Transitions ACR The Learning & Working - PowerPoint Presentation

1. Transitions ACRThe Learning & Working During the Transition to Adulthood Rehabilitation Research & Training Center June 21, 2018, 2:30PM-4PM ESTThe Georgia 2018 System of Care AcademyEffectively Employing Young Adult Peer Support Workers: Toolkit Overview

2. The Transitions ACR aims to improve the supports for youth and young adults, ages 14-30, with serious mental health conditions who are trying to successfully complete their schooling and training and move into rewarding work lives. We are located at the University of Massachusetts Medical School, Worcester, MA, Department of Psychiatry, Systems & Psychosocial Advances Research Center.Visit us at: https://www.umassmed.edu/TransitionsACR/The contents of this presentation were developed under a grant with funding from the National Institute on Disability, Independent Living, and Rehabilitation Research, and from the Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration, United States Department of Health and Human Services (ACL GRANT # 90RT5031, The Learning and Working Transitions RRTC). NIDILRR is a Center within the Administration for Community Living (ACL), Department of Health and Human Services (HHS). Additional funding provided by UMass Medical School’s Commonwealth Medicine division. The contents of this presentation do not necessarily represent the policy of NIDILRR, ACL, HHS, SAMHSA, and you should not assume endorsement by the Federal Government.AcknowledgementsSlide 32

3. PresentersJonathan Delman, PhD, JD, MPHTechnical Assistance Advisor, Transitions to Adulthood Research CenterAssistant Research Professor, University of Massachusetts Medical SchoolVocational Specialist for Young Adult and Early Psychosis program, Boston, MARaphael Mizrahi, B.S.   Research Coordinator, Transitions to Adulthood Research Center3

4. 4Toolkit PDF https://www.umassmed.edu/globalassets/transitionsrtc/publications/effectivleyemployingyoungadultpeerproviders_a_toolkit.pdfToolkit online https://www.umassmed.edu/TransitionsRTC/publication/effectively-employing-young-adult-peer-providers---a-toolkit/

5. What Informed the Toolkit? Multi-dimensional experiences of co-authorsThrough Transitions RTC: SAMHSA/NIDILRR grantExisting & own researchAdvisory boardMany focus groups & other meetings with young adult peers & employers over the last 3 yearsSlide 55

6. Toolkit ChaptersBackgroundYoung Adults in the Peer Provider Role Conceptualizing and Structuring the Young Adult Peer Role in Your Agency- Hiring, training et alEstablishing an Organizational Culture that Supports Young Adult Peers Youth developmentRecruiting, Hiring and Training Young Adult Peers Effective Supervision for Young Adult PeersAddressing Significant Job Difficulties Using the ADA’s Reasonable Accommodation Framework Preparing and Engaging Non-peer Staff-Infrastructure and Framework 6

7. 1. Background7

8.       Young Adults with Serious Mental Health ConditionsRecovery as short term goalRisk per developmental stage Resilience and confidenceHeightened level of shame and stigma818 19 20 21 22 23 24 25 26 27 28 29 According to Dr. Jeffrey Arnett, Adulthood is….1. Taking responsibility for yourself2. Making independent decisions3. Becoming financially independent

9. Young Adults today are generationally different from pastCommunication through social media & technology (disclosure & confidentiality)Opioid crisisEconomic & jobs/career uncertaintyFamily formation- later marriageGreater tolerance of & sensitivity towards diversity“Emerging Adulthood” defined by identity exploration, instability, being self-focused, & exploring possibilities9

10. New MH Services Designed to Meet the Needs of Young AdultsComponentsYouth oriented/developmentStrengths basedPerson centeredWell coordinatedProgramsFirst episode emergence Coordinated specialty careWraparound+- peer mentorsYoung adult E.g., TIP10

11. Peer SpecialistsIndividuals in recovery from mental health and/or substance use issues who strategically share their lived experience with clients to inspire hope, provide emotional support, and aid in developing a recovery plan. * Training * Certification * Treatment team integration (such as Programs for Assertive Community Treatment (ACT).

