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June 9, 2011 Volume 2, Issue 21
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RTP Professional Discipline Situational Analysis Executive Summary
This week, we continue with another Situational Analysis summary. As previously mentioned, we will continue to share summaries from the recently completed Situational Analyses conducted by each of the professional disciplines as part of the Recovery to Practice (RTP) initiative. The RTP Situational Analysis is a holistic description that captures unique characteristics of the current status of recovery-oriented practice within each discipline and then sets forth the approach that each will use to advance recovery principles and practices within its profession.

The teams synthesized findings from their yearlong, comprehensive assessment of both qualitative and quantitative data, collected in terms of (1) definitions and understandings of recovery used in their profession (as compared to the Substance Abuse and Mental Health Services Administration’s [SAMHSA’s] Consensus Statement recovery definition); (2) evidence of recovery-oriented practices being used; (3) evidence of the concept of recovery embedded in organizational infrastructure (i.e., in formal policies and procedures); and (4) evidence of recovery-oriented content in institutional training curricula.

The Situational Analysis forms the basis for determining strengths and identifying gaps as each professional organization designs and delivers its curriculum. Factors that make up the Situational Analysis are fluid and will evolve over time, as learning and practice grow. The Situational Analysis presented here, and in later Weekly Highlights, represent the current status of each discipline and its plans for the future. Readers who would like to provide feedback on these plans to any of the professional organizations involved are invited to do so, using the email address below.
National Association of Peer Specialists
By Steve Harrington, J.D., Executive Director
Peer specialists1 are persons with a lived history of mental illness and recovery journey who help others on their recovery journeys. Because the peer specialist profession is a relatively new phenomenon in mental health services, it is often unknown or misunderstood by other mental health professionals, medical health professionals, and the general public. Confusion and misunderstandings also exist with regard to the roles peer specialists can or should play in mental health services.

Although peer support can be traced to the beginning of humanity, it emerged as a powerful force in mental health in the early 1980s. At this time, mental health institutions were closing across the United States in favor of community-based treatment, where persons with psychiatric conditions could live and obtain support in the communities in which they lived. Peer support outcomes, the popularity of Alcoholics Anonymous, and the reality of recovery from serious and persistent mental health problems combined to create an atmosphere ripe for the creation of a peer support movement in mental health.

Change agents. Peer providers are now commonplace in some mental health systems. Factors driving this trend included
  • The growing recognition of the reality of recovery from even severe and persistent psychiatric conditions
  • A political climate that expected cost-effectiveness for public funds
  • Positive outcomes associated with peer support
  • A ready labor force
  • The establishment of formal peer training and certification of peer specialists
In 2001, Georgia became the first State to obtain Medicaid reimbursement for peer support services (Salzer, Schwenk, & Brusilovskiy, 2010). Since then, 13 other States have followed. In addition to providing direct services to their peers, peer specialists were providing services in a variety of ways (one-on-one support, facilitating support groups, community resource connecting, education, and more)—they were acting as change agents. As employees of mental health providers, peer specialists found themselves in positions to influence organizational policies and practices to enhance service effectiveness (Fukul, Davidson, et al., 2010).

In 2004, the National Association of Peer Specialists (NAPS) was formed to promote the use of peer support in mental health settings. NAPS soon became involved in advising policy makers about peer workforce issues. The organization quickly grew from a handful of dedicated peer specialists to more than 1,000 members representing every State, as well as Australia, the United Kingdom, Japan, Guam, Canada, and several other countries. NAPS acts as a peer support information clearinghouse and frequently responds to inquiries from throughout the United States.

Need for national guidelines, certifications. Our Situational Analysis research has found that the number of States creating peer specialist initiatives has grown dramatically in the past 5 years. The number of States with employed peer specialists is somewhat greater than the number receiving Medicaid reimbursement (an estimate of 25 is not unreasonable), but the exact number is often difficult to determine, as programs are sometimes small and/or isolated. At least two States, North Carolina and Texas, are working toward Medicaid reimbursement for peer support and have made much progress in that regard.

