Introduction

Philadelphia’s Transformation to a Recovery-Oriented System of Care

The City of Philadelphia leads the country in the development of a Recovery-Oriented System of Care for persons with behavioral health conditions and/or intellectual disabilities. The transformation to a resilience and recovery orientation has taken place on many different levels in many different ways throughout this system, and for more information about this overall process, the reader is referred to XX. In addition, readers who wish to learn more about the broader, national context in which transformation continues to evolve, and the service user movements in both mental health and addiction that shaped this agenda, may be interested in viewing a brief video of Philadelphia’s own Joseph Rogers speaking from his experience as one of the founders of the mental health consumer/survivor movement at: . Information about the New Recovery Advocacy Movement in addiction can be found in a number of formats on William White’s website at: .

An advocate whose personal experiences and frustrations with the mental health care system helped propel the field’s consumer movement, Joseph Rogers has provided impassioned, visionary leadership in transforming mental health care in this country for decades. Diagnosed with paranoid schizophrenia at age 19 and told that he was incapable of holding a job, Mr. Rogers descended into a life of homelessness and desolation until he eventually found treatment and a place to stay at a YMCA. After fate led him to a job as an outreach worker, he moved to Philadelphia, where he began work in 1984 at the Mental Health Association of Southeastern Pennsylvania (MHASP), then a small non-profit agency with a dozen staff members. Over the last 20 years, he has helped transform MHASP into a $14-million organization with 300 staff, the majority of whom are in recovery themselves. He is now their Chief Advocacy Officer.

One central component of Philadelphia’s ROSC that is still very much a work in progress involves the provision of peer support by persons in recovery from mental health and/or substance use conditions. This toolkit was developed to assist agencies and organizations in the process of preparing for, recruiting, retaining, and effectively deploying these persons as behavioral health staff to serve a variety of functions that will be described below.

In order to orient the reader, this Introduction will describe the central role of peer support in recovery-oriented systems of care, offer a brief overview of the history of this form of service delivery and the various organizational forms in which it can be delivered, and discuss the purpose and scope of this toolkit. We then will guide the reader through five modules that cover the range of tasks involved in the integration of peer staff in behavioral health programs. An Appendix follows with useful examples of policies, sample job descriptions, and other tools.

The Central Role of Peer Support in Recovery-Oriented Systems of Care

Whydoes peer support play such a central role in recovery-oriented systems of care? For at least the following three reasons:

  • First, mental health and substance use conditions are stigmatized in our society and persons with these conditions have been discriminated against as a result. Some of the effects of these negative attitudes have been feelings of hopelessness, despair, and helplessness in persons with behavioral health conditions and their families. Against this backdrop of misinformation, pessimistic prognoses, and destructive stereotypes, peer staff provide invaluable, concrete proof of the reality of recovery. They instill hope that recovery will be possible and demonstrate to persons with behavioral health conditions, their loved ones, and behavioral health practitioners alike that it is decent, caring, and worthwhile (i.e., ‘normal’) people who experience psychiatric and substance use conditions and who, with sufficient and appropriate support, recover from them as well.
  • Second, in part due to the stigma and misinformation described above, the majority of persons with behavioral health conditions do not seek or receive behavioral health care in a timely or effective fashion. While only one out of three persons with a serious mental illness will access specialty mental health care, only one out of seven with an addiction will access specialty substance use treatment. As living and breathing examples of recovery, peer support staff can attest to the utility and effectiveness of treatment, rehabilitation, and support. They have been found to be very effective in engaging people into care who otherwise would not chose to access it, acting as a bridge between distrusting persons in distress and what many people have seen in the past as an impersonal, imposing, and unresponsive system.
  • Third, by virtue of their own life experiences, peer support staff will have learned many valuable lessons about how to access and use behavioral health care and how to manage and overcome behavioral health condition(s) that enable them to act as role models for persons just entering into, or early in, their own recovery. They will have learned how to navigate the health and social service systems in their community, how to advocate for getting their needs met within behavioral health programs, and how to overcome the stigma and discrimination described above. In addition, they will have learned ways of managing, living with, and recovering from their own behavioral health condition(s). This experiential knowledge complements the clinical and technical knowledge that practitioners acquire in their training and practice, and offers valuable assistance, especially to persons struggling to contend with conditions that respond in only limited ways to existing treatments.

