Psychiatric Rehabilitation Journal 2016, Vol. 39, No. 1, 74 –76
© 2015 American Psychological Association 1095-158X/16/$12.00 http://dx.doi.org/10.1037/prj0000147
BRIEF REPORT
What Makes a Peer a Peer? Colleen Clark, Blake Barrett, Autumn Frei, and Annette Christy
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of South Florida Objective: The purpose of this study was to learn more about which characteristics are considered important for consumers to feel that a person is their peer. Methods: Forty-one participants in a jail diversion program for veterans were asked to rate characteristics in terms of importance for acting in a peer support role. Differences by gender, combat exposure, trauma history, and mental health and substance abuse treatment were analyzed using t tests and Pearson correlations. Results: Having served in the military had the highest average rating; trauma experience second. Participants with combat experience were significantly more likely than those without to indicate this as an important characteristic. Conclusions and Implications for Practice: Increasingly behavioral health programs are recognizing the importance of peer involvement. This study offers guidance on who should be designated a “peer,” suggesting that this should vary according to the population served and be based on the perceptions of the consumers. Keywords: peer support, trauma, veterans, jail diversion
consensus on which life experiences are necessary for the support person to be effective. For the Jail Diversion and Trauma Recovery with a priority for Veterans (JDTR) program, consumers were veterans, eligible for diversion from the criminal justice system with a history of trauma and a trauma-related disorder (for a more detailed description of the program, see Christy, Clark, Frei, & Rynearson-Moody, 2012). JDTR was offered by two nonprofit community agencies and provided primarily case management and trauma specific outpatient groups. A priority for the program was to employ peers as staff, but the literature offers little guidance as to which characteristics should be considered. The purpose of this study was to explore the importance of certain peer characteristics and to examine whether consumers with histories of combat exposure, substance abuse treatment, and mental health treatment were more likely to value those characteristics than those who had not had those experiences. Gender and level of lifetime trauma were also examined.
The concept of people with similar lived experiences assisting and supporting others in their recovery is an important part of the psychosocial rehabilitation movement. There is a body of research supporting the effectiveness of peer support services and the importance of their role in person-centered mental health care (Doughty & Tse, 2011; Miyamoto & Sono, 2012). In mental health, peer specialists are people in recovery who provide peer support focusing on self-determination, health and wellness, hope, communication with providers, illness management, and stigma (Salzer, Schwenk, & Brusilovskiy, 2010) and provide a holistic approach to behavioral health conditions beyond the management of symptoms (Solomon, 2010). For survivors of trauma, actively involving those in their own recovery sends an important message of mutuality, bonding, and focus on strengths (Fearday & Cape, 2004). The Department of Veteran’s Affairs has implemented a number of peer support programs for people with serious mental illnesses with demonstrated benefits for the consumer, peer provider, and the system (Chinman et al., 2008; Resnick & Rosenheck, 2008). Forensic peer specialists are playing a key role in veteran’s courts, alternatives for justice-involved veterans (Slattery, Dugger, Lamb, & Williams, 2013). Although programs involving peers helping peers agree that shared life experiences are crucial to the endeavor, there is no
Methods Procedures This study was approved by an Institutional Review Board. Individuals were screened and those meeting the criteria were invited to participate in the JDTR program. No one declined to participate in this part of the study. Evaluators who were not program staff then obtained informed consent and administered a face-to-face interview.
This article was published Online First May 18, 2015. Colleen Clark, PhD, Blake Barrett, MSPH, Autumn Frei, PhD, and Annette Christy, PhD, Department of Mental Health Law & Policy, Florida Mental Health Institute, University of South Florida. Correspondence concerning this article should be addressed to Colleen Clark, PhD, University of South Florida, MHC 2732, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612. E-mail: [email protected]
Participants Forty-one participants were interviewed within 2 weeks of entering the program by evaluators. The majority of participants were 74
WHAT MAKES A PEER A PEER?