One of the main findings we have come across is the lack of national guidelines or certification for the profession. Each State with a formal peer specialist program exercises control over that program as it relates to certification, training, professional discipline, and other operational issues. Until recently, training was generally offered as 1-week courses to satisfy State certification requirements. A common feature among virtually all training programs is heavy reliance on peers as advisors in basic curriculum development and as instructors. Training courses do appear to be increasing in length and the topics covered, but findings have indicated a great desire among peer specialists for greater emphasis or education on cultural competency, the role of trauma in mental health, and ethics issues.

Meanwhile, certification requirements vary across the States. Some States only require training, while others require training, work experience, successful completion of a comprehensive exam, character references, reference from a psychiatrist, an interview, and background investigations. Despite efforts to foster training and certification reciprocity between States, those efforts have generally resulted in rejections to “outside” assistance or suggestions. Although Kansas, Missouri, and Georgia permit a measure of reciprocity, most States do not and, at this time, appear unwilling to consider doing so.

The number of States with formal certification programs is, at least, growing. In August 2007, the Centers for Medicare and Medicaid Services (CMS) issued guidelines to States wishing to use Medicaid funding for peer support services (Smith, 2007). The guidelines addressed supervision, care coordination, and training and certification. But with the issuing of these guidelines and overall growth in the peer specialist workforce, the demand for continuing education opportunities has grown as well. While many States have spent considerable time and effort to develop the basic certification procedure and requirements, many have yet to reach beyond that to develop continuing education programs.

Role of peer specialists. Another finding in our assessment is just how diverse the peer specialist workforce is. This can prove both a challenge and a reward for our field as a whole. Each peer specialist brings a unique skill set to the mental health workplace. And because the profession is relatively new, there is often great flexibility in how and where those skills are used. Peer specialists work in such settings as general hospital emergency rooms, psychiatric hospitals, jails and prisons, and nursing homes. They also work as educators in communities, drop-in centers, clubhouses, and vocational placement agencies.

The diversity of peer specialists is reflected by more than work setting. Tasks are also variable and include—but are not limited to—individual support, facilitating support groups, educating a variety of individuals and groups about recovery and the true nature of mental illnesses, helping people make the transition from hospital to community, housing and educational support, engagement, wellness coaching, resource connecting, advocacy, supervision, administration, teaching of formal recovery courses, and transportation.2

In recent years, the Department of Veterans Affairs (VA) has made great strides in the training, certification, and hiring of peer specialists for its healthcare facilities. In some ways, the VA’s efforts have encouraged States that once considered peer support meaningless or marginally meaningful to reconsider their positions and, ultimately, create peer specialist programs. Today, the VA has a significant peer workforce that is well-trained and professional and contributes a wealth of positive outcomes (Salzer, 2011; Salzer, Schwenk, & Brusilovskiy, 2010).

Lack of understanding. That said, there appears to be a great number of mental health provider agencies that misunderstand the valuable roles peer specialists can play. Reports from the field reveal that some peer specialists are relegated to roles in which they are unable to use their recovery experiences and knowledge for the benefit of those they serve (or should be serving). There are reports that some peer specialists are providing parking lot security, medication monitoring, office support, or other duties that do not present meaningful peer-to-peer contact.

This may be because peer specialists are often supervised by non-peers who have no specific training on how to supervise peers in the workforce. In addition, peer specialists may work in an environment where coworkers lack knowledge of the recovery paradigm or feel confused or threatened by the presence of people openly in recovery in the workplace.

Failure to understand the important roles peer specialists can play is detrimental to peer specialists, coworkers, persons served, and mental health systems as a whole (Townsend & Griffin, 2006). Lack of understanding often leads to workplace conflicts.