For these reasons and more, peer support has come to play a central role in the transformation of behavioral health to recovery-oriented systems of care and will likely continue to do so for the foreseeable future. Even when stigma and discrimination no longer exist and access to behavioral health care has been rendered uncomplicated, timely, and responsive, peer staff will likely continue to serve the all-important role of sharing their experiential knowledge of recovery and teaching, encouraging, and role modeling effective self-care.

A Brief History of Peer Support in Behavioral Health

How longhas peer support been available within the behavioral health field? Many people think that peer support is a relatively recent development within behavioral health, emerging from the Mental Health Consumer and New Recovery Advocacy movements in the early 1990s. The origins of peer support can actually be traced back much further, though, to the beginning of both of the disciplines of mental health and substance use.

In mental health, records indicate that a primary mechanism for the development of “moral treatment” by Philippe Pinel and his colleagues in France in the late 18th Century—at the birth of psychiatry—was the hiring of recovered patients to staff the new moral treatment asylums or retreats. This strategy was chosen to ensure that the hospital staff were respectful, humane, and compassionate in their treatment of the patients, who, prior to this advance, were shackled in chains and periodically beaten into submission. This strategy was chosen again in the early part of the 20th Century by Harry Stack Sullivan, a founding father of American psychiatry, when he hired persons who had recovered from acute psychotic episodes to staff his programs. Peer support then played a central, if implicit, role in the therapeutic milieu models of inpatient and day hospital care through the 1970s, although in this case the peers were not paid for their contributions to each others’ recovery (which were considered part of their own treatment).

Since the early 1990s, peer support has emerged in its contemporary form in mental health and has virtually exploded across the country, with the number of peer staff in mental health programs reaching the tens of thousands. Peer staff fulfill a variety of roles and serve numerous functions in these programs, from providing traditional services (such as case management or residential support) to offering entirely new services (such as teaching people how to use Wellness Recovery Action Plans). Research conducted on the services and supports provided by people in mental health recovery has been consistently positive, providing evidence that peer support can engage people effectively into care, can enhance the role people play in their own care, can instill hope and a sense of self-confidence, can decrease substance use and despair, and can increase self-care and satisfaction in a number of life domains, including social support (Davidson, Bellamy, Guy, & Miller, 2012). As a result of this research, the Centers for Medicare and Medicaid recognize peer support as an evidence-based practice that can be reimbursed.

There has been a similar history in the substance use field. While the “New Recovery Advocacy Movement” is a relatively recent developmentin the addiction field, earlier forms of peer support by and for persons with addictions have existed at least since the early 1800s. William White’s (1998) record of these forms of peer support include the Washingtonians (1840s); temperance missionaries (1840s–1890s); fraternal temperance societies (1840s–1870s); ribbon reform clubs (1870s–1890s); Drunkard’s Club (1870s);aides and managers of inebriate homes (1860s–1900); Keeley Institute physicians (1890–1920); ‘‘Friendly visitors’’ at the Emmanuel Clinic in Boston (1906); lay alcoholism psychotherapists (1912–1940s); United Order of Ex-Boozers (1914); Alcoholics Anonymous (AA; 1935); managers of ‘‘AA farms’’ and “rest homes’’ (1940s–1950s); halfway house managers (1950s); and “para-professional’’ alcoholism counselors and professional ‘‘ex-addicts’’ (1960s–1970s).

