The International Journal of Psychosocial Rehabilitation

The Impact of Forensic Peer Support Specialists

on Risk Reduction and Discharge Readiness

in a Psychiatric Facility

A Five-Year Perspective

 
 

Robert Short, MA

Karen Woods-Nyce, LISW, CCFC

Susan L. Cross, MSEd, PC

Mark A. Hurst, MD

Lisa Gordish, PsyD

James Raia, PhD

 

Twin Valley Behavioral Healthcare
Columbus, Ohio
A regional psychiatric hospital of the Ohio Department of Mental Health for 
approximately 200 civil, forensic, and maximum-security forensic consumers.

Abstract
This article describes the successful five-year employment of specialized forensic peer supports in a state regional psychiatric hospital, with a focus on the hospital’s unique forensic community re-integration program, “The Community Living, Education and Recovery Program (CLEAR).” The hospital, Twin Valley Behavioral Healthcare (TVBH), located in Columbus, Ohio is an Ohio Department of Mental Health (ODMH) psychiatric treatment facility for approximately 200 civil, forensic, and maximum-security consumers. Although the TVBH peer supporters interact with both forensic and non-forensic TVBH consumers, this article focuses on their unique, risk management services with TVBH forensic consumers, who encounter complex legal issues and community placement challenges as they near conditional release and discharge.

Key Words: Mental Health, Peer Support Services, Inpatient Mental Health Care, Psychosocial Rehabilitation, Psychiatric Care, Inpatient Mental Health Treatment, Specialized Mental Forensic Services

Overview
One of the key recommendations in the 2003 President’s New Freedom Commission on Mental Health report, “Achieving the Promise: Transforming Mental Health Care in America”, is “to involve consumers and families fully in orienting the mental health system toward recovery” (Hogan, 2003).

Since the publication of the Commission’s report in 2003, mental health care has witnessed a wide increase in effective programs to involve consumers in the recovery process as “peer supports” to work with persons having serious mental illness, including those with forensic and criminal justice system involvement. The working definition of a “peer support” identifies a consumer who is recovering from mental illness and providing support to other consumers who can benefit from their life experiences. Peer support differs from other types of support in that the experience of “having been there” and having made progress in one’s own personal recovery comprises a major part of the support and guidance provided. Peer support consumers include non-professionals, paraprofessionals, and licensed professionals, depending upon their educational levels and credentials. Research has shown that peer support programs are cost effective and advance the treatment culture and therapeutic outcomes (Minyard, 2006).  Health and Human Services Secretary, Katherine Sebelius, has been encouraged by Members of the U.S. Congress to include trauma survivor and mental health consumer leadership in publicly funded programs (Sebelius, 2010).

Recovery-oriented peer supports are provided employment with treating facilities by consulting with consumer-run agencies, or they volunteer or work independently as providers in a variety of psychosocial rehabilitative and residential settings, including mental health facilities. Consumers who work as peer supports are able to expand the quality, range and availability of services which professionals may not be able to offer (Dihoff, 2009).

Thirty states have developed criteria for the training and deployment of “peer specialists,” and at least 13 states have initiated a Medicaid waiver option that provides reimbursement for specialized peer-delivered mental health services. One area of “peer specialists” is “forensic peer supports” which involves support from peers with histories of mental illness as well as forensic or criminal justice involvement. This type of forensic peer support provides treatment interventions to meet the needs of people with mental illness who are involved in the justice system; this treatment includes an understanding of the impact of forensic mental hospitalization and/or incarceration on the recovery process. Understanding, recognizing and treating trauma and posttraumatic stress disorders, prevalent among this population, is additionally critical to the specialized services of the forensic peer supporters (Davidson & Rowe, 2008).

The authors of the current article describe the successful five-year employment of specialized forensic peer supporters in a state regional psychiatric hospital, with a focus on the hospital’s unique forensic community re-integration program, “The Community Living, Education and Recovery Program (CLEAR).” The hospital, Twin Valley Behavioral Healthcare (TVBH), located in Columbus, Ohio, is a treatment facility for approximately 200 civil, forensic, and maximum-security forensic consumers of the Ohio Department of Mental Health (ODMH). Although the TVBH peer supporters interact with both forensic and non-forensic TVBH consumers, this article focuses on their unique risk management services with TVBH forensic consumers, who encounter complex legal issues and community placement challenges as they near conditional release and discharge.