And, despite the well-proven abilities of peer specialists to create positive outcomes in these many settings (Salzer, 2011; Salzer, Schwenk, & Brusilovskiy, 2010; SAMHSA, 2009; Davidson, Chinman, Kloos, et al., 1999), the profession remains underpaid. In describing our target audience for the NAPS Situational Analysis, we found that working peer specialists often live in poverty—despite being employed. Workers often feel disrespected and operate without a meaningful career ladder, even though they have a high motivation to work and succeed at employment, and to help others on their recovery journeys.

Next steps for future. Based on historical information, however, it seems a certainty that the peer specialist profession will enjoy considerable (and likely rapid) growth in the next decade. One recent study has shown that peer support can reduce rehospitalization by as much as 72 percent (OptumHealth, 2011).

It is also clear the need for continuing education will grow as a component of State-sanctioned peer specialist programs, in line with the profession’s growth, maturity, and CMS guidelines.

It is in this environment that NAPS will develop, and ultimately implement, training on recovery-oriented practices in our field. Our vision is a peer specialist workforce proficient in all aspects of recovery—and an environment in which others in the mental health field understand not only the value of recovery-oriented practice but the value peer specialists bring to recovery-oriented practice.

Work toward this vision will involve, first of all, educating the peer workforce to increase recovery knowledge and increasing recovery knowledge and practices in the long term. NAPS aims to develop a recovery-oriented curriculum that is as participatory and experiential as possible. Among other topics, the curriculum will address cultural competency, trauma-informed practices, and ethics and boundaries. As a field, we should also work to create professional peer specialist standards that can be applied nationally.

Continuing education is also important—not only formal continuing education, but also access to the many useful recovery resources that already exist. Too many of these resources remain unknown or inaccessible to peer specialists. NAPS hopes to forge collaborative relationships with organizations across the country to encourage access to depositories of evaluated and organized recovery materials.

We also suggest collaborating with other mental health professions to foster recovery knowledge and acceptance of recovery practices and policies. Peer specialists often observe practices and are subject to policies that inhibit their ability to move service providers toward a recovery orientation. Without a peer specialist workforce comfortable with expressing opinions and suggestions, and coworkers and supervisors willing to listen and consider them, the recovery paradigm is inhibited. Ensuring acceptance of recovery-oriented practices will mean working closely with the other disciplines on developing and implementing these practices and, where needed, helping to educate those who work alongside peer specialists on the key aspects of recovery. One basic first step we can take in marketing recovery knowledge is to develop a fact sheet that describes why, how, where, and when peer specialists perform their work.

One Indiana State mental health official has already noted our distribution of the Situational Analysis will help him promote the hiring of peer specialists in that State (B. VanDusen, personal communications, Feb. 8, 2011). With hard work, we will achieve a future in which peer specialists, as well as recovery practices as a whole, will be widely respected and adopted.

1Peer specialists may also be referred to as: peer support specialists, peer support technicians, consumer advocates, peer recovery support specialists, recovery specialists, and a myriad of other titles.
2This list is far from exhaustive. Transportation is included here, but it is sometimes debated whether it is a “true” or “valid” peer support task. Transportation of peers can, however, present meaningful opportunities for discussion and relationship-building that supports a individual’s recovery.

Daniels, A., Grant, E., Filson, B., Powell, I., Fricks, L., & Goodale, L. (Ed.). (2010). Pillars of peer support: transforming mental health systems of care through peer support services. Atlanta, GA: The Carter Center. Retrieved June 8, 2011, from http://www.parecovery.org/documents/Pillars_of_Peer_Support.pdf.

Davidson, L.; Chinman, M.; Kloos, B.; Weingarter, R.; Stayner, D.; & Tebes, J.K. (1999). Peer support among individuals with severe mental illness: A review of the evidence. Clinical Psychology: Science and Practice, 6(2), 165–87.

Fukul, S.; Davidson, L.J.; Holter, M.C.; & Rapp, C.A. (2010). Pathways to recovery: Impact of peer-led group participation on mental health recovery outcomes. Psychiatric Rehabilitation Journal, 34(1), 42–48.