the US armed forces” (M ⫽ 2.87; SD ⫽ 1.12). “Experience with trauma-related issues” was the second highest (M ⫽ 2.41; SD ⫽ 0.74). The characteristic that was rated the least important was “the same race” (M ⫽ 1.08; SD ⫽ 0.35). For the characteristics in the “other” category, participants primarily listed personal attributes such as compassion, patience, and integrity; and communication skills such as being a good listener. Compared to those who reported no combat exposure (n ⫽ 23), those with combat exposure (n ⫽ 18) placed higher importance on service in a combat zone or theater, M ⫽ 2.33 (SD ⫽ 1.14) vs. M ⫽ 1.26 (SD ⫽ 0.75), t(28.07) ⫽ 3.45, p ⫽ .002. The Pearson correlations and t tests for gender, inpatient mental health treatment, and trauma history were all nonsignificant. Compared to those with no history of inpatient substance abuse treatment (n ⫽ 17), those with a history placed higher importance on experience with substance abuse issues in a peer, M ⫽ 2.67 (SD ⫽ 0.92) versus M ⫽ 1.94 (SD ⫽ 0.90), t(35.02) ⫽ 2.52, p ⫽ .016; however this difference does not attain the threshold for significance with the Bonferroni correction.
male (90.2%). Almost two thirds (65.9%) were White, 31.7% Black, and one participant endorsed multiple racial identifications. Five participants (12.3%) were Hispanic/Latino ethnicity. Their ages ranged from 22 to 74 (M ⫽ 43.9, SD ⫽ 12.7).
Measures
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
75
Gender, race, ethnicity, combat exposure, and history of inpatient treatment for mental health and/ or substance use disorders were included in a larger protocol evaluating the JDTR program. Peer characteristics. Participants were asked to rate the importance of 13 characteristics of peer service providers (military, behavioral health, criminal justice involvement, and demographic characteristics) on a 4-point Likert scale ranging from 1 (not important) to 4 (strongly important). Participants were also asked an open-ended question on other characteristics they felt were important for peer providers. Lifetime trauma history. The Posttraumatic Diagnostic Scale modified version (PDS; Foa, Cashman, Jaycox, & Perry, 1997) was used to measure the occurrence of types of trauma experiences in a lifetime. Summary scores range from 0 to 8.
Discussion Analyses
Given that all participants were veterans and the program was clearly identified as veteran-centered, it was not a surprising finding that “having served in the US armed forces” was rated as the most important characteristic in a peer. All participants also had a trauma-related disorder, and experience with trauma issues had the second highest rating. One study has shown that for veterans with PTSD, veteran peers provided relatively high perceived support and little interpersonal stress (Laffaye, Cavella, Drescher, & Rosen, 2008). The strong association between having served in combat and valuing that in a peer support person supports anecdotal information and should be considered in programs focusing on those returning from combat situations. It is also of interest that when asked to express other characteristics, participants primarily focused on interpersonal skills. This study is limited by the small sample. There were only four women in the study; the issue of gender differences should be explored with further research. Additional studies may also want to
Means and standard deviations were calculated for each peer characteristic. Independent t tests were used to examine differences by gender for importance of gender, by mental health treatment history for importance of mental health experience, by substance use treatment history for importance of substance use experience, and by combat exposure status for importance of this experience. Pearson correlational analyses examined associations between magnitude of lifetime trauma history and ratings of the importance of experience with trauma. All tests were two-tailed and evaluated at the Bonferroni family wise error adjusted value of .01 (.05/5).