In its contemporary form, recovery coaching in addiction, as well as a number of other peer-run programs and organizations, build on this rich history to provide an important complement to existing substance use treatment programs. Peer recovery support can be provided as an effective bridge into treatment, as a potent augmentation to treatment, and as a valuable post-treatment resource that enables people to maintain the gains they have made in care, thus helping people to initiate recovery, achieve recovery, and sustain recovery over time. Especially through the U.S. Center for Substance Abuse Treatment’s Access to Recovery initiative, peer-delivered recovery support services have proliferated throughout the country over the last decade and have found an especially warm welcome in the City of Brotherly Love. Rather than targeting substance use, triggers, or relapse directly (as in treatment), these services aim to increase a person’s recovery capital (see below) so that he or she will have the motivation, support, and skills needed to develop and maintain a commitment to long-term recovery.

Recovery capital refers to the combination of external and internal resources that a person can access in initiating, pursuing, and sustaining his or her recovery. In addition to money, a home, transportation, food, and clothing, recovery capital include hope, faith, motivation, self-confidence; participation in meaningful activities; having a valued social role and a sense of belonging within a community of one’s peers; and having supportive social relationships with extended family and other caring people. While all of these factors have been known for a long time to improve a person’s chances for recovery in both mental health and substance use conditions, only more recently have behavioral health services begun targeting increases in these factors in addition to targeting the reduction of symptoms, impairments, or substance use.

Various organizational forms for developing peer support

Peer supportcan be provided in a variety of ways using a variety of organizational forms. In general, these forms fall into three major categories: 1) peer-run organizations; 2) peers hired into existing roles (such as a psychologist, social worker, nurse, psychiatrist, addiction counselor); and 3) peers hired into peer support roles within the context of behavioral health agencies that also offer other, non-peer-delivered services.

This first category refers to the relatively recent evolution of long-standing self-help/mutual support groups into entirely peer-run and peer-staffed agencies that provide a range of behavioral health services and supports. While facing their own unique set of challenges, these agencies do not have to integrate peer and non-peer staff, as all staff are in recovery. The second category refers to hiring persons with histories of behavioral health difficulties and recovery to occupy existing roles in a behavioral health agency. Again, while this process presents its own challenges, such staff are not being hired to perform new roles in new ways. To the degree to which their personal experiences enter into and enrich their work, they and their colleagues may face some of the challenges described in this toolkit, and may find some of the recommendations provided to be useful. This toolkit, however, is primarily focused on the third of these categories. It is aimed at assisting leadership and staff in behavioral health agencies that have traditionally employed non-peers (or persons who did not disclose any history of behavioral health difficulties) in the process of preparing their agency to recruit, retain, and effectively deploy peer staff in a variety of provider roles.

Purpose and scope of this toolkit

This toolkitis oriented to the individual agency level and provides guidance for agency leadership in how to prepare their agency for the effective inclusion of peer staff. The need for this toolkit became evident as more and more agencies in Philadelphia started to hire peer staff without undertaking the kind of self-study, culture change, and clarification of roles described here. As a result, these agencies faced considerable challenges in deploying peer staff and in supporting their existing staff in the process of incorporating peer support into their ongoing work. They experienced difficulties in recruiting and retaining qualified peer staff, in having these staff perform new and valuable functions, and in enabling them to become valued members of the agency community. If this description characterizes your agency, then you may find the guidance provided here useful in overcoming these difficulties. If your agency is preparing to hire peer staff for the first time, we hope you will find this toolkit useful in preventing these difficulties from arising in the first place.

We firmly believe that there are considerable benefits for your agency in hiring peer staff that extend well beyond the benefits reaped by the people receiving the peer support services and the peer staff themselves. These benefits range from the cultivation of a more supportive and nurturing culture for everyone involved to increases in the degree to which existing, non-peer, staff find their work to be enjoyable, meaningful, and gratifying. We hope that this toolkit will enable your agency to reap all of these benefits as a result of taking this important next step.

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Philadelphia Department of Behavioral Health and Intellectual Disability Services