Consumers as service providers: the promise and challenge

Understanding Users' Perspectives of Psychosocial Mechanisms Underpinning Peer Support Work in Chile

This study explores the beliefs and attitudes about the psychosocial mechanisms of peer support work among users who participated in Critical Time Intervention-Task Shifting (CTI-TS), which tested the acceptability and feasibility of a peer support work model to improve community-based mental health care for individuals with psychosis in Latin America. We conducted a secondary analysis of 15 in-depth interviews with CTI-TS participants in Chile, using the framework method and defined the framework domains based on five major mechanisms of peer support work identified by a recent literature review. The analysis revealed that users' perceptions of peer support work mechanisms were strongly shaped by personal motivations, beliefs about professional hierarchies, familial support, and the Chilean mental health system's incipient recovery orientation. The findings underscore the importance of adopting culturally tailored strategies to promote peer support work, such as involving mental health professionals and fostering equal-powered relationships between PSWs and users.

Implementation of peer specialist services in VA primary care: a cluster randomized trial on the impact of external facilitation

Background

Over 1100 veterans work in the Veterans Health Administration (VHA) as peer specialists (PSs)—those with formal training who support other veterans with similar diagnoses. A White House Executive Action mandated the pilot reassignment of VHA PSs from their usual placement in mental health to 25 primary care Patient Aligned Care Teams (PACTs) in order to broaden the provision of wellness services that can address many chronic illnesses. An evaluation of this initiative was undertaken to assess the impact of outside assistance on the deployment of PSs in PACTs, as implementation support is often needed to prevent challenges commonly experienced when first deploying PSs in new settings.

Methods

This study was a cluster-randomized hybrid II effectiveness-implementation trial to test the impact of minimal implementation support vs. facilitated implementation on the deployment of VHA PSs in PACT over 2 years. Twenty-five Veterans Affairs Medical Centers (VAMCs) were recruited to reassign mental health PSs to provide wellness-oriented care in PACT. Sites in three successive cohorts (n = 7, 10, 8) over 6-month blocks were matched and randomized to each study condition. In facilitated implementation, an outside expert worked with site stakeholders through a site visit and regular calls, and provided performance data to guide the planning and address challenges. Minimal implementation sites received a webinar and access to the VHA Office of Mental Health Services work group. The two conditions were compared on PS workload data and veteran measures of activation, satisfaction, and functioning. Qualitative interviews collected information on perceived usefulness of the PS services.

Results

In the first year, sites that received facilitation had higher numbers of unique veterans served and a higher number of PS visits, although the groups did not differ after the second year. Also, sites receiving external facilitation started delivering PS services more quickly than minimal support sites. All sites in the external facilitation condition continued in the pilot into the second year, whereas two of the sites in the minimal assistance condition dropped out after the first year. There were no differences between groups on veterans’ outcomes—activation, satisfaction, and functioning. Most veterans were very positive about the help they received as evidenced in the qualitative interviews.

Discussion

These findings demonstrate that external facilitation can be effective in supporting the implementation of PSs in primary care settings. The lack of significant differences across conditions after the second year highlights the positive outcomes associated with active facilitation, while also raising the important question of whether longer-term success may require some level of ongoing facilitation and implementation support.

Trial registration

This project is registered at ClinicalTrials.gov with number NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600).

Peer mentorship to reduce suicide attempts among high-risk adults (PREVAIL): Rationale and design of a randomized controlled effectiveness-implementation trial

RATIONALE

Novel approaches to suicide prevention are needed to address increasing rates of suicide deaths. Research suggests that interventions led by certified Peer Specialists may improve suicide protective factors such as hope and connectedness; however, the effectiveness of a Peer Specialist intervention for reducing suicidal thoughts or behaviors has not previously been tested empirically.

DESIGN

We describe the methodology of a randomized controlled hybrid effectiveness-implementation trial of a peer specialist intervention known as PREVAIL (Peers for Valued Living). The primary effectiveness aim is to determine whether the 3-month peer mentorship intervention compared to a minimally enhanced usual care condition reduces suicide attempts and suicidal ideation among adults at high risk for suicide who have been psychiatrically hospitalized. Secondary effectiveness outcomes include medically serious suicide attempts according to chart review and self-reported self-efficacy to avoid suicide. We also describe suicide risk management, supervision, and fidelity monitoring in the context of Peer Specialist providers and our methods for assessing implementation barriers and facilitators.

CONCLUSION

The PREVAIL trial will demonstrate novel methods for incorporating peer providers into a suicide prevention effectiveness trial with high-risk study participants. PREVAIL's hybrid effectiveness-implementation design aims to maximize the likelihood of rapid implementation in the community if shown to be effective.

