The Effec(veness of Peer Support Services: Highlights from the Research. BRSS TACS Webinar August 18, :00-3:30 PM Eastern Time

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2 The Effec(veness of Peer Support Services: Highlights from the Research BRSS TACS Webinar August 18, :00-3:30 PM Eastern Time 2

3 Webinar Moderator Jus(ne Hanson Center for Social Innova2on

4 Webinar Instruc(ons Webinar will last approximately 90 minutes Submit ques2ons at any 2me in the box labeled, Submit Ques2ons Here Access to the recorded version of this webinar will be available in about a week Download presenta2on slides and other resources in the box labeled, Access Materials and Links Here

5 Visit the BRSS TACS Webpages tacs

6 New BRSS TACS Resources Knowing Yourself as a Leader Communica2ons Advocacy and Storytelling Cul2va2ng Strong Teams and Partnerships Review archived sessions on: hsp:// tacs/webinars 6

7 Today s Agenda Introduc(on Dr. E. Sally Rogers Dr. Alexandre Laudet Dr. Ellen Bassuk Q&A and Discussion Session Closing Remarks

8 Dr. E. Sally Rogers Execu2ve Director, Boston University Center for Psychiatric Rehabilita2on 8

9 Effec(veness of Peer Recovery Support Services for Suppor(ng Recovery from Mental Health Condi(ons E. Sally Rogers, Sc.D. Execu(ve Director, Director of Research and Research Professor Center for Psychiatric Rehabilita(on Boston University 9 erogers@bu.edu

10 Lessons Learned Systema2c Review of peer literature over 20 years Approximately 10 years of working with peer run services to evaluate outcomes and to conduct randomized trials and surveys of peer specialists Par2cipa2on in the SAMHSA mul2- site study on consumer run programs Special issue of the upcoming Psychiatric Rehabilita2on Journal on peer specialist services

11 Studies Reviewed: Predominant Services We ini2ally examined 175 manuscripts; narrowed to about 75 of peer support when: 1) Added to a tradi2onal mental health service 2) Delivered in mutual support groups 3) Delivered within drop- in centers 4) Delivered as a one- to- one service 5) Delivered in residen2al sedngs 6) Delivered in a structured group interven2on 7) Other types of peer support, such as peer- delivered socializa2on (Variety of sedngs and outcomes added to complexity of the review) *We excluded studies focused only on substance abuse

12 Outcomes Most O]en Studied in Peer- Delivered Services Research Broad Outcomes in Research which adds to complexity of studies Treatment- Related Hospitaliza2on Relapse Psychiatric symptoms Rehabilita(on and Recovery- Related Quality of Life Recovery and Adtudes towards Recovery Social Support Percep2ons of empowerment Self- confidence/esteem/efficacy Process- Related Sa2sfac2on with services Engagement in services Other Outcomes Criminal jus2ce involvement Employment Housing stability Community par2cipa2on Substance use/relapse

13 Results of Systema(c Review Promising data, but s2ll inconclusive about effects of one- to- one peer support services (e.g., Eisen) Growing evidence for structured peer support, including Wellness Recovery Ac2on Planning (WRAP), Building Recovery of Individual Dreams & Goals through Educa2on and Support (BRIDGES), and others (see Cook et al., 2012) There are a growing number of systema2c reviews about peer services (Chinman, et al., 2014; PiS, et al., 2013; Lloyd- Evans, et al., 2014; Fuhr, et al., 2014) Chinman concluded evidence: Moderate for PSS

14 What We Need in Next Itera(on of Understanding Peer- Delivered Services Useful rubric for evalua2ng services: Inputs, outputs, process, outcomes, impact Descrip2ons of the peer- delivered services including: who, when, what, how, how much (inputs, outputs, process) Descrip2ons of the what being delivered are cri2cal to understanding the key ingredients (process) Descrip2ons of the context of service delivery (e.g., not sufficient to say simply drop- in services - include process) Descrip2ons of those delivering the services including training/ educa2on/supervision (inputs) The intensity of services received during the evalua2on period along with the types of services (outputs) Outcomes studied with good standardized and targeted measures

