Peer Support in CMHC’s is an Oxymoron, Peer Support Pioneer Says

Ken Braiterman
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Recently, a Facebook discussion asked if peer support specialists in community mental health centers really do genuine, helpful peer support.  Most people said no.

Peer support pioneer Shery Mead, my long-time friend and colleague, thinks peer support in a CMHC is an oxymoron.  After she started an independent peer support and crisis respite center in New Hampshire, she became world-famous, spreading the theory and practice of peer support.

Shery is an academic, a researcher, and an intellectual.  An ex-patient/survivor, she talks like a teacher in a social work school, even though she believes as passionately as any angry mental health advocate.

Shery Mead
Shery Mead

Consequently, she has been able, over the years, to spread the gospel of peer support all over the world, to academics, bureaucrats, and policy makers as well as consumers.  She is one of the main reasons peer support is so widely accepted by governments and the mental health Establishment as far away as New Zealand.

Still influenced by Shery, NH has kept its PSA’s completely separate from the medically-based community mental health centers (CMHC’s), and Medicaid.  Her thinking prevails to this day in our state:  Peer support must be a voluntary, equal, mutual relationship. Peer support funded by Medicaid, delivered as a medical service in a medical model agency is not really peer support.

If a peer specialist is writing evaluations and progress reports of a peer for medical supervisors, as part of a medical treatment team, to meet Medicaid requirements, the relationship is not equal or mutual, and is not really peer support.  . There has never been a serious effort in NH to seek Medicaid funding for peer support, or make it a medical service.

Other states that had no peer services, because they would not pay for them, thought Medicaid reimbursement was the greatest thing since indoor plumbing.  Suddenly, a federal funding stream was available, and the services could be delivered within an existing institution already qualified to bill Medicaid. The underfunded CMHC’s received a financial windfall, and donsumers could get jobs, a professional credential, and earn a few dollars.

NAMI made Medicaid-funded peer services a major national priority.  Peer support is a good thing, they reasoned, and Medicaid makes it available in places where it is not and probably never will be.  NAMI did not care if the relationship was equal or mutual.  To them, no “therapeutic relationship” with someone who is “mentally ill” is ever equal or mutual, even when the other person is also “mentally ill,” but “high functioning” with a certificate.

A professional certificate is essential in the medical model.  They can’t allow just anybody — untrained people with no qualifications – to use their experience, listening skills, common sense, and sensitivity to help peers improve their lives, recovery skills, and self-esteem.

So people put the initials CPS (certified peer specialist) after their names, to match the initials after all the other names in the agency.  They have a national professional association, the National Association of Peer Specialists (NAOPS), with national and regional conferences, like all the other trained professionals in their agencies.

Shery’s concerns about voluntary, equal, mutual peer support relationships – which are articles of religious faith for her – got trampled in the rush to drink from the Medicaid trough.

In a 2009 interview, the then-head of NAOPS told me there are three pitfalls peer specialists typically experience in CMHC’s:

  1.  They try to change everything, and act like their experience trumps everyone else’s training.
  2. They are not accepted as equal members of the treatment team, whose training and experience is as valuable as an advanced degree.
  3. They are only given menial tasks, like driving people to appointments, not problem-solving or recovery education.  (Since that interview, Medicaid adopted a rule saying chauffeuring is only reimbursable if the two people talk about recovery on the trip.)

Twelve years ago,, I had a very part-time job at a CMHC visiting with three clients in the community every week.  One went to a sub shop and talked about the Red Sox.  One went with me on rides in the country, and one I took grocery shopping.  The job paid $15 per hour.

I had to file monthly reports for Medicaid about each client’s progress.  None of them ever made progress, so my supervisor insisted that I make some up.  The CMHC billed Medicaid $104 per hour for a medical service called MIMS (Mental Illness Management Services).

One day at a mental health conference, a consumer came up to me all excited.  Her mental health center had just hired her to do peer support.  She was doing the same thing I was for $7 an hour.  I got incensed, told her what I was paid, and said the CMHC was underpaying and exploiting her.  Instead of getting mad at the CMHC, she got mad at me.

I left that conference with lead in my stormach.  That’s how peer support in CMXC’s empowers people..

Note:  As Shery’s Parkinson’s Disease progresses, she travels less and less.  Her partner Chris Hansen is an equally good writer, researcher, trainer, advocate, and presenter. Groups who hire Shery lose nothing when Chis comes in her place. 

