Transitions RTC The Learning & Working During the Transition ...

Transitions RTC The Learning & Working During the Transition ...

TRANSITIONS ACR THE LEARNING & WORKING DURING THE TRANSITION TO ADULTHOOD REHABILITATION RESEARCH & TRAINING CENTER Effectively Employing Young Adult Peer Support Workers: Toolkit Overview June 21, 2018, 2:30PM-4PM EST The Georgia 2018 System of Care Academy Acknowledgements 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 Schools 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. 2 Slide 3 Presenters Jonathan Delman, PhD, JD, MPH Technical Assistance Advisor, Transitions to Adulthood Research Center

Assistant Research Professor, University of Massachusetts Medical School Vocational Specialist for Young Adult and Early Psychosis program, Boston, MA Raphael Mizrahi, B.S. Research Coordinator, Transitions to Adulthood Research Center 3 Toolkit PDF https://www.umassmed.edu/glob alassets/transitionsrtc/publicatio ns/effectivleyemployingyoungad ultpeerproviders_a_toolkit.pdf Toolkit online https://www.umassmed.edu/Tran

sitionsRTC/publication/effectively -employing-young-adult-peer-pro viders---a-toolkit/ 4 What Informed the Toolkit? Multi-dimensional experiences of co-authors Through Transitions RTC: SAMHSA/NIDILRR grant Existing & own research Advisory board Many focus groups & other meetings with young adult peers & employers over the last 3 years 5 Slide 5

Toolkit Chapters I. II. III. IV. V. VI. VII. VIII. IX. 6 Background Young Adults in the Peer Provider Role Conceptualizing and Structuring the Young Adult Peer Role in Your Agency- Hiring, training et al Establishing an Organizational Culture that Supports Young Adult Peers Youth development

Recruiting, Hiring and Training Young Adult Peers Effective Supervision for Young Adult Peers Addressing Significant Job Difficulties Using the ADAs Reasonable Accommodation Framework Preparing and Engaging Non-peer StaffInfrastructure and Framework 1. Background 7 Young Adults with Serious Mental Health Conditions Recovery as short term goal Risk per developmental stage Resilience and confidence Heightened level of shame and stigma 18

19 20 21 22 23 24 25 26 27

28 29 According to Dr. Jeffrey Arnett, Adulthood is. 8 1. Taking responsibility for yourself 2. Making independent decisions 3. Becoming financially independent Young Adults today are generationally different from past Communication through social media & technology

(disclosure & confidentiality) Opioid crisis Economic & jobs/career uncertainty Family formation- later marriage Greater tolerance of & sensitivity towards diversity Emerging Adulthood defined by identity exploration, instability, being self-focused, & exploring possibilities 9 New MH Services Designed to Meet the Needs of Young Adults Components Youth oriented/development Strengths based Person centered Well coordinated Programs First episode emergence

Coordinated specialty care Wraparound+ peer mentors 10 Young adult E.g., TIP Peer Specialists Individuals 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).

Unique Qualities of Peer Specialist Use their own recovery story with clients strategically Are role models/exemplars Advocate on behalf of client Engage in mutuality An innovation.. 12 Boundaries and dual relationships Self-disclosure to client of personal life (mental health, see e.g., Ziv-Beiman, 2013) Awareness: Client is aware that provider has a MH

condition Engagement: Provider discusses his/her MH condition and recovery w/client Codes of ethics (CPS, APA, NASW) are generally consistent on self-disclosure Moral and ethical principles Beneficence 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)

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.)

Peers specialists who had been program clients Benefits 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 program Why 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 discomfort Former clients working with current clients Ethical Factors include

Length of time since the job applicant was a client there Existing relationships Apply general organization dual relationship policies 2. Young Adults in the peer provider role 16 Specific Demand and Need for Young Adult Peer Workers Increased funding for young adult peer positions Medicaid reimbursement ACA Housing Criminal justice State MH and SA authorities

Career start 17 Major Benefits of YA Peer Integration Improve organizational culture & expand diversity Boost Engagement Client experience, attitude & learnings

Outcomes 18 Generating hope at rock bottom Reduced symptoms and re-hospitalizations Increased sense of wellness, social integration, educational progress Multiple Factors Impact Success YA Peers on-the-Job A. NATURE OF JOB Complexity Rewards

B. CAPITAL FRAMEWORK 1. Human capital 2. Cultural capital 3. Psychological capital - Resilience - Motivation 4. Personal social capital 19 1. 5. Organizational Social Capital YA Peer Role Implementation Challenges Nature of Job new type of job, rewarding, challenging, confusing to many, clarity, perceived value of other staff

Human 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 disruption Cultural 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, transitioning Social-Personal Capital Family (for single parents, of significant others) friends, allies (employment supports) 20 Social Organizational workplace culture, structure, staff, and communication etc. Workplace social capital paradigm

Employment Supports Workplace culture and infrastructureWork Figure 1 Workplace challenges to implementing peer specialist role 1. Job clarity, confusion, and perceived value 2.

Relations with and support of other staff 3. Supervision 4. Addressing job difficulties - Generating effective reasonable accommodations 5. Wellness supports 6.

Organizational culture- employee beliefs and practices Slide 7. 22Organizational Framework The impact of Organizational Social Capital Organizational Social Capital >>>>>>>> > Challenge categories

Organizational Social Capital Responses Human Capital Training, education opportunities Cultural Capital Psychological

Capital Supervision Accommodations Access to health care Wellness supports Job coach Culture values peer role Job satisfaction et al Social-personal capital Slide 23 Policies- time off, accommodations

3. Conceptualizing & Structuring the Young Adult Peer Role in Your Agency 24 1. Define and clarify the peer specialist role for all staff: a) before hiring, and b) with HR I. Identify the unique features of the peer job (below) II. Describe key functions of this peer position, e.g., navigator, bridger, housing supporter III.

