yale
program
for
recovery
and
community
health
PEER WORK: AN
INTERNATIONAL
PERSPECTIVE
Larry Davidson, Ph.D.
Professor and Director
Program for Recovery and Community Health
Yale University School of Medicine
BASIC CONSIDERATIONS
Peer work is a ‘new’ profession that is
undergoing rapid growth and expansion
and is understood to be different things
by different people
There are some interesting complexities
inherent to peer work of which agencies
and peer workers need to be aware
BRIEF HISTORY, BUT FOR A REASON
Dr. Philippe Pinel at the
Salpetriere, 1795
Pussin
Peer Supporter
EARLIER IN THE 20TH CENTURY
Harry Stack Sullivan
People with psychosis are
much more fundamentally
human than otherwise
Suffered from psychosis
himself, and hired
recovered and recovering
patients to be staff
THERAPEUTIC COMMUNITIES
Dominant form of institutional care in private and
community hospitals from mid-century, which
vestiges to this day (e.g., level systems,
community meetings)
Significant role of peers in providing mutual
support, role modeling, mentoring, etc.
Unpaid, considered part of the person’s own
treatment (similar to peer support and workordered day tasks in Clubhouses)
MAJOR INFLUENCES ON MENTAL
HEALTH POLICY
Dorothea Dix credited with starting state
hospital movement, but wanted quality
and effective care available to all in need
Clifford Beers started mental hygiene
movement with Adolf Meyer (today called
“mental health”)
WHAT IS MY POINT?
Real life (“lived”) experience provides a
crucially important and valuable source of
“evidence”—both of needed policy changes
and of the effectiveness of peer work in
promoting recovery
History suggests that the lessons learned from
these experiences can get separated from the
experiences themselves (and the people who
had them) and can be appropriated by others
for various and sundry purposes
THE MORAL OF THE STORY?
VIGILANCE
VIGILANCE
VIGILANCE
WHERE WE ARE NOW
 Contemporary peer support emerged in the 1980s as a result
of the Mental Health Consumer/Survivor/Ex-Patient Movement
and quickly was taken up into addiction through development
of recovery support services
 Peer Workers are people who have experienced mental illness
and are either in or have achieved some degree of recovery. In
their role as peers, they use these personal experiences of
difficulties and recovery—along with relevant training and
supervision—to facilitate, guide, and mentor another person’s
recovery journey by instilling hope, role modeling recovery,
and supporting people in their own efforts to reclaim
meaningful and self-determined lives in the communities of
their choice.
CONTINUUM of HEALING/HELPING
RELATIONSHIPS
Psychotherapy
Intentional, onedirectional relationship
with clinical
professionals in service
settings
Peers as Providers of
Conventional Services
Intentional, one-directional
relationship with peers
occupying conventional case
management and/or support
roles in a range of service and
community settings
One-Directional
A
Intentional, voluntary,
reciprocal relationship with
peers in community and/or
service settings
Continuum of Helping Relationships
Peers as Providers of
Peer Support
Case Management
Intentional, onedirectional relationship
with service providers in
a range of service and
community settings
Self-Help/Mutual
Support & ConsumerRun Programs
B
Intentional, one-directional (?)
relationship with peers in a range
of service and community settings
incorporating positive selfdisclosure, instillation of hope,
role modeling, and support
Reciprocal
Friendship
Naturally-occurring,
reciprocal
relationship with
peers in community
settings
CONSIDERATIONS
 Note that I am not addressing mutual support outside of the mental
health system—that is not my area of expertise and I am not the
person to do so. May have limited reach?
 Points A and B on the continuum are really different. There appears
to be a lot of A going on, but little B (again, my opinion).
 If A wins out over time, few things will really change within the
mental health system.
 If B, in its current form, wins out over time, some more things will
change but some will stay the same. System will be enriched for
sure, but perhaps not transformed.
 What to do about reciprocity? Can the domain of lived experience
continue to be valued as a guiding spirit?
HOW CAN YOU TELL THE DIFFERENCE?
Do peer staff view service users as their
peers? (as seen in language, attitude, and
relationships)
Are peer staff encouraged to disclose their
own recovery stories and to bring their life
experiences with them to the table?
