Module 3: The Importance of Role Clarity for All Parties
Importance of clarifying expectations and role definitions of new staff
The single most importantthing you can to do to ensure the success of new peer staff—in addition to preparing the cultural climate of your agency as described in Module—is to be as clear as possible about the expectations you have for these staff with respect to their roles and job performance. What is it exactly that you want them to do, and how, for whom, where, over what period of time, and with what expected outcomes? How will you, and they, know when they are doing a good job, and when they might need additional direction or support? How will the other (non-peer) staff know when their new colleagues are doing what they were hired for, and how can they expect this work to impact on their own?
As you will see below, expecting peer staff to provide peer support, as simple and obvious as that may sound, does not provide sufficient clarity either for the new peer staff or the existing, non-peer staff with respect to what the staff member will be doing while he or she is inspiring hope, sharing his or her own recovery story, engaging a person, or role modeling self-care.
Do these conversations, for example, take place in an office, at the local coffee shop, in an agency car on the way to and from medical appointments, or perhaps in the client’s own home? Do peer staff connect clients to other community resources, do they work collaboratively with their clients to develop Wellness Recovery Action Plans (WRAPs) or person-centered recovery/care plans, or do they lead support groups focused on wellness strategies? Are they more like personal trainers who encourage exercise, good nutrition, and smoking cessation, or are they more like case managers who assess and help clients address their basic needs for housing, income, education, and employment? And to the degree that aspects of their roles appear to be similar to those of non-peer staff (e.g., case management), how is overlap or duplication in roles and expectations between peer and non-peer avoided?
This module addresses these central questions. We suggest that it is important to address these questions early and often for at least two reasons. First, because it will be essential for new peer staff to know what is expected of them in their new roles. This kind of clarity is essential for all staff, of course; it does not have to do specifically with the new staff’s peer status. But for most behavioral health staff, clarifying their roles was an important function of their pre-service training in graduate or professional schools. You leave graduate nursing or social work programs with a fairly clear idea of what nurses or social workers do and the ways in which a nurse or social worker functions differently from each other and from other professionals. At the present time, peer staff may perform a wide range of roles and serve a number of different functions, depending on the jobs for which they are hired and the agencies hiring them. It therefore is incumbent on these agencies to be very clear about which roles and functions they are hiring each person for and the ways through which the person will be expected to inspire hope, share his or her recovery narrative, engage clients, and role model self-care.
The second reason that it is important to be clear about expectations and roles, including the ways in which the work of peer staff complements (rather than duplicates) that of non-peer staff, is because non-peer staff need to understand what their new colleagues will be doing to contribute to the agency’s mission and how that work interfaces with their own. Non-peer staff are less likely to worry about their own job security, for example, when they see new peer staff offering services and supports that they themselves do not already offer and in ways that they do not. It also will be easier for non-peer staff to appreciate the unique contributions that the new staff can make to engagement, resilience, self-care, and recovery when they see peer staff doing new things and acting in new ways that embody the values and principles of peer support. In this regard, it is important for agency leaders to dispel rumors or myths that peer support is either opposed to clinical care (e.g., anti-“medical model”) or a replacement for clinical care (e.g., clients don't need care plans if they have WRAP plans). From the start, peer support should be framed as an exciting new development that complements and enriches clinical and rehabilitative care, helping to ensure that clients make the most effective use of, and derive the optimal benefit they can from, the services and supports available to them.
Description of various rolespeerstaff may play
The following are brief descriptions of various functions peer staff may serve based on their own life experiences, the pre-service training they will have received, and any on-the-job orientation and training, and on-going supervision, they will receive once hired. While these functions are described separately for clarity and ease of comprehension, any one peer staff member may play more than one of these roles at any given time. As we pointed out above, peer staff are often doing other things in addition to offering peer support per se, and how many of these different things they may be doing at the same time will depend on the needs of the agency and the clients being served. We thus begin the list with the role of peer supporter before going on to describe various mechanisms through which peer support may be offered, beginning with the most established and evidence-based roles (e.g., outreach and engagement) and ending with the most recent developments (e.g., health navigation).
