Peer counseling is not new to Kings County Hospital Center (KCHC). In fact, it began more than ten years ago when a former patient—a tireless advocate and pioneer of the consumer mental health recovery movement—was hired as a part-time intern to work on inpatient services. In 2004, through a New York City Health and Hospitals Corporation (HHC) Foundation grant, four peer counselors were hired to function as case managers helping consumers bridge the much-too-frequent gap between acute and after care. Today, there are 22 full-time peer counselors working in inpatient, outpatient, primary care, partial hospitalization, and emergency care services at KCHC. A licensed professional who is also a peer supervises them.
Peer counseling is engagement used not only in mental health, but also in education, substance abuse treatment, and HIV services (Ault, 2006). Peer counselors use their personal experience to provide companionship, compassion and hope; they are ambassadors of empathy, and foster identification between themselves and consumers.
Peer counselors receive training from advocacy organizations and human service programs, and/or have commensurate experience working in a human service field such as teaching or nursing. They also receive additional training at their work site once hired. The scope of their work is extensive. They orient consumers to the service setting and care they will receive; facilitate recovery-oriented groups to improve adult living, coping, and relapse prevention skills; assist consumers in setting meaningful goals and developing action plans. They focus on helping others feel empowered by sharing resources that will connect them with their community after discharge. Peer counselors also convey, in plain, non-clinical language, consumers’ experiences to other staff helping to widen the lens through which traditional providers may have been trained to view people living with mental illness. Above all, peer counselors carry the message that recovery is possible. They are the evidence.
Peers facilitate integration of a recovery model in behavioral health services at KCHC. They exemplify and articulate Guiding Principles of Recovery (SAMHSA, 2011) such as hope, self-determination, personal responsibility, and person-centeredness. They play a crucial role in preparing consumers for and representing them in treatment and aftercare planning. Several processes have been created to ensure the inclusion of peer input. The Patient Assessment and Goals PAG) form, for example, is a document that is completed by a consumer prior to his or her treatment-planning meeting. Peer counselors assist consumers, making themselves available to advocate during treatment team at the consumer’s request. Their input in the treatment process illustrates one of several inherent paradoxes they experience being both advocate and team member. This dichotomy also suggests that one does not become a peer counselor simply to have a job; rather, it is a calling. People are driven to do this type of work because of a deep passion to help others believe in themselves.
Studies indicate consumers who receive peer support experience fewer hospitalizations, use fewer crisis services, reduce their substance abuse, and improve their employment outcomes. Their social functioning and quality of life improve more when compared to those who only receive professional services (Besio & Mahler, 1993; Solomon & Draine, 2001; Ault, 2006: Kling, Dawes, & Nestor, 2008; Sledge, Lawless, & Sells et al., 2012). In addition, peer support encourages participation in treatment by helping consumers counter loneliness, rejection, discrimination, and/or frustration they may feel when dealing with the mental health care system (Deegan, 1992; Solomon, 2004). Having this unique role can also have a positive impact on the recovery of the peer counselor (Anthony, 2000; Solomon, 2004). Through participation in this work, peer counselors can experience an increased sense of self-efficacy, empowerment, and healing (Akabas & Gates, 2007; Solomon, 2004).
As an employer of one of the largest hospital-based peer programs nationally, KCHC has begun to explore the effectiveness of using peers added to traditional providers in service delivery. This is a challenging process that requires leadership to often revisit ideas about the work of peers and its impact on both perceptions about recovery as well as treatment outcomes. Despite descriptions of the work done by peers, demonstrating their effectiveness is a process that eludes quantification and measurement. Research is limited in terms of linking peer services with treatment outcomes. Many studies are descriptive and reveal great variability of services provided by peers and the programmatic structures within which they operate. In addition, definitions of terms used to describe these services have not been standardized. Categories describing peer services include consumer-operated services, peer support, mutual support, and self-help, to name a few (Campbell, 2005; Solomon, 2004).
Despite the variability in models and terminology, there are some commonalities among peer support models. Most peer-provided mental health services believe that consumers can benefit from interacting with people who have themselves experienced similar difficulties, and who have learned to cope with them and found reasons for hope for the future. Peer services are founded on core values such as empowerment, taking responsibility for one’s own recovery, the need to have opportunities for meaningful life choices and the valuation of lives of disabled people as equal to those of people without disabilities (Resnick & Rosenheck, 2008).
In 2012, KCHC presented “Developing Metrics to Measure Effectiveness of Peer Counselors Working in Acute Care Settings: A First Look” at both the American Psychiatric Association (APA) Institute for Psychiatric Services (IPS) in October, and at the Sixth Annual NYC Peer Specialist Conference in July. In addition to providing national and organizational contexts for integrating a recovery model including the use of peers, peer counselors and department leadership discussed the development of KCHC’s peer program and highlighted their work; the psychosocial processes that underpin this work; tools created to capture and categorize this work; and metrics established to measure consumer satisfaction as well as knowledge and integration of recovery principles among staff. These preliminary steps helped create operational definitions for such variables as consumer satisfaction, engagement, empathy, and hope.