Is there clarity in roles or does the peer staff
role overlap with existing staff roles?
HOW YOU CAN TELL, PART 2
 Do peer staff spend the majority of their time
doing things (i.e., solving problems) or
listening?
 Do peer staff have a “champion” in a senior
leadership position to endorse and ensure
the integrity of peer work?
 Are peer staff viewed as one element of a
broader agency- or system-wide
transformation to a recovery orientation?
HOW TO TELL, PART 3
 Is inevitable discrimination addressed within
the work place? Is it understood to be
discrimination?
 Are peer staff trained and supervised for the
roles they are being asked to perform?
 Are peer staff supervised by someone who
understands the value of life experience?
 Are there opportunities for upward mobility?
HOW TO TELL, PART 4
Is there at least a tension between …
Engaging people into existing system of services
and supports by encouraging attendance and
adherence (e.g., “helping people stay on their
meds”)
Advocating for the system itself to change in order
to become more responsive to the needs of the
people it serves (e.g., peer facilitator in personcentered care planning)
EMPIRICAL EVIDENCE TO DATE
 First generation studies showed that it was feasible to hire
people in recovery to serve as mental health staff
 Second generation studies showed that peer staff could
generate at least equivalent outcomes to non-peer staff in
similar roles; could also engage people into care and reduce
readmissions
 Third generation studies are investigating whether or not
there are unique contributions that peer support can make;
these have thus far been in hope, alcohol & drug use, and
activation for involvement in treatment and self-care
ENGAGE STUDY
(NIDA R01 #DA13856)
Demographics:
 134 Participants
 Standard Care n = 44
 Skills Training n = 47
 Engage n = 43
 83% not employed at
baseline (n = 113)
 56% African American
 32% Caucasian
 14% Hispanic (n = 19)
66% never married
6% married
11% participants lived
with someone else
65% male (n = 88)
34% female (n =46)
ALL had co-occurring
psychosis & substance
use disorder
CCCS (COLLABORATIVE AND
CULTURALLY COMPETENT SERVICES)
80.00
70.00
60.00
Standard Care
50.00
Skills Training
40.00
Engage
30.00
20.00
10.00
0.00
Baseline
3-months
9-months
Engage participants demonstrated significantly greater improvement in CCCS scores
from baseline to 9-months than Standard Care (est.= -16.36, p=.04) and Skills
Training (est.= -19.04, p=.01)
SOCIAL FUNCTIONING
2.90
2.80
2.70
Standard Care
2.60
Skills Training
2.50
Engage
2.40
2.30
2.20
baseline
3 months
9 months
Engage participants have a significantly greater increase in social functioning from
baseline to 9-months than Standard Care (est.= -.43, p =.01) and Skills Training (est.= -.31,
p=.05)
PROBLEMS WITH ALCOHOL
IN LAST 30 DAYS
4.00
3.00
2.00
1.00
0.00
-1.00
-2.00
Standard Care
baseline
3 months
Skills Training
Engage
-3.00
-4.00
-5.00
-6.00
Engage participants demonstrated a significantly greater reduction in problems with
alcohol use in the past 30 days from baseline to 3 months than Standard Care (est.=
8.84, p<.001) and Skills Training (est.= 7.89, p<.001)
TOTAL DURATION OF SERVICES DURING
1ST AND 2ND YEAR POST-BASELINE
2000
1800
1600
1400
1200
1000
800
600
400
200
0
Standard Care
Skills Training
Engage
pre-baseline
baseline to 1 year
post baseline
1-2 years post
baseline
Engage have a significantly greater increase in time spent in services from before baseline
to the first year after baseline than Standard Care (est.=-765.26, p = .04) and Skills
Training (est.= -1183.19, p<.001)
Peer Engagement Study
People
not receiving
People receiving
Not engaged - Control Group
Not engaged - Intervention Group
peerLinear
specialists
peer
(Not engaged - Control Group) Linear
(Notspecialists
engaged - Intervention Group)
10
Level of engagement
9
8
Average Contacts Per Month
Randomized, controlled
trial of assertive
outreach with and
without peer specialist
staff for people who
would be considered
eligible for outpatient
commitment in other
states.
