Peer support specialists are individuals who have had experience with emotional distress, trauma, or other emotional challenges and have been trained to assist others experiencing emotional distress. Peers’ interventions improve self-esteem and confidence, the ability to bring about changes, and the feeling that treatment is addressing the real needs of individuals.
In the past few years, peer support specialists have been officially recognized as essential figures by Medicaid, managed care organizations, and other public health institutions for the delivery of integrated and coordinated behavioral health services.
However, this substantial progress is just one face of the coin. With institutional recognition comes also the risk of loss of identity. Recognition of peers’ official role under Medicaid could undermine the very nature of their interventions by morphing them into a hybrid of traditional medical and clinical recovery principles, structured and supervised by “mainstream” trained clinicians. The result could be the loss of peers’ identity and functions.
This article intends to spearhead a dialogue on the critical issue of maintaining the integrity of the original peer support model.
The role of the peer specialist
Although the recovery movement is not a single entity and includes a variety of approaches, the role of the peer specialist has gained prominence, showing promising and concrete outcomes.
The role of peer specialists is based on the principles of recovery, which are essentially different from the medical model. The medical-biological model views mental illness and diagnosis as a lifelong combination of symptoms and behaviors, which impact one’s ability to manage basic milestones, adaptation to change, and any other essential tasks.
However, the recovery movement provides solid evidence that individuals with a history of emotional distress, commonly labeled as mental illness, can overcome the challenges they face and recover from their negative effects.
Recovery, essentially, is about cultivating a sense of hope, developing a realistic understanding of one’s abilities and challenges, engaging actively in life, fostering and maintaining a deep sense of autonomy, personal and social identity and purpose in life. To attain these goals, individuals in recovery acknowledge the importance of freeing oneself of the conceptual constraints of the medical-biological model, which views emotional distress as a chronic condition from which it is impossible to heal.
Peers focus on assisting others in crafting their own recovery goals; they provide constructive feedback for developing, learning, and practicing new skills and strategies; they communicate a sense of “realistic hope”; they share coping strategies and provide help in monitoring individual progress; they encourage others to advocate for themselves.
Moreover, they encourage input from consumers for the development of recovery plans focused primarily on coping successfully with challenges to achieve the best quality of life possible. These fundamental core competencies are pivotal to the attainment of positive outcomes.
Within this framework, emotional distress is not viewed as a chronic biological disorder, but as a fluid state that can be modified and overcome in different ways, according to individual needs.
Using these skills, peer specialists have been extremely successful in improving the delivery of mental health services. Their interventions are particularly effective in preventing episodes of hospitalization, re-hospitalization, and emotional crisis and in fostering a sense of hope, self-empowerment, and self-efficacy. Also, their ability to promote a sense of connection, especially by sharing individual stories and strategies to cope with life, is one of the main reasons for their success. Their interventions promote a sense of hope, a better quality of life, and a more positive attitude.
There are fundamental differences between peer support and psychiatric and psychological interventions, which cannot be ignored if we want to support the peer specialist’s original role in assisting individuals with emotional distress.
We cannot ignore, for instance, that the relationship between a peer and the individual with a history of emotional distress is essentially egalitarian. Their interaction is between individuals, sharing similar experiences, techniques and strategies on how to cope with the challenges of life.
Therefore, it is radically different from the traditional health provider-patient’s relationship, based on the medical model, in which the individual is in the “sick role” and is viewed as a “passive entity” and just the recipient of treatment and care. Although health care providers have somewhat modified their inflexible roles, the difference between the two approaches remains substantial.
It has been reported that consumers often complain about the condescending and non-inclusive attitudes of health care providers. In this context, it should be clear that peers do not strive to become “clinical” in a traditional sense, but they are willing to support and “balance” the work of health care professionals.
Moreover, the role of peer specialists is critical for an efficient delivery of behavioral health services. As is well-documented, access to mental health and psychotherapy services can be rather cumbersome due to several factors, including insufficient resources and stigma.
This problem has been magnified by the Covid-19 epidemic, which has caused so much emotional distress and has shown the shortcoming of the current behavioral health system. Peer support during the current epidemic is certainly a viable venue for persons who cannot access behavioral health services.
