Consumers as Service

Providers: Relevance to ACT

Phyllis Solomon, Ph.D.

Professor
School of Social Policy & Practice
University of Pennsylvania

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 Outline of Presentation

Introduction
Definitions & Examples of Consumer Providers,
including as ACT team member
Theoretical & Historical base
Summary of the Evidence
Impact of COS on consumer outcomes
Value of consumer providers
Challenges
Strategies for hiring consumer providers
Consistency with Recovery

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 Introduction
Currently interest in Consumer Operated
Services (COS) very high internationally
US. President’s New Freedom Commission
report in 2002 put spotlight on COS
Recovery orientation internationally significant-
Canada, Scotland, England, Australia – to name
a few
Consumer providers means to translate recovery
orientation into service delivery

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What are Consumer Operated
Services (COS)?

Services planned, operated, administered, &

evaluated by indivs. w/ mental illness

– Indivs. ID as consumers
– Administration & primary activities independent
of mh provider orgs.
– Consumers control Board of Directors, staff, &
budget
– Self contained programs

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 Example of COS - BRIDGES
BRIDGES of Tenn (Building Recovery of Individual
Dreams and Goals through Education and Support)
Decade old
Started by a federal grant
Education program to help other peers establish &
maintain wellness & recovery
Involves education about illness, role modeling,
using personal experiences & standard manual for
imparting educational material – 15 week course -2hr
class
Replicated in other states & Canada

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 What are Consumer
Partnerships?

Services provided by consumers

Self contained programs
Consumers self identify as having mental
illness
Administration, budgeting shared by non-
consumers
Control shared w/ non-consumers
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 Example of Peer Partnership –
Friends Connection
Promotes recovery from dual diagnosis
Program of local MH Assoc.
Started in response to closing of local
state hospital
Provides peer-to-peer support, sponsors
group social activities, & alumni program
Clients are in intensive case management
& referred often by case manager
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 Consumers as Employees
Individuals who self identify as consumer
& hired in designated consumer position or
traditional MH position

Designated consumer positions – peer

specialists, case manager aids, peer
advocates, peer companions, etc.

Prosumer – consumer & MH professional

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 Consumers as Employees

Existing jobs such as case managers

Adjunctive jobs like case manager aids
Hired as ACT team members
A number of community mental health
agencies hire consumers

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 Consumers as ACT Team
Members
Logical context for consumer-professional
collaboration
– Multidisciplinary team
– Strong outreach component
Program standards for ACT teams in Ontario
Canada require minimum 1 FTE paid staff as
peer support worker
Must be paid commensurate with other staff
Peers with experience can be hired in other
team positions & paid at professional rate

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 Consumers as ACT Team
Members
Peers provide experience not replicated by
professional training
Fully integrated in team & generalist role
Individualized services & promote self
determination & decision-making
Expertise & consultation to team to
promote culture client’s point of view &
preferences recognized, understood, &
respected (Ontario Ministry of Health, 2005)

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 Consumers as ACT Team
Members
Peer Support Services serve to
– promote active participation of client in
service planning
– validate clients’ experiences
– Guide & encourage clients to take
responsibility for & participate in own recovery
– Help to combat stigma & discrimination
– Help to develop strategies to reduce self-
imposed stigma (Ontario Ministry of Health, 2005)
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 Consumers as ACT Team
Members
Peer Support Services include:
– judicious self-disclosure & sharing life
experiences to serve as mentor & role model
– Assist clients to recognize & develop coping
mechanisms to deal with symptoms & social
stigma
– Educate team regarding consumer
perspective on mental health system & to
maintain client-centered approach maximizing
client participation & empowerment

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 Consumers as ACT Team
Members
- advocating for development of
consumer initiatives in community &
identifying opportunities for client
empowerment
- introducing & referring clients to
consumer self-help programs &
advocacy organizations that promote
recovery (Ontario Ministry of Health, 2005)

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 Consumers as ACT Team
Members
Consumers powerful effect on non-
consumer providers –changing nature of
team meetings & serving to humanize
team by introducing their perspective
(Solomon & Draine, 1998; Salyers & Tsembris, 2007)