12. Unique Qualities of Peer SpecialistUse their own recovery story with clients strategicallyAre role models/exemplarsAdvocate on behalf of clientEngage in mutuality An innovation…..12

13. Boundaries and dual relationshipsSelf-disclosure to client of personal life (mental health, see e.g., Ziv-Beiman, 2013) Codes of ethics (CPS, APA, NASW) are generally consistent on self-disclosureMoral and ethical principlesBeneficence Non-maleficence - “Do no harm” (See APA, 2002). “Wounded Healer”Boundary crossing v. boundary violation (Reamer, 2003; see also Gutheil & Gabbard, 1993)Boundary crossing Intentional and deliberate self-disclosure.Violation: Risk of exploitation or potential harm to the client (manipulative, deceptive, coercive)Engagement: Provider discusses his/her MH condition and recovery w/clientAwareness: Client is aware that provider has a MH condition

14. Codes of ethics Massachusetts CPS code of ethics“10. Certified Peer Specialists will not enter into dual relationships or commitments that conflict with the interests of those they support. 11. Certified Peer Specialists will never engage in sexual/intimate activities with those to whom they are currently providing support, or have worked with in a professional role in the past year….13. Certified Peer Specialists will not engage in business, extend or receive loans, or accept gifts of significant value from those they support.”Social Workers {NASW} Code of Ethics“Conflicts of interests(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients…(b) Social workers should not take unfair advantage of any professional relationship or exploit others to further their personal, religious, political, or business interests. (c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client…(Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.)…”

15. Peers specialists who had been program clientsBenefits of peer specialist as a former client:Best guide for current clients in navigating a complex treatment and vocational system of support.Direct evidence of recovery via this programWhy not have clinician and former client work on the same team? Ethical or management issue?Therapist/Peer specialist discomfort Management Introduce through staff discussions and workshops regarding this discomfortFormer clients working with current clients EthicalFactors includeLength of time since the job applicant was a client thereExisting relationshipsApply general organization dual relationship policies

16. 2. Young Adults in the peer provider role16

17. Specific Demand and Need for Young Adult Peer Workers Increased funding for young adult peer positionsMedicaid reimbursementACAHousingCriminal justiceState MH and SA authoritiesCareer start17

18. Major Benefits of YA Peer IntegrationImprove organizational culture & expand diversityBoost EngagementClient experience, attitude & learningsOutcomesGenerating hope at rock bottom Reduced symptoms and re-hospitalizations Increased sense of wellness, social integration, educational progress 18

19. Multiple Factors Impact Success YA Peers on-the-JobA. Nature of job ComplexityRewardsB. CAPITAL FRAMEWORKHuman capitalCultural capital Psychological capital - Resilience - MotivationPersonal social capital 195. Organizational Social Capital

20. YA Peer Role Implementation Challenges Nature of Job – new type of job, rewarding, challenging, confusing to many, clarity, perceived value of other staffHuman Capital (& hiring)– educational attainment, soft skills, skills gained through training & any system involvement, e.g., peer specialist training Negative Human Capital- criminal records, little work history, education disruptionCultural Capital – job inexperience, challenging b/c one has to be peer and be young adult while also being “professional”Psychological Capital – Impact on persistence, resilience on of e.g., learning disabilities, Social Security, symptoms, stress, living conditions, treatment, transitioningSocial-Personal Capital – Family (for single parents, of significant others) friends, allies (employment supports) 20Social Organizational – workplace culture, structure, staff, and communication etc.