7
6
5
4
3
2
1
0
0
1
2
3
4
Month from the Baseline Interview
5
6
CULTURALLY-RESPONSIVE PERSONCENTERED CARE FOR PSYCHOSIS
(NIMH #R01-MH067687)
Demographics:
278 participants
143 Hispanic origin
135 African origin
Conditions
IMR = 84
IMR & Peer Advocate = 94
IMR & Peer Advocate = 100
and Connector
Mean age 44
Average education
level 11 years
15% employed
57% male (n = 88)
43% female (n =46)
6-Month Process and Outcome Data
↓ Psychotic Symptoms but ↑ Distress from Symptoms
Peer-Run
Community
Integration
Program
↑ Satisfaction with Family Life, Positive Feelings about Self & Life, Sense of Belonging, & Social Support
↑ Engagement in Managing Illness & Use of Humor as Coping Strategy
↑ Sense of Responsiveness & Inclusion of Non-Treatment Issues in Care Planning
↓ in Spiritual Coping
Peer-Facilitated
PersonCentered Care
Planning
↑ Sense of Control in Life & Power of Anger to Impact Change
↓ Satisfaction with Work Status
↓ Paranoid Ideation & Medical Problems
Illness
Management
& Recovery
↑ Social Affiliation & Satisfaction with Finances
↑ Coping & Sense of Participation
↓ Sense of Activism
Psychosis
Medication
Monitoring
& Case
Management
African and/or Hispanic
Origin
Poverty
RECOVERY MENTOR STUDY
 Randomized controlled design
 Inpatients 18 years and older, with a diagnosis of:
Schizophrenia
Schizoaffective disorder
Major depression
Bipolar disorder
 Follow up
3 and 9 months
EXPERIMENTAL CONDITION
“Usual care” plus: Community-based interactions
with recovery mentor as desired by participant
Mentors were trained in
 Engaging people in trusting relationships
 Using positive self-disclosure to instill hope
 Role modeling of adaptive problem solving
DEMOGRAPHICS
Characteristic
Age
Male Gender
Experimental (n=38)
Control (n=36)
% or
Mean (SD)
% or
Mean (SD)
P (two-tailed)
42.37 (11.47)
38.69 (8.35)
.12
17 (44.7%)
21 (55.3%)
.24
Race
.37
African-American
12 (32.4%)
9 (25.0%)
Caucasian
19 (51.4%)
24 (66.7%)
Hispanic
4 (10.8%)
3 (8.3%)
Other/Unknown
2 (5.4%)
0 (0%)
Currently Married (yes)
8 (21.1%)
1 (2.8%)
.02
Number of Hospitalizations in Prior 18 months
3.76 (1.08)
3.94 (1.31)
.52
Number of Hospitalization Days in Prior 18 months
40.0 (20.70)
42.31 (19.69)
.63
Diagnosis
.92
Mood Disorder
12 (31.6%)
11 (30.6%)
Psychotic Disorder
26 (68.4%
25 (69.4%
ADMISSIONS & DAYS
Condition
Participants
Hospitalizations
Mean
(SD)
Peer Mentor
Usual Care
38
36
.89 (1.35)
1.53 (1.54)
Significance: F = 2.90, df = 1, p = .05 (one tailed)
Partial Eta Squared = .04
Hospital Days
Mean
(SD)
10.08
(17.31)
Significance: F = 3.63, df = 1, p = .03 (one tailed)
Partial Eta Squared = .05
19.08
(21.63)
ADMISSIONS & DAYS BY DIAGNOSIS
Average Hospitalizations
Condition
Mentor
Usual Care
Psychotic
N
26
Events
.92 (1.41)
N
24
Non-psychotic
8
.83 (1.27)
6
Significance:
ANCOVA,
p (one tailed)
Events
1.80
(1.68)
.91 (.94)
Average Days in Hospital
Mentor
Usual Care
Condition: F = 1.47, p = .12
Days
Days
11.30
17.39
(18.05)
(21.41)
10.0 (15.46)
12.13
(20.07)
Cond. F = 1.51, p = .12
Partial eta squared=.03
Dx. F = 3.96, p = .025
Diagnosis: F = 2.22, p = .07
Cond. X Dx: F = 1.23,
p = .14
Cond. X Dx: F = 1.28, p = .13
SIGNIFICANT DIFFERENCES BETWEEN
CONDITIONS OVER TIME FOR
INTERVENING VARIABLES
Condition
Drug Use
Hope
Depressed
Poor SelfCare
Base9
line
Mos.
