In April of this year, Sera Davidow authored a blog on Mad in America titled “The Downfall of Peer Support: MHA & National Certification.” I’ve read several pieces written by Ms. Davidow and had the opportunity to watch a couple of videos she was featured in, and I have to admit that she is very sharp and that there are some areas where we probably agree. When she talks about reactions to trauma and what I would call the “cheapening” of the experience by breaking it down to a series of symptoms, which supposedly can best be dealt with by traditional treatment and medications, I believe I’m with her. Powerful emotional and physical changes due to trauma are natural reactions to intense negative experiences.
There is no doubt in my mind that much of what is called mental illness is in reality a reaction to the way we are treated once we are labeled with a diagnosis. I’m sure that there are a number of other areas where she and I could come to some manner of agreement, such as involuntary outpatient treatment, forced medication, social rejection and exclusion, and enforced poverty among others.
The Bell of Hope
With that said, is she serious when she equates MHA’s certification to the downfall of peer support? Does anyone believe that a single certification process that is totally voluntary and conceived of and implemented by people with lived experience could actually diminish the power of peer support? I do not agree with much of what she says and the conclusions she arrives at in her blog, and as the vice president of Peer Advocacy, Supports and Services at Mental Health America I’d like to respond.
Completely setting aside her issues with our CEO, Paul Gionfriddo (Paul is completely capable of addressing them himself if he thinks it is worthwhile), I first want to address the MHA Bell of Hope. The message of the bell is far more than her interpretation of the inscription “Cast from the shackles which bound them, this bell shall ring out hope for the mentally ill and victory over mental illness.” As Ms. Davidow points out, the bell was cast in the 1950’s, a time when terms like “for the mentally ill” were far more acceptable. In my opinion, though, the real meaning of the bell is captured in the first part of that sentence, “Cast from the shackles which bound them.”
Mental Health America, in all of its iterations, has stood against the barbaric use of seclusion and restraints. The first sentence of our Position Statement #24, Seclusion and Restraints, states: “Seclusion and restraints have no therapeutic value, cause human suffering, and frequently result in severe emotional and physical harm, and even death.” It is neither presumptuous, paternalistic nor condescending to be against brutal treatment and to be in favor of instilling hope and seeking victory over what has traditionally been thought of under the single classification of an illness. I do not find creating a symbol which encourages hope from fear and brutality to be “tone deaf and gross.” Every day the MHA bell reminds us of the inhumanity that took place in the past, the tendrils of which reach even into the present. It is a symbol of the overwhelming need to end it.
MHA & the Peer Community
Throughout the years of the existence of MHA, the national office has periodically been peer-run — that is to say that it has had over 50% of the board and the staff, along with the CEO, be self-disclosed individuals living with significant mental health challenges. Currently about 25% of our board, and more than 50% of our staff meet this criteria. Many of our largest affiliates do meet the SAMHSA standard of being a peer-run organization, and several of them are larger than our national office. In my department, Peer Advocacy, Supports, & Services, all of my staff are self-disclosed peers with direct experience with a less than adequate mental health system.
For 13 years MHA ran one of the national SAMHSA TA Centers assisting states to develop independent peer-run organizations. Over the years, we have supported the creation of numerous peer-run networks through financial and technical assistance. We firmly believe that peers should be involved at all levels of the healthcare system, and we have fought for that right throughout our history.
I agree that the term “peer” can be problematic but it seems to be the one most widely used currently. When Ms. Davidow states that “when one carefully considers the peer role — and how ‘being with’ and ‘connecting with’ are at its very core — a costly online exam is precisely what comes to mind,” I get the sarcasm, but she seems to imply that the cost of the examination somehow affects the core values of the peer to peer relationship. Maybe not: anyway, we will get into more detail about the cost later in this post.
“Subject Matter Experts” Advisory Committee
The fact that one writer in an independent publication referred to the individuals with lived experience that we chose as our subject matter experts as “something of a who’s who of peer support” is not a negative about our certification. It simply shows that an accomplished writer feels that we made very good choices in choosing our advisors. We feel that we have been able to work with some incredible people who have been involved in all of the aspects of peer support for many years and who bring a wealth of wisdom and insight to the task.
The individual who “confessed” to feeling beholden to their employer was not referring to us since they are not an employee of our office. As far as I’m concerned, I welcome new and different ideas from all of the participants. I firmly believe that when people stay true to their principles the outcomes are better for all.
In our group we had nine self-disclosed individuals including a primary care physician who lives with a mental health diagnosis and who has participated in peer support. The three other clinical professionals were there to provide insight into the cultures of private clinical environments where peer support could prove to be very beneficial and still stay true to its standards. They were not there to impose any clinical standards or ideology on our work. I feel safe in saying that our peer subject matter experts are confident in their knowledge and their abilities to share it.
For development of our domains and core competencies we relied on the SAMHSA national core competencies list and the iNAPS national standards as our starting place. We examined certification standards from a number of states and studied their planning processes.
