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The Peer-Provider Collaboration as a Platform for Research and Service Delivery. Anthony O. Ahmed, PhD Assistant Professor Dept. of Psychiatry and Health Behavior Medical College of Georgia Georgia Regents University. Disclosures. Contract/Grant Support.

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The Peer-Provider Collaboration as a Platform for Research and Service Delivery

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The Peer-Provider Collaboration as a Platform for Research and Service Delivery

Anthony O. Ahmed, PhD

Assistant Professor

Dept. of Psychiatry and Health Behavior

Medical College of Georgia

Georgia Regents University


Contract/Grant Support

  • Educational grant from U.S. Department of Health Resources and Service Administration (HRSA) Bureau of Health Professions (BHPr)

2012 Award for Creativity in Psychiatric Education

from the American College of Psychiatrists


  • Peers and peer-led interventions: clinical research update

  • The GMHCN-Project GREAT collaborative study of recovery in certified peer specialists

  • Peer-led interventions, services, and research in the state of Georgia: whither are we bound?

Peer Specialists as Cornerstones of Recovery

  • Traditional interventions in the mental health field have won some battles…lost the war

    • Little has been gained in promoting wellness, personal growth, quality of life, personhood…

    • There is some increasing recognition of the importance of recovery among traditional providers but psychiatry and psychology are still lagging behind

    • The consequence is high rates of treatment disengagement

  • Peer-led interventions are necessary to sustain the gains of the recovery movement

    • Need to give voices to individuals receiving services

    • Need to maintain adjunctive interventions to traditional care

    • Need to maintain alternative services to traditional care

    • Peer-led programs outnumber traditional mental health organizations

Peer-Led Interventions

Mutual Support/Self-Help

Intentional, voluntary,

reciprocal or non-reciprocal

relationship with

peers in community and/or

service settings

Peer Support

Intentional, voluntary,

non-reciprocal relationship

with peers in service settings

Consumer-Operated Services

Intentional, voluntary,

reciprocal or non-reciprocal

relationship with

peers in community and/or

service settings

Classification of Peer-Led Interventions

Peer-Provider Research: An Opportunity

  • Traditional psychiatry research has been good for discovery and treatment innovation but suffers important limitations

    • Social distance and stigma

  • Peer-led recovery-based research has potential to provide an important perspective

    • Decrease social distance

    • Increase involvement

    • Serve activist objectives

  • How then may peers collaborate in research?

Peer-Led Interventions: Feasibility

  • Feasibility studies demonstrated that it is possible to train peers to provide mental health services

  • Four seminal studies conducted in the 1990s

Peer-Led Interventions: The Evidence

Courtesy Davidson et al., 2006

Peer-Led Interventions: The Evidence

  • Peers are able to deliver services that are at least as effective as services delivered by traditional providers

  • In some cases slightly better outcomes

Peer Staff Versus Non-Peer Staff

  • Since year 2000, there has been an increased focus on comparing peers to non-peers—are peers really better at case management?

  • Comparison trials have consistently shown that peers do better at engaging “difficult-to-treat” clients, reduce hospitalization rates, duration of hospitalization, and decreasing substance use

    • Example: Rowe et al. (2007)--Peer support significantly reduced alcohol, drug use, and criminal justice involvement in individuals with dual diagnosis over traditional treatment

Future Research Into Peer-led Interventions

  • New third generation research interest is to—

    • Identify the ways peer-led interventions are different and outperform tradition treatment

    • Identify the interventions that only peers are uniquely qualified to provide

    • Distill the active ingredients of peer-led interventions

    • What are the experiences of peers providing interventions? In what ways does the Peer Specialist role influence peers’ lives?

Third Generation Studies

  • NIMH-funded studies by Larry Davidson’s team:

    • Tondora et al. (2010): 290 adults with SMI randomly assigned to a) usual care plus IMR; b) usual care plus IMR plus a peer-facilitated person-centered planning process (PCP); and c) usual care plus IMR and PCP with the addition of the peer-run community connector program.