15 Program Evalua(on Framework Consider some combina2on of inputs, outputs for funders what and how much PSS you deliver Tie the service provided to the outcomes and processes measured use a PAR* framework Find standardized measures with manageable burden that best capture the outcomes you believe you will effect Can assess unintended consequences Consider a qualita2ve study for impact a semi- structured interview for example

16 Some Measures We Have Used With Success Recovery Assessment Scale- Corrigan Empowerment Scale- Rogers, et al. Interpersonal Support Checklist- Cohen Working Alliance Inventory- Horvath Client Sa2sfac2on Scale- Atkisson Quality of Life- Lehman BASIS- 24- Eisen Herth Hope Scale (Consider others based on intended effects, e.g., s2gma, stress, moods)

17 WRAP Measured symptom change Also assessed: Physical health Social support Hope Recovery Advocacy (because advocacy was taught in the interven2on)

18 Par(cipatory Ac(on Research (PAR) A cri2cal component of any peer services research or evalua2on PAR requires that researcher/evaluator not be objec2ve or removed Researcher can become a part of the community or group that he or she is studying provides more sensi2vity to cultural differences PAR has gained momentum in educa2on and social sciences Par2cularly useful when some kind of policy change or community or social ac2vism needs to follow the research findings PAR- - Findings arrived at through broader stakeholder par2cipa2on will integrate their interests and facilitate organiza2onal change There will be more buy- in, self- determina2on and involvement in addressing their felt needs PAR methods reflect the saying: nothing about us without us

19 Par(cipatory Ac(on Research (PAR) PAR is useful and consistent with values of peer movement, but requires role shirs Using PAR, researchers not seen as the only experts about research This new paradigm values the lived experience Researchers and evaluators take on roles as educators/consultants to consumers and other stakeholders who wish to have an ac2ve role in the research process Consumers/stakeholders can be viewed as co- inves2gators Researchers share the decision- making process which is oren difficult PAR is consistent with the Affordable Care Act and PCORI the Pa2ent Centered Outcome Research Ins2tute - pa2ent- centered decision- making

20 Survey of Peer Specialists (Cronise, et al.) LiSle is know about roles/tasks of PSS this is par2cularly true as the workforce has burgeoned inaps (Interna2onal Associa2on of Peer Specialists) undertook a na2onal survey to examine roles, compensa2on, sa2sfac2on Results suggest that PSS are in many mental health sedngs (i.e. tradi2onal MH, but also residen2al, criminal jus2ce sedngs, and beyond) PSS perform a wide variety of tasks, including clinical and administra2ve, in addi2on their role as peers 20

21 Survey of PSS Salaries for PSS were quite low, and confirmed by another salary survey performed by Daniels (2016) Male PSS earn significantly more even when controlling for important factors; Geography masers Peers report being sa2sfied on their jobs and derive sa2sfac2on from helping others and report helping others helps them in their recovery ( helper- therapy principle) 21

22 Survey of PSS Peer specialists are being trained on a wide variety of topics, and in some cases, are being asked to assume professional roles This raises ques2ons about their unique and complementary roles Some peers ask: what happens to our peerness when we are trained to assume tradi2onal roles? What began as a voluntary rela2onship emphasizing mutuality and being egalitarian, is now complicated by accountability and more tradi2onal concerns 22

23 Peer Survey Sources of sa2sfac2on similar to those in the general popula2on: feeling like they are prepared for their job and their skills are u2lized, that they are respected S2ll, a good percentage of PSS report feeling that they are not equal members of their team/workforce Ques2ons remain about how best to insure good experiences for peers in workforce training, supervision, integra2on 23

24 Peer Sa(sfac(on Survey (Johnson, et al., 2014) Performed a survey of one large employer of peer specialists in the southwest U.S. Similar findings peers reported that being a peer specialists helped in their own recovery Peer specialists reported benefits in a wide range of domains: financial, family, social, self esteem 24