 

 

 

 

 

 

20 COMMENTS

  1. I found your article interesting since I am a peer guide in a state hospital. I’ve been trained in Shery’s model of IPS with its Four Pillars. I’ve been at the hospital over a year but still do not get to have contact with residents on the units. I can welcome them in the Admissions Department but I cannot do any follow up on the units with them. There is another peer worker in the same hospital who has never been trained in anything. The idea is that as long as you’ve had experience in the system you can be a peer worker. He’s assigned to an adult unit and does mentoring on the adolescent units. He believes strongly in the drugs and uses every opportunity to get residents to develop the same devotion to the drugs as he has. I am for freedom of choice in treatment. He is allowed direct access to residents and I am not and I suspect that it’s due to his view of “treatment” as opposed to my view of “treatment.” Although our services as peer workders here are not paid by Medicare, the situation shows once again how peers are coopted and used by the system rather than allowing the mutual, human relationships to develop that are crucial for true peer work. I work in what is called the Department of Consumer Services. When I had a supervisor it was a department of two people since she would not allow the other peer worker in since he had no training. She has since left the hospital for another position, leaving me as a department of one person with no supervisor and no job description. I was told after she left that the job description which I was hired under and written by her was not “workable.” So, I sit in an office all day long with no department, no supervisor, and no job description. I’ve asked for resolution to the situation and four moths later I’m still sitting here. This particular part of the “system” wants nothing to do with true peer workers who strive to work in the model that Shery developed.

  2. True peer support has been founded and implemented before Shery. It’s called Alcoholics Anonymous. They don’t have four pillars; they have the 12 steps. The radical standards are that the person must actually stop drugging and stop blaming their character deficits on nebulous other factors (such as dysfunctional family upbringing, societal position and discrimination, and genetic predisposition) before they can be in “recovery”. The peer has to work within the system and with a more experienced member longer than a year (usually multiple years) before they can then offer themselves as a sponsor. The person, as a sponsor, offers their services for free because they were originally helped for free. The motivation is to extend freedom to another fellow sufferer. Why does the mental health industry have to look any further for “alternative” solutions? The wheel has already been invented as far as I am concerned.

    When I saw myself as someone suffering from severe mental illness, I didn’t have the humility to realize I could be in control of my health and happiness. I wanted the pills to do that for me. Funny thing is that they didn’t do that. They made things worse. Eventually, I had the grace to face facts and quit the drugs. From there, I could work from a place of honesty on my personality defects. With a year in, I’m just getting started.

    Peers who get paid (no matter how much or nominally) to say pills manage their problems don’t help those suffering with mental illness. They add to the problem. Peers who get off the pills and the biomedical excuses…. well, that would nearly be like AA!

  3. Note, written with pro-Peer bias that is hopefully balanced by the reality that most state-funded centers provide poor and harmful medical model care and people within those systems do not support recovery if they participate in a way that is necessarily complicit with harm.

    Hmmm, this is interesting, as just last night I was writing about how Peer Support can actually challenges the formal system. Of course, I was also writing about a kitten named Mr. Feelings and so, really, I’m not a strong adherent to any blanket statements, other than that Mr. Feelings is a pretty lousy name for a cat.

    I think of the current landscape and continuum of services and practice as being very much in a strange juxtaposed limbo between the coercive medical model and the empowered recovery model. It’s interesting to see all the different forms that roles and experience take in different context. However, as interesting as it is, there is some urgency in trying to prevent any more people being harmed by terrible ideas like mental illness and antipsychotics. Which are actively harming people right now.

    Clearly the system challenges Peer Support. My thinking is that you’re absolutely correct in that medical model care directly conflicts with what I believe to be the ethos of peer support, which grows from mutual aid traditions. I think that in many instances Peers are used in a way that undermines recovery and that, often, recovery is just a word that is tossed around because it looks good on brochures.

    Then again, in some settings that receive state-funding, Peers are encouraged to participate in people’s recoveries in ways that hold a high-caliber of direct humanity. I facilitate recovery education classes and even in the role of the person at the front of the room, the dynamic is mutual and responsive and co-learning is acknowledged and celebrated. In keeping with the principles of WRAP I do not refer to people in clinical terms and I support them in advocating with other providers within the organization, such as the psychiatric nurse practitioner that I sometimes share an office with. Yes, it is not an ideal scenario.

    At some point, I’d like to work in a Peer Respite center. However, I cannot deny the value of having Peers participating in the state-funded mental health system, even if the fidelity to the ethos of Peer Support is often compromised by the culture and practice within state-funded mental health centers. The core of the work that I do is helping people transition their ideas about illness and wellness and encouraging them to be self-directed in considering what is helpful to them and what is harmful to them, what they are hopeful for within their lives.

    I understand that the organization I work for, and the particular center that I work for, is somewhat rare in provisioning the role of recovery educators to Peers within a setting that maintains clinical elements so that they are able to offer support to people who may not have access to any services at all if it weren’t for state-funding…in some cases, depending on what services are available, no services might be better than bad services. Of course, with communities strained and people really struggling, sometimes it seems like people just like to have somewhere to go that they believe might help them to feel better. Sad that people receive help that is actually unhelpful and that so often they are harmed under the auspices of care.

    Within the curricula we work from, people learn skills to help them to rebuild the support networks that were damaged in the course of circumstance and experience. Just today, I made copies of a S. Mead essay on Peer Support to use in WRAP next week. One of our experienced students has been discussing recovery skills with some of the people that live in the poorest neighborhoods in the semi-rural county. Thus, true peer support – such as that which occurs between neighbors and friends – is empowered.

