Part 3: Public Policy and the Professionalization of Peers

In our last blog of this series, The Development of Peers in the United States and Other Regions of the World, we discussed two views of the peer movement as seen through the lenses of New Zealand versus United States cultures. The New Zealand view favored a focus on community and service users while peers in the United States were becoming part of the mental health care system as evidenced by SAMHSA’s support. In this blog, we will discuss how peer’s roles in recovery was further solidified as a fundamental part of the United States healthcare system despite some ongoing philosophical disagreements and how important national policies were in shaping the peer movement as we know it today.

What began as a grassroots experience in the United States started becoming public policy with the passage of the Americans with Disabilities Act in 1990. This Act redefined serious forms of mental illness as disabilities and in doing so made it mandatory for employers and businesses to provide accommodations for those with these illnesses just as they did for people with physical disabilities. The Act emphasized an important point that recovery is not a prerequisite for inclusion in everyday life. That is, it did not have to be earned. Rather, inclusion was itself a foundation for recovery. While requiring accommodations for people with serious mental illnesses was a welcome change in policy, it raised the question of what was the “reasonable accommodation” for someone with a mental illness? That is, if providing access to someone with a wheelchair is an accommodation for someone with a physical disability what is its equivalent for someone with a serious mental illness? It became clear that what people with mental illnesses needed was a network of people to provide support.

It was around this time that peer supports started to become available as paid positions versus solely volunteer roles. In 2003, the President’s New Freedom Commission Report broke new ground by proposing to transform the mental health system into one that was recovery oriented. This report also recommended the development of a strong peer workforce. The Department of Veterans Affairs (VA) was an early mover for this initiative. In 2005, they began funding positions for veterans with lived behavioral health experience to provide peer support services to other veterans with behavioral health needs. By 2017, the VA had employed over 1,200 peer workers. Ironically, though the substance use treatment industry has long been employed by people in recovery, peer recovery coaching (the predominant term used in the substance use treatment industry) did not formally begin until the early 2000s.

Peer support positions have grown in the behavioral health industry with support from the New Freedom Commission on Mental Health in 2003 and the Affordable Care Act in 2010. About 25% of behavioral health facilities have designated peer workers using a variety of titles (see Demographics section below) and as of 2018, 41 states reimburse for peer workers in some form. According to Gagne et al., (2018) regardless of title used, the activities done by these workers generally fall into four categories:

• Connecting through lived experience
• Mentoring, coaching or teaching
• Linking to community resources
• Facilitating the achievement of recovery goals

All peer support workers are required to function under supervision which, according to Beck et al (2018), “peer recovery specialists seem to be hired by health systems or substance use treatment centers as service extenders.”

Despite this growth and general acknowledgment of the value of recovery and peer support, there have been critics of peers in professional settings and the recovery movement in general.

Penney (2018) has noted that, “one can differentiate between two major categories that are often conflated in the literature: peer-developed peer support and the practice of employing peer staff in traditional mental health programs.” According to the author the former is non-clinical and is based solely on the shared empathy of two people who are peers regarding their lived experience. While programs such as these started out as informal support systems, some have evolved into more structured systems while maintaining the original values and intent of true peer relationships.

One example of such an organization is Intentional Peer Support (IPS) created by Shery Mead. These groups are contrasted with mental health facilities that hire peer support workers. Penney takes issue with the term “peer” being used in this context by implying that the mutuality of shared lived experience is diminished or lost when peers are employed in a professional capacity. This is apparently due, in part at least to the “hierarchical” relationship between a peer worker in a mental health facility and the “equal” relationship in traditional peer organizations such as IPS. This argument has interesting parallels to the comparison O’Hagan writes about between the United States and New Zealand. Despite these concerns, Penney cites positive benefits that have been demonstrated in the research literature when peers are added to professional teams.

In his 2013 book The Manufacture of Recovery, Joel T. Braslow, MD, PhD said,

“I believe that we might be better off without the word ‘recovery’ since it seems to hide as much as it reveals…. While the recovery ideology contains many important values that most of us share, it shifts the focus away from the larger problems that those with severe mental illness face and, instead, emphasizes an almost impossible-to-define outcome.” (Tupper, JT 2013)

Braslow advocated resources used to support recovery would be better directed towards more comprehensive psychosocial supports for people with mental illness, presumably to be controlled by healthcare providers.

Despite these concerns, the recovery movement and peer support have continued to grow and increase in popularity. There are now several different models that incorporate recovery and/or peer support. These include:

• Intentional Peer Support
• Hearing Voices
• Soteria House
• Open Dialogue
• Alternatives to Suicide
  
  

In the next installment of our series, we will explore an important part of the story of peers in behavioral health – the foundational role Alcoholics Anonymous has played in elevating the role of mutual support in recovery.

A look back on the rest of the peer support series:

Part 1: Origins of Peer Support in Mental Health

Part 2: Development of Peer Support in the United States and Other Regions of the World