Peer Specialists as Educators for Recovery-Based Systems Transformation

The past 3 decades have witnessed an ongoing transformation of mental health care systems around the world, beginning in the United States and followed by New Zealand and Western European countries. With decreasing enthusiasm among consumers and consumer advocates for the traditional model of care that has dominated clinical practice for about a century, the recovery model has become the centerpiece of systems transformation.^1,2 As articulated by former patients who are living a full and meaningful life beyond illness, the recovery model underscores hope, empowerment, independence, strengths, and the patient’s ability to adapt.^3,4 This notion of recovery stands in contrast to traditional views that focus on clinical outcomes such as symptom remission, an asymptomatic state, cure, and functional improvements maintained for a given duration.⁵

In the United States, the influence of this newer view of recovery is underscored in the 2003 President’s New Freedom Commission on Mental Health, which endorses recovery as the guiding vision and framework for restructuring the national mental health service delivery system.⁶ In treatment settings, this recovery vision has guided innovations in mental health service delivery and includes⁷:

• Reframing treatment goals, objectives, and outcome indicators from the traditional focus on symptom reduction to one centered on “the whole person,” reclaiming a meaningful life, increasing hope, empowerment, and overall well-being

• Reducing power differentials inherent in traditional care by promoting self-management, self-directed care, and shared decision making

• Fostering a collaborative relationship among practitioners, consumers, relatives, community, advocates, and stakeholders

As the recovery model has wielded its influence in mental health care systems worldwide, there has emerged a need to develop and implement curricula focused on increasing knowledge about the model and promoting attitudes consistent with recovery among patients, family members, practitioners, and the general public. These efforts have been particularly pronounced in New Zealand, where recovery-based clinical training is incorporated into mental health education and required of service providers.⁸

A similar mandate for recovery education is not currently available in the United States. Although there is growing enthusiasm about the recovery model in treatment settings, it is not reflected in psychiatric training programs. Lacking recovery-based competencies, many US mental health care providers are unprepared to provide care in ways consistent with the recovery model or to provide recovery-relevant information that can help patients.

With the recovery model, the patient’s unique experiences and perception inform treatment and serve as a springboard for collaboration in treatment decision making. Traditional care has failed in this regard-more often than not, patients’ strengths, coping abilities, suggestions, and interpretations and attributions of their unique experiences have been ignored, devalued, and excluded in treatment planning. This may very well explain the feelings of disenfranchisement, dependence, disability, and hopelessness patients have often experienced with traditional care.⁹ Fostering a truly collaborative doctor-patient relationship requires a commitment on the part of the mental health provider to listen and attend to the patient’s perspective and expressed needs.

Project GREAT

Recognizing a need to foster recovery readiness among trainees in the department of psychiatry at Georgia Health Sciences University, we collaborated with the Georgia State Department of Human Resources to develop Project GREAT (Georgia Recovery-Based Educational Approach to Treatment)-a peer and provider endeavor to champion the recovery model. Our goal was to develop, appraise, and dispense a recovery-based educational curriculum for trainees and providers in our department as well as for providers in the community.

We envisioned a 2-tiered effort targeted toward mental health providers and patients. The Project GREAT provider curriculum is centered on teaching the Substance Abuse and Mental Health Services Administration–defined principles or elements of recovery and is currently taught in the department of psychiatry and health behavior at Georgia Health Sciences University.¹⁰ Services provided for patients and family members revolve around interactions with certified peer specialists (CPSs), who support and serve as models of recovery and provide recovery-based information and resources.

What is already known about psychoeducation and the role of certified peer specialists?
? Traditional psychoeducation involves practitioners in the role of educators, and patients and family members as recipients of information about psychiatric illness, treatment options, coping strategies, and crises management. As part of ongoing recovery-based systems transformation, peer specialists have emerged to assume supportive roles for patients in mental health care systems.

