With the introduction of Managed Behavioral Health Care in October of 2015 and the soon to be implemented Home and Community Based Services (HCBS), engagement of “peers” in the workforce has become a topic of considerable interest. HCBS introduces peer support as a Medicaid billable service giving organizations a financial interest in providing the service. In order to provide billable peer support, an organization must be formally designated to do so under HCBS, peer staff must be certified, and the scope of billable practice is defined by CMS. A peer is loosely defined as someone who has the lived experience of being a recipient of mental health services and/or someone who has been given a psychiatric label. The introduction of peer support as a billable service has the potential to mark progress in the delivery of mental health services. This potential will be compromised, however, if provider agencies are not able to absorb the distinct values, ethics, and intent of peer support as an alternative to traditional approaches to care delivery.
Peer support for people with psychiatric diagnoses is an evidence-based practice that has been demonstrated to improve quality of life outcomes for people who receive mental health services. While peer support has been a part of substance use recovery for some time, it has not been as quick to gain traction among many traditional mental health service providers. Peer support in mental health should be transformative for people and for systems. Drawing from the wisdom of Intentional Peer Support (IPS) developed by Sherry Mead, genuine peer support “doesn’t start with the assumption of a problem. With IPS, each of us pays attention to how we have learned to make sense of our experiences, then uses the relationship to create new ways of seeing, thinking, and doing” (www.intentionalpeersupport.org). Certified Peer Specialists thus have the potential to introduce a radically different approach to those experiences that non-peer providers see as barriers to mental health.
In part, Certified Peer Specialists help service-users develop the skills and confidence to advocate for themselves in a system that often works against their chosen interests. Certified Peer Specialists may advocate on behalf of service-users to ensure that they receive proper informed consent, participate in shared-decision-making, and receive truly person-centered care in an atmosphere that can too often dismiss these as unimportant. Certified Peer Specialists are ethically prohibited from either encouraging or discouraging people around issues of medication. It is not appropriate for providers to ask a peer support specialist to assist in this task. It is crucial as peer support becomes an integral part of mental health service delivery that organizations understand both the values of peer work, the Code of Ethical Conduct by which they are expected to abide, and ideally the history of peer work. Job descriptions should reflect the particular skills and contributions peer support specialists offer. All of this being in place, peer support is positioned to truly improve the quality of services on offer in mental health care.
As peer support finds a home under HCBS, it is critical that non-peer providers understand that peer support offers a path to recovery from trauma incurred in systems of care that are often alienating and stigmatizing as much as it offers recovery support from psychiatric distress itself.
This requires non-peer providers to consider what role systems play in constructing and sustaining illness rather than recovery. It may require non-peer organizations to rethink the way care is delivered and structured. For Community Access taking the peer perspective seriously has meant transforming an entire organizational culture.
At Community Access the value of a person’s experience in systems of care is taken seriously, and for over 20 years, the organization has actively sought to develop a workforce with the goal of becoming 51% “peer.” What this means at Community Access moves far beyond common understandings of peer work particularly as it is defined under HCBS.
At Community Access, service-user experiences and perspectives are represented at every level of organizational structure from executive staff and senior management through direct service providers. This creates a culture that is sensitive and responsive to the needs of our tenants and program participants in a way not accessible when the voices of service-users are absent. There are very few peer specific positions, functionally eliminating the distance between peers and non-peers. Moreover, all direct service staff receive core training that is peer-informed, reducing stigma and common misperceptions about what it means to be a service-user.
Building a behavioral health workforce that employs service requires an evaluation, and sometimes an amendment, of organizational policies and protocols that may place barriers to the employment of people who have been or continue to be service-users.
At Community Access, respect and value for service user experiences is written into the organization’s mission statement which explicitly states, “We are built upon the simple truth that people are experts in their own lives.” Human rights, peer expertise, self-determination, harm reduction, and healing and recovery are the central organizational core values. Living into this commitment begins when a person applies for a job and continues throughout an employee’s training and work tenure. Regardless of position – whether or not a particular job is designated for a peer – regard for service-user experiences is taken seriously. Several mechanisms exist to ensure this attitude permeates organizational culture.
Central to building a workforce that incorporates service-user perspectives is a robust Human Resources department that recruits, hires, and retains people with diverse experiences. This includes removing barriers to employment for people who have experienced incarceration, homelessness, poverty, trauma, etc. This may require eliminating some educational barriers. It means understanding how to assess for lived experience during an interview while respecting legal limits. It means establishing organization-wide policies and protocols that make workplace accommodations available to all employees. It means assuring that all employees receive regular and quality supervision and support. Perhaps most of all, it requires flexibility and continued conversations between Human Resources and organizational leadership. Human Resources departments, however, cannot singularly sustain an atmosphere that welcomes and highly regards service-users in the workforce. Organization-wide training is essential.
At Community Access, all direct service employees receive the organization’s core training. This core training is designed and delivered by peers and non-peers. It supports new workers as they learn to implement the organization’s mission and values into their day to day work (including peer expertise). Core training extends for approximately 20 sessions and covers topics such as Committing to the Work and to Ourselves, Developing Ethical and Supportive Relationships, Mental Health, Healing and Recovery, Self-Determination, Trauma-Informed Services, and Working with Individuals in Extreme States and Crisis. The training department also hosts open workshops on topics of interest to which all employees, tenants, and program participants are invited. Continuing training framed around the organization’s mission and values helps to sustain a work culture that learns, grows, and succeeds because of the added-value of employee lived experiences.
Establishing a culture that fully incorporates the service-user experience and perspective places a demand on organizations to look carefully at their own culture, policies, and programs. A strong Human Resources department and training arm are necessary, but not sufficient. Organizational culture must be open to change, from the leadership through direct service providers. Community Access has made this transition over time and has become a more effective provider as a result.
The goal of mental health services ought to be supporting people in the processes of personal recovery. Supporting recovery requires that mental health providers reduce system-induced trauma, stigma, and alienation. It requires giving respect and consideration to the voices and wisdom of those who have lived experience of both the mental health system and psychiatric struggles. It means giving those who have had such experiences a seat at the table. In the end, peer support is underwritten by values that respect the humanity and personhood of peers and non-peers alike. Peer values, at their core, are human values. Too often, however, people receiving mental health services are not offered these basic values, a consequence perhaps of the inevitable impersonal logic of systems. Re-establishing these values and overriding systems logic requires a committed human effort. The introduction of peer support under HCBS provides an opportunity to engage this effort. Non-peer providers can choose to take advantage of this opportunity to transform the very ethos of mental health service delivery. The decision rests on how seriously non-peers take the personhood of people who are currently in psychiatric crisis or who have experienced such a crisis and moved through it.
While billable peer support under HCBS is a particular service with a fairly narrow scope of practice, mental health service providers can choose to engage peer perspectives more fully. Doing so does not undermine services already offered; it improves current best efforts to support people in personal recovery. Working together, peers and non-peers can better achieve New York State’s Medicaid Redesign Goals that mirror the triple aim of improved quality, lower per capita costs, and better population health. The beginning step in working together, however, is not building a peer workforce; it is acknowledging the deep absence and need for such a workforce in the first place.