[Models of peer support in psychiatric care]

In the past decades, psychiatric care has changed from the traditional medical model to a more person-centered and recovery-focused approach. In this process, peer support workers are essential, because with their lived experience of crisis and recovery they are able to spread hope.This article gives an overview of the recent literature describing the current change model of peer support, reporting the evidence of peer support, as well as the current stage of implementation of peer support in different psychiatric contexts.An overview of the current state of research, selected by the authors, based on repeated systematic literature searches in peer support research projects, is given. Additionally, some examples of user involvement from the Hamburg EX-IN Curriculum, trialogs between sufferers, relatives and professionals, as well as the so-called psychosis seminars are described in more detail.Peer support has shown promising results in one-to-one and group settings, case management, crisis interventions, and the reduction of coercive measures.Although there are promising results of peer support in various clinical contexts, multiple challenges in the implementation of peer support are reported. They need to be overcome by the inclusion of all staff members in the change process of the system in order to further develop user-oriented and recovery-oriented psychiatric care.

Peer Workers in the Behavioral and Integrated Health Workforce: Opportunities and Future Directions

The growth of the peer workforce in behavioral health services is bringing opportunities to organizations and institutions that serve people living with mental and substance use disorders and their families. Peer workers are defined as people in recovery from mental illness or substance use disorders or both that possess specific peer support competencies. Similar roles are identified for families of people in recovery. Peer support has been implemented in a vast range of behavioral health services, including in the relatively new use of peer support in criminal justice and emergency service environments. Behavioral health services are striving to integrate peer workers into their workforce to augment existing service delivery, in part because peer support has demonstrated effectiveness in helping people with behavioral health conditions to connect to, engage in, and be active participants in treatment and recovery support services across all levels of care. This article describes the experiences that organizations and their workforce, including peer workers, encounter as they integrate peer support services into the array of behavioral health services. Specific attention is given to the similarities and differences of services provided by peers in mental health settings and substance use settings, and implications for future directions. The article also addresses the role of peer workers in integrated behavioral and physical healthcare services.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Making a reality of user involvement in community mental health services

User centred services as an ideology have not become a reality of everyday clinical practice. In this paper we introduce a series of articles which describe user centred practice in a south London community-based rehabilitation service for the severely mentally ill. We emphasise the medical consultation style adopted, the service management style and specific initiatives allowing users to influence our practice and shape functional and structural components of the service.

Provision of peer specialist services in VA patient aligned care teams: protocol for testing a cluster randomized implementation trial

Background

Over 1100 Veterans work in the Veterans Health Administration (VHA) as peer specialists (PSs). PSs are Veterans with formal training who provide support to other Veterans with similar diagnoses, primarily in mental health settings. A White House Executive Action mandated the pilot reassignment of VHA PSs from mental health to 25 primary care Patient Aligned Care Teams (PACT) in order to broaden the provision of wellness services that can address many chronic illnesses. An evaluation of this initiative was undertaken to assess the impact of outside assistance on the deployment of PS in PACT, as implementation support is often needed to prevent challenges commonly experienced when first deploying PSs in VHA settings. We present the protocol for this cluster-randomized hybrid type II trial to test the impact of standard implementation (receive minimal assistance) vs. facilitated implementation (receive outside assistance) on the deployment of VHA PSs in PACT.

Methods

A VHA Office of Mental Health Services work group is recruiting 25 Veterans Affairs Medical Centers to reassign a mental health PSs to provide wellness-oriented care in PACT. Sites in three successive cohorts (n = 8, 8, 9) beginning over 6-month blocks will be matched and randomized to either standard or facilitated implementation. In facilitated implementation, an outside expert works with site stakeholders through a site visit, regular calls, and performance data to guide the planning and address challenges. Standard implementation sites will receive a webinar and access the Office of Mental Health Services work group. The two conditions will be compared on PS workload data, fidelity to the PS model of service delivery, team functioning, and Veteran measures of activation, satisfaction, and functioning. Qualitative interviews will collect information on implementation barriers and facilitators.

Discussion

This evaluation will provide critical data to guide administrators and VHA policy makers on future deployment of PSs, as their role has been expanding beyond mental health. In addition, development of novel implementation strategies (facilitation tailored to PSs) and the use of new tools (peer fidelity) can be models for monitoring and supporting deployment of PSs throughout VHA.

