An increasingly common workforce issue is preparing “traditional” providers for working beside peer providers, that is, individuals with the lived experience of mental health issues. SAMHSA (Substance Abuse and Mental Health Services Administration) defines a peer provider as “a person who uses his or her lived experience of recovery from mental illness and/or addiction, plus skills learned in formal training, to deliver services in behavioral health settings to promote mind-body recovery and resilience” (SAMHSA, 2013). The use of peer specialists in different roles and different settings has been growing steadily especially since 2001 when Medicaid made peer services billable under Medicaid rules (Daniels, Grant, Filson, Powell, Fricks, and Goodale, 2010).
To be sure, the existence of peer providers predates, by far, the 2007 CMS memo that laid out the Medicaid billing rules (Smith, 2007) and we saw a rapid expansion of peer specialist services. However, until this point the services provided had been primarily volunteer and outside the realm of “traditional” services. Now we were seeing the professionalization of peer providers within the traditional system of services (Chapman, Blash, and Chan, 2015). As Chapman, Blash and Chan (2015) also noted, stigma continues to be an issue impacting the hiring and acceptance of peer workers in traditional treatment programs. However, properly leveraging the lived experience of peers will help define their role in the program and assist with the integration of peers onto the treatment team (Resources for Integrated Care, 2015a).
The burden is necessarily on the mental health program to create an environment which aids the integration of peer providers into the workforce. The most common barrier to the use of peer specialists was the acceptance of the positons within traditional mental health centers (Daniels, Grant, Filson, Powell, Fricks & Goodale, 2010). In 2009 at the Pillars of Peer Support Services Summit, one of the pillars that was identified was “a Comprehensive Stakeholders Training Program that communicates the role and responsibilities of Certified Peer Specialists and the concepts of recovery and whole health wellness to traditional, non-peer staff (peer specialist supervisors, administration, management and direct care staff) with whom the Certified Peer Specialists are working” (Daniels, Grant, Filson, Powell, Fricks, and Goodale, 2010). The call for training recognizes acceptance as the most significant barrier to the peer specialist workforce.
The organization intending to hire peer specialists must also have a strong philosophy of recovery without which may not have the “attitudinal and structural supports to successfully employ peers/coaches in their workplace” (SAMHSA, 2012). These strong principles of recovery are essential for integration of peer supports into the service array. Likewise, a strong program commitment is necessary for the transformation of service delivery to include a peer support component.
At the fourth annual Pillars of Peer Support conference three years later, there was still a call for “creating recovery cultures that support peer specialists” (Daniels, Tunner, Bergeson, Ashenden, Fricks, Powell, 2013). At the sixth annual conference two years later, conference participants began prescribing supervisory roles for the integration of peer specialists into the workforce. The conference monograph found “A key element of peer specialist supervision is to create a supportive and stimulating environment where the job role and expectations of the peer specialist are open to collaborative discussion” and that “The peer specialist’s supervisor should also be an advocate and should convey the importance of the peer specialist’s roles with human resources and others in the organization” (Daniels, Tunner, Powell, Fricks, Ashenden, 2015).
As we have said, the burden is necessarily on the mental health program to create an environment which aids the integration of peer providers into the workforce. The Dimensions: Peer Support Program Toolkit (Morris, Banning, Mumby & Morris, 2015) organization assessment makes it clear the responsibility falls to the mental health program with questions such as: • Is your leadership team in support of implementing a peer support program?
- Is a peer support program consistent with your organization’s mission and values?
- Does your organization have identified champions of peer support?
- Do the benefits of implementing of a peer support program at your organization currently outweigh the perceived barriers?
Support from leadership and identification of peer support champions will both be crucial to paving the way for successful integration of peer specialists to the workforce. Typical concerns include whether peer specialists may relapse, whether they have the requisite skills and experience, and a perceived risk that peer specialists may supplant other team clinicians (Morris, Banning, Mumby & Morris, 2015). Only leadership from the top can impart the clear message that the organization is fully committed to integrating peer specialists and receiving the expected benefits of doing so. Only then can
the champions smooth the path for full integration.
Tips to Reduce Negative Attitudes Faced by Peer Support Staff (Resources for Integrated Care, 2015b) also made clear the expectations of the mental health program with its key considerations:
- Recognize that people can be both clients and providers
- Identify stigma in your organization
- Prepare your organization
- Develop a plan to train and educate peer support staff and supervisors
- Create an inclusive culture
- Ensure effective supervision
Again, these steps need to be initiated by leadership and receive implementation support from the peer support champions.