Inclusion of consumer providers on ACT

natural way to enhance recovery-
orientation

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Survey of ACT Providers in Ontario

Key findings

– personal experience most important qualification

– Constraints not being accepted by hospital staff, not
being seen as credible by staff outside team
– Some variation in roles & degree of integration of
consumers, consumer generally well incorporated into
team with equal or better job satisfaction compared to
other staff

(Whie, Whelan, Barnes & Baskerville, 2003)

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 Peer Specialists
Peer Specialists – current or former
recipients of mh services who provide direct
services to consumers in emergency, outpt,
inpt settings. Perform a range of tasks
designed to assist consumers in regaining
control over own lives & control over their
recovery processes. Model competence &
possibility of recovery. Assist consumer in
developing perspective & skills that facilitate
recovery. Have taken training & certified

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 Peer Specialists

Requirements of Peer Specialist

– High school degree or equivalent
– Current or former recipient of services
– Experience, e.g., 1 year advocacy exp.,
demonstrate effort at self-directed recovery
– Skills & knowledge- verbal & written skills, good
interpersonal skills, good problem solving skills,
basic knowledge of community supports, state &
federal benefits

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 Peer Specialist Training
Georgia training - 8 days
– Training to assist consumer in skill building, goal
setting, problem solving, conducting Recovery
Dialogue, setting up & sustaining mutual self help
groups, assist consumers
– Medicaid reimbursable
Depression & Bipolar Support Alliance –
provide 5-day trning nationally
– Topics include: role of peer support in recovery,
problem solving; effective listening & art of
asking questions; combating negative self talk;
power, conflict & integrity in workplace

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 Peer Specialist Training

Number of Peer Specialist Training

Programs in existence
– META Arizona (now Recovery Innovations,
Inc) does national training
– Philadelphia recently started trning

National org. – Peer Specialists Alliance of

America – formed as National Association
of Peer Specialist in 2006

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 Self Help- Mutual Support Groups

Self help groups different from COS

– Peer support services not same peer involved services
Voluntary small group structures for mutual aid formed
by peers to satisfy common need, overcoming common
handicap or disrupting problem, or bring about desired
&/or personal change
– Face-to-Face
– Internet Support Services
Offer hope, information, & opportunity to help each other
Share some features in common as Peer Support
Services

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Theoretical Basis for Consumer
Providers
Emotional support – demonstrating &
communicating acceptance & approval
Experiential learning or reciprocal learning
process – provided specialized information
& perspective
Social learning theory – competent role
models- learning through active examples

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Theoretical Basis For Consumer
Providers
Social comparison theory – Upward
comparison – hope & incentive;
Downward – things could be worse

Helper-therapy principle – helping others,

helps oneself

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 Historical Roots of Consumer
Providers
Early 20th Century Clifford Beers promoted
consumer advocacy voice – started MH
Association

1940’s – self help group of discharged

psychiatric patient started Fountain House –
psychosocial rehab center

Other psychosocial rehab centers promoted

consumer empowerment

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 Historical Roots of Consumer
Providers
1970s ex patient movement – consumer developed
alternatives like drop-in centers, crash pads;
consciousness raising support groups – Anti-
psychiatry movement

Late 1970s – Community Support Program Federal

program promoted development of COS through
grant program

Some states supported development of COS through

grants

Currently most states dept of MH have Consumer

Affairs director position

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 Anecdotal Data on COS
Environments
Non-threatening environment

Minimal disclosure of personal information

Accept services at own pace

Engender feelings of safety

Greater ability to engage consumers –

difficult & resistant to tx

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 Critical Ingredients of
Consumer-Operated Services (COS)
National study of experts using modified
Delphi method
Structure
– Emphasizing value of consumerism
– Consumer involvement in operation & decision-
making
Process – Belief Systems
Emphasizing recovery & empowerment
Process – Social Support
Emphasizing sense of belonging, friendship,
giving receiving – helper principle
(Holter, et al., 2004)