Peer supporter
A primary role of peer supporters is to share their own life experiences of whatever behavioral health condition(s) they have dealt with and the expertise in resilience and recovery they have developed as a result of these experiences. The reasons for doing so are multiple, and include: inspiring a sense of hope that resilience and recovery are possible; demonstrating credibility and earning the trust of persons who are reluctant to engage in any forms of health care; role modeling self-care; encouraging people to take on more active roles in their own lives, health care, and recovery; extending the benefits and expertise of someone who has “been there” and successfully negotiated the health and human services systems to others who are newer to, or less practiced in, these challenges.
Given the dedication and compassion that comes from their own personal experiences, peer supporters mayview their role as involving doing whatever is necessary to empower other people to do what they want to do, both in managing behavioral health conditions and in pursuing full and meaningful lives. Within the context of care planning, peer supporters assume the roles of assisting clients in identifying and articulating their own life goals and then empowering them to pursue those goals most important to them. At times, this will also require peer supporters to empower clients to take a more active role in their own care, including in their own care planning processes.
For example, while many clients may readily identify their own aspirations, hopes, and goals in conversations with a peer supporter, they may also be reluctant to entrust these matters to behavioral health professionals who, in their experience, have not been interested in such highly personal matters in the past, focusing instead primarily on symptoms and impairments. Having had their own similar experiences of symptom and deficit-based care in the past, the peer supporter can anticipate and address this form of reluctance, and the experiences of demoralization that underlie it, and encourage the client to consider how services can be useful in supporting his or her own efforts to pursue the kind of life he or she wants to lead. Also having had his or her own battles with mental illness and/or addiction, the peer supporter can understand, and support the client through, the common struggles with fears, self-doubts, negative self-talk, and avoidance of risks that otherwise may impede the care planning process.
Peer change agent
Advocating for a client in the care planning process—to make sure that his or her own goals drive the development of the plan—is only one example of the ways in which peer staff may advocate for changes in agency practice. In fact, the role of agency or system change agent was one of the first for which peer staff were hired, in addition to the provision of peer support, as it was hoped that they would serve as role models for existing staff as well as clients.[1]A change agent within an organization enables others to look at beliefs underlying habitual behavior, the validity of long-held values and assumptions, and the effectiveness or ineffectiveness of the “we have always done it this way” attitude. One of the strengths a peer staff member brings to this role comes from the fact that the peer workforce is the first and only workforce in the behavioral health system to come into being on this side of the shift to a resilience and recovery orientation. This means that while psychiatrists, nurses, social workers, clinicians/ counselors, case managers, etc., are trying to re-define and re-create their roles in light of this paradigm shift, the peer staff are already focused on promoting resilience and recovery as their primary task. Peer staff also have an insider’s perspective on some of the barriers that get in the way of effective care and the promotion of resilience and recovery. Highlighting and helping to address these barriers is a unique and valuable role that change agents can play.
Peer staff are living examples of resilience and recovery, making them ideal change agents. An example of the change agent role is that the very presence of a peer staff member in a staff meeting, case discussion, or gathering with other staff often changes the tenor of the conversation. Staff often become more sensitive about how they talk about clients if a peer staff member is in the room. The presence of peer staff also has a positive impact by challenging stigma and old beliefs that people with serious mental illnesses or addictions cannot function, cannot think straight, cannot make sound judgments, and, in general, cannot be trusted with responsibilities. Having co-workers who are peer staff–who have been through a training program and are productively employed service providers–offers staff a concrete and daily reminder of the possibility, and reality, of recovery.
Some of the other ways in which peer staff can help to change practice is by focusing on clients’ interests and strengths, promoting wellness, and, based on their own experiences of overcoming adversity, approaching everyone with the attitude that recovery is possible, not only for individuals but for organizations as a whole. In this respect, peer staff often come into their jobs already aware that, in addition to whatever else they may be doing, changing provider beliefs is a major contribution they make to agency transformation.