I, personally, would like to see peer support become available throughout healthcare as a supplement and alternative to traditional care. One of our goals has been to work with private health insurance companies to help them recognize its value and to understand the core principles and standards of peer support so that it can become insurance reimbursable as a non-clinical service. Such recognition will create many new opportunities for individuals to work in peer support for a livable wage and with the potential for career growth.
What the Heck is this Thing?
Ms. Davidow is concerned that our certification does not include training. Many states that provide certification do not have proprietary trainings. They often accept training from a list of approved trainers or they contract with a single one to do all of the state’s peer support training. It is interesting to note that, according to their website, the much admired Canadian Peer Support Certification group, PSACC, does not offer peer support training.
Our certification has been designed to meet the development standards of the Institute for Credentialing Excellence. In order to achieve accreditation standards we have partnered with the Florida Certification Board, a fully accredited professional credentialing agency that provides certification in four states. Interestingly, their Director of Certification is a self-disclosed peer. They have provided the system for developing the credential and we have provided all of the expert information on peer support. MHA maintains an advisory council for effective management of the credential and to function as the ethics committee, and we will continue to market peer support and the certification.
The full cost of the certification is $425. $225 for the application and certification and $200 to take the national online examination. MHA makes a total of $162.50 per certification. The additional $262.50 goes to the Florida Certification Board, the proctored testing sites, and the company that provides the online examination. Developing the certification has taken three years and approximately 3500 hours of intense work. It will take several years to bring in an amount equal to the costs, but that is okay because “profit” is not the point.
In state certifications, the cost of certification and testing is frequently covered by the state or county. To mitigate the costs of our credential we initially offered 110 scholarships worth $225 each and are now offering a limited number of scholarships for testing. We intend to provide additional scholarships in subsequent years.
The MHA National Certified Peer Specialist (NCPS) credential is not training based, it is examination and qualification based. It is not our intention to make state qualified peer specialists go through another full training. If you are a state certified peer specialist with a minimum of 40 hours of training you are eligible to apply for our certification. It is important to recognize, though, that 40 hours of training alone is not sufficient to pass the examination. The credential also requires 3000 hours of peer support experience. The primary qualifications for certification the hours of experience and passing our rigorous 125 question examination.
We refer to our certification as an advanced level credential. This is because we require additional knowledge in comparison to existing certifications. The expanded knowledge base includes the areas of adult learning and mentoring, trauma-informed care, activation and self-management, and the foundations of healthcare systems. Individuals with the NCPS credential will be prepared to work in a rapidly changing and diverse work environment.
For many people,the additional knowledge learned on the job will be sufficient to pass the examination. The best way to know if you are sufficiently prepared to take the examination is to download the “MHA NCPS Training and Test Self-Assessment” at www.nationalpeerspecialist.org. This will walk you through what core competencies and skill sets are necessary to pass the examination. Additional training needs can often be met by participating in webinars and conference workshops to supplement your knowledge. It is this experiential and additional formal training that we refer to when we talk about enhanced training. Perhaps a better term would be enhanced knowledge and skill sets.
If you are not state certified (a number of states currently do not have certification) you are required to take an MHA approved training course. Currently we have five trainings on our approved list, but if you have taken a different training please submit it to us and we will examine the training to see if it qualifies. We hope to approve as many trainings as possible. Qualification for approved trainings is based on:
1. Does the training cover the substance of our 6 domains of practice:
- Foundations of Peer Support
- Foundations of Healthcare Systems
- Mentoring, Shared Learning, and Relationship Building
- Activation and Self-Management
- Professional and Ethical Responsibilities
2. Was the training developed by peers?
3. Are the majority of trainers peers?
4. Is it a minimum of 40 hours?
5. Is the training well documented and presented?
We took on this project as a peer-conceived, peer-designed, and peer-implemented endeavor. All of the work to bring the certification to fruition has been done by my staff, our subject matter experts, and a peer who is the Director of Certifications for the Florida Certification Board. MHA has over 100 years of experience in peer support and engagement.
No doubt someone else will create a national credential, perhaps even an advanced one similar to ours. We are not in this to monopolize the market, rather, we are dedicated to furthering the provision of peer support throughout healthcare and to helping peer supporters earn a living wage and to gain opportunities for career advancement.
During the process of developing our core competencies we sent a link to our document to over 10,000 peers through our own mailing lists, TA Centers, other organizations and our affiliates. Over 1500 people logged on and we used their feedback to modify the original concepts. We then sent out a role validation study to the same audience plus additional people we identified through our website. Each one of our 55 core competencies were scored for importance and frequency of use. This information was interpreted by a psychometrician to create the blueprint for our examination.
On a side note, I have no qualms about saying that all of the peers, including me, involved directly in the creation of this credential have just as much right to claim membership in the peer community as anyone else. When other people, particularly those with large audiences, try to disparage our “peerness” I have visions of a so-called recovery center I once visited which required proof of diagnosis before people were allowed access to the facility. It makes the hair on the back of my neck stand up.
To continue, peer support is growing rapidly but one essential area that has shown very little advancement is the private health sector. MHA has worked on peer workforce development for several years and we recognize that expansion into the private sector will open up many thousands of new opportunities for peer employment. According to a recent survey, peers working in healthcare provider organizations and health plan/managed care organizations make on average 16% higher wages for the same or similar work than do individuals working in the public sector.