Results Table 1 presents the findings of the importance of each characteristic by participants. The highest score was given to “served in
Table 1 Perceptions of Characteristics Defining “Peers” Among Veterans Participating in a Jail Diversion Program (N ⫽ 41) Not important (1)
Somewhat important (2)
Important (3)
Extremely important (4)
Peer characteristic
%
%
%
%
M
SD
Served in the U.S. armed forces Experience with trauma-related issues Experience with substance abuse issues Experience with mental health services Experience with criminal justice issues Served in combat zone or theater Served in the same era Served in the same branch Same status Same gender Same age Same rank Same race
17.1 7.3 17.1 22.0 22.0 63.4 73.2 73.2 75.6 82.9 80.5 85.4 92.7
17.1 51.2 46.3 43.9 43.9 9.8 12.2 22.0 17.1 9.8 14.6 9.8 2.4
26.8 34.1 19.5 22.0 24.4 17.1 12.2 2.4 4.9 4.9 2.4 4.9 2.4
39.0 7.3 17.1 12.2 9.8 9.8 2.4 2.4 2.4 2.4 2.4 0.0 0.0
2.87 2.41 2.37 2.24 2.22 1.73 1.44 1.34 1.34 1.27 1.27 1.20 1.08
1.12 0.74 0.97 0.94 0.91 1.07 0.81 0.66 0.69 0.69 0.63 0.51 0.35
CLARK, BARRETT, FREI, AND CHRISTY
76
explore more about participants past experience with peer providers or examine pre and post ratings of the importance of characteristics. Findings can only be generalized to the population studied, that is, veterans with trauma in a jail diversion program. The philosophy behind the peer movement is one of acknowledging the voices of those receiving services. This is an important first step in better understanding which characteristics are valued by consumers.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
References Chinman, M., Lucksted, A., Gresen, R., Davis, M., Losonczy, M., Sussner, B., & Martone, L. (2008). Early experiences of employing consumerproviders in the VA. Psychiatric Services, 59, 1315–1321. http://dx.doi .org/10.1176/ps.2008.59.11.1315 Christy, A., Clark, C., Frei, A., & Rynearson-Moody, S. (2012). Challenges of diverting veterans to trauma informed care: The heterogeneity of Intercept 2. Criminal Justice and Behavior, 39, 461– 474. http://dx .doi.org/10.1177/0093854811433539 Doughty, C., & Tse, S. (2011). Can consumer-led mental health services be equally effective? An integrative review of CLMH services in highincome countries. Community Mental Health Journal, 47, 252–266. http://dx.doi.org/10.1007/s10597-010-9321-5 Fearday, F. L., & Cape, A. L. (2004). A voice for traumatized women: Inclusion and mutual support. Psychiatric Rehabilitation Journal, 27, 258 –265. http://dx.doi.org/10.2975/27.2004.258.265 Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic
Diagnostic Scale. Psychological Assessment, 9, 445– 451. http://dx.doi .org/10.1037/1040-3590.9.4.445 Laffaye, C., Cavella, S., Drescher, K., & Rosen, C. (2008). Relationships among PTSD symptoms, social support, and support source in veterans with chronic PTSD. Journal of Traumatic Stress, 21, 394 – 401. http:// dx.doi.org/10.1002/jts.20348 Miyamoto, Y., & Sono, T. (2012). Lessons from peer support among individuals with mental health difficulties: A review of the literature. Clinical Practice and Epidemiology in Mental Health, 8, 22–29. http:// dx.doi.org/10.2174/1745017901208010022 Resnick, S. G., & Rosenheck, R. A. (2008). Integrating peer-provided services: A quasi-experimental study of recovery orientation, confidence, and empowerment. Psychiatric Services, 59, 1307–1314. http:// dx.doi.org/10.1176/ps.2008.59.11.1307 Salzer, M. S., Schwenk, E., & Brusilovskiy, E. (2010). Certified peer specialist roles and activities: Results from a national survey. Psychiatric Services, 61, 520 –523. http://dx.doi.org/10.1176/ps.2010.61.5.520 Slattery, M., Dugger, M. T., Lamb, T. A., & Williams, L. (2013). Catch, treat, and release: Veteran treatment courts address the challenges of returning home. Substance Use & Misuse, 48, 922–932. http://dx.doi .org/10.3109/10826084.2013.797468 Solomon, P. (2010). Peer support/peer-provided services: Underlying processes, benefits, and critical ingredients. In M. Swarbrick & L. T. Schmidt (Eds.), People in recovery as providers of psychiatric rehabilitation: Building on the wisdom of experience (pp. 56 – 69). Linthicum, MD: United States Psychiatric Rehabilitation Association.