Trial registration

ClinicalTrials.gov, NCT02732600 (URL:https://clinicaltrials.gov/ct2/show/NCT02732600)

A cluster randomized trial of adding peer specialists to intensive case management teams in the Veterans Health Administration

Use of peer specialists (PSs)--individuals with serious mental illness who use their experiences to help others with serious mental illness--is increasing. However, their impact on patient outcomes has not been demonstrated definitively. This cluster randomized, controlled trial within the Veterans Health Administration compared patients served by three intensive case management teams that each deployed two PSs for 1 year, to the patients of three similar teams without PSs (Usual Care). All patients (PS group = 149, Usual Care = 133) had substantial psychiatric inpatient histories and a primary Axis 1 psychiatric disorder. Before and after the year PSs worked, patients were surveyed on their recovery, quality of life, activation (health self-management efficacy), interpersonal relations, and symptoms. Patients in the PS group improved significantly more (z = 2.00, df = 1, p = 0.05) than those receiving Usual Care on activation. There were no other significant differences. PSs helped patients become more active in treatment, which can promote recovery.

Peer Support Providers' Role Experiences on Interprofessional Mental Health Care Teams: A Qualitative Study

This study explores how peer support providers' roles are defined and integrated in inter-professional mental health care teams, and how these providers relate to other practitioners and clients. Interviews were conducted with peer support providers in two different formal models of peer support employment. Qualitative data analysis was undertaken. The findings indicate that: peer support providers experience ambiguity and that some ambiguity may offer benefits; peer support providers enhance team acceptance of their role through several means and strategies; setting boundaries with clients is a delicate issue that requires several considerations that we discuss.

Participants' employment status and experiences in the year after the Experienced Involvement training

BACKGROUND

Peer support workers (PSWs) are an emerging workforce within the Swiss mental health system. The 'Experienced Involvement' (EX-IN) training programmes prepare and certify individuals who have experienced mental health problems to work as PSWs.

AIMS

This study examined the influence of EX-IN training on participants' employment status and their experiences in the year after training.

METHOD

We employed quantitative and qualitative methods. Quantitative data were collected at baseline, immediately after completion and at 1 year post-training. Additionally, individual narrative interviews were conducted with 10 participants at 1 year post-training.

RESULTS

At 1 year of completion, the majority of participants were in paid employment. Difficulties included unclear PSW roles. The qualitative analyses revealed the following categories: 'Evolving from the patient role despite experiencing effects or consequences of mental illness', 'Feeling welcome and being confronted with conflicting expectations', 'Helping others while being needy at the same time' and 'Doing something worthwhile and the fear of failure'.

CONCLUSION

Clear role descriptions, well-defined expectations, team preparation, acknowledgement of vulnerabilities and institution-level support PSWs are important to safeguard both PSWs and service users by minimising the destabilisation risk. Future EX-IN training graduates can benefit from the establishment of remunerated PSW roles in psychiatric services.

Cooptation of Peer Support Staff: Quantitative Evidence

Objective

In 2007, the Centers for Medicare and Medicaid Services (CMS) sent a letter to state Medicaid directors outlining requirements for implementing peer-based recovery support services (P-BRSS) as a Medicaid-funded service. Since then, 30 states have implemented these services. Although the literature describing implementation of P-BRSS has identified the cooptation of peer support staff (PSS) as a barrier to the effective provision of P-BRSS, the evidence for it remains anecdotal. This study attempts to determine if the context of employment in either a treatment organization or peer organization affected cooptation.

Methods

We conducted a survey of PSS in the fall of 2013. In all, 92 of the 181 respondents were working as PSS at the time, 53 in treatment organizations. Chi-square analysis was used to determine if the context of employment had an effect on the cooptation of peer staff.

Results

Peer staff working in treatment organizations reported that they were supervised by treatment staff and participated in employment-related training to improve their skills at providing treatment services more frequently than their counterparts in peer organizations. Peer staff working in treatment organizations also participated in training and education to prepare for employment as treatment professionals more frequently than peer staff working in peer organizations.

Conclusions and Implications for Practice

Peer staff members working in treatment organizations are subject to processes of acculturation into professional cultures that peer staff working in peer organizations are not. Effective implementation of P-BRSS should include specific efforts to minimize the cooptation of peer staff.

Mechanisms underpinning effective peer support: a qualitative analysis of interactions between expert peers and patients newly-diagnosed with bipolar disorder

BACKGROUND

The increasing burden on mental health services has led to the growing use of peer support in psychological interventions. Four theoretical mechanisms have been proposed to underpin effective peer support: advice grounded in experiential knowledge, social support, social comparison and the helper therapy principle. However, there has been a lack of studies examining whether these mechanisms are also evident in clinical populations in which interpersonal dysfunction is common, such as bipolar disorder.