What new information does this article provide?
? The Project GREAT program-recipient of the 2012 American College of Psychiatrists’ “Award for Creativity in Psychiatric Education”-is the collaborative effort of peer specialists and practitioners at Georgia Health Sciences University to provide recovery-based education for both patients and providers. Project GREAT incorporates peer specialists in educational, advisory, and provider roles in an academic department, thus highlighting a changing role for people who have experienced mental illness in contemporary psychoeducation.

What are the implications for psychiatric practice?
? Peer-led psychoeducational efforts are beneficial to providers and patients and represent a critical strategy to advance recovery in modern psychiatric practice.

CPSs as agents of systems transformation

Mental health systems that have embraced the recovery model have endeavored to give consumers greater voice in organizational policies and practices by using CPSs as members of the treatment team.^11-13 CPSs are individuals who have had experience with mental illness but have embarked on a self-directed journey of recovery. They are thus in a unique role that allows them to provide insights and perspectives for mental health providers, patients and their families, and other stakeholders (Table 1).

After training and certification, Project GREAT CPSs:

• Provide direct support and give voice to patients

• Educate and provide feedback for residents and other trainees on how to listen, collaborate, empower, and foster a partnership with patients

• Represent the efforts of Project GREAT in the larger community through membership on advisory boards

There has been growing support among professionals for using CPSs to provide recovery-based services for patients with mental illness as well as recovery-based training for practitioners.^2,14 The empirical support for such peer-led interventions is somewhat limited; however, studies of CPS-driven services and training have demonstrated an association with better outcomes.¹⁵

The positive impact of CPS-driven educational efforts on patients is seen in the peer-led Wellness Recovery Action Plan (WRAP) training initiative in Minnesota and Vermont.¹⁶ In the study, CPSs who had been trained and had used WRAP for symptom self-management provided a training intervention for 381 patients. Participants showed improvements on domains such as recovery attitudes, knowledge of symptoms (eg, early indicators of decompensation), and implementation of coping skills.

A 12-week recovery education workbook program delivered by CPSs was compared with assertive community treatment on a range of outcomes.¹⁷ Participants who completed the 12-week recovery education program reported a higher level of hope, empowerment, and improvement in recovery attitudes (the study assessed attitudes consistent with patient-defined recovery rather than clinical recovery).

Pickett and colleagues¹⁸ reported on the effects of an 8-week, CPS-led educational intervention-Building Recovery of Individual Dreams and Goals through Education and Support-on outcomes such as symptom severity, hopefulness, empowerment, social support, self-advocacy, coping, and recovery. The educational intervention was presented to 160 participants who completed pre- and post-outcome assessments. Participants reported improvements in symptoms, hopefulness, empowerment, self-advocacy, coping, and overall recovery following the intervention, although pre-post effect sizes were modest and ranged from .26 to .44 for significant effects.

Of greater importance to Project GREAT is the impact of peer-led educational efforts on trainees and practitioners. Wood and Wahl¹⁴ evaluated In Our Own Voice (IOOV)-an education program geared toward improving knowledge of and attitudes about mental illness. Undergraduates were assigned to either IOOV training or a control condition (career seminar). Participants in the IOOV condition showed significant improvements in their knowledge and attitudes postintervention.

Peebles and colleagues¹⁹ evaluated the Project GREAT recovery curriculum to determine its effectiveness for instilling knowledge about recovery and fostering recovery-promoting attitudes. A team of CPSs, psychologists, and psychiatrists taught the Project GREAT curriculum to doctoral-level practitioners (psychiatrists and psychologists) and psychiatry and psychology residents in a 2-part workshop. Part 1 focused on didactic materials on recovery principles. Part 2 was presented by a panel of patients and CPSs and focused on traditional care versus recovery-oriented care. Data showed that although recovery principles were effectively taught, it was not until patients and CPSs “told their recovery stories” that provider attitudes shifted to a recovery model direction.

The role of Project GREAT CPSs

The recognized roles of CPSs in ongoing systems transformation efforts have been limited to supporting and educating consumers and their families about recovery, guiding consumers to community resources, advocating for consumers, and providing input in treatment team meetings.¹⁴ Our strategy is to empower CPSs-all persons with a history of mental illness-to become active participants not only in their own care but also in the training of prospective mental health providers (Table 2).