Peer outreach and engagement specialist
This is the peer role for which the most evidencecurrently exists, showing that peer staff can be highly effective in engaging into trusting relationships and behavioral health care those persons who are reluctant to receive behavioral health services.[2]This reluctance may stem from the behavioral health condition itself (e.g., auditory hallucinations and/or paranoid delusions that convince the person not to trust behavioral health providers) and/or from the person’s previous negative experiences of care, which at times has been involuntary or court-ordered. Against this backdrop of distrust, suspicion, or anger, peer staff can gradually earn the person’s trust by establishing their credibility (having “been there” themselves), accepting these negative feelings and beliefs as understandable and legitimate reactions to unfortunate circumstances, and offering clients hope that their experiences can be different this time around. Peer staff can attest to, and provide concrete living proof of, the value of behavioral health services and persuade skeptical people that their lives can be improved by allowing others in to help them, whether that be through medications, an empathic ear, or access to such resources as housing, health care, and income support.
In addition to physically connecting with people in community settings (outside of behavioral health agencies), outreachinvolves removing barriers to receiving care, including bureaucratic red tape, intimidating or unwelcoming physical environments and program procedures, scheduling requirements, and modes of service provision that conflict with the life situations and demands of persons with behavioral health conditions. It also involves moving away from certain philosophies of treatment previously adhered to by some practitioners—including hitting bottom (e.g., “Addicts can’t be helped until they hit bottom and have lost everything”) and incrementalism (e.g., “We can’t house people with addictions until they’ve been in recovery for 6 months”)—toward stages of change approaches, recognizing that addressing basic needs, employment, and housing enhances motivation for treatment and rehabilitation.
Finally, engagement involves making contact with the person rather than with the diagnosis, building trust over time, attending to the person’s stated needs and, directly or indirectly, providing a range of services in addition to access to clinical care. The process of engagement incorporates new understandings of motivational enhancement, which see people standing at various points on a continuum from pre-readiness for treatment to being in recovery, rather than being either motivated or unmotivated. Engagement also involves the peer staff’s sensitivity to the thin line between persuasion and coercion and paying attention to the power differential between the service provider and the person receiving or potentially receiving services, and the ways in which these factors can undermine personal choice. Rather than using coercion or intimidation, peer staff make every effort to ensure that clients are actively choosing those services and supports which they believe to be in their own best interest, as this is the only way to ensure that clients will actually follow through with the care they receive.
Thus far, peer outreach and engagement have been used to target persons who have refused services in the past or who are unwilling to engage in services currently, such as persons who have become chronically homeless and are disaffiliated from any helping systems. It also has been used to target persons who have multiple inpatient or detox admissions and who routinely choose not to follow through with care once discharged to the community, and is most recently being explored as an alternative to mandated outpatient treatment. In addition to engaging such persons into behavioral health treatment and rehabilitation, peer outreach and engagement staff have been effective in connecting them to various components of the recovery community, including recovery community centers.
Peer bridger or advocate
A somewhat natural extension of the outreach and engagement function is the so-called “bridger” function that peer staff can continue to play once a person is engaged into behavioral health services. A bridge connects two areas that are separated by an obstacle that would otherwise be difficult to cross. In the current behavioral health system, these two areas can be the perspective shared by staff and that shared by clients. The obstacle in this case is the lack of familiarity with, and understanding of, the other’s point of view; his or her pressing concerns, needs, and values. Because of peer staff’s experiencesas both ‘client’ and ‘staff’, they are in a unique position to continue to provide a bridge between ‘client’ and ‘staff’ and between ‘staff’ and ‘client’ once the person is engaged into care. Hopefully, this bridge will be a conduit for increased understanding and acceptance of different perspectives, clarifying roles and expectations, and creating healthy working relationships.
An example of such a bridging function would be helping a staff member understand why a client may be choosing not to take prescribed medications while at the same time helping the client understand the staff’s concern about this choice and its potential consequences. Hospital staff can greatly benefit from listening to a peer staff member share what it has been like for him or her to be an inpatient, just as detox staff may benefit from hearing about what was most useful to people early in their substance use recovery. Clarifying the ‘client’ and ‘staff’ perspectives, concerns, and values can serve a very productive function for an organization. Peer support staff can be crucial to the success of this dialogue.