Module 1: Preparing the Organizational Culture
Why do we have to “prepare” our organization for the hiring of peer staff?
This toolkit was developed in response to concerns agencies have raised related to the hiring of peer staff. Some of these concerns relate specifically to the peer staff themselves and their ability to perform the desired functions, and these concerns will be addressed later in this module. But many of these concerns relate more to the challenges that having peer staff on board have posed for the agency as a whole. These concerns range from the relatively concrete—such as do peer staff get keys and can they access medical records—to the more complex—such as if peer staff use self-disclosure effectively in their work with clients, does that mean that all staff should use self-disclosure, even if what they disclose is not a personal history of a behavioral health condition. This toolkit encourages agency leadership to address many, if not all, of these concerns ahead of time, in preparation for the hiring of peer staff, rather than waiting for the concerns to emerge once the staff are hired, when emotions may be heightened and effective resolutions may be harder to reach.
There is another important reason why leaders need to reflect on and prepare their agency for the integration of peer staff. This reason has to do with the history of the behavioral health system, and it is a reason that, unfortunately, is often the source of misunderstandings. Everyone working today in the behavioral health system, in Philadelphia or anywhere in the United States, inherited a system that is based on a stigmatized and discriminatory view of behavioral health conditions and the people who experience them. As is true of most deeply entrenched prejudices, this view of persons with behavioral health conditions often operates outside of the staff’s awareness and is not intentionally directed at specific people. Rather, it skews the staff’s perspective of an entire group of people and is directed at those people both indiscriminately and globally. As a result, people hold attitudes and beliefs about all people with mental illnesses, and/or all people with substance use disorders, who they see as being …
As an initial self-reflective exercise, have your leadership team complete the sentence above. Are there ways in which all persons with mental illnesses are alike? Are there ways in which all persons with substance use conditions are alike? Then consider what these perceptions or beliefs are based on. For example, are these beliefs based on empirical data (i.e., research)? Are these perceptions based on the staff’s experiences of providing services? Were these beliefs perhaps handed down by previous generations of practitioners? Do these beliefs apply to all people with behavioral health conditions, including your own loved ones, or do they apply only to those persons served in publicly-funded agencies and programs? How willing are the staff to reconsidering the accuracy of these perceptions and beliefs?
Hiring people from this stigmatized population to serve as staff immediately poses direct and indirect challenges to these discriminatory assumptions and beliefs. If all people with mental illnesses are “crazy,” “irresponsible,” “too sick to work,” etc., then how can a person with a mental illness be hired to be my colleague? Similarly, if all people with substance use disorders “can't be trusted,” are “irresponsible,” or have “addictive personalities,” then how can a person in recovery from an addiction work for this agency? These were the kinds of questions that were asked openly and with much affect in the early 1990s, when agencies first started hiring people in recovery for peer positions. While these questions may no longer be asked as directly or openly by staff, it is very common for the concerns to still be there and for them to surface in less direct ways. In fact, the two questions we mentioned above about keys and medical records we will describe later in this module as stemming from precisely this kind of prejudice.
In reflecting on and addressing this form of discrimination, it is important that leadership frame the issue historically and socially rather than personally. It may be useful to point to SAMHSA’s Action Plan implementing the recommendations of the 2003 President’s Commission on Mental Health, for example, where it is straightforwardly and unabashedly stated that: “a keystone of the transformation process will be the protection and respect of the rights of adults with serious mental illnesses” (DHHS, 2005, p. 3). The same can be said for adults with substance use disorders. In order to make effective use of peer staff, agency leadership has to be committed to protecting and respecting the rights of all persons with behavioral health conditions, both those hired and those being served. This also includes those who are already working for the agency but who have yet to decide to disclose this aspect of their personal history to others.
Hiring Peer Staff can be Only One Component of Recovery and Resilience Transformation
Another way of arriving at the kind of culture change that will be needed by most agencies in order to prepare for the integration of peer staff is to frame it as one component of the overall transformation to resilience and recovery in which the Philadelphia system has been engaged since 2005. If the transformative power of hiring peers is not conveyed clearly to existing staff prior to the peers being hired, then it will most likely become clear by virtue of the resistance some staff will show in response. On the other hand, the most effective route to bringing about the kind of culture change needed for the integration of peer staff is to ensure that your agency is as fully re-oriented to promoting resilience and recovery as possible. This section thus addresses the challenges involved in moving fully to a resilience and recovery orientation.
Where to start? In the organizational life of many agencies, the notions of recovery and resilience may first have been introduced by direct care staff, program managers, advocates, family members, or service users. They also may have been introduced by DBHIdS system leaders. None of these stakeholders may hold a traditional leadership position within your agency, however. For culture change to occur, a first prerequisite is for someone in a position of significant authority and leadership in the agency to make the transformation process an agency-wide priority so that these initial ideas can be acted on and developed further.
Regardless of where the impetus for transformation comes from, for recovery and resilience to take root and fully re-orient your agency culture, it is essential that the transformation process be endorsed and promoted from the top down, as well as implemented from the bottom up. As we will see later in this module, integration of peer staff requires changes in agency policy and performance improvement processes along with changes in practice. Affording peer staff an active and substantial role in the agency’s operation needs to be complemented by affording an active and substantial role to service users, family members, and allies in agency governance, monitoring, and evaluation. All of these changes, and more, require the active efforts and strong support of agency leadership in articulating a clear vision of where the agency is headed, addressing the inevitable barriers that will get in the way of achieving that vision, and institutionalizing the changes made so that they will endure.