Baseline
9
Mos.
Baseline
9
Mos.
Baseline
9
Mos.
.54
(1.23)
.53
(1.17)
39.03
(11.45)
38.63
(7.75)
4.21
(2.06)
3.20
(1.91)
2.04
(1.40)
.85
(1.52)
.05
(.21)
43.467
(12.52)
45.68
(10.59)
4.03
(2.28)
2.64
(1.99)
2.09
(1.69)
Well-Being
Baseline
9 Mos.
2.80
(1.36)
43.56
(28.20)
53.65
(19.76)
1.68
(1.04)
44.70
(29.41)
61.40
(28.41)
Usual Care
Mentor
Significance
p = .004
p = .04
p = .002
p = .02
p = .016
Peer support can be considered an evidence-
based practice. Practice guidelines and
provider competencies are being established.
Have we arrived? Is the story over?
PEER WORK HAS BEEN FOUND SO FAR TO…
 reduce readmissions by 42%
 reduce days in hospital by 48%
 decrease substance use
 decrease depression
 increase hopefulness
 increase engagement with care
 increase activation and self-care
 increase sense of well-being
 improve relationship with provider
Recent review by Chinman et al in psych services
CURRENT SITUATION
 Moving away from symptom management that has (falsely)
accepted long-term disability as inevitable
 Moving toward promoting the recovery, social inclusion, and
citizenship of persons with mental heath conditions and
addictions through the use of community-based supports,
including peer-based support
 Medicine is shifting to self-management of health care
conditions, including behavioral health
 Who better to promote self-management than peers?
WHAT DO PEOPLE NEED IN ORDER TO
ENGAGE IN SELF-CARE?
Available and consistent social support
Accurate and accessible information (and, if
needed, health education and modeling)
Internal locus of control
Personal sense of efficacy
FACTORS THAT MAY HAVE BEEN
DETRIMENTALLY AFFECTED BY HAVING A
MENTAL ILLNESS OR ADDICTION
√ Availability and consistency of social support (through stigma,
rejection, and alienation)
√ Accurate and accessible information (and, if needed, health
education and modeling) (through stigma and
discrimination)
√ Internal locus of control (through illness/symptoms)
√ Personal sense of efficacy (through illness, repetitive failures,
demoralization, and discrimination)
BEFORE THEY CAN EXERCISE
SELF-CARE, THEN
People may need to:
Acquire or have social support
Be provided with accurate and useful
information about “self-care”
Re-establish an internal locus of control
Regain a personal sense of efficacy
THE ‘VALUE ADDED’ OF PEER WORK
No matter how people may look on the
outside, peer staff remember that there is still a
person there on the inside
Peer staff strive to connect with that person,
bring out and amplify that person’s voice,
make it safe for that person to come out and
join in with others
FIRST, THROUGH BASIC RESPECT
“Common courtesy works because it’s common; it’s
something every human being gets just because they’re
human. Things like saying “excuse me” when you reach over
someone to reach for a piece of paper, like saying “God
bless you” when someone sneezes, things like asking you if
you’d like some water when you get up to get some for
yourself. It’s basic, but it means so much to someone who’s
been treated like an unhuman for decades. It’s basic, and it
may seem trivial to you, but to people like me, it’s water to a
dying parched husk of a person. Interactions like the[se] …
have more positive impact on the consumer than any
elaborate treatment plan ever could.” -- Amy Johnson
REGAINING A SENSE OF BEING
LOVED AND ACCEPTED …



“I’m nobody till somebody loves me. That’s the way I look
at it.”
