Veteran recovery

Practice and Strategy Suggestions

Mutual Learning: A VA Peer Support & Education Conference

The first VA peer support conference was held November 1-3, 2005 in Memphis, Tennessee. The conference consisted of participants from 45 VA sites or Vet Centers. The participants included veterans who are actively engaged in peer support services, VA staff who work as partners with peers, VA administrators and researchers, and non-VA community partners with extensive expertise in peer support and recovery services. Panel presentations and breakout sessions were designed to address a range of important topics related to the strategic implementation of peer services for veterans in recovery. The presenters included VA clinical staff, veteran peers, non-VA peer experts, and VA researchers and administrators. The following notes summarize some of the highlights of the principal discussion panels and roundtable discussions. While not comprehensive, these notes convey some thoughts from the discussions for those who could not attend, and hopefully may be of use for furthering the development of recovery-oriented services in VHA and implementation of peer support:

I. Program Structure:

  • Peer support services are broad ranging in nature, varying with respect to the degree of staff or peer ownership and with respect to the degree to which services are supportive or more like traditional mental health treatments.
  • In many VA programs, peer support has evolved from initial stages involving higher levels of professional guidance and input to later stages largely overseen by peers, with professional staff providing as needed consultation.
  • One of the most common models of peer support is the peer support group, in which a small group of persons with serious mental illness (e.g., 6-12) present their problems and receive empathy and suggestions from other members based on their own similar experiences.
  • Another popular model of peer support is the “consumer as provider” model. In this model, individuals with a history of serious mental illness provide services to others with similar mental health problems. They usually perform outreach and engagement, case management, and a variety of other rehabilitation functions (e.g., job coach). Although they usually operate in traditional mental health settings, they use their own experience, for example as role models, to do their work. In particular, “Peer Specialist” is a new category of provider created for peers to use their unique recovery experience to assist consumers.
  • There are many different types of peer support models, and thus no single “right” answer to the question “What kind of peer services should we offer”? When selecting a model, carefully consider current resources and the goals the peer support program is hoping to achieve.

Panel Correspondents:

II. Recruitment, Training and Education

  • Different types of peer service require different types and levels of commitment. Across the board, peer specialists need to be open, non-judgmental, hopeful, good listeners, advocates and team players. Staff can be involved in the recruitment process but are not the final decision makers.
  • The panelist did not agree on amount of sober time nor relationship to present treatment involvement although all felt some period of sobriety and stability was important.

Some specific recommendations were made concerning peer-support-VA partnership models and these included:

  • Training is extremely important especially in the following areas: dealing with confidentiality, boundaries, safety issues, conflict management, dealing with difficult personality qualities and managing acute symptoms in a group setting. Another area of training needs focused around how and when to ask for staff help and assistance.
  • Ongoing, weekly supervision is essential. The issues addressed should be those identified by the peer specialists. The staff person role is to guide the peer in their skill development.
  • All agreed that it is important to identify a lead peer facilitator/peer specialist to manage the interface between peers and peers and staff.

Panel Correspondent: Laurie Harkness, VISN 1, 203-931-4062, Laurie.Harkness@med.va.gov

III. Diversity of Veteran Peer Support

  • There is a wide range of peer support services outside the VA which can help inform us about the possibilities for future programming
  • Clarity about expected roles and how accountability is determined for peer specialists is a key issue for successful implementation
  • There may also be opportunities for contracting with wholely peer run organizations to provide peer services
  • A thorough understanding of and support for recovery based care is a key underpinning for successful implementation

Panel Correspondent: Miklos Losonczy, VISN 3, 973-676-1000 x 1421 vhalynlosonm@med.va.gov

IV. Boundaries and Confidentiality

  • There are clear limits of confidentiality related to threat to hurt oneself or someone else. Peers should provide such information to clinical staff, preferably by accompanying the veteran.
  • Some decisions regarding confidentiality are program specific (e.g., reporting substance abuse or smoking in a residential program) and should be determined by the peer program.
  • It is important that informed consent occurs in provision of peer services, where veterans receiving peer services are made aware of the limits of confidentiality.
  • Peers are often seen as friends or mentors, rather than professionals. The boundaries are more diffuse, given the focus on helping by sharing one’s own experience in recovery. Role modeling is important for peers, therefore the boundaries tend to be more informal.
  • Peer support veterans must find a healthy balance between their role as helpers and taking care of themselves. To help maintain this balance and recognize over-involvement, it is important for there to be more than one peer support veteran working together.
  • Some concerns of VA staff and/or veterans that need to be addressed related to boundaries and confidentiality include (a) role differentiation and will there be a need for professional staff, (b) peers becoming “stool pigeons”, (c) how much information is and should be shared between clinical staff and peer staff, (d) are peers capable of determining when information needs to be shared with staff, and (e) can peers “handle” the role, given their own recovery.