Forensic Peer Support Services
The CLEAR program services are provided on a uniquely managed TVBH unit, designed to facilitate the earliest possible discharge and appropriate residential placement for forensic residents while simultaneously identifying and managing risk factors. CLEAR services are individually planned for all forensic consumers who are working towards a conditional release, or are nearing discharge with an expired forensic commitment status. CLEAR consumer forensic statuses include Incompetent-to-Stand Trial, Unrestorable-to-Competency, Not-Guilty-by-Reason-of-Insanity (NGRI), and NGRI-on- Conditional Release. The CLEAR program provides these consumers with an opportunity to live in a more independent hospital living arrangement compared to the other hospital units. In addition to ongoing medical and mental treatment, CLEAR consumers have the opportunity to engage in work programs within the hospital, hold community jobs, participate in weekday community educational and leisure activities, and weekend supervised community events.

The CLEAR forensic residents participate in a quarterly “Consumer Care Satisfaction Survey” to assess and assure that their personal needs and treatment goals are being fulfilled to their satisfaction.  Each CLEAR consumer is additionally assigned a TVBH professional staff member as a “mentor” to facilitate the quality of their care, and to assist in the continuity of their services and their preparation for discharge. This Survey helps consumers identify and relate their individual special needs to all staff. Copies of the CLEAR program, and the Consumer Care Satisfaction Survey, are available in PDF upon request; request contact is Lori.Bowsher@mh.ohio.gov.

The TVBH forensic peer supporters consist of former, forensic consumers within the TVBH treatment system; therefore, they have “first hand” experience dealing with the specific challenges of managing forensic risks in the hospital and, upon discharge, in a Columbus, Ohio residential placement. The peer supporters are staff who were hired for their demonstrated competency skills in the area of providing peer services; the TVBH clinical and administrative managers provide peer staff supervision.

The forensic peer supporter’s work to help each forensic resident manage risk is paramount for each consumer’s mental stabilization, completion of the CLEAR program, and for the most expedient discharge. A forensic consumer’s continuous recovery in the community with a lasting residential placement, and without future criminal activities, or legal involvement, or re-hospitalization, is dependent upon his or her risk management abilities. Peer supporters can provide residents with durable forensic risk management skills. Preparing community placement for forensic consumers upon discharge is often difficult as providers of residences such as group homes, supervised apartments or independent apartments are characteristically prejudiced or fearful of tenants with a past mental-criminal history. Therefore, careful attention to minimizing risk factors for recidivism, including maximizing treatment adherence, is operative to securing each TVBH consumer a successful community placement.

Forensic Peer Support Function and Roles
Peer supporters have defined office space in the consumer care areas. They greet all hospital admissions with a description of TVBH’s peer support services and attend consumer treatment planning meetings to assist in the development of each consumer’s personalized recovery objectives and goals. After the treatment plan is completed, peer supporters meet individually with the consumers to guide them in the achievement of the treatment plan’s recovery targets. Peer supporters often can answer questions and process issues that residents may not feel comfortable discussing with a professional staff or with their mentor or in a group treatment meeting. Peer supporters also assist consumers, who may have reading or writing problems during their completion of forms or the usage of computer formats. Peer supporters hold meetings on the consumer care units offering teaching materials on various mental health topics, physical wellness, self-empowerment, legal issues, risk containment, education and employment opportunities and community adjustment skills. Peers involve consumers in social and recreational activities. Peers coordinate their support work with the other members of the consumer’s treatment team, the consumer’s mentor and family members. The peer supporters are directly supervised by the TVBH Clients’ Rights Specialist, a full-time employee of the hospital.

Additionally, peers supporters are active members of TVBH’s standing committees, such as Research and Education, Behavior Therapy, Cultural Competence, Coercion Free, and Ethics. They are involved in the planning and execution of special activities, for example, the completion of consumer satisfaction surveys, the TVBH newsletter, the TVBH professional publications, the “Speak-up Program”, the hospital health fairs and the staff-consumer respect initiatives. These activities are in keeping with the U.S. Congress’ request to include “mental health consumer leadership” in publicly funded programs and services (Sebelius, 2010).

When performing the above peer functions, supporters serve as

Specific Forensic Risk Management Interventions
A. Role Models for Risk Free Effective Behaviors
As role models for risk free effective behaviors, peer supporters are able to relate to consumers through their own experiences when they were consumers at TVBH, and were successful to overcome various risky situations or challenges that could have put their stability in jeopardy.  Treatment sessions involving peer-to-consumer role-playing, drawing on the experiences of peers, can provide consumers with effective solutions for avoiding risk in the hospital and in the community. The peer supporter can describe risky situations they have encountered, explore with the consumer what they would do or did to remain risk free, and then work with the consumer on understanding the best risk free resolutions.  This type of peer-consumer role-playing enables a consumer to practice coping strategies and empowers them with hands-on behavior skills.  