In the past few years, due to its efficiency and success, peer support interventions have become an integral part of the healthcare system.
The recognition of its value has come from numerous entities, including SAMHSA and the American Psychiatric Association. Peer support services are currently available in every state and are reimbursable under Medicaid.
Concerns regarding the integration of the peer’s role
What has been said, so far, would convey the impression that peer specialists have found a respected and independent role within the American behavioral health system.
However, several peer specialists working in New Mexico have expressed substantial doubts about their roles and future in behavioral health, which may reflect similar concerns nationwide.
Donald Hume, an experienced peer specialist and one of the authorities in the field of recovery in the state of New Mexico, provided a clear account of the current issues peers are facing in New Mexico. Donald stated that, with the formalization of the peers’ role under Medicaid and managed care, their functions are becoming progressively more constrained within the boundaries of a medical/business model.
He stressed that peers will be required to perform interventions following specific diagnostic categories and relative billing codes. They may also be compelled to accept mainstream clinical measures instead of focusing on the experience and the narrative provided by individuals in recovery.
Without a doubt, this shift will interfere with the original goal of providing recovery-based interventions based on the development of realistic hope, along with skills leading to a better quality of life. Recovery language will be reabsorbed by, or blended with, clinical and medical language, which will shift the focus from achieving existential balance to targeting signs and symptoms of mental illness.
The peer model has been already lumped in with other credentials, such as those of community health workers and community support workers. This has created a general air of confusion surrounding the actual role of peer support workers. The courses, offered in New Mexico, on cross-training community support workers and peer support workers, sharing the same code of ethics and the same essential functions, are a clear example of this trend.
Moreover, although peer workers have been included in many different treatment modalities in New Mexico (i.e., outpatient medication-assisted treatment facilities, abstinence-based treatment facilities, outreaches, drop-in centers), they are still frequently seen as merely low-ranking, eager workers who can help with patient retention.
Over the previous years, several new initiatives have been created to further regulate the peer support profession, mostly with the goal of providing more extensive oversight or to offer a way to bill for services that peer support workers are capable of offering. These changes have been endorsed by the managed care companies under Medicaid.
By establishing new modalities to offer peer support-based services, managed care organizations are slowly changing the essence of this type of recovery work. A provider working under a community support worker structure may be earning more money, but he/she is also losing out on “raw feel” and techniques that built and maintained peer support as a necessary staple in the world of recovery.
Many peer specialists who have tenure in their field have begun to recognize that the changes proposed by managed care organizations and state-funded facilities could mean that peer specialists may slowly evolve to offer services according to models based on regulatory and administrative paradigms rather than lived experience.
As stated by one of the peers, “There is an inherent danger in losing the foundations that built the peer support field. As we begin to take comfort in complex documentation, long taxonomies of billing codes, and the writing of treatment plans for every service, we are also letting go of the hands-on model that started with one person in recovery giving back to another.”
Therefore, the very nature of the recovery process could be altered and reduced to a hybrid of clinical and recovery principles, controlled by traditionally trained clinicians operating under the managed care model. One of the most dire consequences is that individuals who want to follow a recovery-based plan and not necessarily get involved with a traditional clinical paradigm will potentially be deprived of a substantial source of support.
This shift in peers’ roles and functions could be particularly harmful for frontier states like New Mexico, which experience consistent problems of access to mental health services.
Also, given that there may be no alternative resources to Medicaid for the provision of peer support, recovery-oriented agencies utilizing peer specialists will have two options: accepting the new trends and rules, or trying to survive without Medicaid funds, which will put their survival at stake.
In conclusion, according to Donald Hume and other peers in New Mexico, this shift to incorporating peer specialists under the umbrella of the medical model has the potential to undermine the core tenets of recovery. Without the freedom to engage with individuals as equals, peers will lose the essential elements that make them successful.
Their testimonial should be followed up by a nationwide survey exploring the views of peer support specialists on their changing roles and functions under Medicaid.
- Substance Abuse and Mental Health Services Administration. Core Competencies for Peer Workers. https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers/core-competencies-peer-workers
- Jeffery L. Ham. (2009). Medical model versus recovery model: an analysis of the SC department of mental health’ s approach to treatment.
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.