For a useful summary of these, and other elements, of what is required for transformative change to be successful see the article “Leading Change: Why Transformation Efforts Fail” by John Kotter (2000), included in the Appendix. Also in the Appendix, find the “Peer Specialist Integration Leadership Commitment Checklist” adapted from Cohen (2005), which will provide you with an overview of the different ways in which leadership will be key to the success of this initiative.
A first set of questions for agency self-reflection therefore includes:
To what degree, and in what ways, is agency leadership engaged in, promoting, and supporting the transformation process as a whole?
How is agency leadership currently communicating its vision of resilience and recovery-oriented transformation to staff?
What is agency leadership doing to cultivate the sense of urgency that Kotter emphasizes or Cohen outlines?
Which additional leaders, if any, need to be engaged in the process?
And, finally, in what ways does my agency’s culture still need to change in order to more fully promote resilience and recovery and support the work of peer staff?
In order to answer this last question, see the following section.
Tools for Agency Self-Assessment
Several tools already exist that you can use to conduct a thorough self-assessment of different aspects of organizational culture to see where you are, and where you may need to go, in the overall transformation to a resilience and recovery orientation. These tools are included in the Appendix and address such domains as the involvement of service users, family members, and allies in positions of influence at different levels of the agency; the customer service orientation of the facility and staff; and the honoring and celebrating of diversity. We introduce each below.
We hope that these tools are useful in identifying priority change areas for your agency. As these tools cover a wide territory, you may want to consider enlisting a larger coalition of people, both inside and outside of your agency, to work on the culture change process while you continue the more focused process of preparing for the integration of peer staff.
Recovery Self-Assessment Checklist and Planning Companion
The Recovery Self-Assessment (RSA) is a self-reflective tool designed to identify strengths and target areas of improvement as agencies strive to offer resilience and recovery-oriented care. We have adapted the RSA so that your team can use it as a checklist and discuss opportunities for growth as well as existing strengths.
The RSA contains concrete, operational items to help agency staff, service users, family members, and allies to identify practices in your agency that facilitate or impede the promotion of resilience and recovery. To learn more about the RSA, and view different versions of the instrument, visit the Yale Program for Recovery and Community Health online at:
http://www.yale.edu/PRCH/tools/rec_selfassessment.html
The RSA Planning Companion is a tool that was developed by The University of Texas Center for Social Work Research based on the RSA and the Practice Guidelines for Recovery-Oriented Care for Mental Health and Substance Use Conditions developed by the Yale Program for Recovery and Community Health (CT DMHAS, 2008).
The following is a set of questions that you might consider after reviewing the RSA:
Which items on the RSA stand out to members of your team, either because they have already been achieved or because they seem particularly difficult to achieve?
Which of the five RSA domains are currently of the most interest to your agency (e.g., Involvement, Life Goals)?
What strengths have you identified from items on the RSA that you can build on in your on-going transformation efforts?
Are there ideas from the planning companion that you can act on?
Diversity and Inclusivity Organizational Self-Assessment Tool
An effective, and perhaps necessary, route to addressing discrimination is to cultivate an inclusive organizational culture that honors and celebrates diversity. Here we are talking not only about diversity in race, culture, ethnicity, and sexual orientation—although these certainly remain important—but also diversity in life experience and challenges. To protect and honor the rights of persons with behavioral health conditions, both as service users and as staff, you will need to emphasize the benefits of diversity and embed inclusion strategies in all aspects of your work. To provide you with a starting point to determine the inclusiveness of your current agency culture, we have included this Diversity and Inclusivity Organizational Self-Assessment Tool, developed by the YWCA of Minneapolis in partnership with the Charities Review Council.
To assess your diversity and inclusion practices and consider how you might further develop an inclusive workplace, complete the included checklist and consider the set of questions below:
What items on the checklist are activities that your agency is already doing well?
What items on the checklist presented new ideas or challenges to members of your team? What will you need to do to address and overcome these challenges?
What items has your team identified as priorities or first steps?
Guide to Conducting a Walk-Through
In order to help members of your team look at your organization’s processes with “new eyes,” you may want to conduct a series of walk-throughs. Take a look at the guide provided in the Appendix, and think about whether it would be useful to do a walk-through of a certain process or aspect of your agency—e.g., walking in the front door, the intake process, a request for records, or care planning. In order to ensure that you are using “new eyes,” we recommend including persons currently receiving services in the process as well.
One dimension that may be especially important to pay attention to, that is not specifically targeted in the walk-through guide, is that of the language used by staff at your agency. Many professional organizations, government bodies, and media outlets have now endorsed the use of person-first language in order to overcome long-standing, discriminatory attitudes toward certain groups of persons (e.g., persons of color, persons with disabilities). Person-first language is language that emphasizes the common humanity and personhood of any given individual prior to characterizing the person in any particular way. This approach to language has been strongly endorsed by the recovery movement.