21. Workplace social capital paradigm

22. Workplace challenges to implementing peer specialist roleJob clarity, confusion, and perceived value Relations with and support of other staff SupervisionAddressing job difficulties - Generating effective reasonable accommodationsWellness supportsOrganizational culture- employee beliefs and practicesOrganizational FrameworkSlide 22

23. The impact of Organizational Social CapitalChallenge categoriesOrganizational Social Capital Responses>>>>>>>>>Human CapitalTraining, education opportunitiesOrganizational Social CapitalCultural CapitalSupervisionAccommodationsAccess to health careWellness supportsJob coachCulture values peer rolePsychological CapitalJob satisfaction et alSocial-personal capitalPolicies- time off, accommodationsSlide 23

24. 3. Conceptualizing & Structuring the Young Adult Peer Role in Your Agency24

25. 1. Define and clarify the peer specialist role for all staff: a) before hiring, and b) with HR Identify the unique features of the peer job (below)Describe key functions of this peer position, e.g., navigator, bridger, housing supporter Establish job qualifications, compensation, and career growth opportunities commensurate with job requirementsWritten clear job descriptions for the peer provider roleSlide 25

26. Minimize role confusion26Share and discuss job description and peer ethical code with all staff:Work directly with HREffective dissemination and messagingEventsPR- first person accountsEveryone should know- hiring, cultureAll staff are recruiters to the degree they understand and value of the peer specialist roleTraining, Orientation…

27. Peer job classification and payClassification systems define and evaluate a job’s responsibilities, functions, and authority levelsGradesCompensation AdvancementWorking with HR, clinical leadership, and unionsCareer trackNew classification is I think best… or not27

28. Qualifications, Recruiting & Hiring:Criminal history Avoid common direct services job criteria that tend to screen out [exclude] people with SMHC, often the most optimal candidates:Criminal history (TK p.46)More relevant: Has overcome barriers and can discuss thisJob applications and notice “Ban the box”-…........ Interviewing TK p. 48Even if there are relevant questions re criminal history, do not ask them first thingHelp candidates to remove artificial barriersExpungements- referrals at the very least TK p. 4650 state comparisonLegal aid Slide 28

29. Training peers specialists: BasicsEssential workplace skills SoftHard (Memo format to organize and share information- TK, Appendix D)Personnel policies and benefitsWorkplace rights and responsibilitiesBuilding resilience through stress management, self-care, & wellness planning Reinforce required staff trainingsSupervision as an ideal space for on-going employee development.

30. 4. Establishing the requisite organizational culture for YA Peer Provider Success1. Valuing peer support2. Understanding the experience and culture of today’s young adults3. Recognizing and addressing workplace stigma4. Embracing legal obligations to not discriminate against employees with disabilities5. Diversity of person, perspective, and experience6. A positive [young adult] development approach to treatment and services7. Self-determination and dignity of risk8. Employee access to wellness tools, supports and services

31. Recognizing & Addressing Workplace Stigma: Myths & Misconceptions MythFactsInsufficient work experience or education to workMitigate with: -Resilience and persistence, -Workplace supports, and/or -Health care supportIf not working out may just be not a good matchCan’t work full-time, many using SSDI/SSIBut can when: -FT job has sufficient salary & benefits -Human resources understand federal/state laws the promote FT (e.g, Medicaid [insurance] buy-in, Ticket to Work…) Always in crisisNo. This is simply not the case!-Non-peer staff often use clinical explanations for work difficulties, this is not always the case-Professionalism

32. Embracing legal obligations to not discriminate against employees with disabilitiesFederal & state lawProhibit discrimination in all aspects of employment, including job application procedures, hiring, advancement, discipline, firing, compensation, training, and other terms and privileges of employment… as well as “hostile” workplaceStaff awareness of laws’ specifics itself reduces discriminationEmployer clarity and messagingMany excellent on-line resources (p. 36)

33. Addressing Stigma in the WorkplaceContactTrainingLess formalPresence of peer servicesCo-learningCross-trainingEducation/Training- “real plays”

34. Provider Staff Must Embrace Positive Youth Development ParadigmApproach is to empower youth and young adults with disabilities to take an active role in decisions about their lives, so capable of developing plans toward accomplishing tasks and projects. Domains of staff skill setsBuilding trusting relationshipsDrawing out young adults’ prioritiesMotivating clients to learn and practice meta-developmental skills