25 Special Issue of the Psychiatric Rehabilita(on Journal (Rogers and Swarbrick) Due out in Fall of 2016 Examines several innova2ons in the field in PSS and the state of the field from the perspec2ve of SAMHSA Contributors include the VA the largest employer of peer specialists, Salzer, Swarbrick, and colleagues 25

26 References 1. Chinman, M., George, P., Doughertry, R., Daniels, A., Goose, S., Swir, A., & Delphin- RiSmon, M. (2014). Peer support services for individuals with serious mental illness: assessing the evidence. Psychiatric Services, 65(4), Cook, J. A., Copeland, M. E., Jonikas, J. A., Hamilton, M. M., Razzano, L. A., Grey, D. D.,... Boyd, S. (2012a). Results of a randomized controlled trial of mental illness self- management using Wellness Recovery Ac2on Planning. Schizophrenia Bulle:n, 38(4), doi: /schbul/sbr Cook, J. A., Steigman, P., PickeS, S., Diehl, S., Fox, A., Shipley, P.,... Burke- Miller, J. K. (2012b). Randomized controlled trial of peer- led recovery educa2on using Building Recovery of Individual Dreams and Goals through Educa2on and Support (BRIDGES). Schizophrenia Research, 136(1-3), Cronise, R., Teixeira, C., Rogers, E. S., & Harrington, S. (2016). The peer support workforce: Results of a na2onal survey. Special Issue on Peer Support Services. Psychiatric Rehabilita:on Journal. 5. Daniels, A.S., Ashenden, P., Goodale, L., Stevens,T. (January, 2016). Na2onal Survey of Compensa2on Among Peer Support Specialists. The College for Behavioral Health Leadership ( hsps:// 6. Eisen, S. V., Schultz, M. R., Mueller, L. N., Degenhart, C., Clark, J. A., Resnick, S. G.,... Sadow, D. (2012). Outcome of a randomized study of a mental health peer educa2on and support group in the VA. Psychiatric Services, 63(12). 7. Fuhr, D. C., Salisbury, T. T., De Silva, M. J., A2f, N., van Ginneken, N., Rahman, A., & Patel, V. (2014). Effec2veness of peer- delivered interven2ons for severe mental illness and depression on clinical and psychosocial outcomes: a systema2c review and meta- analysis. Social Psychiatry and Psychiatric Epidemiology, 49(11), doi: /s Johnson, G., Magee, C., Maru, M., Norman, K., Rogers, E.S., & Thompson, K. (2014). The personal and societal benefits of providing peer support: a survey of peer support specialists. Psychiatric Services, 65, Lloyd- Evans, B., Mayo- Wilson, E., Harrison, B., Istead, H., Brown, E., Pilling, S.,... Kendall, T. (2014). A systema2c review and meta- analysis of randomised controlled trials of peer support for people with severe mental illness. BioMed Psychiatry, 14(39). hsp:// 10. Miyamoto, Y., & Sono, T. (2012). Lessons from peer support among individuals with mental health difficul2es: A review of the literature. Clinical Prac:ce & Epidemiology in Mental Health, 8, PiS, V., Lowe, H., Prictor, M., Hetrick, S. E., Ryan, R., & Berends, L. (2013). Consumer- providers of care for adults clients of statutory mental health services: The Cochrane Collabora2on. 12. Rogers, E. S. K.- M., M., & Brucker, D. (2009). Systema:c review of supported educa:on literature Retrieved from hsp:// syntheses/psychiatric- disabili2es/peer- delivered- services/ Updated version Feb 2015 available from author. 13. Sledge, W. H., Lawless, M., Sells, D., Wieland, M., O'Connell, M. J., & Davidson, L. (2011). Effec2veness of peer support in reducing readmissions of persons with mul2ple psychiatric hospitaliza2ons. Psychiatric Services, 62(5), Van Gestel- Timmermans, H., Brouwers, E. P., Van Assen, M., & van Nieuwenhuizen, C. (2012). Effects of a peer- run course on recovery from serious mental illness: A randomized controlled trial. Psychiatric Services, 63(1),