Received September 26, 2014 Revision received April 3, 2015 Accepted April 6, 2015 䡲
© 2015 American Psychological Association 1095-158X/16/$12.00 http://dx.doi.org/10.1037/prj0000147
BRIEF REPORT
What Makes a Peer a Peer? Colleen Clark, Blake Barrett, Autumn Frei, and Annette Christy
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
University of South Florida Objective: The purpose of this study was to learn more about which characteristics are considered important for consumers to feel that a person is their peer. Methods: Forty-one participants in a jail diversion program for veterans were asked to rate characteristics in terms of importance for acting in a peer support role. Differences by gender, combat exposure, trauma history, and mental health and substance abuse treatment were analyzed using t tests and Pearson correlations. Results: Having served in the military had the highest average rating; trauma experience second. Participants with combat experience were significantly more likely than those without to indicate this as an important characteristic. Conclusions and Implications for Practice: Increasingly behavioral health programs are recognizing the importance of peer involvement. This study offers guidance on who should be designated a “peer,” suggesting that this should vary according to the population served and be based on the perceptions of the consumers. Keywords: peer support, trauma, veterans, jail diversion
consensus on which life experiences are necessary for the support person to be effective. For the Jail Diversion and Trauma Recovery with a priority for Veterans (JDTR) program, consumers were veterans, eligible for diversion from the criminal justice system with a history of trauma and a trauma-related disorder (for a more detailed description of the program, see Christy, Clark, Frei, & Rynearson-Moody, 2012). JDTR was offered by two nonprofit community agencies and provided primarily case management and trauma specific outpatient groups. A priority for the program was to employ peers as staff, but the literature offers little guidance as to which characteristics should be considered. The purpose of this study was to explore the importance of certain peer characteristics and to examine whether consumers with histories of combat exposure, substance abuse treatment, and mental health treatment were more likely to value those characteristics than those who had not had those experiences. Gender and level of lifetime trauma were also examined.
The concept of people with similar lived experiences assisting and supporting others in their recovery is an important part of the psychosocial rehabilitation movement. There is a body of research supporting the effectiveness of peer support services and the importance of their role in person-centered mental health care (Doughty & Tse, 2011; Miyamoto & Sono, 2012). In mental health, peer specialists are people in recovery who provide peer support focusing on self-determination, health and wellness, hope, communication with providers, illness management, and stigma (Salzer, Schwenk, & Brusilovskiy, 2010) and provide a holistic approach to behavioral health conditions beyond the management of symptoms (Solomon, 2010). For survivors of trauma, actively involving those in their own recovery sends an important message of mutuality, bonding, and focus on strengths (Fearday & Cape, 2004). The Department of Veteran’s Affairs has implemented a number of peer support programs for people with serious mental illnesses with demonstrated benefits for the consumer, peer provider, and the system (Chinman et al., 2008; Resnick & Rosenheck, 2008). Forensic peer specialists are playing a key role in veteran’s courts, alternatives for justice-involved veterans (Slattery, Dugger, Lamb, & Williams, 2013). Although programs involving peers helping peers agree that shared life experiences are crucial to the endeavor, there is no
Methods Procedures This study was approved by an Institutional Review Board. Individuals were screened and those meeting the criteria were invited to participate in the JDTR program. No one declined to participate in this part of the study. Evaluators who were not program staff then obtained informed consent and administered a face-to-face interview.
This article was published Online First May 18, 2015. Colleen Clark, PhD, Blake Barrett, MSPH, Autumn Frei, PhD, and Annette Christy, PhD, Department of Mental Health Law & Policy, Florida Mental Health Institute, University of South Florida. Correspondence concerning this article should be addressed to Colleen Clark, PhD, University of South Florida, MHC 2732, 13301 Bruce B. Downs Boulevard, Tampa, FL 33612. E-mail: [email protected]
Participants Forty-one participants were interviewed within 2 weeks of entering the program by evaluators. The majority of participants were 74
WHAT MAKES A PEER A PEER?