35. Need to understand & value:Self-determination & Dignity of RiskPresumption of competenceClash with clinical cultureDevelopmental learning through trying things outPeer specialists as allies in decision making, or adversariesBig challenge for parents/guardiansTIP and “futures planning” are self-determination approaches

36. Promoting Employee WellnessLegally requiredReasonable accommodationFMLAKey principles for preventing problemsAct earlyHealth insurance- access to careEducate all staffPromoteLeave and Return to work programsCBTStress reduction

37. 6. Effective Supervision of YA Peers

38. Facilitator & Supporter of YA Peers in developing strong working alliances with their clientsChampion & Advocate for the YA Peer Role in your contextRole Model & Coach YA Peers Remain aware & conscious of well-being as you would with any employee – but with the knowledge of the unique challenges of being a YA Peer (e.g., discrimination & exclusion)Employs Reflective Supervision practice to guide & support YA Peers. (No, this is not therapy, but reflection is key!)Understanding and belief in peer specialist role Unique Role of SupervisorSlide 1438

39. Essential Supervision TopicsFosters On-the-jobResiliency!Slide 1539

40. TrustContinuous Reflection upon Peer “Relational Processes” in Supervision(Adapted from Spencer, 2006)CollaborationCompanionshipAuthenticityEmpathyWORKING ALLIANCESlide 1740

41. Building Strong “Working Alliances” between Supervisor & YA PeersIncreases likelihood that a YA Peer will discuss on-the-job struggles with supervisorIncreases likelihood that YA Peer will feel comfortable discussing the pros & cons of supervisor suggestions & directives.Excellent opportunity for modeling relationship building skills with YA Peers on how to work with YA clientsSlide 18Relationships between YA Peers & ClientsRelationship between Supervisor & YA PeerRelationships between YA Peers & Colleagues (Peer & Non-Peer)41

42. E.g., Follow up after a new kind of assignment Guidance for New Task Assignment: Put in writingOffer specificsDefine termsInclude examples for formatting, style and lengthSchedule a time to discuss shortly after assignment is made and/or send a follow-up email to support task completion.

43. Reasonable AccommodationsModifications or adjustments to ordinary business operations toward supporting a qualified employee with a disability perform essential job functions, E.g, flexibility re/hours, extra training/supervision, & time off. Slide 2243

44. Reasonable AccommodationsEven when mitigated by treatmentWhen to take action: Request; No particular communication method required“Other obvious” RA Threshold Standards (legally required)Reasonableness: Will it address the issue, and the likelihood of doing so?Undue Hardship: Will the suggested accommodation put an Undue Hardship on the organization (productivity, quality, impact on other staff)? Developing, Implementing & Evaluating Accommodations is an Interactive Process Pgs. 67-70, Appendices F, GSlide 2344

45. Part IV. Establish RAImplement RAMonitor & change as neededEvaluate process Process for achieving RAPart I. Questions to be addressed in this order: 1. What are the job’s primary functions/tasks? 2. What primary functions/tasks is the peer is having difficulty with?3. What are the challenges & barriers to successful execution of functions/tasks?4. What type(s) of accommodations may help peer to perform these functions/tasks? 5. What is the most effective and reasonable accommodations(s)?  Part II.Independent Preparation by employee and/or supervisor: Review of questions Information gatheringPart III. Co-party Interactive Dialogue Elements:ADA rules of interactivityPrinciples of solution focused negotiationStrengths/Needs analysis Toolkit pp. 71-77Slide 2445

46. Staff Awareness of Opportunities & ResponsibilitiesCompany-wide use of Effective & Efficient RA Assessment ProcessClearly & structured- formsFocus on process of interaction & information assessment, while lowering emotional content and blamingProviders need to educate/train staff on the American Disabilities Act (ADA), particularly the concept & practice of RAsSupervisors have confidence to address rather than ignoreTransparency in RA Request & Assessment Process Clear to all staffMany young adult peers would rather stop showing up to work instead of discussing on-the-job struggles Toolkit pp. 77-78Slide 2546