Peer supporters provide role modeling through interacting with consumers in a variety of situations. In addition to hospital work, they take the residents out of the hospital for outings to restaurants, stores, parks, ball games, and cultural events, where they can engage in open discussions about a variety of community life issues and problems, including how to get their needs met and how to negotiate services in the community. The peer supporters provide their perspectives of maintaining responsibility for oneself in the community as they navigate within a complicated community mental health system.  Peer supporters share experiences how to use personal skills to keep community mental health treatment schedules, and thus maintain medication compliance, and how to refrain from drug and alcohol abuse when other people around them are using and abusing substances.

The peer supporters at TVBH also provide role model commentary to other consumers in training DVD they created and star in “Making a Difference through Hope and Respect.” In this DVD, they detail the history of their own recovery.  This DVD is played on the in-hospital TV closed circuit, which is used to educate staff and newly admitted consumers. 

B. Unique Communicators between Consumers and the Professional Staff
Peer supporters can share unique communications with consumers and staff since they are able to use language or “lingo” which can be closely representative to a consumer’s idiosyncratic thoughts and emotions. TVBH consumers relate they perceive their peer supporters as providing unique insights from a perspective of “real life knowledge” rather than “second hand professional training.” This perception of a peer’s “real life knowledge” can facilitate the consumer’s acceptance and practical use of treatment advice and enable the consumer to unify cognitions and feelings seamlessly in a solidified pathway to recovery. This is especially true during sensitive therapies such as post-traumatic stress disorder treatment; for example, when a peer has suffered a similar trauma event, such as a mugging or sexual assault. These types of unique communications, such as defining a trauma in the framework of peer supporter’s experience, can provide a bond between the consumer and the peer supporter that can be a crucial agent for therapeutic change.

A young TVBH consumer with a diagnosis of schizophrenia was struggling to accept this diagnosis and the explanation of his related symptoms from his treatment team members.  He saw the team members as authority figures who were trying to keep him in the hospital, and thus rejected their attempts to educate him on the symptoms of his schizophrenic illness.  However, this consumer’s insight improved significantly after engaging with his peer supporter in an educational meeting and hearing the peer supporter’s lead discussion about his own schizophrenic disorder and the symptoms he experienced.  The following day, the consumer expressed to his treatment team, “I think I have a schizophrenic mental illness” and he was willing to explore the various symptoms he was having in relation to needed treatment. This example emphasizes the peer supporter’s communication role as teacher and coach in the recovery process.  Residents repeatedly say that when they arrived at the hospital they knew nothing or little about mental illness, and everything they learned about it came from the staff.  TVBH consumers remark and emphasize that their recovery journey would not have been possible without this understanding of their mental illness, and the specific symptoms of their mental illness. When consumers understand the nature of their mental illness, they recognize the rationale for psychiatric treatment and the need for complying with psychiatric medication.

Overall, the peer supporters have the unique opportunity to be able to relate their own life story of recovery so that the TVBH consumers feel comfortable, and, in turn, to tell their own life stories.  The residents feel that the peer supporters can truly understand the problems they are experiencing which make for a more open sharing of feelings.  This appears to build trust and provides hope across all recovery experiences.  The peer supporters are able to “meet the consumers where they are mentally and emotionally” given their own hospital experiences.

C. Identifiers and Innovators for Improved Consumer Care Procedures
Peer supporters are able to recall and assess experiences when they were consumers in terms of what “worked” or “did not work” for them. At the time when peer supporters were TVBH residents, their energies were occupied with their own treatment, thus they may not have been able to become active as identifiers and innovators for changes, which could improve mental care. When they were residents, peer supporters may have recognized the need for improvements, and discussed these with their treating sources, but at that time, their focus was inward on their own recovery. However, now employed as peer supporters, their identified mental care improvements can be addressed as one of the special goals of their work. At TVBH, peer supporters are included on organizational committees, and thus have a voice and direct input for improvements at all levels. In addition to their own ideas for change, peers supporters can survey TVBH consumers and bring the consumer’s valued ideas for changes forward for institutional consideration and action. Positive results of consumer care improvements at TVBH can then be shared to activate broader systemic changes at the state and federal level. Such sharing can take place by peer supporters when they attend state and federal committees or when they participate on the academic and professional communities.