    While I wish that our publicly funded systems were managed by Peers and employed only Peers and let Peers make all the decisions about how they wanted to run services and how they wanted to participate in them…well, that isn’t the case.

    There is a fellow in Vermont who is opening a respite house that is based on Soteria and yet will include a psychiatrist and draw state-funding. The psychiatrist is for the purpose of helping people practice harm-reduction in coming off of medication and to support people who choose to use medication as a conscientious tool.

    It’s not Peer Support in true form…but, it’s much better than nothing. Recovery education is vital as it helps people learn how to manage their experiences in a way that reduces crises. Of course, these same skills can be learned in community and in families, but many communities and families are not meeting people’s needs either, due to compounded challenges, such as joblessness, substance use, and the general hard time that a lot of people have been going through these past, oh, several thousand years.

    It was disheartening to see that some Peers advocate for medication usage, as advocating for any specific treatment is itself in conflict with the boundaries of power and presumption that support mutuality between Peers and also undermines “Be the Expert on Yourself.” I’m sure that medical model settings are padding themselves with complicit and brainwashed Peers who just want some job and might be a little inclined to enjoy having the power of influence and to abuse the privilege of trust…because some people are opportunistic and unethical.

    By the way, I like the letters behind my name. To me they signify scraping myself away from a death’s door state of complex disorder to apply for a job that, at that point, was probably the only job I could have gotten. Suddenly all the things that precipitated the gaps in my resume were something that could get me an interview. Additionally, the letters represent specific training and experience as an entry-level professional. I’m proud of that and it seems peculiar that Peers would tell other people what they should or shan’t be proud of. In content, the training actually supported the perspectives I gleaned from the radical mental health movement and made me really hopeful that perhaps things may be changing, bit by bit. The clinical director of the organization actually taught me the word iatrogenic, in a discussion on stigma and where it comes from.

  4. Darn, you’re right. It is a total oxymoron. Well, between this post and C. West’s post over < yonder…this little jaunt on MiA completely changed my thinking about that snarl of dynamic, semantic, and real-world consequence. Have a good night, all.

  5. Good night to you Faith and a good morning from me in Fife, Scotland where it’s just past 6am.

    I’ve just been reading your posts and enjoying your reflections. They are giving me food for thought on the role of peers within medical model services. About there being no black and white to it, and yet it isn’t grey. Very interesting.

    Regards, Chrys

    • Yes, not black nor white nor grey. In fact, I’d say it’s a bit of a worrisome jumble, with no clear fidelity to practice from organization to organization, or even from Peer to Peer. I try to use my position to present ideas to people who might not otherwise have access to them, because just like bad ideas can wreck a life, good ideas can heal. However, the idea of working within a state-funding structure that also foots the bill for ECT, well…it’s pretty repulsive to me.

      Still, if all the people with integrity refuse to work in the systems, then the people that seek services within the systems will be more likely to be harmed?

      No, I’m not a martyr. After all, I do make a whole 10 and half dollars per hour! With no insurance! :/

      Gee, maybe I am a martyr…

      Always, it comes back to that core question…how to change the system, how to change the system?

      I hope you enjoy your day. Seems the sun will be rising there soon. I’d best call it a night.

      With Appreciation,
      Faith

        • The hospital where I work also does not use ect. Like you, if it did I wouldn’t be there at all. It’s very difficult to work “within” the system because there are so may branches of so-called “services” whick, if not totally against peer workers they are totally ignorant of anything about such work. The only person who really understands what peers are about is the woman from the Disability Rights person who keeps a sharp eye on us. And of course, she was once in the system herself so that’s why she understands.

  6. All I can say is: Oh, how I longued for some kind of independent ” peer support” to explain what exactly was going on when my son was sectioned three years ago. I had never had anything to do with the psychiatric services before. I didn’t know what rights we had, nobody told me that I could have contested his section. Nobody told me what a section was and why exactly they were sectioning him. Nobody told me that it was illegal to name his father as his legal guardian and refuse to give me that title. His father hadn’t seen him for months but he gave the doctors free hand and I didn’t. I wished somebody impartial, who had been through a similar crisis, would have enlightened us about psychiatric medication and its side effects. I would have appreciated somebody just to hold my hand and to treat us as human beings-not things…Such peer support would have been very precious to my son and me when he was in hospital. I suspect though that the psychiatrists in charge would have considered such support as an impediment to their power and a right nuisance.

  7. I am Hiroyuki Matsuda, an associate professor at Osaka Prefecture University, Japan. I have been interested in what professionals can not or should not do. I am studying on alternative approaches in mental health. I am worried that alternative approaches in mental health are modified and co-opted by professionals from the traditional mental health system. I read your article and sympathized with your perspective. (I met Shery twice in Japan. I sympathize with her idea.)
    Reading your article, I had one question. Your article tells “They try to change everything, and act like their experience trumps everyone else’s training”. Could you give me more specific explanation please?