Module 5: Retention and Career Mobility
Retention and Career Mobility
These two issues are addressed together because the single most important factor in
promoting retention is to create opportunities for upward mobility for peer staff who
perform well in their jobs. As was already mentioned earlier, a number of agencies in
Philadelphia have expressed concerns about losing competent and effective peer staff after
they have been working for around five years. We suggest that this has not had as much to
do with “burnout”—although that can certainly be a factor as well—as it has with the lack
of career mobility within those agencies.
In addition to allowing for upward mobility, it is critical in promoting retention to offer
competitive salaries, good health benefits, and vacation packages — just like for any other
employee. Aside from these basics, other major factors that may contribute to the rapid
turnover of peer staff have to do with a staff member feeling isolated and alone in his or her
role (which is why it is so important not to hire only one peer for any given program or
setting), staff members feeling exploited or like “tokens” when their assigned roles are not
consistent with their training and life experiences, emotional exhaustion and the need for
self-care, and experience of micro-aggressions in the workplace (to be explained below).
The remainder of this module is devoted to approaches to addressing these issues.
Avoiding exploitation and tokenism
One unintended consequence of the Philadelphia transformation process has been that
some agencies have gotten the impression that by hiring one or two peer staff they will
have fulfilled the requirements for peer culture and leadership spelled out in the Practice
Guidelines. In this case, peer staff are not hired as much to advance culture change within
an agency (as are the peer change agents we described in the previous module) as they are
to relieve the agency from having to change anything else about its culture. But we know
that peer staff report higher job satisfaction when they perceive their places of
employment to have shifted their culture to be more recovery-oriented.1 Hiring peers as a
way of avoiding further transformation is thus only likely to end in unhappy peer staff who
will be quick to leave for greener pastures.
Burnout prevention through self-care
As a new workforce, peer staff are faced with unique challenges every day—colleagues and
supervisors frequently do not understand their roles, they may experience discrimination
from other staff, the organizations where they work may not have a strong recovery
1Brooks,
W., Kaufman, L,. & Stevens-Manser, S. (2011). Peer specialist training and certification program outcomes
evaluation report: September 2011. The University of Texas at Austin.
Philadelphia Department of Behavioral Health and Intellectual Disability Services
orientation, they may work in isolation from other peer staff, and they regularly are not
appreciated for the enormously complex work that they perform. Considering all of these
factors in addition to the challenges of providing peer support, it can be especially
challenging to retain peer supporters. All of the strategies included in this workbook are
ultimately aimed at promoting retention of the peer workforce within organizations within
the Philadelphia behavioral health system, from the essential work required to create a
strong recovery orientation, clearly define roles, pay people a fair and equitable wage, to
the provision of opportunities for co-supervision and professional development. Not all
aspects of an organization will change at once, and most peer support workers face
substantial organizational challenges on an everyday basis.
Add to these challenges the need all behavioral health practitioners have for appropriate
self-care and you can see that there continues to be a need to address the emotional
exhaustion, or “burnout,” that peer staff experience even in the presence of opportunities
for upward mobility. Self-care is considered crucial to burnout prevention in behavioral
health for all direct care staff, and effective supervision—with its educational and
consultative elements—has been linked to less emotional exhaustion and lower turnover
rates. 2 While heeding the warning above about not confusing supervision with
psychotherapy, it thus remains a core responsibility of the supervisor to monitor for
emotional exhaustion and to encourage any staff member who is becoming vulnerable to
burnout to engage in appropriate self-care strategies.
Preventing and addressing micro-aggressions
A final contributor to peer staff leaving positions prematurely is their experience of “microaggressions” in the workplace. The concept of micro-aggressions comes originally from the
social science literature related to racism and other forms of prejudice, and was first
applied to the topic of hiring and integrating peer staff by Patricia Deegan, Ph.D., a leader in
mental health consumer/survivor movement and a clinical psychologist by training. On her
website (www.patdeegan.com), she devotes a couple of pages of her blog to what she
entitles: “Mentalism, Micro-Aggression, and the Peer Practitioner.”
The term “mentalism” has been used to describe the form of prejudice and discrimination
that has historically been directed toward persons with mental illnesses that we
highlighted in Module 1. In this blog, Pat makes the point that the same kinds of microaggressions that persons of color have experienced in their interactions with persons of
European descent, or that women have experienced in their interactions with men, also
2Knudsen,
H., Ducharme, D., & Roman, P. (2008). Clinical supervision, emotional exhaustion, and turnover
intention: A study of substance abuse treatment counselors in NIDA’s Clinical Trials Network. Journal of Substance
Abuse Treatment, 35(4): 387-395.
Philadelphia Department of Behavioral Health and Intellectual Disability Services
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happen in the lives of persons with mental illnesses who are working in mental health
settings. The same can be said for persons in recovery from substance use working in
addiction settings. And while this form of stigma and discrimination has been addressed
and reduced to some degree on the “macro” and system, city, and national levels, the
experiences of peer staff suggest that it has continued on a more “micro” level within the
behavioral health programs and agencies where they work.
