  Support is flexible
•  Support is available on a consistent basis
•  Ideally, support (as separate from supervision) is outside of the work environment
•  Support is easily accessible

Many peers are working in very new situations. Some are employed after long absences from the work environment. Because of these dynamics, peers in workplace settings often express the need for support out of the work environment. The committee concluded early on that peer work is vastly different from that of the clinician’s. This understanding is fundamental for the successful employment of peer workers. Without clear guidelines and support, peers may feel isolated and irrelevant to the work environment. Outside contact rules set for clinicians are often difficult for the peer to maintain due to the interrelation of activities peers engage in. Peers are apt to attend or facilitate recovery groups with people who are or could be recipients of their employers’ services.

Peer work is based on the peer ability to communicate their personal experience in a way that supports, empowers and brings hope to other peers. Licensed or credentialed clinicians are taught that self-disclosure is to be used sparingly, if at all. Although everybody recognizes this importance of the peer experience, this role is frequently minimized.

When asked, peers stressed the importance of having more than one peer in an agency. A local peer run agency has adopted the group support system for its peer team. The group meets with a paid facilitator outside of the agency who is knowledgeable in mental health and peer services. The meeting is away from the work site, creating a safe environment to address workplace issues. No supervisory people attend and no reporting is done except for the numbers attending. The peers rate this process highly.

Self-facilitated work support groups within an agency have not been as successful. It set the facilitator apart from the rest of the group and often became a work “gripe” outlet without resolution to specific individual issues.

IX) Conclusion

Our Western New York area is noted statewide for its comprehensive approach and commitment to the betterment of mental health services. It is the hope of this sub-committee that this report will inform the members of the Erie County Partnership, which will result in better understanding between peers and non-peer providers as they work together. In addition, it is hoped that the contents of the report will serve as a catalyst for action by the leadership of the system of service in Erie County so that recovery can become a reality for all its customers.

We recognize that this is a beginning. Issues remain that require further attention to the roles peer play in the mental health workplace and the community. Some of these are related to supervision of peer employees, a subject on which we spent considerable time. It should be emphasized that all employees need support and supervision to do their jobs, not just peers. But like other types of employees, peers require consideration of their particular capabilities. Proper management of their role is among areas that should be further explored.

As stated earlier in this paper, our task was to promote trust and understanding between peer workers and non-peer providers to clearly understand the roles and responsibilities of participants to achieve a proactive, respectful, and mutually agreeable working relationship. We set guidelines early on in an attempt to create that same atmosphere of openness and trust for this committee. Nevertheless, in our discussions and writings we found our biases peeking through. Through honest engagement and some risk taking, we were able to agree and compromise until we found consensus on important issues and terminology. We never lost sight of the fact that we all work towards increasing life satisfaction for the persons we serve.

X) Acknowledgements and Committee Participants

This document has been prepared with extensive participation from the non-peer and peer service providers and customers of mental health services listen below. First and foremost, our deepest thanks goes to all participants for their knowledge, sharing and respectful approach to difficult topics.

We thank the Lake Shore Behavioral Health staff for contributing the comfortable space and refreshments. A special “thank you” is extended to Mary Senger, who was gracious in responding to all our requests even when they were duplicative.

Housing Options Made Easy donated printing and packaging of our final product which we gratefully acknowledge.

Finally, we would like to thank the Erie County Partnership for giving us this opportunity to deepen inclusiveness within the system of service in Erie County.

Sub-Committee Members: Co-Chairs: Sandra Hooten, Howard Hitzel, Psy.D.