In our discussions with private health insurers and large healthcare organizations about what would be necessary for them to fund and offer peer support services, we heard repeatedly that the primary barrier was the lack of a uniform high national standard. Under the state and county certification system standards vary significantly. Some states have developed high standards while others may require as little preparation as taking a 30 hour training and having 100 hours of peer support experience.
Like most certifications we do not promise individuals employment, but we do think that providing employers with highly experienced candidates with advanced knowledge and skill sets will help peers find better paying, more career-oriented positions. In our private sector pilot programs involving peers who meet our certification standards, pay scales have equaled or surpassed a 16% increase over average wages for the region.
Clinical: I Don’t Think So
I stand by my statements made in an open letter to the peer community and in the numerous workshops I have conducted at Alternatives, the iNAPS conference, the NYAPRS conference and in multiple webinars: “We have never intended to move peers towards doing clinical work in any way. Our efforts are to give peers every tool they need to perform as true peer supporters in a wide variety of settings. Peers are never expected to cross the line into a clinical role or to promote any clinical practice.”
Ms. Davidow cites a quote of a statement made by me in an interview to substantiate her belief that we are crossing that line. As written, the quote is pretty accurate. What is not said, through no fault of Ms. Davidow, is that in the initial interview I accentuated that individuals choosing to participate in DBT do so voluntarily and arrive at treatment goals and methods in concert with their therapist. In my work as a peer supporter I have witnessed on more than one occasion peers in a support role who have interpreted an individual’s interaction, or lack of interaction, with their therapist as a threat to the wellbeing of the person receiving support and have encouraged the individual to seek a new therapist or file a grievance. Most of the time the individual will let the peer supporter know that the nature of the relationship with the therapist has been arrived at mutually, but on occasion either the individual is influenced by the support worker and the relationship with the therapist is adversely affected, or the person becomes conflicted because they are caught between two people that they trust. In either case it is the individual being served who loses. I don’t suggest that the peer participate in the therapy in any way, but I do feel that it is important to understand DBT if only to know what questions to ask.
In any case, the only relationship this discussion has with the MHA certification is that our core competencies include having a general understanding of treatment modalities so that peers can support people in their chosen treatment. This strengthens the values of peer support by supporting self-determination, voice, and choice. Neither the peer supporter nor the therapist determine an individual’s goals and direction. This can only be effectively done by the individual with any assistance they choose to accept.
And Let’s Not Forget to Mention: Ethics
Ms. Davidow’s comments on the Code of Ethics are her opinion. They are the same as the majority of codes of ethical behavior that any certified professionals agree to. I thank her for pointing out an error in the code that says people agree to a “random criminal history check to ensure compliance.” That was a holdover from a state certification where the state required that language in order to use state funds for peer support services. We have amended it to say:
“When creating their online certification system account, all applicants must complete a section agreeing to allow the FCB (Florida Certification Board) to conduct a criminal history check in response to an ethical allegation of non-compliance with the FCB Code of Ethical and Professional Conduct standards related to criminal activity.”
It is clearly stated that we do not conduct a criminal history background check unless an allegation of criminal activity is filed against a certified individual.
On the issue of not performing services outside the individual’s training, expertise, competence, or scope of practice, the discussion of the rule states:
- When a consumer’s therapeutic issues are outside their level of professional functioning or scope of practice, the certified professional must refer the consumer to another professional who will provide the appropriate therapeutic approach for the consumer
This is a self-regulated rule unless a formal grievance is filed. As to who decides what constitutes a violation of any of the code, we have an Ethical and Professional Conduct Advisory Committee made up of peers who will rule on a complaint or grievance.
On the item that refers to putting their credential on inactive status for any mental, physical, or behavioral related adversity that interferes with their professional functioning, that last part is the key. Again Ms. Davidow has left out the discussion of that rule.
- The private life of an applicant or certified professional remains a personal matter to the same degree as any other person. However, when a personal issue begins to adversely affect professional performance, affecting the quality of service delivered and thus putting the consumer at risk, the applicant or certified professional must take sufficient and timely action to resolve any adversity that interferes with their professional functioning.
Closing with a Poisonous Kiss
Like my earlier comment about questioning someone’s “peerness” this last section is offensive. By including her thoughts on “so-called peers” and people who act a certain way because they have a job they can’t afford to lose so they follow the “party lines,” she is being personally insulting. Ms. Davidow is writing this in a blog about Mental Health America, so the clear implication is that MHA is shrouding itself in “so-called peers” and “party liners.” The comments about not being able to see through their own medicated haze and tokenism are even more revolting.
If you want to critique MHA’s certification just do that. Don’t try to trivialize or put down the peers who have worked on bringing it to fruition. These tactics are an insidious type of journalism, casting aspersions on the validity of people’s experience and motivations without anything to back it up. To me that is the same kind of thinking that equates MHA’s credential with the “Downfall of Peer Support.” Ridiculous.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.