Macro-aggressions are the more blatant forms of prejudice and discrimination that we are
familiar with from the various civil rights movements in the U.S. In terms of behavioral
health, macro-aggressions are such things as refusing to hire someone based on their
history of a behavioral health condition, refusing to allow for the siting of a housing
program because persons with behavioral health conditions are claimed to be dangerous,
ending a romantic relationship because a person finds out that their lover is taking
psychiatric medications, insisting on transporting persons in acute distress to the hospital
via police car and handcuffs because persons with mental illness are unpredictable, and
having only clients go though a metal detector at a substance use treatment facility. These
are somewhat obvious forms of discrimination that can be more readily addressed.
Micro-aggressions, on the other hand, are less overt or more subtle, they can be easily
overlooked as innocent slights or missteps, or the person experiencing the aggression may
be dismissed and told that he or she is simply being overly sensitive, or worse, paranoid.
Early examples that we have already mentioned were questions about which bathrooms
peer staff should use, where they should eat lunch, or whether or not they should have
keys. More recent examples include not acknowledging a person as a colleague in the ways
in which other colleagues are routinely acknowledged, assuming that any difficulties a
person may be having or any mistakes he or she might make would necessarily stem for his
or her behavioral health condition, and omitting to include peer staff in social gatherings. In
her blog, Pat includes the following examples:
“I had been a patient in a mental hospital. Some time later I returned as a
worker to the same hospital. My paid, full time job was to work with patients as
a peer educator. I overheard staff grumbling that my very presence on the unit
was a violation of professional boundaries.”
“Once I went to escort a patient to a peer group meeting off the hospital unit
and a staff person said: ‘Only staff can do that.’ I felt like saying: ‘I am staff.’”
Philadelphia Department of Behavioral Health and Intellectual Disability Services
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“I was working at a clubhouse and they had a holiday party. There was a keg of
beer but they said only staff could have the beer. I figured that meant me so I
went and served myself and they said I couldn’t have any.”
In Philadelphia, peer staff have described similar instances of being made to feel like a
“second class citizen” or encountering non-peer staff who did not believe that they actually
were staff despite the fact that they had ID badges, had assigned roles and tasks, and
received pay checks just like other staff. In such cases, it is the person’s history as a
recipient of behavioral health care that is taken by some staff as an indication that this
person cannot be fully capable of being a staff member or, as in the last example, not fully
capable of making his or her own decisions or taking care of him or herself.
But there is no middle ground between staff and clients because these are not opposite
ends of a spectrum of functioning or capacity; they are roles that people play at different
times and in different contexts. We are all health care clients in our own lives, this is not
different for persons with behavioral health conditions who also have lives outside of their
roles as clients. These roles are increasingly including the role of staff in behavioral health
settings. This recognition explodes the discriminatory view that staff and clients are
fundamentally different, depicted below.
Basis for microaggressions:
STAFF
PEER
STAFF
?
X
CLIENTS
Spectrum of … (functioning? responsibility? maturity?)
An important insight that comes from hiring peer staff is that staff and clients are not
fundamentally different in this, or any other, way. Staff and clients are not on different ends
of a spectrum or in mutually exclusive categories, but the same person can be in both roles,
albeit in different settings. As far as a behavioral health organization goes, a basic
expectation of mutual respect for all parties sets a foundation for preventing and
addressing micro-aggressions as they arise, as micro-aggression are disruptions to the
respectful relationships between people that should be upheld regardless of each person’s
role at the time. Consistent with using person-first language, it is the personhood of each
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party that is first and foremost, with roles playing secondary importance, and health status
playing tertiary importance, as depicted below.
Basis for preventing and addressing micro-aggressions:
In this diagram, what is most important about each
person is represented by their name. Their role
within the program, while also important, is
secondary, and whether or not the staff member is a
peer is even secondary to his or her role as staff. The
“?” indicates that we do not necessarily know a staff
member’s behavioral health history when they do not
accept being assigned a formal “peer” status. There
have always been effective staff who did not disclose
their personal struggles and histories of recovery.
Dorion
Deitra
Staff
Staff
(peer)
(?)
Dave
client
To prevent micro-aggressions it is useful to educate the staff about them, and the
likelihood that they occur, as early in the process of hiring peer staff as possible and
to indicate that such instances will be identified and addressed should they occur. In
addressing micro-aggressions, it is then important to adopt an organizational
framework rather than a personal or interpersonal one.
Micro-aggressions are typically not intentional actions, the micro-aggressor is
ordinarily unaware of the impact of his or her behaviors or omissions on the other
person. Committing a micro-aggression does not make someone a “bad” or evil
person, rather it indicates that he or she is human and is susceptible to the same
social structures and deeply embedded prejudices that all of us hold to some degree.
Identifying a micro-aggression is thus not cause for a personnel investigation or
disciplinary action as much as it is an impetus to reflect on the program or agency
culture and make clear the assumptions upon which such behaviors are (often
unwittingly) based. In short, micro-aggressions are most often cultural issues that
reflect an ageny’s social climate rather than an individual issue limited to one
specific staff member. Preventing and addressing micro-aggressions thus requires
the kind of culture change work that we discussed at length in the first module of
this toolkit, bringing us full circle back to where this toolkit began.
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