The uniqueness of the peer role is premised on their willingness to publicly disclose their lived experience using mental health services. Recovery knowledge and experience, empathy, and role modeling are some of the core skills required of peer counselors. Recovery, notwithstanding its myriad definitions, requires change. Peer counselors frequently talk about how stigma has affected them. However, they also talk about setting goals that are meaningful and help them move beyond discrimination that often accompanies the illness experience. Growth requires disavowing the illness paradigm constructed by institutions, family members, and society as a whole. What could require greater change? Peers must not only embrace this message, but convey it to others seeking recovery. Peers provide evidence that recovery requires change and that change is possible.
There is an unparalleled therapeutic boundary between peers and consumers with whom they work. When engaging consumers using disclosure of personal recovery experiences, peers must constantly monitor their identification with, and tendency to react to people they are helping. Supervision can be an ideal forum to explore countertransference often experienced by peers who frequently relive or are retraumatized by hearing about or seeing a consumer’s experiences. Having insight into one’s own recovery is also necessary to understand how this work impacts personal recovery. Helping others requires a rigorous application of self-care.
Empathy is one of the greatest assets any human service worker brings to the table. Peers in particular relate to those they work with by listening attentively and putting themselves in the other person’s shoes. Although peers may not have experienced the same situation as someone they are engaged with, they identify with the feelings associated with feeling hopeless, disenfranchised, abandoned, and traumatized. The ability to meet a person where they are and offer conditional regard is a skill associated with peer workers (Rapp & Chamberlain, 1985). Peers role model using recovery-oriented language that helps other staff understand the power language holds. This helps reduce stigma through education about how words impact a person’s self-esteem and belief about their ability to set goals, live a meaningful life, and recover in a manner that is self-defined.
“Tools of the Trade”
Paradoxically, peer counselors contribute to consumers’ treatment and recovery experience in ways that are both visible and intangible. Hence, leadership within the Division of Wellness, Recovery, & Community Integration created in collaboration with peer counselors tools to capture, describe, and quantify their work: Activity logs document service provision in four areas including individual and group engagement, treatment planning, and other activities that support consumer care; Weekly orientation tracking reports capture the detailed process conducted with newly admitted consumers consisting of eight domains ranging from understanding the milieu to learning about advance directives; Patient Assessment and Goals (PAG) forms foster empowerment by helping consumers identify goals and concerns prior to attending treatment team meetings; Peer-run groups address such topics as advocacy, goal setting, ambivalence, conflict resolution, and crisis and aftercare planning; Counseling and collaboration with other team members optimizes aftercare planning and identifies appropriate community resources, as well as exemplifies “out-of-the-box” thinking rather than pathologizing when it comes to addressing consumers’ concerns and discomforts.
Consistent with the literature on peer engagement, trends commonly identified are that peer counselors help consumers recover by providing hope, showing empathy and conditional regard, and fostering identification. They help change organizational culture by promoting recovery in attitude and practice. Peer Counselors support their personal recovery by helping others. They provide evidence that recovery is real. They are the evidence.
In response to nine statements relating to the impact peer counselors made on consumers’ level of engagement, sense of empowerment, and presence of hope, consumers reported during a six-month period that peer counselors often made a positive impact on their hospital stay in numerous ways (N=290; 85-90%). The vast majority of non-peer staff agreed with eleven statements relating to visibility, integration, and perceived effectiveness of peer counselors working on six adult inpatient units (N=120; >90%).
As we continue to move forward we look for ways in which to expand, professionalize, and refine the role of the peer counselor at KCHC. The peers on the inpatient units have recently begun documenting in the electronic medical record, giving them an additional venue to communicate their work with consumers to the other members of the treatment team; solidifying their role as an interdisciplinary team member.
Performance metrics are vital in healthcare. All disciplines work closely with quality management to create and track competency and performance from both a quantitative and qualitative perspective. We have recently created a supervisory review that allows us work closely with the peer counselors on areas at which they excel, and to identify and guide supervision around areas of struggle. As the peers move forward with documenting their work, we will move toward a peer chart review, where they can continue to support and learn from each other.
Leadership is also looking for new avenues in which to incorporate the role of peer counselor. At KCHC there are 6 adult inpatient units. One of the most important times in a consumer’s care continuum is immediately following discharge. The transition from an inpatient setting back to the community is often quite difficult. KCHC is looking to utilize the role of the peer counselor during this transition. The linkage of consumers with a peer is a normalizing intervention that can help ease the transition from the highly structured inpatient setting, providing supportive bridging that is accepting and empowering.
It is the responsibility of leadership to create opportunities for peer counselors to grow both in the role as a peer (creating a supervisory structure), as well as in other areas of services within the hospital setting. Many of the peer counselors have moved into other roles, specifically within the social work department at KCHC. Education is also encouraged with all staff, and many peer counselors are enrolled in college as well.
Peer counselors have a positive impact on consumers in various settings throughout the hospital, helping them recover by letting then know that they have been there. They are “ambassadors of empathy” and agents of change, by helping change the culture of the institution. They do this by promoting recovery in attitude and practice. Peer counselors provide evidence that recovery is real, because they are the evidence. Most importantly, they maintain their own recovery by helping others.
We wish to acknowledge Joyce B. Wale, Sr. Assistant Vice-President, HHC Central Office of Behavioral Health for her vision and support of integrating peers in HHC’s Behavioral Health workforce; Dr. Joseph P. Merlino, Deputy Executive Director, Behavioral Health Services, KCHC; and Behavioral Health Services overall, with whom we collaborate to further advance a Wellness and Recovery model benefitting both consumers of care and staff.