TVBH peer supporters interview residents who have had an incident of seclusion or restraint and then provide feedback to the hospital administration about the consumer’s point of view and experience.  Such feedback is related directly to various hospitals committees, which, in turn, enables the committee members to develop and introduce seclusion and restraint strategies to reduce traumatic experiences to the consumer and improve training for the staff.

D. Mediators during Complaint or Grievance Resolutions
Peer supporters can be mediators between consumers and treatment staff during complaint or grievance resolutions, since complaints are a sensitive or difficult topic for residents to address themselves directly with staff. Without this mediation, residents may never express dissatisfaction and staff would not have the opportunity to assess the complaints and improve hospital procedures accordingly.

Consumer dissatisfaction or complaints can be obstacles or deterrents to their recovery process. There is a tendency for residents to “live with” dissatisfaction and not to complain to professional staff since they perceive professionals as “authorities who know what they are doing.” “The staff knows better than me” and “I should just be quiet and follow what is provided to me” are found to be common coping devices among residents as a means to manage dissatisfaction. In addition, TVBH consumers have expressed fears that if they complain to professionals, they believe that this could negatively affect their therapeutic relationship with the treatment staff, and affect the overall quality of their care, or prolong their discharge date, or the staff’s interest in finding them the best possible community, residential placement.

On the other hand, residents express that they are less fearful and more trusting with their peer supporters in terms of disclosing their discontent and complaints. Residents relate that they believe their peer supporters are closer to them in overall identity, and thus will be empathic listeners to complaints or grievances. When peer supporters facilitate the completion of the Consumer Care Satisfaction Surveys, consumers are informed that they can document dissatisfaction on the survey to be discussed later confidentially with their peer supporter. The Consumer Care Satisfaction Survey has proven to be an effective bridge for beginning the process whereby consumers can work with peer supporters on their concerns. Since the peer supporters report to the TVBH Clients’ Rights Specialist, they can bridge communication between the consumer with this clients’ rights specialist who oversees all consumer complaints and grievances.

E. Mentors and Teachers for Self-Advocacy Skills
Forensic peer supporters, during the course of their own recovery, learn strategies to advocate for themselves in the community. Peer supporters recognize that self-advocacy strategies are important survival skills, which have enabled them, on their own, to obtain or utilize community resources for treatment, to secure and maintain housing, and to achieve education and employment opportunities. Upon discharge, consumers often begin to feel isolated and deserted when they do not have daily contact with treatment staff. They realize that they have to fend for themselves and draw on their own strengths to meet their physical and emotional needs. The success to which consumers can meet these physical and emotional needs post-discharge depends largely on the adequacy of their survival skills. Therefore, one of the essential functions of the peer support staff is to work as mentors and teachers for self-advocacy skills. Peer supporters can uniquely impart or teach the lessons they learn about self-advocacy to consumers utilizing their experiences in the community after their own discharge from the hospital. 

By way of example, the peer supporters indicate that they help the consumers to feel empowered to speak up if they feel their rights are being violated. The TVBH peer supporters are involved in an initiative in the hospital called the “Speak Up” program.  The goal of this program is to educate the residents on the various appropriate means of speaking up and discussing any concerns they have about their care or the facility. The “Speak Up” initiative begins early in the admission process when peer supporters meet with newly admitted consumers to review their client’s rights. The peer supporters also attend community meetings on the direct care units, and encourage residents to speak up to the treatment staff about any concerns they may have, ranging from their treatment, to the behavior of other consumers on the unit, or to facility and safety concerns.   
           
Since the peer supporters have administrative, working relationships with staff, they can often help solve consumer-staff problems in an expedient and collaborative manner.  The peer supporters’ input can help to formulate advocacy policies that are more sensitive to the consumers’ needs, concerns, and worries.  The peer supporters are in a unique situation of knowing the TVBH environment and “seeing” both sides (consumer vs. treating source).