METHOD

This qualitative study, conducted alongside a randomized controlled trial, examined whether the four mechanisms proposed to underpin effective peer support were expressed in the email exchange between 44 individuals newly-diagnosed with bipolar disorder and their Informed Supporters (n = 4), over the course of a supported online psychoeducation program for bipolar disorder. A total of 104 text segments were extracted and coded. The data were complemented by face-to-face interviews with three of the four Informed Supporters who participated in the study.

RESULTS

Qualitative analyses of the email interchange and interview transcripts revealed rich examples of all four mechanisms. The data illustrated how the involvement of Informed Supporters resulted in numerous benefits for the newly-diagnosed individuals, including the provision of practical strategies for illness management as well as emotional support throughout the intervention. The Informed Supporters encouraged the development of positive relationships with mental health services, and acted as role models for treatment adherence. The Informed Supporters themselves reported gaining a number of benefits from helping, including a greater sense of connectedness with the mental health system, as well as a broader knowledge of illness management strategies.

CONCLUSIONS

Examples of the mechanisms underpinning effective peer support were found in the sample of emails from individuals with newly-diagnosed bipolar disorder and their Informed Supporters. Experiential knowledge, social support, social comparison and helper therapy were apparent, even within a clinical population for whom relationship difficulties are common. Trial registration number ACTRN12608000411347.

What do peer support workers do? A job description

Background

The extant literature suggests that poorly defined job roles make it difficult for peer support workers to be successful, and hinder their integration into multi-disciplinary workplace teams. This article uses data gathered as part of a participatory evaluation of a peer support program at a psychiatric tertiary care facility to specify the work that peers do.

Methods

Data were gathered through interviews, focus groups, and activity logs and were analyzed using a modified grounded theory approach.

Results

Peers engage in direct work with clients and in indirect work that supports their work with clients. The main types of direct work are advocacy, connecting to resources, experiential sharing, building community, relationship building, group facilitation, skill building/mentoring/goal setting, and socialization/self-esteem building. The main types of indirect work are group planning and development, administration, team communication, supervision/training, receiving support, education/awareness building, and information gathering and verification. In addition, peers also do work aimed at building relationships with staff and work aimed at legitimizing the peer role. Experience, approach, presence, role modeling, collaboration, challenge, and compromise can be seen as the tangible enactments of peers’ philosophy of work.

Conclusions

Candidates for positions as peer support workers require more than experience with mental health and/or addiction problems. The job description provided in this article may not be appropriate for all settings, but it will contribute to a better understanding of the peer support worker position, the skills required, and the types of expectations that could define successful fulfillment of the role.

Challenges faced by mental health peer support workers: peer support from the peer supporter's point of view

OBJECTIVE

This study aimed to identify the various challenges encountered by peer support workers in Western Australia in the course of their work and to identify possible solutions to those challenges.

METHOD

We used the nominal group technique to collect and analyze the data.

RESULTS

The main challenge encountered by participants was a lack of understanding of the peer support worker role which caused them to experience a sense of exclusion. The main solution focused on strategies to educate consumers, managers, and health professionals about the peer support worker role.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

Managers have a responsibility to be informed about the peer support worker role and communicate role related information to other team members to ensure that peer support workers are included as part of the health team. Implications for practice therefore center on training for managers and inclusion of the peer support worker role in orientation programs. Further, if these steps are not undertaken, a valuable resource could be lost to a health service to the detriment of persons with a mental illness.

Stigma in the mental health workplace: perceptions of peer employees and clinicians

Informed by a structural theory of workplace discrimination, mental health system employees' perceptions of mental health workplace stigma and discrimination against service recipients and peer employees were investigated. Fifty-one peer employees and 52 licensed behavioral health clinicians participated in an online survey. Independent variables were employee status (peer or clinician), gender, ethnicity, years of mental health employment, age, and workplace social inclusion of peer employees. Analysis of covariance on workplace discrimination against service recipients revealed that peer employees perceived more discrimination than clinicians and whites perceived more discrimination than employees of color (corrected model F = 9.743 [16, 87], P = .000, partial ŋ (2) = .644). Analysis of covariance on workplace discrimination against peer employees revealed that peer employees perceived more discrimination than clinicians (F = 4.593, [6, 97], P = .000, partial ŋ (2) = .223).