the US armed forces” (M ⫽ 2.87; SD ⫽ 1.12). “Experience with trauma-related issues” was the second highest (M ⫽ 2.41; SD ⫽ 0.74). The characteristic that was rated the least important was “the same race” (M ⫽ 1.08; SD ⫽ 0.35). For the characteristics in the “other” category, participants primarily listed personal attributes such as compassion, patience, and integrity; and communication skills such as being a good listener. Compared to those who reported no combat exposure (n ⫽ 23), those with combat exposure (n ⫽ 18) placed higher importance on service in a combat zone or theater, M ⫽ 2.33 (SD ⫽ 1.14) vs. M ⫽ 1.26 (SD ⫽ 0.75), t(28.07) ⫽ 3.45, p ⫽ .002. The Pearson correlations and t tests for gender, inpatient mental health treatment, and trauma history were all nonsignificant. Compared to those with no history of inpatient substance abuse treatment (n ⫽ 17), those with a history placed higher importance on experience with substance abuse issues in a peer, M ⫽ 2.67 (SD ⫽ 0.92) versus M ⫽ 1.94 (SD ⫽ 0.90), t(35.02) ⫽ 2.52, p ⫽ .016; however this difference does not attain the threshold for significance with the Bonferroni correction.
male (90.2%). Almost two thirds (65.9%) were White, 31.7% Black, and one participant endorsed multiple racial identifications. Five participants (12.3%) were Hispanic/Latino ethnicity. Their ages ranged from 22 to 74 (M ⫽ 43.9, SD ⫽ 12.7).
Measures
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
75
Gender, race, ethnicity, combat exposure, and history of inpatient treatment for mental health and/ or substance use disorders were included in a larger protocol evaluating the JDTR program. Peer characteristics. Participants were asked to rate the importance of 13 characteristics of peer service providers (military, behavioral health, criminal justice involvement, and demographic characteristics) on a 4-point Likert scale ranging from 1 (not important) to 4 (strongly important). Participants were also asked an open-ended question on other characteristics they felt were important for peer providers. Lifetime trauma history. The Posttraumatic Diagnostic Scale modified version (PDS; Foa, Cashman, Jaycox, & Perry, 1997) was used to measure the occurrence of types of trauma experiences in a lifetime. Summary scores range from 0 to 8.
Discussion Analyses
Given that all participants were veterans and the program was clearly identified as veteran-centered, it was not a surprising finding that “having served in the US armed forces” was rated as the most important characteristic in a peer. All participants also had a trauma-related disorder, and experience with trauma issues had the second highest rating. One study has shown that for veterans with PTSD, veteran peers provided relatively high perceived support and little interpersonal stress (Laffaye, Cavella, Drescher, & Rosen, 2008). The strong association between having served in combat and valuing that in a peer support person supports anecdotal information and should be considered in programs focusing on those returning from combat situations. It is also of interest that when asked to express other characteristics, participants primarily focused on interpersonal skills. This study is limited by the small sample. There were only four women in the study; the issue of gender differences should be explored with further research. Additional studies may also want to
Means and standard deviations were calculated for each peer characteristic. Independent t tests were used to examine differences by gender for importance of gender, by mental health treatment history for importance of mental health experience, by substance use treatment history for importance of substance use experience, and by combat exposure status for importance of this experience. Pearson correlational analyses examined associations between magnitude of lifetime trauma history and ratings of the importance of experience with trauma. All tests were two-tailed and evaluated at the Bonferroni family wise error adjusted value of .01 (.05/5).