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 Summary of the Evidence
Early studies demonstrated consumer
capability
No detrimental effects from consumer
providing service
No detrimental effects to consumers
providing services
Limited research – most descriptive studies,
few RCTs
Sometimes difficult to distinguish COS from
Consumer Partnership

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 Summary of the Evidence
COS/Consumer Partnership Marginally more
effective
Generally as effective as non-consumer in
providing conventional services
Consumer on team generally equivalent
outcomes for clients served as non-consumer
Some studies found more positive outcomes for
clients - fewer hospitalization, increased
empowerment, self efficacy, growth, & improved
quality of life

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 Summary of the Evidence
Some studies positive outcomes for
systems- reducing costs, improved
outreach & engagement, improved
provider attitudes
Continue to show NO detrimental effects
Shows promise – President’s New
Freedom Commission considers COS
“Emerging Best Practice”

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 Importance of Evidence Based
Practice for Consumer Providers

Credibility of services
Financial resources
Organizational support
Stability of services
Sustainability as part of MH service
delivery system

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 Impact of COS Environment on
Consumer Outcomes

Greater involvement & control in COS greater gains

in personal empowerment & social functioning (Segal
& Silverman, 2002) increase in recovery (Corrigan, 2006

Greater use of COS greater increase in well-being

(Teague, et al., 2005)

Greater participation larger social network, impr. self

concept, dec. hosp. (Corrigan, et al, 2005)

Attendance assoc. w/inc. social functioning (Yanos, et al,

2001) 32
 Impact of COS Environment on
Consumer Outcomes
Opportunities to participate in decisions
about care result in positive outcomes (Segal &
Silverman, 2002)

Quality of participation (meaningful involved)

result in short term positive outcomes –
quality of life, daily activities, & community
integration (Nelson & Lomotey, 2006)

Environmental acceptance result in engagement of

consumers who don’t want or have had negative
experiences w/ conventional MH services
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Value of Consumer Provided Services

Consumer Operated Services – offer real

value to consumers
Offer hope, acceptance, insight & recovery
orientation
Demonstrate to professionals, families, &
society capability of consumers
Help to engage individuals that may not
otherwise be engaged but need services &
supports
Offering an accepting environment

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 Value of Consumer Providers

Offer consumer perspective

Engage other consumers at a personal
level
Help other consumers with
socialization & support
Knowledgeable about diversity of
human services & health systems
Offer successful coping strategies
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 Value of Consumer Providers

Offer coping & problem solving skill

development
Offer role models for other consumers
Providers see consumers in new roles
& as capable individuals
Help to change providers attitudes
Help to transform systems
Help to combat discrimination
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Benefits to Consumer Providers
Work opportunity
Build a work resume & career trajectory
Personal growth- assume responsibility &
increase awareness of own capabilities
Learn time management skills
Socialization into world of work

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 Challenges to Professionals of
Consumer Providers
Professional attitudes
– Believing in capabilities of consumers
– Paternalistic attitudes – fear of stress
– Easier to change heads than hearts –
Georgia experience
Boundary issues
– Concerns of violation of confidentiality
– Concerns about dual relationship

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 Challenges to Professionals of
Consumer Providers
Role conflicts
– Power struggles between peer providers &
professionals
– Balancing peer status with professional
identity
Require special accommodations

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Challenges to Consumers as Providers

Having to cope with dual role

Peers do not want to receive services from
other peers
Socialize consumers to professional
beliefs & roles – diminishing unique
perspective

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Consumer Methods for Coping with Dual
Role
Participating in support groups
Following own treatment plan
Being active in care of one’s illness/self-
monitoring
Seeking support of supervisor
Attending trainings
Seeking support from peers, friends,
family/using diverse support network
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 Challenges to Families Regarding
Consumers as Providers
Lack of belief in capability of consumers
Paternalistic view of consumers – concern
regarding stress
Concern that their relative receiving
“lesser quality” services
Too stressful

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Challenges to Hiring Peer Workers

Need to know how to involve peers

How to support them
How to resolve potential conflicts
How to weigh different perspectives of
clinicians & peers