Peer interventions to promote health: conceptual considerations

Peers have intervened to promote health since ancient times, yet few attempts have been made to describe theoretically their role and their interventions. After a brief overview of the history and variety of peer-based health interventions, a 4-part definition of peer interveners is presented here with a consideration of the dimensions of their involvement in health promotion. Then, a 2-step process is proposed as a means of conceptualizing peer interventions to promote health. Step 1 involves establishing a theoretical framework for the intervention's main focus (i.e., education, social support, social norms, self-efficacy, and patient advocacy), and Step 2 involves identifying a theory that justifies the use of peers and might explain their impact. As examples, the following might be referred to: theoretical perspectives from the mutual support group and self-help literature, social cognitive and social learning theories, the social support literature, social comparison theory, social network approaches, and empowerment models.

A review of consumer-provided services on assertive community treatment and intensive case management teams: implications for future research and practice

BACKGROUND

Assertive community treatment (ACT) is an evidence-based practice that provides intensive, in vivo services for adults with severe mental illness. Some ACT and intensive case management teams have integrated consumers as team members with varying results.

METHODS

The authors reviewed the literature examining the outcomes of having consumer providers on case management teams, with attention devoted to randomized controlled trials (RCTs).

RESULTS

Sixteen published studies were identified, including eight RCTs. Findings were mixed, with evidence supporting consumer-provided services for improving engagement and limited support for reduced hospitalizations. However, evidence was lacking for other outcomes areas such as symptom reduction or improved quality of life.

CONCLUSION

Including a consumer provider on an ACT team could enhance the outreach mechanisms of ACT, using a more recovery-focused approach to bring consumers into services and help engage them over time. More rigorous research is needed to further evaluate integrating consumer providers on teams.

Culture, stress and recovery from schizophrenia: lessons from the field for global mental health

This cultural case study investigates one U.S. psychosocial rehabilitation organization's (Horizons) attempt to implement the recovery philosophy of the U.S. Recovery Movement and offers lessons from this local attempt that may inform global mental health care reform. Horizons' "recovery-oriented" initiatives unwittingly mobilized stressful North American discourses of valued citizenship. At times, efforts to "empower" people diagnosed with schizophrenia to become esteemed self-made citizens generated more stressful sociocultural conditions for people whose daily lives were typically remarkably stressful. A recovery-oriented mental health system must account for people diagnosed with schizophrenia's sensitivity to stress and offer consumers contextually relevant coping mechanisms. Any attempt to export U.S. mental health care practices to the rest of the world must acknowledge that (1) sociocultural conditions affect schizophrenia outcomes; (2) schizophrenia outcomes are already better in the developing world than in the United States; and (3) much of what leads to "better" outcomes in the developing world may rely on the availability of locally relevant techniques to address stress.

Family network support and mental health recovery

Family members often provide critical support to persons living with a serious mental illness. The focus of this study was to determine which dimensions of the family support network were most important to the recovery process from the perspective of the recovering person. Consumers of a community mental health program completed in-depth structured interviews that included separate measures of social network support and recovery. Consumers named an average of 2.6 family members on the social network, interacted with family on a weekly basis, and were quite satisfied with their contact. This study revealed that support and reciprocity with family members are important dimensions of a personal support network that relates to the recovery process.

Oil and water or oil and vinegar? Evidence-based medicine meets recovery

With the increasing prominence of the notions of "recovery" and "recovery-oriented practice," practitioners, program managers, and system leaders are increasingly asking about the relationship between "evidence-based practices" and recovery. After reviewing the concepts of recovery from mental illness, being in recovery with a mental illness, recovery-oriented care, and evidence-based medicine, the authors argue for a complementary relationship between recovery and evidence-based practices. This relationship is neither simple nor straightforward, but results in a whole that is greater than the sum of its parts through which each element benefits from the influence of the other.

Peer Support Shows Promise in Helping Persons Living with Mental Illness Address Their Physical Health Needs

The physical health of individuals with long-term mental illnesses has long been of concern. In Western Australia, the overall mortality rate from preventable causes of people living with mental illness was reported to be 2.5 times greater than that of the general population. A trial peer support service was initiated to assist people with mental illness to attend to their physical health needs. This paper presents the planning, implementation, and results of this collaborative initiative involving nongovernment agencies, the public mental health service, consumers of mental health services, and the University of Western Australia.

Developing Strategies to Integrate Peer Providers into the Staff of Mental Health Agencies

This study informs new strategies that promote integration of peer providers into the staff of social service agencies. Executive directors, human resource managers, supervisors and co-workers at 27 agencies in New York City were interviewed in-depth. Focus groups with peers were conducted. Consistent with previous research, respondents identified attitudes toward recovery, role conflict and confusion, lack of policies and practices around confidentiality, poorly defined job structure and lack of support as problems that undermined integration. Emerging from the data are strategies related to human resource policies and practices and workgroup relationships and operations that can improve employment of peer staff.