      • Peer-facilitated care planning increased the sense that treatment was responsive and inclusive of outcomes that mattered to peers

      • The peer-run community connector program increased hope, belongingness, treatment engagement, and decreased psychotic symptoms

    • Sledge et al. (2011): 74 participants who had been hospitalized at least twice in the last 18 months randomly assigned to usual care versus usual care plus peer recovery mentor

      • The inclusion of peer mentorship decreased the number of hospitalizations (Cohen’s d = 0.41) and the duration of hospitalization (Cohen’ d = 0.44)

      • There was also a significant decrease in substance use and depression with peer mentorship

The GMHCN-Project GREAT Collaborative Study of Recovery among CPSs

  • Objectives:

    • Study the professional experiences of CPSs trained through the GMHCN

    • Identify the correlates of recovery among CPSs that may inform experiential aspects of recovery


  • Mailed out packets to GMHCN CPSs that included survey questions and psychometric measures

    • 20% completion rate for mail-outs (N = 84)

    • Sample survey domains:

      • Income and sources of Income

      • Employment and work status

      • Housing and neighborhood

      • Peer professional status and responsibilities

      • Quality of CPS professional experience

      • Challenges of the CPS role

    • Psychometric measures:

      • Maryland Assessment of Recovery for SMI (MARS); Connors-Davidson Resilience Scale (CD-RISC); Brief-COPE; Social Functioning Scale (SFS); Social Support Questionnaire (SSQ); Internalized Stigma of Mental Illness (ISMI); Brief Symptom Inventory (BSI); the NEO Five Factors Inventory (NEO-FFI-3)

Results: Demographic Characteristics

Vocational and Financial Status of CPSs

  • Approximately 85% of CPSs have at least some college education/post-high school and over 40% have a bachelors degree

  • Most CPSs earn between $10,000 to $20,000 per year

  • The unemployment rate of CPSs is high at 38.30%

  • 49.40% reported that they were “Mostly Dissatisfied” or “Very Dissatisfied” with their financial status and 37.50% for their employment situation

  • There was an association between income satisfaction and employment satisfaction (r = .54, p < .0001)

CPS Professional Role

  • Only a minority of peer specialists are working for pay in that role

  • Peer specialists reported working 18.47 hours a week on average

    (range = 0-85 hrs)

  • The majority of peer specialists feel included as part of the treatment team

  • The majority of respondents are at least “Mostly Satisfied” with their role as a CPS

Peer Specialist Employment Benefits

  • 72.4%% of peer specialist received no employment benefit

  • The benefits for CPS positions are low compared to other professions of similar levels of education

Housing and Living Situation

  • Most respondents own their own apartment

  • Most peer specialists reported being at least “Mostly Satisfied” with their housing

  • Most respondents were at least “Mostly Satisfied” with their neighborhoods

What are some things you do to help peers?

  • Peer Mentoring and Support (60%)

    • Goal setting, leading recovery groups; sharing recovery stories; providing support services; hospital visits, etc.

  • Teaching or Leading Treatment Groups (51.11%)

    • E.g., skill-based groups and wellness activities such as WRAP, IMR, social skills, etc.

  • Case Management (29%)

    • Housing assistance; employment; transportation; entitlements; legal support; community resources etc.

  • Advocacy (11.11%)

  • Consultation Services to Treatment Teams (6.7%)

What do you find rewarding about being a CPS?

  • The Helping Role: Assisting others to embark on the recovery journey, empowering peers, instilling hope, etc. (71.18%)

  • The Power of the Narrative: Sharing recovery stories and positive experiences (15.25%)

  • Personal Growth: Better insight, knowledge through education/training, growing with peers, etc. (12.00%)

  • The Reciprocity: Developing friendships and partnerships with other peers and other providers (20%)

What are the most difficult challenges of the CPS role?

  • Limited Compensation/Resources (25.45%)

  • Conflicts and Misunderstandings with Traditional Providers (25.45%)

  • Paperwork (21.81%)

  • Peer Difficulties (21.82%)

  • Maintaining Personal Wellness (10.91%)

  • Limited Peer Specialist Positions (7.27%)

Current Problems in Place of Employment

  • Limited compensation and benefits (32%)

  • Stressful work environments/millieu (22.03%)

    • Untenable productivity standards; difficult co-workers; problematic shifts; too much paperwork

  • Underemployment (15.25%)

  • Issues of appreciation and respect (13.56%)

  • Limited workplace resources for optimal service delivery (8.47%)

    • Inadequate supervision; office space; equipment issues

  • Poorly defined roles and responsibilities (4%)

What steps did you take to deal with relapse?

  • Recruiting Positive Coping Skills

    • WRAP; 12 steps; recovery tools; support network; peer support

  • Modifying Work Schedule

    • Taking time off; fewer work hours; reducing work load;

  • Psychiatric Services

    • Medication reevaluation; hospitalization; psychotherapy; counseling;

Support and Accommodations Provided by Employer

  • Employer Provided Time Off

    • Day off, extended time off, paid sick leave, unpaid leave etc.

  • Employer Provided a Lighter Work Load

    • Fewer cases, additional help, etc.

  • Employer Adjusted Roles

    • New job, flexible schedule

  • Clinical Support

    • EAP, Onsite Intervention, Hospital Transport

  • None

    • Employer unaware, employer viewed relapse as inconvenience,

What opportunities, tools, and supports could improve your experience as a peer specialist?