27 Dr. Alexandre Laudet Founder and (Emeritus) Director, Center for the Study of Addic2ons and Recovery, Na2onal Development and Research Ins2tutes 27

28 The Role of Peer Support in Recovery from Substance Use Disorders Alexandre B. Laudet Center for Study of Addic2ons & Recovery 28

29 Acknowledgements The presenta2on uses data collected through a project supported by Grant Awards Number R01DA14409, R01DA and R21DA from the Na2onal Ins2tute on Drug Abuse to the Na2onal Development and Research Ins2tutes, Inc. (NDRI). The content is solely the responsibility of the author and does not necessarily represent the official views of the Na2onal Ins2tute on Drug Abuse or the Na2onal Ins2tutes of Health. 29

30 Relevance of Peer Support to Addic%on Recovery Substance use (and thus, substance use disorders) begins and is maintained in the social context Substance use disorders ( addic:on ) are highly s2gma2zed, leading persons seeking recovery to shame and secrecy about their experiences Gedng support from others who share the same experiences (i.e., peers ) 1. Is easier because there is a shared s2gma that cannot be discussed with non peers 2. Allows the individual to benefit from the personal experience of others who have had and overcome a problem oren regarded by society as a moral failing and/or a crime 3. Advice and support from peers is more difficult to dismiss, especially early in recovery when ambivalence and denial are high, because peers have been there, done that and can recognize your excuses/denial and call you on it 30

31 Typical Addic(on Career Age first drink Age first drug Impairments in Physical health Mental health Family/social Age first treatme nt Age first Tx Legal status 31.1 Housing Employment Economic/financial Relapse/ recovery cycle +/- 10 years Stable recovery? 41 LOSS TO THE INDIVIDUAL & TO THE NATION = 16 years of ac(ve use + up to a decade of cycling

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35 12-Step Fellowships: The original peer support model for addiction recovery

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38 Percent did not use drugs or alcohol since prior interview as a func(on of 12- step mee(ng onsite during treatment step onsite No 12-step onsite % % 0 Discharge Threemonths Six-months One-year post discharge No use since discharge All p<.05. Laudet et al. Eval. Review, 2007

39 Collegiate Recovery Programs Peer Support for Young People in Recovery AND in College...

40 Youth: The Fork in the Road Substance use typically begins in early adolescence Substance use disorders (SUD) start in late adolescence/emerging adulthood, making this transi2onal period cri2cal to SUD onset and progression Effec2ve treatments exist for youths but as with adults, relapse is common in the absence of con2nuing support

41 Young and In Recovery, Now What? Fork #2 For youths in SUD remission wishing to pursue educa2onal goals, the high rates of substance use on college campuses represent a serious threat to con:nued sobriety. 41

42 Importance of Peer Support to Recovery Peer support is especially important among young people as fidng in with one s peer group is key to iden2ty and psychosocial adjustment Peer influence especially important in college, oren away from home and needing to establish new social group 42

43 Collegiate Recovery Programs (CRPs) The newest and most innova2ve peer support model for addic2on recovery Developed in response to the needs of college students with a history of SUD who have successfully remised from the disorder and now seek to pursue educa2onal goals in an abs2nence hos2le environment (high rate of substance use on college campus) Peer- driven approach typically informed by 12- step tenets Exponen2al growth star2ng around 2005 More info on CRPs: Associa2on of Recovery in Higher Educa2on 43 (ARHE) hsp://collegiaterecovery.org/

44 Growth & Expansion of Collegiate Recovery Na(onwide fold growth past 10 years! * 59 CRPs as per ARHE website hsp://collegiaterecovery.org/programs/ 6/14/16

45 Collegiate Recovery Programs: Are They Useful?

46 Inquired about availability of campus based recovery support PRIOR to applying to ins(tu(on Yes: 29% No 71% (Next 6 data slides) Laudet, Harris, Kimball, Winters & Moberg, 2016

47 Importance of CRP availability to amending or returning to college at this (me 34% 30% Not at all important: I was determined 18% 18% Slightly Important: Would have attended anyway Somewhat Important: Would have probably attended anyway Very Important: would NOT be in college if no CRP

48 Importance of recovery support on campus to decision to enroll Not at all important:1.4% Slightly important- other issues considered: 2.5% Somewhat important- would have attended anyway, 3.7% Very important- would NOT be here otherwise: 21.4% Did not inquire: 79%

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50 Reasons for enrolling in a CRP What are the main reasons why you decided to enroll in the recovery support program in your school?