Peer support relationships: an unexplored interpersonal process in mental health

Consumer-survivors (C/Ss) identify peer support as a resource that facilitates their recovery. However, little is known about the factors that influence or how the peer support relationship (PSR) develops/deteriorates. The purpose of the study was to explore and describe the PSR within the subculture of mental health. Using an ethnonursing method, the study focused on informants from two C/S organizations who received peer support (n = 14). Findings revealed that the PSRs may develop or deteriorate through three, overlapping phases. Contextual factors that influenced the development/deterioration of the PSR are discussed. Understanding the processes and factors that contribute to the development/deterioration of PSRs will enable clinicians and C/Ss to assess and promote the development of healthy, supportive PSRs in mental health.

Introduction of an intensive case management style of delivery for a new mental health service

Mental health case management emerged in the 1960s in response to the shift in focus from inpatient to community care. Case management per se had been used by other service industries for some time previously, particularly those involved with people with intellectual disability. The term case management describes a range of service approaches and strategies in mental health rather than a single model of care. One method of delivering case management is with an intensive model of care. Intensive case management is differentiated from other forms of case management through factors like a smaller caseload size, team management, outreach emphasis, a decreased brokerage role, and an assertive approach to maintaining contact with clients. Research has demonstrated that case management, in particular, intensive case management, can improve clients' and families' experience of mental health services but only when introduced and used for appropriately targeted client populations and suitably resourced. Determining which model of case management best suits the client population and how to introduce it is a major challenge for any mental health service. With a focus on intensive case management, a review of this process is outlined.

Toward the Implementation of Mental Health Consumer Provider Services

Encouraged by the New Freedom Commission, mental health systems such as the Veteran Administration (VA) are now becoming more recovery-oriented. Consumer providers (CPs)--those with serious mental illness who are further along in recovery who provide services to others with similar mental health problems--are viewed as a key part of this change. However, organizational change theories suggest that careful consideration of implementation issues is critical when disseminating new and sometimes controversial services into existing organizations. Therefore, to guide the dissemination of CP services, the literature on the effectiveness of CPs was reviewed, and interviews, focus groups, and a brief survey of 110 administrators, providers, and patients were conducted at three large VA clinics in Southern California. Questions focused on their perceptions of feasibility and acceptability of CP services. Using literature and study findings, an organizational change framework and other strategies to overcome potential implementation challenges of CP services are suggested.

Transforming systems of care: the American Association of Community Psychiatrists Guidelines for Recovery Oriented Services

Thinking about recovery has grown significantly over the last 70 years, and particularly in the past fifteen. Promotion of recovery has recently been recognized as an organizing principle for the transformation of behavioral health services. Recovery is a personal process of growth and change which typically embraces hope, autonomy and affiliation as elements of establishing satisfying and productive lives in spite of disabling conditions or experiences. Recovery oriented services replace paternalistic, illness oriented perspectives with collaborative, autonomy enhancing approaches and represent a major cultural shift in service delivery. Recovery oriented services replace the myth of chronicity and dependence with a message of individualism, empowerment and choice in the context of collaborative relationships with service providers. The American Association of Community Psychiatrists has developed Guidelines for Recovery Oriented Services to facilitate the transformation of services to this new paradigm. The guidelines are divided into three domains: administration, treatment, and supports, each consisting of several elements for which recovery enhancing characteristics are defined. Several example indicators are also provided for each element. This paper presents these guidelines and discusses their application.

Implementing peer-assisted case management to help homeless veterans with mental illness transition to independent housing

Formerly homeless mentally ill veterans are at an important crossroads when they move from living in an institutional setting such as a shelter or supportive residential facility to independent living. We hypothesized that peer advisors, veterans with severe mental illness who had been homeless previously, graduated from a Healthcare for Homeless Veterans program, and subsequently maintained independent, stable housing could assist other veterans make a successful transition to independent living. Pilot data suggests that participants who received peer advisors were more likely to follow up with assessments than were controls. In this report, we describe a pilot peer advisor program, its implementation, and pilot data on program administration.

Design and initial results from a supported education initiative: the Kansas Consumer as Provider program

Despite increased attention to consumer-providers, there remains a lack of models that prepare, support, and sustain consumers in provider roles. This article describes the Consumer as Provider (CAP) Training program at the University of Kansas School of Social Welfare, which creates opportunities for individuals with severe psychiatric disabilities to develop knowledge and skills to be effective as human service providers. CAP fosters a partnership between colleges and community mental health centers where students experience classroom and internship activities. Outcome from a 2-year longitudinal study on CAP graduates indicates increased employability, especially in social services field, and higher post-secondary educational involvement.