Results Table 1 presents the findings of the importance of each characteristic by participants. The highest score was given to “served in
Table 1 Perceptions of Characteristics Defining “Peers” Among Veterans Participating in a Jail Diversion Program (N ⫽ 41) Not important (1)
Somewhat important (2)
Important (3)
Extremely important (4)
Peer characteristic
%
%
%
%
M
SD
Served in the U.S. armed forces Experience with trauma-related issues Experience with substance abuse issues Experience with mental health services Experience with criminal justice issues Served in combat zone or theater Served in the same era Served in the same branch Same status Same gender Same age Same rank Same race
17.1 7.3 17.1 22.0 22.0 63.4 73.2 73.2 75.6 82.9 80.5 85.4 92.7
17.1 51.2 46.3 43.9 43.9 9.8 12.2 22.0 17.1 9.8 14.6 9.8 2.4
26.8 34.1 19.5 22.0 24.4 17.1 12.2 2.4 4.9 4.9 2.4 4.9 2.4
39.0 7.3 17.1 12.2 9.8 9.8 2.4 2.4 2.4 2.4 2.4 0.0 0.0
2.87 2.41 2.37 2.24 2.22 1.73 1.44 1.34 1.34 1.27 1.27 1.20 1.08
1.12 0.74 0.97 0.94 0.91 1.07 0.81 0.66 0.69 0.69 0.63 0.51 0.35
CLARK, BARRETT, FREI, AND CHRISTY
76
explore more about participants past experience with peer providers or examine pre and post ratings of the importance of characteristics. Findings can only be generalized to the population studied, that is, veterans with trauma in a jail diversion program. The philosophy behind the peer movement is one of acknowledging the voices of those receiving services. This is an important first step in better understanding which characteristics are valued by consumers.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
References Chinman, M., Lucksted, A., Gresen, R., Davis, M., Losonczy, M., Sussner, B., & Martone, L. (2008). Early experiences of employing consumerproviders in the VA. Psychiatric Services, 59, 1315–1321. http://dx.doi .org/10.1176/ps.2008.59.11.1315 Christy, A., Clark, C., Frei, A., & Rynearson-Moody, S. (2012). Challenges of diverting veterans to trauma informed care: The heterogeneity of Intercept 2. Criminal Justice and Behavior, 39, 461– 474. http://dx .doi.org/10.1177/0093854811433539 Doughty, C., & Tse, S. (2011). Can consumer-led mental health services be equally effective? An integrative review of CLMH services in highincome countries. Community Mental Health Journal, 47, 252–266. http://dx.doi.org/10.1007/s10597-010-9321-5 Fearday, F. L., & Cape, A. L. (2004). A voice for traumatized women: Inclusion and mutual support. Psychiatric Rehabilitation Journal, 27, 258 –265. http://dx.doi.org/10.2975/27.2004.258.265 Foa, E. B., Cashman, L., Jaycox, L., & Perry, K. (1997). The validation of a self-report measure of posttraumatic stress disorder: The Posttraumatic
Diagnostic Scale. Psychological Assessment, 9, 445– 451. http://dx.doi .org/10.1037/1040-3590.9.4.445 Laffaye, C., Cavella, S., Drescher, K., & Rosen, C. (2008). Relationships among PTSD symptoms, social support, and support source in veterans with chronic PTSD. Journal of Traumatic Stress, 21, 394 – 401. http:// dx.doi.org/10.1002/jts.20348 Miyamoto, Y., & Sono, T. (2012). Lessons from peer support among individuals with mental health difficulties: A review of the literature. Clinical Practice and Epidemiology in Mental Health, 8, 22–29. http:// dx.doi.org/10.2174/1745017901208010022 Resnick, S. G., & Rosenheck, R. A. (2008). Integrating peer-provided services: A quasi-experimental study of recovery orientation, confidence, and empowerment. Psychiatric Services, 59, 1307–1314. http:// dx.doi.org/10.1176/ps.2008.59.11.1307 Salzer, M. S., Schwenk, E., & Brusilovskiy, E. (2010). Certified peer specialist roles and activities: Results from a national survey. Psychiatric Services, 61, 520 –523. http://dx.doi.org/10.1176/ps.2010.61.5.520 Slattery, M., Dugger, M. T., Lamb, T. A., & Williams, L. (2013). Catch, treat, and release: Veteran treatment courts address the challenges of returning home. Substance Use & Misuse, 48, 922–932. http://dx.doi .org/10.3109/10826084.2013.797468 Solomon, P. (2010). Peer support/peer-provided services: Underlying processes, benefits, and critical ingredients. In M. Swarbrick & L. T. Schmidt (Eds.), People in recovery as providers of psychiatric rehabilitation: Building on the wisdom of experience (pp. 56 – 69). Linthicum, MD: United States Psychiatric Rehabilitation Association.
Received September 26, 2014 Revision received April 3, 2015 Accepted April 6, 2015 䡲