51 Reasons For Enrolling in a CRP: Details PEER RECOVERY SUPPORT NETWORK 56.40% Need/want emo2onal/l peer support for recovery 33.1 Want fellowship/same age peers, understand each other/can talk about issues 23.2 SAFE PLACE ON CAMPUS/DEAL WITH STRESS & PREVENTS RELAPSE 31.30% Want to stay sober, could not do it in stressful college situa2on without support 19.3 To complete college in one shot/in sober sedng/ integrate school & recovery 7.1 Want Sanctuary/a safe place to hang out away from all of the using people 4.7 OPPORTUNITY TO HELP OTHERS/SERVICE 13.60% Service opportuni2es (to be of service to people in recovery)/help build program 11.1 Help tear down s2gma of addic2on by showing pple in recovery can thrive in college 2.5 PRACTICAL BENEFITS 9.10% Financial benefits 4.1 Academic benefits (e.g., grade forgiveness) 2.9 Other benefits 2.0 RECOMMENDED BY OTHERS 7.60% Friend/peer recommended/saw it work for others 5.8 Recommended by professionals 1.9 PROGRAM ASPECTS (REPUTATION, STAFF) 3.90% Recovery program reputa2on 2.5 Great staff who understands recovery 1.4 a Total is greater than 100% because up to three answers were coded.

52 Student Feedback on CRPs WANTING PEER SUPPORT: I wanted support from peers with similar goals within my age group, and I recently moved to the area, I needed that immediate network of sober people. WHAT DO YOU LIKE ABOUT YOUR COLLEGIATE RECOVERY SUPPORT PROGRAM? It's where my friends are, I can be apart of something bigger than myself. It's not what it does for us but what we can do for each other. OVERALL, WHAT HAS BEEN YOUR EXPERIENCE WITH YOUR CRP? I have been sober for 5 months and these have been the happiest months of my life and I am really turning myself around. Thank you for what you are doing! Change is difficult for me. Over the years I have learned my paserns of possible relapse ( ) The stressors of college can be difficult. I need a recovery support system to stay sober! My life depends on it.

53 Worked w/ CRP peer tutor on academic work/issue Helpfulness of Par(cipa(on in Other CRP Services (Descending order of helpfulness) Not at all/ a little Moderately Quite a bit Extremely Hung out with other CRP members at the program Hung out with other CRP members outside of the program site Met with a CRP academic advisor to discuss academic issues Attended CRP Seminar class on addiction/relapse prevention Attended a CRP non 12-step recovery support group Participated in community service as part of your CRP

54 Overall Helpfulness of CRP Par(cipa(on

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56 CRP Site- Level Outcomes: Relapse Rate in Past Year (29 CRPs in 2012) Relapse rate past academic year (mean, range): 8% (0 25%)

57 CRP Site- Level Outcomes (29 CRPs in 2012) Academic Performance: CRP vs. Ins(tu(on- wide 100" 91.8% CRP" 89% Ins+tu+on" 75" 80.8% 60.5% 50" 25" 0" Reten+on" Gradua+on"

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59 Remember this? Typical Addic(on Career Age first drink Age first drug Impairments in Physical health Mental health Family/social Age first treatme nt Age first Tx Legal status 31.1 Housing Employment Economic/financial Relapse/ recovery cycle +/- 10 years Stable recovery? 41 LOSS TO THE INDIVIDUAL & TO THE NATION = 16 years of ac(ve use + up to a decade of cycling

60 CRP Students Addic(on Career Impairments in Age first drink Age first drug Physical health Mental health Family/social Age first treatme nt Age first Tx Stable Recovery/ college Legal status 21 Housing 26 Employment Economic/financial CRP BENEFIT TO THE INDIVIDUAL & TO THE NATION = 15 years reduc(on in addic(on & relapse cycling + EDUCATED CITIZENS!