Outreach to the homeless: craft, science, and future implications

Outreach is a treatment modality for engaging underserved populations in health care. Nowhere is outreach more relevant than in delivering services to homeless persons with mental illness. Programs providing outreach to homeless people have been in existence for at least two decades and a craft has developed naturalistically. However, there has been insufficient formal examination of factors that influence the effectiveness of outreach and how it is actually performed. The authors present an in-depth examination of issues related to outreach to the homeless. They review different outreach modalities, the role of the individual clinician, and the art of teamwork. They also discuss external issues such as financing, access to housing, interactions with other professions, and working conditions. The authors conclude with a brief discussion concerning the application of outreach to populations other than homeless individuals with psychiatric disorders and suggest future directions for improving our understanding of this important modality.

Peer support/peer provided services underlying processes, benefits, and critical ingredients

The article defines peer support/peer provided services; discusses the underlying psychosocial processes of these services; and delineates the benefits to peer providers, individuals receiving services, and mental health service delivery system. Based on these theoretical processes and research, the critical ingredients of peer provided services, critical characteristics of peer providers, and mental health system principles for achieving maximum benefits are discussed, along with the level of empirical evidence for establishing these elements.

Discovering recovery

This paper describes the interaction between a micro-history of recovery and a personal recovery history. It begins with a narrative of the author's own recovery experience as he participates in a series of recovery initiatives in a Midwestern state. The impact of these history-graded experiences on his human life-span development is then examined in the context of recovery. Lessons learned are discussed, and some conclusions are drawn. Implications for mental health professionals and people receiving mental health services are also explored. The benefits of getting involved are highlighted, as well as some concerns.

Representation of the governed: leadership building for people with behavioral health disorders who are homeless or were formerly homeless

Many organizations that provide services to individuals with behavioral health disorders are required to include people with psychiatric disabilities on their boards and action groups, yet this requirement rarely results in successful, ongoing representation. We report on a pilot project that trained people who were homeless and formerly homeless, most of whom were diagnosed with behavioral health disorders, for internships on boards and action groups that provide services to people who are homeless. We relate the project's goals to the theme of empowerment, present our findings, discuss key implementation issues, and offer recommendation for future program efforts and research.

Systematic review of involving patients in the planning and development of health care

OBJECTIVE

To examine the effects of involving patients in the planning and development of health care.

DATA SOURCES

Published and grey literature.

STUDY SELECTION

Systematic search for worldwide reports written in English between January 1966 and October 2000.

DATA EXTRACTION

Qualitative review of papers describing the effects of involving patients in the planning and development of health care.

RESULTS

Of 42 papers identified, 31 (74%) were case studies. Papers often described changes to services that were attributed to involving patients, including attempts to make services more accessible and producing information leaflets for patients. Changes in the attitudes of organisations to involving patients and positive responses from patients who took part in initiatives were also reported.

CONCLUSIONS

Evidence supports the notion that involving patients has contributed to changes in the provision of services across a range of different settings. An evidence base for the effects on use of services, quality of care, satisfaction, or health of patients does not exist.

Beneficence vs. obligation: challenges of the Americans with Disabilities Act for consumer employment in mental health services

Involvement of mental health service consumers in the provision of mental health services is a growing model in community mental health. It is, however, a complicated issue, made ever more so by the passage of the Americans with Disabilities Act. In this ethnographic case study, we seek to explore the changes one social services agency has made to adjust to the requirements of the ADA and the impact of these changes on their consumer employees. Our results indicate potential for positive progress as a result of the ADA, but also unexpected pitfalls as organizational cultures change as well.

Development and evaluation of a training program in peer support for former consumers

While mental health policy in Australia promotes the involvement of mental health consumers in service planning, implementation and evaluation, little has been reported on the training required for the new roles that consumers are being expected to undertake. In this study, 10 former consumers of mental health services participated in a 16-week training program in peer support. The impact of the program on the psychological well-being of the participants was assessed using a battery of self-evaluation questionnaires and focus group interviews. Findings suggest that exposure to people with acute mental health problems (i.e. inpatients), did not, in this instance, adversely impact on the psychological well-being of the participants. Barriers to consumer participation in the mental health field are discussed and recommendations for the content and structure of future consumer peer support training initiatives are proposed.

