square bulletBest Practices When Working with Peers in Clinical Settings

January 25, 2017

From Martha L. Spiers, LCSW, Safety Net Services Manager, Clackamas County Behavioral Health, Centerstone

Setting the Stage for Peer Support Services

I was asked to write something about “best practices” when working with peers in clinical settings. What follows is a short history designed to give you some idea about how I formed my opinions on this topic.

When I moved to Oregon in 1991, I left a Boston metro area community mental health agency where I was the Director of Crisis Services. Literally as I was leaving, peers were ceremoniously evicting the agency clinical staff from their offices in what had been a day treatment program, now converted to a Club House (Fountain House model). Staff were all abuzz about how people they had experienced for years as being unable to sit through a 20-minute skills group could now focus on the meaningful work of their community’s recovery during four-hour Club House strategic planning meetings. The inspiring Dr. Patricia Deegan came to speak to our community (staff and peers) about her experience as a patient at Danvers State Hospital, and her own path to recovery. There was an established warm line in Leominster. It was the late 80’s, and it was an exciting time for peer services on the East Coast.

Moving to Oregon was a major culture shock. My first job was with Clackamas County Behavioral Health (CCBHD), where I still am 25 years later.

CCBHD has always been a little ahead of the game in Oregon with regards to Peer services. In the early to mid-1990’s, one of our case managers (Jan Miller) attended a peer conference in Philadelphia and returned “on fire” and ready to make some changes.  She teamed up with others to create a peer program. The peers were called Peer Outreach Workers (with an unfortunate, but ultimately apt, acronym). The goal of the program was to provide county jobs to individuals with mental illness to supplement their social security disability income, and to provide the county with the much needed peer perspective.  The peers in this program coordinated commitment hearings, conducted skills training groups and even performed some clerical work.  They essentially performed county work at lower pay.  The program was cut with budget reductions in the early 2000’s. Around the same time Jan teamed up with the late Pat Risser, Angel Prater (then Moore), and another case manager to offer the Service Provider Individualized Recovery Intensive Training (SPIRIT) program. SPIRIT was a local version of Shery Mead’s Intentional Peer Support (IPS) training that has become the foundation for current peer recovery specialists. The SPIRIT program also went the way of budget cuts but fortunately IPS has become ubiquitous.

Tackling Different Parts of the System

In 2009 the Behavioral Health system in Clackamas County underwent a complete redesign. Cindy Becker, at the time our new Health, Housing and Human Services Department Director, convened focus groups and committees to tackle different parts of the system. I invited Scott Snedecor to join the Crisis Services redesign committee.  I had met Scott at the monthly Metro Acute Care Advisory Council meetings when he was working as a peer at the state hospital in Salem.  His input was foundational to our program today. Scott and Cindy were together responsible for creating a Peer Services Systems Coordinator position in 2010. In the intervening years our Peer Services Systems coordinator, Ally Linfoot, has been responsible for supporting and pushing funding out to an impressive array of peer-run organizations who provide a network of peer support services in Clackamas County.

In 2011 we began designing Centerstone, our county’s crisis walk-in clinic. Area peer leaders provided input in the design and work flow. For example, what started as an “Observation Room” in the architectural drawings, became a Peer Lounge in the final draft. This represented a significant paradigm shift. A peer focus group came up with a naming convention that we have held to. Their advice was to create the least stigmatizing setting possible, and to avoid reference to “mental health”, “urgent care”, “crisis” and even “clinic” in the name. One memorable comment was, “there are two places you never want to be seen parking in front of: 1) an ‘Adult Fantasy’ venue or 2) a county mental health clinic.”  Centerstone is located in a strip mall, and the fact that we are a county clinic can be discerned by reading the small print on our window. Our first team of peers, provided through contract with a peer agency, moved with us when Centerstone opened in March of 2012.

Opening Centerstone

(As a side note, Centerstone will soon be changing its name to Riverstone in advance of a lawsuit threatened from the national organization with the trademark on the name Centerstone.)

To prepare for working with peers some staff read Whittaker’s Anatomy of an Epidemic and others were sent to an Alternatives Conference. One even attended an IPS training. We had some converts and some skeptics.

Our experience with peers at Centerstone (Riverstone) has been life altering. Our peers, employees of FolkTime, Inc., are co-located with clinical staff but report up through their own agency. For our county staff it has not always been easy to tell what makes a peer different from a case manager, or another warm body to take on an outreach. The “mutuality” concept inherent in peer support is difficult for us to get our heads around in a system that has been traditionally so driven by “professional boundaries.” Our peers are empowered to remind us (always graciously) that they have their own jobs, and though we partner together, they don’t take orders from us. They are not part of the treatment team. Therein lies their power. Through their incredibly good humored and patient educational strategies (a part of IPS, I believe) we  have all but eliminated terms like “resistant”, “manipulative”, “baseline” and “poor insight” from our language. We have started viewing “in recovery” as valuable resume experience for prospective job candidates.

Our county staff at Centerstone (Riverstone) are effective, powerful, and mission-driven people. Having said that, we are all over the spectrum in terms of how we understand peer support services, and in our comfort level with the peer role. One wonderful but unanticipated consequence of working with peers is that many of us have found renewed hope for recovery through their stories and their examples, and have become “true believers”. For many of us it’s a relief not to always have to be the expert in this difficult work and to be less focused on diagnosis and more focused on the personal connection. As hiring managers, we have come to believe that years of lived experience in the mental health system as a “survivor” of the system can be as, if not more, comprehensive an education than a two year master’s degree.  It is humbling.  Peers bring a perspective and way of working that is generous, open, forgiving and relentlessly hopeful about the power of recovery. Their outcomes are astonishing.

Best Practices

I was asked to write something about “best practices” for using peers in clinical settings. My experience has led me to this:

  • Leadership must understand peer support and either be on-board with the radical idea of peer support or trusting of you while you make audacious (perhaps offbeat) decisions about your clinical model.
  • Assign staff reading, then talk about it.
  • Send clinical staff to peer conferences where they are in the minority—warn them to have a thick skin and prepare them to have an open mind.
  • Understand and embrace the differences between peer boundaries and clinical boundaries.
  • Contract with a peer-run agency to provide the workforce. This is critical. What happened with Clackamas County’s first foray into peer services happens in one form or another in many agencies that hire peers directly. They become the lowest paid person on the clinical team. Peers have to be able to “speak truth to power”, and when that power is the boss who assigns your work, truth loses.
  • Have peers self-refer to the individuals you serve. Clinicians tend to try to evaluate who is “appropriate” for peer services and are often over protective.

The fact is that there has been a historical power imbalance between mental health professionals and our clients/patients/survivors. With some exceptions, there really hasn’t been room for the individual dissenting voice in this profession. Our clinical language alone dismisses disagreement with overused phrases like “no insight” or “resistant”. Efforts to get needs met can be cast aside with shaming terms like “manipulative” or “attention seeking”. There is often a terrible divide between patient and provider. Until this changes, independent peer specialists are critical to the health of our system and the people we serve.