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Workplace Strategies to Respond to
Problems & Promote Integration
Problem: Attitude toward Recovery
– Clear recovery position in mission statement
– Leadership commitment to recovery well
communicated
– Leadership to support recovery
– Peer position viewed as essential rather than
an add-on

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Workplace Strategies to Respond to
Problems & Promote Integration
Problem: Role Conflict & Confusion
– Well defined recruitment strategies
– Consistent application of workplace policies
to peer & non-peer staff
– Written job descriptions for all staff including
peers
– Well developed qualifications, including
exclusion criteria e.g., substance abuse,
location of service receipt

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Workplace Strategies to Respond to
Problems & Promote Integration
Problem: Role Conflict & Confusion
– Supervision to ensure actual job expectations
same as written job expectations
– Training to staff & clients to provide
understanding of roles
– New employees receive formal orientation

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Workplace Strategies to Respond to
Problems & Promote Integration
Problem: Lack of Confidentiality
– Neutral job titles not disclosing peer status
– Implement formal disclosure process for peers
– Keep previous treatment records of internally
recruited peers in confidential files

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Workplace Strategies to Respond to
Problems & Promote Integration
Problem: Lack of Confidentiality
– Do not allow peers to receive services in units
where employed
– Training on policies & practices related to
confidentiality
– Establish formal process for sharing work-
related information between peer & non-peer
staff

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Workplace Strategies to Respond to
Problems & Promote Integration
Problem: Job Structure
– Accepts experience in lieu of formal
credentials a HR policy
– Peer positions paramount
– Peer positions balance professionalism &
consumer experimentalism
– Peer positions have clear path for promotion

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Workplace Strategies to Respond to
Problems & Promote Integration
Problem: Job Structure
– Apply same performance standards to peers
& non-peers
– Compensate peers & non-peers equally in
comparable positions
– Provide benefits counseling to help inform
peer’s decisions on hours to work

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Workplace Strategies to Respond to
Problems & Promote Integration
Problem: Social Support
– Opportunities for interaction in agency life
(team meetings)
– Include peer input in treatment planning &
case notes
– Training in dressing for work, good hygiene, &
regular attendance & timeliness at work
– Training in emotional detachment, objectivity,
listening & providing support, focus on
problem solving

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Workplace Strategies to Respond to
Problems & Promote Integration
Problem: Social Support
– Offer peers training to learn language of
workplace
– Supervision & support in work place
– Meet ADA requirements for accommodation
( adapted from Gates & Akabas, 2007)

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 Vision for Consumer Operated &
Provided Services
Hire Consumer Providers
– Create positions
Help to develop Consumer Operated
Services/Consumer Partnerships
– Offer technical assistance & support
– Offer resources & funding
– Offer acceptance & belief
– Define clear roles – build on consumer strengths
– Offer training for peer specialists
Hire Consumers into existing positions

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 Recovery Orientation
Hiring peer providers does not necessarily
equal recovery oriented services
Recovery oriented services are different
way of viewing & working with clients
Don’t assume hiring of consumers
absolves providers of all sins

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Consumers as Providers Consistent with
Components of Recovery
Self-direction – consumer leads & chooses
direction
Individualized & person-centered – varies by
strengths, needs, experiences & preferences
Empowerment – consumers authority to
participate in all decisions about their life
Holistic – encompasses all aspects one’s life,
including mind, body, & spirit
Non-linear – continual growth, occasional
setbacks & learning from experience

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Consumers as Providers Consistent with
Components of Recovery
Strengths-based – builds on personal
strengths, capabilities, resiliencies,
talents, coping abilities & personal
worth
Peer support – mutual support from
other consumers essential
Respect –community systems, &
societal acceptance
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Consumers as Providers Consistent with
Components of Recovery

Responsibility – consumers have

personal responsibility for own
self-care & journey of recovery
Hope catalyst for recovery & can
be fostered by others
National Consensus Conference on mental Health
Recovery – SAMHSA- 2004

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 Conclusions

Although the evidence may not be very

strong – the values are strong
There will be challenges to developing
these services, but the beneficial values
are great
Believing in people & treating with respect
accomplishes a lot – these services can
communicate these values

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