Creating job opportunities for people with psychiatric disabilities at a university-based research center

The consumer empowerment movement has led to an increase in opportunities for people with psychiatric disabilities to take on roles in the development and delivery of mental health services. However, to date there has been less involvement of people with psychiatric disabilities in services research. In this paper, we describe our experiences creating employment opportunities for people with psychiatric disabilities in a university-based mental health services research center. Working with two local clubhouse programs we developed research assistant positions using both transitional and supported employment approaches. We describe the development of the jobs, employee characteristics, the orientation and training provided to new employees, job characteristics and typical responsibilities, supports and accommodations provided to employees, boundary issues we encountered, and the perspectives of employees on rewards and challenges of the jobs. We offer recommendations to mental health researchers wishing to create these types of opportunities for people with psychiatric disabilities.

Chronicity reconsidered: improving person-environment fit through a consumer-run service

In the past, the term "chronic" referred to people who had serious mental illness and who typically received long-term care in a state mental hospital. Although this term recently has fallen out of favor, we resurrect the term here, not to revive a demeaning euphemism, but rather to redefine it as the result of a poor person-environment fit between the complex and challenging needs of those with serious psychiatric disorders and a community-based service system that often is ill-equipped to treat them. Previous research indicates that recurrent acute hospitalizations and an inability to establish or maintain tenure in the community may be due to a disconnection from community-based services and supports, social isolation, and demoralization. One promising approach to addressing these issues is that of peer support. To illustrate the potential utility of peer support in improving person-environment fit and decreasing the chronicity of the subsample of people who continue to have difficulty in establishing viable footholds in the community, we describe a peer support-based program, the Welcome Basket, developed, staffed, and managed entirely by mental health consumers. Preliminary analyses that evaluate Welcome Basket's effectiveness are included, and we discuss the implications of these data for future research and program development in this area.

Development of a consumer advocacy program

OBJECTIVE

The aim of the present paper was to describe the development of a consumer advocacy program within the Eastern Suburbs of Sydney (NSW, Australia).

METHODS

The program was developed within the context of a research project that investigated the effect on outcome of client-focused approaches to community case management for clients with schizophrenia and bipolar disorder.

RESULTS

While the development of the advocacy program was limited by the constraints imposed by the research methodology, the study provided the opportunity to delineate the process involved and identify key components that need to be incorporated into future advocacy programs.

CONCLUSIONS

The main guidelines determined were that consumer participation in service delivery needs to be flexible, consumer driven, have broad-based support, ready access to supervision and debriefing, ongoing training and clear job descriptions. Given adequate support, autonomy and funding, consumer advocates can provide a much needed resource for their fellow consumers.

Consumers as mental health providers: first-person accounts of benefits and limitations

Community support programs are increasingly establishing paid service positions designated exclusively for consumers. Project WINS (Work Incentives and Needs Study), a hybrid case management-vocational program for individuals with severe mental illness, used consumers as peer support specialists (PSSs) to supplement professional roles. Semistructured interviews were conducted with PSSs about 12 months after their employment ended. They identified substantial personal benefits specific to consumer-designated roles (e.g., a "safe" employment setting with accommodations) and general benefits from employment. Problems described were just as numerous, encompassing attitudes toward assigned peers and costs to their own well-being. Critical commentary addressed program operations (structure, supervision, and training needs) and problems in the mental health system. The authors discuss the changed sense of self that service provider roles can create for consumers and suggest that mental health administrators provide anticipatory socialization for this service innovation throughout their agencies and ongoing supports for consumers in their new roles.

Consumers as providers in psychiatric rehabilitation

Issues that arise in employing consumers as providers in psychiatric rehabilitation programs include readiness of the sponsoring agency, consumer disclosure, and adjustments in employment practices. Psychiatric rehabilitation agencies are obligated to seriously consider employing consumers, since they frequently ask the same of the other organizations.

Mexican American clients' perceptions of services in an outpatient mental health facility in a border city

This descriptive-exploratory pilot study analyzed the perceptions of services in an outpatient mental health facility located in a border city in southwest Texas among Mexican American clientele with chronic mental illness. Face-to-face interviews using structured questionnaires were conducted with high functioning mentally ill clients. The questionnaire, with both English and Spanish versions, consisted of items on sociodemographics, support networks, illness experiences, reasons for seeking health services, reactions to being visited in the home setting for follow-up care, receiving care from a mental health professional with a similar cultural background, satisfactions, problems encountered in the mental health delivery system, and suggestions for improving health services. Data from 56 respondents yielded generally highly favorable and positive ratings of services received in the facility. Overall, these baseline data present challenges and implications for delivering culturally competent mental health care to Mexican American clients with chronic mental illness.