OptumHealth. (2011). Poster presentation from Association for Community Mental Health Administration Summit.
New Orleans, La.

Salzer, M.S. (2011). Presentation from Texas USPRA Conference 2011: Present and future of certified peer specialists: A research overview. Austin, Texas.

Salzer, M.S.; Schwenk, E.; & Brusilovskiy, E. (2010). Certified peer specialist roles and activities: Results from a national survey. Psychiatric Services, 61(3), 520–23.

SAMHSA. (2009). What are peer recovery support services? (HHS Publication No. [SMA] 09–4454.) Rockville, Md.: U.S. Department of Health & Human Services.

Smith, D.G. (2007). Letter to State Medicaid directors. Baltimore, Md.: Department of Health & Human Services, Centers for Medicare & Medicaid Services.

Townsend, W., & Griffin, G. (2006). Consumers in the mental health workforce: A handbook for providers. Rockville, Md.: National Council for Community Behavioral Healthcare.

Invitation to Submit Personal Stories
Personal stories are a powerful way to share information, influence others, and advance recovery-oriented practice. The RTP team would like to hear from military family members about your recovery-oriented experiences.

We're also interested in receiving your personal stories about how healthcare reform has affected your recovery journey.

We will add your stories to our library of resources that will soon become available to our ListServ subscribers.

To submit personal stories or other recovery resources, please contact
Stephanie Bernstein, MSW, at 1.877.584.8535,
or email recoverytopractice@dsgonline.com

New National Report: Adults With Mental Illness are 4 Times More Likely to Develop Alcohol Dependency Than Those Without Mental Illness
More Serious Levels of Mental Illness Have Higher Rates of Alcohol Dependency
A new report shows that alcohol dependence is four times more likely to occur among adults with mental illness than among adults with no mental illness (9.6 percent versus 2.2 percent).

Based on a nationwide survey conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), the report also shows that the rate of alcohol dependency increases as the severity of the mental illness increases. For example, while 7.9 percent of those with mild mental illness were alcohol dependent, 10 percent of those with moderate mental illness and 13.2 percent of those with serious mental illness were alcohol dependent.

“Mental and substance use disorders often go hand in hand. This SAMHSA study adds to the evidence of this connection,” said SAMHSA Administrator Pamela S. Hyde, J.D. “Co-occurring mental illness and substance use disorders are to be expected, not considered the exception. Unfortunately, signs and symptoms of these behavioral health conditions are often missed by individuals, their friends, and family members, and unnoticed by health professionals. The results can be devastating and costly to our society.”

The SAMHSA Spotlight report, Alcohol Dependence is More Likely Among Adults With Mental Illness Than Adults Without Mental Illness, was developed as part of SAMHSA’s strategic initiative on data, outcomes, and quality—an effort to inform policy makers and service providers of the nature and scope of behavioral health issues. The report is based on data from the 2009 National Survey of Drug Use and Health, a state-of-the-art scientific survey of a large representative sample of people throughout the United States.

The full report is available online, at http://oas.samhsa.gov/spotlight/Spotlight027AlcoholDependence.pdf. For related publications and information, visit http://www.samhsa.gov.

The RTP Resource Center Wants to Hear From
Recovery-Oriented Practitioners!
We invite practitioners to submit personal stories that describe how they became involved in recovery-oriented work and how it has changed the way they currently practice.
The RTP Resource Center Wants to Hear From You, Too!
We invite you to submit personal stories that describe recovery experiences. To submit personal stories or other recovery resources, please contact Stephanie Bernstein, MSW, at 1.877.584.8535,
or email recoverytopractice@dsgonline.com.

We welcome your views, comments, suggestions, and inquiries.
For more information on this topic or any other recovery topics,
please contact the RTP Resource Center at
1.877.584.8535 or email recoverytopractice@dsgonline.com.

The views, opinions, and content of this Weekly Highlight are those of the authors and do not necessarily
reflect the views, opinions, or policies of SAMHSA or the U.S. Department of Health and Human Services.