47. 8. Preparing and engaging non-peer staff47

48. Educating and supporting non-peer staffRequired trainings:The peer role, disclosure, boundaries, CPS code of ethics et al.Person-first language Myths of mental illnessPerson centered care and planningShared decision makingInteracting with peers, including protocol for asking personal questionsActive role for people with lived experienceMaking referrals to YA peersTK Chapter 8

49. Management tools“Meaningful Roles for Peer Providers in Integrated Healthcare” manualƒƒ “Staff concerns self-assessment,” which helps to identify staff training needs (page 98);ƒƒ Responses to staff on their concerns about the peer role (page 99);ƒƒ Discussion questions for staff and peers (page 107).49California Association of Social Rehabilitation Agencies (CASRA)

50. Key components of effective trainings Young adult peers take an active role in developing and presenting the training. led or co-led by peers conditions (SMHC), and share their recovery stories.Trainings are offered on a regular basis, with materials available via agency intranet.Active learning methods (e.g., discussion; games), “role plays” b “Real-Plays”,50

51. Workshop 1 SHARED DECISION MAKINGIN FIRST EPISODE PSYCHOSISJonathan Delman, PhD, JD, MPHAssistant Research Professor, Transitions to Adulthood Research and Training Center, https://www.umassmed.edu/transitionsrtc, UMass Medical School Slide 51

52. Informed Consent, Providers’ responsibility“A description of the condition being treated;An explanation of the proposed treatment;An explanation of the risks, side effects and benefits of the proposed treatment; An explanation of alternatives to the proposed treatment as well as the risks, benefits and side effects of the alternatives to the proposed treatment;An explanation of the right to freely consent to or refuse the treatment without coercion, retaliation or punishment, including loss of privileges, threat/use of restraints, discharge, guardianship or Rogers orders…An explanation of the right to withdraw one’s consent to treatment, orally or in writing, at any time…”* Subject to capacity to provide consent- Rogers guardianship.*DMH Informed Consent PolicySlide 52

53. Shared decision making model

54. Prescribers, recommendations, and decisions: Balancing risk and reward with young adultsFactorsPersonal/clinical valuesDevelopmental stagePracticalProbability of effect(s)Intensity of effect(s)“Short” v. “Long” term ViewE.g., Wants to go off meds: *Prevention of further psychosis *Safety* Trust/alliance* Personal growth re developmental stage

55. Critical competencies and best practicesPsychiatric competencies and practices“Demonstration” of knowledge Relational Openness to and/or direct interest in the client’s perspective on treatment Extend oneself beyond expected duties Strategy for outside of office hours- triageClient support Decision aids/supportFormalElectronicE.g., “Power statement”InformalInternet, Social mediaCoaching and instruction manualsPeer specialist Other providersParents/families See Delman J, Clark JA, Eisen SV, Parker VA. Facilitators and barriers to the active participation of clients with serious mental illnesses in medication decision making: the perceptions of young adult clients. J Behav Health Serv Res. 2015 Apr;42(2):238-53.

56. Workshop 2 Boundaries and Dual Relationships in first episode programs: The value of strategic disclosure Jonathan Delman, PhD, JD, MPHAssistant Research Professor, Transitions to Adulthood Center for Research, https://www.umassmed.edu/transitionsrtc, UMass Medical School Slide 56

57. Integrate Team Building Activities Co-learning & cross training.Share:Personal expertisePersonal stories Employee mentorshipOpportunities for informal interaction

58. Organizational approach to support peersDefine and clarify the peer specialist role for all staff Enhance capacity to recruit and hire peer specialistsPromote workplace culture that supports peersEducate and support non-peer staffEstablish effective supervisory practices;Address job difficulties using reasonable accommodation (RA) framework and health support accessEnhance positive psychological capital through employee self-helpEnhance critical elements of organizational infrastructure to drive above58