  • Professional Development/Continuing Education:

    • Literature to assist in facilitating groups

    • Training in working with peers with dual diagnosis

    • Training in working with peers during acute episodes

    • Training specific to running peer groups

    • Operating as a peer specialist on an ACT team

    • Socializing and professional networking

    • Dealing and resolving ethical dilemmas

  • Vocational Resources:

    • More job opportunities for peers

    • Create opportunities for vocational training

What opportunities, tools, and supports could improve your experience as a peer specialist?

  • Financial Compensation and Resources:

    • Pay advancement

    • Provide support for activities and supplies

    • Increase range of benefits

    • Transportation

    • Housing

  • Increase Awareness:

    • Educate traditional providers about peers provider competencies

    • Educate traditional providers about peer-led interventions

    • Educate peer providers about the value of peer specialists

In What Roles or Activities Would You like to see CPSs in the Future?

  • Administrative and Supervisory

    • advisors to regional offices and hospital administrators, program directors, decision-making teams, etc.

  • Education and Training

    • Staff training, family psychoeducation, anti-stigma etc.

  • Hospital/Clinical Roles

    • Nursing, counseling, case management, treatment planning, crises intervention, physical health training, etc

  • Judicial System

    • In police departments; more involvement in the court system

In What Roles or Activities Would You like to see CPSs in the Future?

  • Academic Settings

    • Schools alongside guidance counselors and other staff

    • University psychology clinics and counseling centers

  • Proliferation of Peer-Led Interventions

    • Increase the number of peer centers

    • Develop more peer-led interventions

    • Provide services in social security and DHR

    • Provide services in private practice clinics

  • Other Activities

    • Spiritual counseling

    • Life coaching

    • Political activism

The Peer Specialist Position Confers Clinical Benefits

  • Psychiatric diagnosis does not impact CPS status

  • Low past year hospitalization rate among CPSs

  • Over 40% of CPSs reported relapse while functioning as CPS but almost all took effective steps to manage relapse

Summary of the Correlates of Recovery in Peers Specialists

  • Measured recovery with the Maryland Assessment of Recovery in Severe Mental Illness (MARS)

    • Factor analysis distills recovery into—Hope/holistic, Empowerment, Self-Direction, and Strengths

  • Recovery predicted:

    • Positive coping

    • Resilience—control, commitment, action-orientation, faith, and tolerance

    • Community living—social engagement, communication, recreation, independence

    • Frequency and satisfaction with social support

    • Internalized Stigma—positive association with stigma resistance and inverse association with alienation, stereotype endorsement, withdrawal

    • Recovery attitudes as a Cognitive Antidote..

  • Recovery does not depend on personality organization

Recovery (MARS)




Community Functioning (SFS)

-.23* (-.10)

Recovery Attitudes Promote Community Functioning

Recovery (MARS)






-.82* (-.13)

Recovery Attitudes are Protective From Stress

What do Peer Specialists in Recovery Do to Cope?

  • Religion

  • Use of Emotional Support

  • Active Coping

  • Positive Reframing

  • Use of Instrumental Support

  • Planning

  • Venting

  • Humor

  • Acceptance

Strategies for Proliferating Peer Services

  • Involve people in recovery and non-peer stakeholders in the process of creating peer positions

  • A clear job description and role clarification

  • Identifying and valuing the unique contributions that peers can make to the programs and settings where they will work

  • Providing CPS jobs that reflect the diversity of strengths and educational background of peers

  • Provide compensation commensurate with background and experience

  • Sponsored education and training for peers to enhance the quality of their services

  • Senior administrator take on the role of peer staff “champion” who can address issues and problems (Davidson et al., 2012)

  • Providing training and education for non-peer staff that covers relevant disability and discrimination legislation and its implications (Davidson et al., 2012)

  • Providing supervision for peer staff that concentrates on job skills, performance, and support

  • Disseminate success stories of the impact of peer-led interventions


  • The Georgia Mental Health Consumer Network

    • Ms. Sherry Jenkins-Tucker

    • Mr. Charles Willis

  • All Certified Peer Specialists of the Georgia Mental Health Consumer Network

    • “Thank you for being missionaries of hope”

  • Mr. Mark Baker~ Center for Recovery Transformation


  • Current Peer Specialists

    • Linda Johnson

    • Vanessa Dunton

    • Stacy Camille

    • Barry Jones

  • Past Peer Specialists

    • Sherry Evans

    • Julie Roberts


Project GREAT

Project GREAT Emeritus Peer Specialists

Certified Peer Specialists

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