Panel Correspondent: Marcie Hebert, VISN 1, 781-687-2640, Marcie.Hebert@med.va.gov

V. Financial Considerations

  • Peer support has been successfully implemented in VA on both a voluntary and paid basis depending on program goals and veteran preferences and both approaches should be continued and expanded.
  • The option of paid peer support should be widely available in VA and there was a consensus among participants that diverse programs, such as those funded through the FY 2005 recovery RFA and others, should receive expanded support as recommended in the Undersecretary’s Strategic plan for Mental Health.
  • Diverse payment mechanisms have been used to support peer support activities of diverse kinds and should be further explored including: 1) paid VA employment (some sample job descriptions are available at veteranrecovery.org); 2) payment through CWT for peer support work (which requires HIPPA waiver by veteran participants); 3) payment through a community non-profit; 4) fee basis payments and 5) “set aside” positions for disabled veterans.
  • Although experience with these options and others is limited, no one option is clearly superior to the others and all merit careful exploration locally and judicious review by VA administrators and lawyers.
  • Veterans working in peer support are not at risk of being held legally liable for their activity as peer support staff under VA auspices.

Panel Correspondent: Robert Rosenheck, VISN I, 203-932-5711 x3850, Robert.Rosenheck@yale.edu

VI. Systems Issues

  • Peer support is not entirely new to the VA. Early Peer Support was introduced by the Vet Center program as a way to engage Vietnam Veterans.
  • While motivation, sobriety and identification are a good start for helping others, continuing training and supervision must be a part of any peer program.
  • Peer Specialists / Consumer providers are responsible for their continual learning and growing and earn credibility by holding themselves accountable to the same standards as the professional treatment team members. This includes maintaining professional boundaries.
  • The power in a system that embraces Peer Support, are consumers providers and professionals working together to enhance services. In such a system neither role is diminished, but consumer providers are well integrated on to the team.
  • Implementation of Peer Support programs will frequently face resistance. Transforming a health care system takes time and patience on the part of those individuals championing the change. Staff often need education on how Peer Support enhances the health care delivery system and helps to improve outcomes of their patients, without detracting from the professional’s role.

Panel Correspondent: Mara Kushner, VISN 3, 718-584-9000 x3719, Mara.Kushner@med.va.gov

VII. Policy and Legal Issues

  • Liability concerns should be anticipated and thoughtfully considered in the development of peer support programs, but should not prevent development of programs.
  • Program development must include clear documentation of organizational structures and accountabilities, supervisory methods, responsibilities and limitations of VA supervision and program goals.
  • Ideally, national policies and procedures should be developed to ensure consistency among VA programs.
  • Although peer counselors usually develop a group "contract" about confidentiality, veterans should be informed, in writing, of the limitations or absence of privacy protections related to information that is disclosed in such programs (i.e. peers have no legal duty to protect confidentiality).
  • Peers generally do not have access to VA medical records or computerized databases. If a program model requires or contemplates medical record access, Regional Counsel and Information Technology consultations are critical.
  • As with all VA treatment programs, practitioners who provide peer support services that are within the scope of their VA duties are protected from any individual liability. Claims or suits arising from alleged negligence in VApeer support programs areinvestigated and adjudicatedunder the Federal Tort Claims Act (28 USC Sect. 2675).

Panel Correspondent: Henrietta Fishman, VISN 3 (718) 584-9000, ext. 6800 Henrietta.Fishman@med.va.gov

VIII. Research and Peer Support

  • There is a great diversity of peer support models. These vary, for example,in consumer vs. professional control, and the extent to which they provide traditional treatment vs. supportive services.
  • Rates of use of peer support are currently quite low. At present, most group-based peer support persists for only a short period of time.
  • Most research on peer support groups is uncontrolled, so it is not yet possible to quantify the effects of peer support. However, there is a large body of uncontrolled research supporting the effectiveness of peer support, and no research indicating that it is harmful.
  • There is controlled research on consumer providers. Compared with non-consumer providers, outcomes are generally similar. Outcomes may be superior with regard to outreach, community tenure, and drop-in programs.
  • Efforts to disseminate peer support should be accompanied by program evaluation. Evaluation should characterize the models that have been implemented, make use of established qualitative research methods and recovery scales, and evaluate model effectiveness.
  • Research is needed on strategies for implementing specific peer support models. There is also a need for controlled trials to evaluate the effectiveness of peer support and consumer provider models.

Presenter: Alex Young, VISN 22, 310-268-3416, ayoung@ucla.edu

As a result of a nationwide survey of peer support programs in VA, we have compiled the following examples of Peer Support Services currently in the VA. These services have a variety of names including vets helping vets, vet to vet, warmline, house manager program, and community outreach:

  • Warmlines for veterans to provide support to veterans via telephone
  • Peer support groups focusing on recovery, PTSD, writing, dual diagnosis, stigma
  • Individual peer mentoring
  • Drop in center
  • Resident managers serving as peer mentors
  • Outreach workers