61 Importance of CRP availability to amending or returning to college at this (me

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63 Studies Cited Laudet, A., Savage, R. and Mahmood, D. (2002) Pathways to long- term recovery: A preliminary inves2ga2on. Journal of Psychoac2ve Drugs, 34(3), Laudet, A., White, W. and Storey, G. (2006, June) Three- year paserns of 12- step asendance and involvement as predictors of stable recovery from polydrug use. 68 7h Annual Scien2fic Mee2ng of the College on Problems of Drug Dependence (CPDD), ScoSsdale. Laudet, A., Stanick, V. & Sands, B. (2007). The effect of onsite 12- step mee2ngs on post- treatment outcomes among polysubstance- dependent outpa2ent clients. Eval. Review, 31(6), Laudet, A., Harris, K., Kimball, T., Winters, K. & Moberg, D. P. (2014) Collegiate Recovery Communi2es Programs: What do we know and what do we need to know? Journal of Social Work Prac2ce in the Addic2ons. (14) Laudet, A., Harris, K., Kimball, T., Winters, K. & Moberg, D. P. (2016). In college and in recovery: Reasons for joining a Collegiate Recovery Program. Journal of American College Health, 64(3),

64 Dr. Ellen Bassuk Founder, Center for Social Innova2on 64

65 Peer- Delivered Recovery Support Services for Addic(ons in the U.S.: A Systema(c Review Ellen Bassuk, MD, Founder Center for Social Innova2on 65

66 Background Field moving toward recovery- oriented approaches Increased asen2on to peer support services Strong body of research on mental health peer support and mutual aid peer support for substance use disorders Less known about effec2veness of peer recovery support services delivered by peer recovery coaches 66

67 Systema(c Review A structured approach to iden2fying, appraising, and summarizing the evidence on effec2veness Based on strict inclusion criteria 67

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69 Our Results Search yielded 1,221 peer- reviewed studies + 39 from grey literature 1,104 abstracts screened for eligibility 991 excluded 113 ar2cles screened by two reviewers Only 9 ar2cles met inclusion criteria 69

70 Full- Text Review Range of study designs Focused on adults with alcohol or drug use problems Interven2ons and service sedngs varied Role and training of peer recovery coaches not well explained Studies examined outcomes related to substance use and a holis2c defini2on of recovery 70

71 Conclusions Par2cipants receiving peer interven2ons showed improvements in substance use or a range of recovery outcomes, or both Our conclusion: Peer- delivered recovery support services have a salutary effect on par2cipants. 71

72 Contextualizing the Findings Limited research with methodological limita2ons, wide varia2on in par2cipants, interven2ons, service sedngs, peer training and level of peer involvement 72

73 Importance of Findings This study documented what is known by prac22oners Aligns with the prac2ce- based knowledge of the power of peer recovery support that it works. Need for more research 73

74 Recommenda(ons for Future Research Improve methodological rigor Provide more detail on role and training of peers and informa2on about the nature of peer services More research on peer recovery support in different contexts 74

75 References Bassuk, E. L., Hanson, J., Greene, R. N., Richard, M., & Laudet, A. (2016). Peer- delivered recovery support services for addic2ons in the United States: A systema2c review. Journal of Substance Abuse Treatment, 63, 1-9. (Open access un2l November 2016) hsp:// fulltext Erratum hsp:// Bassuk, E. and Hanson, J. (2016). Recovering from addic2on: Do peer- delivered services help? Atlas of Science. (Plain language summary) Available at: hsp://atlasofscience.org/recovering- from- addic2on- do- peer- delivered- services- help/ Reif, S., Braude, L., Lyman, D. R., Dougherty, R. H., Daniels, A. S., Ghose, S. S.,... Delphin- RiSmon, M. E. (2014). Peer recovery support for individuals with substance use disorders: Assessing the evidence. Psychiatric Services, 65(7),

76 Q & A Session

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78 Thank You!