“When I was going through my psychotic changes she was
always there for me. She never turned her back on me.”
“I think [riding the horse] helped me ... It relaxed me. And,
well, I guess it made me feel like the horse loved me.
Spending time with the horse, it felt like unconditional love...
you connect with the animal and with yourself and you’re
outdoors and it does something to you. It’s hard to explain,
but when you go home you think, ‘Wow, another lesson!
Wow, I’m getting better!’”
A sense of self is the basic… Now, I have a very fleeting, very fragile sense of self. I
am thwarted by visual disturbances, auditory hallucinations, tactile flashbacks,
waves of intense emotion, and paranoia. I get caught up in me easily, where I
literally can’t see what’s in front of me. A sense of self gives one the right to speak, it
fuels the indignation required to speak… A sense of self makes all other behaviors
possible; without a self, nothing can happen. This is why schizophrenia is so
debilitating.
Modeling self-respect and how to respect others involves active listening and
improv; you must be ready at any moment to demonstrate respect. Little moments
pop up … where the consumer’s weakness in self-esteem become apparent, and
your job … is to pay attention to those maybe quiet holes and fill them. Self-esteem
doesn’t point out where it’s been hurt, and that’s why listening is so important. You
have to listen for the holes in self-esteem. Each person has a personality, and each
person has a history, so the remedy for each hole may be a bit different, so you’ll
have to think quickly on your feet and sort of craft a makeshift self-esteem for your
client. It’s not dissimilar to a crisis triage in that you are working quickly and
efficiently to save a person’s life. Self-esteem is critical to an individual’s sense of
self, to an individual’s sense of efficacy, to a person’s recovery. I didn’t enter
recovery until someone else thought I was worth recovery, until someone else loved
me. I didn’t think I was worth recovery until someone else did.
-- Amy Johnson
“You need a little love in your life and
some food in your stomach before you
can hold still for some damn fool’s
lecture about how to behave”
–Billie Holiday
REGAINING A SENSE OF
PERSONAL EFFICACY
 Unclogging a toilet
“It is being active, and I take pride and I’m
independent to a certain extent . . . like in my jazz
music, like I‘ll turn on my jazz radio, and I’ll love it . . .
It’s my interest. I turn the radio on myself, no one had
it going to nourish themselves, to entertain
themselves, like parents would at a house. I turn it on,
I’m responsible, I enjoy the music, I make notes and
draw while I’m hearing it. . . Then I turn it off, then I
have some evidence, I’ve got something done, I’ve
been productive, I have the drawings to look at. . .
It was for me and by me. My own nurturing. So
I’m proud of this effort.”
“I have a good will, it just takes the right amount, the
um, the kitchen has to be right, so to speak, before I
do … the endeavors. The feeling has to be right.
Everything has to be right before you can make a
cake … If you don’t feel like buying the flour for six
months … then you don’t feel like it. Then you get
your flour, and then you notice you don’t have
enough cinnamon, so you wait a while …”
REGAINING A SENSE OF CONTROL
”Basically, if you know recovery…it is more about taking
control of your life and what you are going to do….”
“I'm in a contest of will with the world, with
nature ... and I say to myself: ‘Well, damn it, you
just calm down and drink your coffee.’ And I say
to myself: ‘You'll just have to wait five minutes.’
So I wait. And then the roommate's still bugging
me out [but] then I have the control, the selfesteem, the confidence, and it's manageable.
Then I just proudly walk to my room and take
space. I mean, it's successful.”
“there is this wicked side of me that can stop me.
Just like when I’m looking for a job and see a job
that would suit me, there is a voice that says, ‘Ah,
that’s no job for you’, and stuff like that. And so I
have to work a lot with that voice, ‘Oh, shut up, I’m
going to apply for that job anyway’.
It’s a struggle going on inside me all the time.”
“[Having] schizophrenia means you must invite
me to my own party because I don’t know to
bring myself. [You must use] nice language to
describe this stranger who’s coming to the party
(i.e., me), [make her] sound like a nice person,
[so that] I'd like to meet her when she arrives.”