Supervision of the peer specialist is also crucial to success. The role and services offered are different from any other position on the clinical team. The peer specialist is expected to form a mutual relationship- ordinary clinical boundaries do not apply (Hendry, Hill & Rosenthal, 2014). The peer specialist role is different from any model that programs may attempt to fit it into. A peer specialist is not delivering case management or functional support services. They are delivering a level of support that can only be classified by what it is- peer support. It is essential that team members understand this key difference in roles.
It can also not be avoided that there will be some stigma attached to the idea of peer specialists. It is the role of leadership to educate and supervise the other team members to help them grow beyond this. Coaching is the preferred method of supervision (for all staff) as it best communicates the strengths of peer support and concepts of recovery. It is essential that the entire treatment team understand what is required for the implementation of recovery-based services (SAMHSA, 2005). Matthew Federici said that training of peer specialists “places a large focus on preparing the environment to employ them in ways that transform the behavioral health system to be more recovery-oriented” but the same can be said of supervision.
Indeed, peer specialists have said that lack of strong supervision tends to reduce the “peer-ness” of their role as they find themselves identifying with the clinical staff to secure some level of support (SAMHSA, 2012). When peer receive the strong supervision required of this model of services they “are able to stay faithful to and engaged in their peer roles (SAMHSA, 2012). Drifting from the peer role into the realm of the other professionals usually creates role confusion and competition which unbalances the entire team.
Another concern expressed by peers regarding supervision is uncertainty about their own success. The unclear nature of the peer role and perhaps even unclear job descriptions make it difficult for peer specialists to judge on their own how well they are doing. This is where strong and consistent supervision is crucial to providing that feedback so the peer specialist remains comfortable as they work toward defining their role. Ideally, there is supervision by another peer or other arrangements for peer-to-peer support.
The evidence base for effective peer support is growing in leaps and bounds but effective peer support requires effective supervision and organizational support. With these in place, the peer specialist and the mental health program are both positioned for greater success.
Building a Foundation for Recovery: A Community Education Guide on Establishing Medicaid-Funded Peer Support Services and a Trained Peer Workforce. DHHS Pub. No. (SMA) 05-8089. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2005.
Chapman, S., Blash, L., and Chan, K. (2015). The Peer Provider Workforce in Behavioral Health: A Landscape Analysis. San Francisco, CA: UCSF Health Workforce Research Center on Long-Term Care.
Daniels, A., Grant, E., Filson, B., Powell, I., Fricks, L., Goodale, L. (Ed), Pillars of Peer Support: Transforming Mental Health Systems of Care Through Peer Support Services, www.pillarsofpeersupport.org; January, 2010.
Daniels, A. S., Tunner, T. P., Bergeson, S., Ashenden, P., Fricks, L., Powell, I., (2013), Pillars of Peer Support Summit IV: Establishing Standards of Excellence, www.pillarsofpeersupport.org ; January 2013.
Daniels, A. S., Tunner, T. P., Powell, I., Fricks, L., Ashenden, P., (2015) Pillars of Peer Support VI: Peer Specialist Supervision. www.pillarsofpeersupport.org; March 2015.
Hendry, P., Hill, T., Rosenthal, H. Peer Services Toolkit: A Guide to Advancing and Implementing Peer-run Behavioral Health Services. ACMHA: The College for Behavioral Health Leadership and Optum, 2014
National Mental Health Consumer’s Self-Help Clearinghouse. Focus on certified peer specialists. Retrieved at: www.mhselfhelp.org. 2010.
Resources for Integrated Care. Leveraging the lived experience of peer support staff in behavioral health. www.ResourcesForIntegratedCare.com. 2015.
Resources for Integrated Care. Tips to reduce negative attitudes faced by peer support staff. Retrieved at: www.ResourcesForIntegratedCare.com. 2015.
SAMHSA. Equipping behavioral health systems and authorities to promote peer specialist/peer recovery coaching services. Expert Panel Meeting Report. 2012.
SAMHSA-HRSA Center for Integrated Health Solutions. Who Are Peer Providers?, <http://www.integration.samhsa.gov/workforce/peer-providers> (2013).