Routine exposure to recovery stories. At Project GREAT, we encourage CPSs to draw from their personal experience when working with patients and providers. Exposing mental health providers to patients who recount their own recovery stories will potentially make the providers more empathetic to persons with mental illness.²⁰ The testimonials help change practitioners’ attitudes about a patient’s competence and ability to contribute to his or her own care and demonstrate the value of the recovery model.

The Project GREAT curriculum uses recovery stories as a means of teaching providers core recovery principles and influencing their beliefs and attitudes. CPSs describe the challenges of mental illness in their recovery stories but also underscore the individual strengths, coping resources, and supports (including providers) that contributed to successful recovery.

Routine interaction with providers outside the traditional patient role. The role of CPSs as educators in Project GREAT puts them in a context outside of the traditional patient role. CPSs co-lead recovery lectures and seminars and are involved in answering questions, educating, facilitating, and presenting role-plays. CPSs and patients interact with providers, trainees, and administrators in monthly behavioral advisory council meetings in which they engage in discussions about issues that affect the welfare of patients in mental health settings.

CPSs also participate in program team meetings in which patient care is reviewed and supervised as well as in didactic sessions in which recovery principles/perspectives are integrated within discussions of clinical diagnosis and treatment issues. By interacting in contexts that foster personal contact and decrease the power differential between providers and patients (ie, CPSs), stigma, stereotypes, and other negative attitudes that providers may have can be dispelled.^14,21

Providing ongoing feedback and education for trainees. CPSs shadow residents and other trainees during intake, rounds, medication evaluation, or psychotherapy sessions. CPSs provide feedback and encouragement that underscore the importance of treating the patient with respect and dignity, promoting patient independence, focusing on the patient’s strengths, and fostering shared decision making. (Table 3 lists other ongoing Project GREAT recovery education activities.)

A contemporary approach to psychoeducation

Project GREAT efforts in psychoeducation are geared toward educating providers about recovery so that they can, in turn, transform their own practices to be in concert with the recovery model. Our aim is to change practitioners’ attitudes about mental illness and recovery so that the conversations they have with patients are focused on recovery rather than on illness. In the Project GREAT approach, CPSs (and other patients) play an active role in educating practitioners, thus reinventing the role that people who have dealt with the challenge of mental illness play in psychoeducation. In their interactions with consumers, CPSs use their life experiences and recovery stories to disseminate information about recovery and teach positive coping skills. This also stands in contrast to how psychoeducation is traditionally disseminated.

Counteracting the long-held conceptions about mental illness and recovery can present a significant challenge. Residents, trainees, and mental health providers used to the traditional medical model are often reluctant to switch to the recovery model. In a survey of trainees about their perceptions of recovery, Buckley and colleagues²² determined that trainees often held traditional views consistent with the medical concept of recovery and expressed skepticism about the feasibility of the patient model in their own practice.

Conclusion

By being sensitive to the pragmatics of time management in psychiatric care and by fully integrating recovery training, CPS services, and recovery practice tools into the traditional structure of psychiatric training and services, we believe that Project GREAT has had success in allaying fears that recovery-based care is not feasible. There have been rare occasions when a trainee expressed concerns that the consumer movement and some aspects of the curriculum seemed “antipsychiatry.” We have endeavored to address this concern within the curriculum by underscoring the invaluable roles that providers have played in the recovery movement and the recovery journey of individuals.

The recovery model has been at the center of ongoing systems transformation to provide innovative services that are more sensitive to patient needs and that empower them to be partners with practitioners as they embark on objectives that help them reclaim a full and meaningful life beyond illness. CPSs are necessary change agents in traditional care settings, where they provide education and support for patients and their family members as well as for mental health practitioners.

CPSs have been crucial in the Project GREAT attempt to transform an academic department into a recovery model and produce psychiatrists and psychologists guided by the recovery vision. We hope that other departments will embrace a recovery-based educational curriculum and incorporate the services of CPSs in its implementation.

(See “Recovery-Based Services and Education Resources” for a brief list of available programs and materials.)

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