Conclusion
Treatment facilities can be viewed as a care system of complex people communicating and interacting with each other across multifaceted formats. Each person in this system has the opportunity to uniquely influence each other’s thinking, behaving, performing and ability to change or improve. Medical and administrative staff has traditionally dominated the information exchange in most treatment systems. By contrast, the formal introduction and addition of peer support services into the care processes at TVBH has significantly enhanced its therapeutic options and cultural attributes. TVBH peer supporters and consumers can communicate and support each other in distinctive ways not available by the traditional medical and administrative personnel. TVBH recognizes the worth and respects the effectiveness of peer supporters as providers of mental health care, especially in the areas of forensic risk reduction and discharge preparedness. The addition of peer supporters at TVBH has expanded the range of services to the consumers and improved the overall quality of recovery for its residents. The presence and services of the peer supporters imply "hope" to the TVBH consumers.  Hope that they do not have to live in the state hospital all their lives and hope that they can live successfully and independently in the community.
 
Implications for Psychiatric Rehabilitation Services
A. Peer supporters can be role models for risk free effective behaviors. They are able to relate to consumers through their own experiences when they were consumers and were successful to overcome various risky situations or challenges that could have put their stability in jeopardy.  Treatment sessions involving peer-to-consumer role-playing, drawing on the experiences of peer supporters, can provide consumers with effective solutions for avoiding risk in the hospital and in the community.

B. Peer supporters can share unique communications with consumers and treatment staff since they are able to use language or “lingo” which can be closely representative to a consumer’s idiosyncratic thoughts and emotions. Consumers relate they perceive their peer supporters as providing unique insights from a perspective of “real life knowledge” rather than “second hand professional training.” This perception of a peer supporter’s “real life knowledge” can facilitate the consumer’s acceptance and practical use of treatment advice, and enable the consumer to unify cognitions and feelings seamlessly in a solidified pathway to recovery.

C. Peer supporters are able to recall and assess experiences when they were residents in terms of what “worked” or “did not work” for them during treatment at TVBH. At the time when peer supporters were residents, their energies were occupied with their own treatment, thus they may not been able to become active as identifiers and innovators for changes, which could improve care. When they were residents, peer supporters may have recognized the need for improvements, and discussed these with their treating sources, but at that time, their focus was inward on their own recovery. However, now employed as peer supporters, their identified care improvements can be addressed as one of the special goals of their work to provide feedback to the hospital administration, and to the various consumer care committees. 

D. Peer supporters can be mediators between consumers and treatment staff during complaint or grievance resolutions, since complaints or grievances can be a sensitive or difficult topic for residents to address themselves directly with staff. Without this mediation, residents may never express dissatisfaction and staff would not have the opportunity to assess the consumer’s concerns and thereby improve hospital procedures related to a concern.

E. Peer supporters, during the course of their own recovery, learn strategies to advocate for themselves in the community. Peer supporters recognize that self-advocacy strategies are important survival skills, which have enabled them, on their own, to obtain or utilize community resources for treatment, to secure and maintain housing, and to achieve education and employment opportunities. Peer supporters can teach the lessons they learn about self-advocacy to other consumers, to help them feel empowered, and to speak up if they feel their rights are being violated. The peer supporters have been involved in an initiative in the hospital named the “Speak Up” program, which begins at the time of admission.

References:

Davidson, L., & Rowe, M. (2008) Peer Support within Criminal Justice Settings: The Role of Forensic Peer Specialists. The CMHS National GAINS Center.  Retrieved July 1, 2011, From http://gainscenter.samhsa.gov/pdfs/integrating/Davidson_Rowe_Peersupport.pdf

 Dihoff, D. (2009) Peer Support/Recovery Task Force Report, August 2009. Prepared by the Peer Support/Recovery Task Force NAMI NC. Subcommittee of the Coalition for Persons Disabled by Mental Illness.   Retrieved July 1, 2011, from http://nationsnet.com/naminc/peer_support_task_force/Peer%20Support%20Report%208%200          9%20Entire.doc

 Hogan, M. F. (2003) President’s New Freedom Commission on Mental Health; Achieving the Promise: Transforming Mental Health Care in America. Retrieved July 1, 2011, from
http://www.mentalhealthcommission.gov/reports/FinalReport/toc.html

 Minyard, K. J. (2006) The Effect of Peer Support on Recidivism Rates for Mental Health Hospital Admissions and Crisis Stabilization Episodes. Georgia Health Policy Center.           Retrieved July 1, 2011, from http://aysps.gsu.edu/ghpc/long_term_care/reports/Final%20Peer%20Support%20Report%209-             27-06.pdf

 Sebelius, K. (2010) Public Policy Update May 13, 2010. Congress of the United States, House of Representatives, Letter to the U.S. Department of Health and Human Services, Retrieved July 1, 2011, from  http://www.thenationalcouncil.org/cs/public_policy_update_newsletter/may_13_2010