The peer-employment-training approach of Recovery Innovations in Arizona

Recovery Innovations is an Arizona-based NGO which provides services to adults with serious mental illness and substance use issues. In recent years, the organisation has undergone a fundamental transformation in the way it provides services to its users. Today, in some of its mental health services almost three-quarters of staff are peers, in other words people who have previously used the service. It is an inspiring example of what is possible when service users are properly trained and supported to co-produce better outcomes.

The expert patient programme is one of the best known examples of co-production in the UK, harnessing the expertise of patients to improve self-care and offer peer support. The approach is based on the insight that patients with chronic conditions such as diabetes and HIV may well have a better knowledge of their own case histories, symptoms and care management needs than medical staff (DH, 2006). It involves co-production since medical staff play a role in offering diagnosis and supporting patients in self-care as well as facilitating access to peer support networks. There is some evidence that the scheme has demonstrated improved efficacy and energy among participants, and reduced demand on hospital facilities (DH, 2006).

However, there are some concerns that the programme has not been transformative enough, with peer support being an ‘add on’ to a set of doctor-patient relationships that remain largely unchanged (Wilson, 2001). This may be a particular concern in services such as mental health where patients have to deal with the stigma of the condition and the assumption that they don’t have the stability required for self-care or peer support.

The Recovery Innovations in Arizona can provide some pointers to how such transformation may be achieve through peer support.

The recovery programme developed ten years ago, out of a concern to change a mental health service that was too much focussed on crisis management and patient stabilisation. Gene Johnson, CEO of Recovery Innovations, and colleagues identified the need to move away from stabilisation towards a recovery model. One of the ways they sought to achieve this was through bringing peer support services from the fringes (where they had been seen as a nice ‘add-on’) to the mainstream of provision. Johnson and others developed a Peer Employment Training programme which is now used in 16 US states, which gives people who have used psychiatric services the opportunity to train as Peer Supporters. The national Center for Medicare/Medicaid Services has endorsed peer support as a best practice and now encourages the use of peer support within mental health services.

The 70-hour training programme is designed to train people who have been diagnosed with serious mental illness to develop the skills to gain competitive employment providing peer support. Evaluation by Boston University has shown high levels of employment in psychiatric services for people completing the programme and higher retention rates than for conventional staff (Hutchinson et al, 2006).

The evidence-base for improved outcomes is robust, according to Johnson. In the first year that peers worked in one of the hospitals, there was a 56% reduction in hospitalizations, a 36% reduction in seclusion and a 48% reduction in restraints.

The programme is now being expanded to facilitate access to housing for people with mental health problems. Working with peers, people who would have had a high likelihood of being in hospital, in jail or homeless were able to move to self-sufficient housing, with a goal of being able to pay their own rent within 12 months (Johnson, 2009b).

Participants reported feeling more empowered after completing the programme and having higher self-worth. As well as improving their own recovery and those they support, Johnson believes that the programme helps the ‘organization/system’ to recover, improving staff attitudes and redesigning organisational protocols. Compared to traditional staff, peers were likely to have higher expectations of those they supported and were less likely to ‘catastrophize or pathologise’ people’s situations (Johnson, 2009a).

With every drop in hospitalizations comes a big cash saving. Johnson notes that a 15% drop in hospitalisations over 15 months represents a saving of roughly $10 million. For this reason, he suggests that peer-based services are particularly appropriate at this time, given the severe budgetary problems facing mental health providers in the US – a message that resonates in many other countries.

The course is 80 hours of classroom time.  The pricing varies some depending on whether instructor travel and accommodation has to be included.  The price per student ranging from $1,195 to $1,395 depending on class size with the minimum required of 12 and a max of 20.  The per student price includes all materials and the textbook.

The language used by Johnson affirms the value that ex-patients can bring to the service, beyond what traditional staff can provide. He says, it’s ‘the natural credibility, the natural credential of life experience that they bring, they’ve been there. We encourage our peer staff to use the credential ITE after their names – I’m the evidence. It’s me, I’m a real person and yes, I was in your shoes’ (Johnson, 2009b).  

Recovery Innovations is supporting mental health services in five states in the US, and its training programmes have been used in England, Scotland and New Zealand as well as in the US. Johnson is clear that if peer support is to be effective a cultural shift is required, so that the peers are not seen as amateurs working alongside the ‘real’ staff. As he says, it is ‘real work, not sheltered work or therapy’, and it needs a salary that reflects that. Quality training is crucial, for peers and for existing staff. There also needs to be specific, tailored jobs for peers, along with a career training ladder so that peers can progress to more senior positions. This will not happen if peer support remains peripheral. Johnson highlights the need to move to a critical mass of peers to provide a tipping point within an organisation (2009a.b).

Watch the video of Gene Johnson’s views on the ‘Implementing recovery in mental health – the US perspective’.

For more information on Recovery Innovations please see the website. An overview of the training programme is given here.

For details of the UK Department of Health’s Expert Patient Programme please check https://www.gov.uk/government/case-studies/the-expert-patients-programme.

References

Department of Health (DH) (2006) National Evaluation of the pilot phase of the Expert Patient Programme, London: Department of Health.

Hutchinson, D., Anthony, W., Ashcraft, L., Johnson, E. (2006), ‘The Personal and Vocational Impact of Training and Employing People with Psychiatric Disabilities as Providers’, Psychiatric Rehabilitation Journal, 29 (3).

Johnson, G. (2009a) ‘Recovery – the US perspective’, presentation to the Sainsbury Centre for Mental Health, September - https://www.youtube.com/watch?v=3re1KvUlGFs

Wilson, P. M. (2001) ‘A policy analysis of the Expert Patient in the United Kingdom: self-care as an expression of pastoral power?’ Health and Social Care in the Community, 9(3), 134–142.