59. Peer specialists influencing policy and practicePeer specialists can have the most influence on organizational planning and learning when they:Make up a significant portion of the service provider workforce;Are educated on the best & evidence based practices;Are active participants on committees and workgroups relevant to their work;Are in organizational leadership roles.Peer specialists integration into organizational leadershipCentralize peer educationPeer specialist(s) in senior managementBuild relationships with peer run organizations TK Pp. 95-98Slide 59

60. Strong Organizational Communication Endorsing the Peer RoleInternal messagesChampionsTrainers with direct experiencePeer specialistsManagement and supervisorsInternal publicationsOffice walls and corridorsPresence of peer specialistsExternal messagesMission and policy statementsWebsitesNewslettersSlide 60

61. ReferencesDelman J, Clark JA, Eisen SV, Parker VA. Facilitators and barriers to the active participation of clients with serious mental illnesses in medication decision making: the perceptions of young adult clients. J Behav Health Serv Res. 2015 Apr;42(2):238-53 Delman, J., & Klodnick, V. V. (2017). Factors supporting the employment of young adult peer providers: Perspectives of peers and supervisors. Community mental health journal, 53(7), 811-822.Delman, J., Kovich, L., Burke, S., & Martone, K. (2017). The promise of demand side employer-based strategies to increase employment rates for people living with serious mental illnesses. Psychiatric Rehabilitation Journal, 40(2), 179.Gopalan, G., Lee, S. J., Harris, R., Acri, M. C., & Munson, M. R. (2017). Utilization of peers in services for youth with emotional and behavioral challenges: A scoping review. Journal of adolescence, 55, 88-115Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and risk-management dimensions. The American journal of psychiatry.Reamer, F. G. (2003). Boundary issues in social work: Managing dual relationships. Social work, 48(1), 121-133.Simmons, M. B., Coates, D., Batchelor, S., Dimopoulos‐Bick, T., & Howe, D. (2017). The CHOICE pilot project: Challenges of implementing a combined peer work and shared decision‐making programme in an early intervention service. Early intervention in psychiatry.Walker, J. S., Baird, C., & Welch, M. B. (2018). Peer Support for Youth and Young Adults who Experience Serious Mental Health Conditions: State of the Science. Zur, O. (2010). Self-disclosure & transparency in psychotherapy and counseling, http://www.zurinstitute.com/selfdisclosure1.html. Slide 61

62. 10 Toolkit Takeaways62

63. Toolkit Takeaways: Preparation for the YA Peer Provider RoleAll staff should understand the purpose and unique qualities of the young adult peer role via orientation, training, teambuilding and supervision. [Chapters 1, 3, 8]Agency staff must understand the unique developmental experiences of young adults in today’s society. [Chapter 4]Organizational leadership must proactively address discrimination and prevent discrimination toward young adult employees diagnosed with mental conditions. [Chapters 4, 8, 9]63

64. Toolkit Takeaways: Recruiting & Hiring4. Establish YA peer provider job qualifications, functions and pay grade before starting the hiring process and in collaboration with HR. [Chapter 5]5. Avoid job qualification exclusions related to criminal history; do not inquire about criminal history on job application or at the first interview. [Chapter 5]6. All staff should be recruiters: “Your son is looking for work? We have a job opening for people with lived experience that may be a good fit. Let me help you look into it.”7. Orientation and training for YA peers should clarify organizational policies, including those on communications, absences, accommodations, and health benefits. [Chapter 5]64

65. Toolkit Takeaways: Practice8. Individualized & regular supervision that is reflective and addresses career and skill development, wellness, & relationship development is essential for YA on-the-job peer success. [Chapter 6]9. When a supervisor is considering an accommodation or job support for a peer, start by identifying the job functions the person is having trouble with before focusing on the person’s mental health status and symptoms. [Chapter 7] 10. Team building activities such as cross training, co-learning and mentoring are important approaches toward YA peers and non-peer staff developing high quality working relationships. [Chapter 8]65