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National Coalition for Mental Health Recovery | NCMHR

Growing Evidence Points to Peers Directly Affecting Client Outcomes

Mental Health Weekly February 15, 2010

While peer support services generally have been seen as a pivotal element in recovery-focused mental health programming, much of the formal research into the services has focused simply on the presence of peer support staff and their level of training. Now mental health facilities that have prioritized peer involvement have begun to probe peers’ actual effects on consumer outcome, and are finding that their ability to establish an alliance with clients is yielding results that would be the envy of some trained professionals.

At next month’s National Council for Community Behavioral Healthcare conference in central Florida, the chief of clinical services at Southwest Behavioral Health Services in Arizona will offer two presentations on his agency’s experiences in integrating peer support services over the past decade. In adapting a consumer satisfaction instrument originally designed to evaluate mental health professionals’ recovery orientation, Southwest recently found that 94 percent of its peer workers surpassed standard levels for recovery promotion.

“We view the involvement of peers as integral to the recovery journey,” Bob Bohanske, Ph.D., told MHW. And to indicate the seamlessness of this integration in his agency, Bohanske explained that these workers with a mental illness history are not referred to as “peers” at Southwest — they are “recovery support specialists,” a title adopted after the workers demanded that they not be stereotyped as a group.

Southwest’s Experience

Bohanske explained that Southwest Behavioral Health Services, which operates in Maricopa County and several other Arizona counties, began developing peer services a bit before various funding sources started to request their presence. He said that the agency generally looks for individuals who have the personal skills necessary to establish a meaningful relationship with a client, and he warns that a mental health diagnosis and peer training alone do not guarantee a successful recovery support specialist.

“We look for people who are people-oriented, who are willing to view things in a strengths-based fashion,” Bohanske said. “They need to look beyond the person as a diagnosis and instead as someone capable of making change.”

In essence, Bohanske said, the agency looks for the same qualities in its recovery support specialists as it does in its trained mental health professional staff. The only difference in the hiring process lies in the checking of credentials, and the lines are blurring even there as more peer workers pursue certifications through groups such as the United States Psychiatric Rehabilitation Association (USPRA), he said.

In an attempt to more closely examine the true effects of its recovery support specialists’ work with consumers, Southwest set out to measure consumers’ perceptions of their interactions with these individuals. The agency used for this purpose an instrument developed by one of the nation’s leading authorities in psychiatric rehabilitation, William Anthony, Ph.D., of Boston University. It adapted the instrument, originally designed to measure mental health professionals’ recovery-affirming activity, and found that the vast majority of clients said their recovery support specialist had a recovery-promoting effect on them. (Bohanske will present these results at the National Council meeting; they have not yet been published.)

Looking deeper into the components of the recovery support specialists’ activity, Southwest found that the most telling quality was their ability to forge a relationship with the consumer. While Bohanske says the work of recovery support specialists “clearly still flies in the face of some of the traditionalists,” findings such as these actually reinforce an emerging truth in both the mental health and addiction service fields — that the relational issues between worker and client are many times more important to outcome than the method of “treatment” used, he said.

Bohanske added that his agency has found that the two biggest predictors of success in a peer-consumer relationship are mutually agreed-upon goals and the peer’s availability. Bohanske said Southwest Behavioral Health generally has seen the most success in integrating its recovery support services for clients in its “semi-independent living” settings.

These are apartment complexes for individuals with mental illness who need some assistance with activities of daily living or socialization but don’t necessarily require that those services be delivered by mental health professionals. He said the agency has had less success with placing recovery support specialists in inpatient or crisis stabilization settings, areas that require a different skill set.

Southwest also has seen some variation in the degree to which the counties where it does business emphasize various aspects of peer support. In some of the more rural counties, regional behavioral health authorities (RBHAs) want to see a defined percentage of overall services delivered by peers, whereas in Maricopa County the emphasis has been more on development of peer run organizations.

Peer-Run Agencies

At the same time that community behavioral health organizations are integrating peer activity into their operations, organizations run solely by peers are becoming more influential in the mental health system as well.

Also at next month’s National Council meeting, the executive director of a New York-based organization that has been in existence since the early 1990s will relate his experiences with a movement that now is having an international reach.

PEOPLe, Inc. (the acronym stands for Projects to Empower and Organize the Psychiatrically Labeled) establishes working relationships with mental health agencies, operating in a six-county area in the Hudson Valley. One of its signature projects is the four-bed Rose House crisis diversion program serving Orange and Ulster counties.

Executive director Steve Miccio told MHW that this alternative to hospitalization was not receiving much attention a decade ago, but now community providers are referring clients in crisis to the home.

“They can stay one to five nights free and receive wellness tools and peer support,” said Miccio, who described the home as having the feel of a bed and breakfast inn. State mental health dollars financed the Rose House project. PEOPLe, Inc. is developing a similar site in Putnam County, and Miccio also is involved in projects in Nebraska and overseas in the Netherlands.

With more monies shifting to peer-run services in recent years, Miccio said the mental health provider community has begun to pay more attention. He said he will try to emphasize potential partnerships between peer-run organizations and mental health provider agencies in his comments at the National Council meeting. “It’s important not to look at it as us vs. them,” he said.

Asked why he got involved in such pursuits in the first place, Miccio immediately replied that it was because he got sick, got hospitalized (in his 30s), and got angry at how he was treated.

“I was diagnosed with bipolar disorder, and nobody in the hospital told me what the diagnosis meant,” he said. “They didn’t explain the medications they were giving me, and they sure didn't talk about recovery."

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