-- Amy Johnson
I can be a
friend
I can ride a
horse!
I can make
drawings
I can turn on
and off my
own radio
Scaffolding a new sense of self
ATTENTION TO MICRO-DECISIONS
AND ACTS
“People take for granted that you just do
things. A person with mental illness, it’s
sometimes hard … it’s like you’re
distracted, you can’t get involved because
you’re not sort of all there.”
GETTING THERE STEP BY STEP
“So I take it step by step. I have learned to hurry
slowly and do it in stages and set partial goals when I
have discovered that it makes sense … doing it by
partial goals and making it manageable, then you get
positive feedback that it’s going okay and then you don’t
hit the wall. That’s my strategy, the strategy for success:
partial goals and sensible goals and attainable goals,
and that’s something I’ve learned to do in order to
achieve things. When I have been able to deal with
something that’s been a struggle and feel secure, I
move on. Step by step, put things behind me.”
“Before … everything was in the long term… Instead, having to
hang on, to find strength, I live small moments more intensely.
Now we’re here, you and I, and my whole life is all here, only
here. It doesn’t matter what else happens… This moment here is
more important than anything that might happen tomorrow.
This was definitely decisive for me, this fact of living intensely
what I’m doing instead of worrying about the future or other
things was a real support, a cornerstone for everything … a very
difficult awareness, a difficult position to take, but living
intensely whatever I’m doing, being very concentrated, for me
personally … I did this and no one told me to do it. I did it on my
own and it works. For me.”
“Each time I recover enough, I borrow a dog and go
for a walk”
“My first step after getting out of bed was to come
here (to the centre); I’d come here even if it were
only for 5 or 10 minutes a day. And those 5, 10
minutes turned into hours, weeks and finally I
became the secretary and district representative,
and now I write for Revansch! (magazine) and the
local newspaper…”
IMPLICATIONS FOR PRACTICE AND CARE
Most people will be able to figure out how to take
care of themselves while living a meaningful and
gratifying life in the face of the disorder
In order to do so, they may first have to regain a
sense of being loved and accepted as a worthwhile
person who can have some control over his or her
life and be somewhat effective in the world
This may represent a first and essential step toward
recovery and a first focus of efforts of peer staff to
engage people in self-care
WHAT PEERS CAN DO
In order to lay this essential foundation, peer staff
need to pay particular attention to the microprocesses and micro-decisions of everyday life.
This is because recovery is made up of the same
innumerable small acts of living in which we all
engage, such as walking a dog, playing with a
child, sharing a meal with a friend, listening to
music, or washing dishes.
It is nothing more but also nothing less.
“YOU CAN DO IT. WE CAN HELP.”*
 Focus on eliciting and enhancing the person’s own
sense of control and efficacy, as only the person him
or herself can enter into, pursue, and maintain his or
her own recovery
 Focus on identifying and building upon each
person’s assets, strengths, and areas of health and
competence to support the person’s efforts to
manage his or her condition while establishing or regaining a whole life and a meaningful sense of
belonging in and to the community.
*The Home Depot
THEN WHAT?
‘Invite’ people to take up an active role in
their own care (i.e., self-care)
Explore person and family’s own
understanding of the situation
Provide information, education, and role
modeling related to self-care
Connect self-care to personally relevant
goals, aspirations, and understanding
EXAMPLES
People may want to:
 Go to school
 Get a job
 Get a boyfriend/girlfriend
 Open a checking account
 Go fishing
 Learn to sew, cook, or knit
Challenge: How will self-care help people to participate in
these activities???
RECOVERY CANNOT BE SIMPLY THE LATEST
THING WE DO TO PEOPLE WITH BEHAVIORAL
HEALTH CONDITIONS
Recovery
IN THE END …
“all they’ve got to get close to me and save me
from the death of alienation, is compassion.
They must be super compassionate, trying to
imagine all the time what it must be like for me,
and, willing to sit down with me and give me lots
of their time, as we struggle to understand each
other, as we map out a common language that is
translatable in both my native tongue and
theirs.”
-- Amy Johnson
REACTIONS, QUESTIONS …
???