Establish job qualifications, compensation, and career growth opportunities commensurate with job requirements IV. Written clear job descriptions for the peer provider role Slide 25 Minimize role confusion Share and discuss job description and peer ethical code with all staff: Work directly with HR

Effective dissemination and messaging Events PR- first person accounts Everyone should know- hiring, culture All staff are recruiters to the degree they understand and value of the peer specialist role Training, Orientation 26

Peer job classification and pay Classification systems define and evaluate a jobs responsibilities, functions, and authority levels o Grades o Compensation o Advancement Working with HR, clinical leadership, and unions Career track New classification is I think best or not 27 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 this Job applications and notice Ban the box-........ Interviewing TK p. 48 Even if there are relevant questions re criminal history, do not ask them first thing Help candidates to remove artificial barriers Expungements- referrals at the very least 50 state comparison Legal aid

Slide 28 TK p. 46 Training peers specialists: Basics Essential workplace skills o Soft o Hard (Memo format to organize and share information- TK, Appendix D) Personnel policies and benefits Workplace rights and responsibilities Building resilience through stress management, self-care, & wellness planning Reinforce required staff trainings

Supervision as an ideal space for on-going employee development. 4. Establishing the requisite organizational culture for YA Peer Provider Success 1. Valuing peer support 2. Understanding the experience and culture of todays young adults 3. Recognizing and addressing workplace stigma 4. Embracing legal obligations to not discriminate against employees with disabilities 5. Diversity of person, perspective, and experience 6. A positive [young adult] development approach to treatment and services 7. Self-determination and dignity of risk 8. Employee access to wellness tools, supports and services Recognizing & Addressing Workplace

Stigma: Myths & Misconceptions Myth Facts Insufficient work experience or education to work Mitigate with: -Resilience and persistence, -Workplace supports, and/or -Health care support If not working out may just be not a good match But can when: -FT job has sufficient salary & benefits -Human resources understand federal/state laws Cant work full-time,

many using SSDI/SSI the promote FT (e.g, Medicaid [insurance] buy-in, Always in crisis Ticket to Work) No. This is simply not the case! -Non-peer staff often use clinical explanations for work difficulties, this is not always the case -Professionalism Embracing legal obligations to not discriminate against employees with disabilities Federal & state law Prohibit 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 workplace Staff awareness of laws specifics itself reduces discrimination Employer clarity and messaging Many excellent on-line resources (p. 36) Addressing Stigma in the Workplace Contact Training Less formal Presence of peer services Co-learning Cross-training Education/Training- real plays Provider Staff Must Embrace Positive Youth Development Paradigm

Approach 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 sets Building trusting relationships Drawing out young adults priorities Motivating clients to learn and practice meta- developmental skills Need to understand & value: Self-determination & Dignity of Risk Presumption of competence Clash with clinical culture Developmental learning through trying things out Peer specialists as allies in decision making, or

adversaries Big challenge for parents/guardians TIP and futures planning are self-determination approaches Promoting Employee Wellness Legally required Reasonable accommodation FMLA Key principles for preventing problems Act early Health insurance- access to care Educate all staff Promote Leave and Return to work programs CBT Stress reduction

6. Effective Supervision of YA Peers Unique Role of Supervisor Facilitator & Supporter of YA Peers in developing strong working alliances with their clients Champion & Advocate for the YA Peer Role in your context Role 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

38 and belief in peer specialist role Slide 14 Essential Supervision Topics Fosters On-the-job Resiliency! 39 Slide 15 Continuous Reflection upon Peer Relational Processes in Supervision Collaborati on

Trust Authentici ty Companions hip WORKING ALLIANCE Empat hy 40 Slide 17

(Adapted from Spencer, 2006) Building Strong Working Alliances between Supervisor & YA Peers Increases likelihood that a YA Peer will discuss on-the-job struggles with supervisor Relationships between YA Peers & Clients Increases likelihood that YA Peer will feel comfortable discussing the pros & cons of supervisor suggestions & directives.

Relationship between Supervisor & YA Peer Excellent opportunity for modeling relationship building 41skills with YA Peers on how to work with YA clients Slide 18 Relationships between YA Peers & Colleagues (Peer & Non-Peer) E.g., Follow up after a new kind of assignment

Guidance for New Task Assignment: Put in writing Offer specifics Define terms Include examples for formatting, style and length Schedule a time to discuss shortly after assignment is made and/or send a follow-up email to support task completion. Reasonable Accommodations Modifications 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. 43 Slide 22 Reasonable Accommodations Even when mitigated by treatment When 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 44Accommodations is an Interactive Process Slide 23 Pgs. 67-70, Appendices F, G Process for achieving RA Part I. Questions to be addressed in this order: 1. What are the jobs 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 45 Information gathering Slide 24 Part III. Co-party Interactive Dialogue Elements: ADA rules of interactivity Principles of solution focused negotiation Strengths/Needs analysis

Part IV. Establish RA Implement RA Monitor & change as needed Evaluate process Toolkit pp. 71-77 StaffAwarenessofOpportunities &Responsibilities Company-wide use of Effective & Efficient RA Assessment Process Clearly & structured- forms Focus on process of interaction & information assessment, while

lowering emotional content and blaming Providers need to educate/train staff on the American Disabilities Act (ADA), particularly the concept & practice of RAs Supervisors have confidence to address rather than ignore Transparency in RA Request & Assessment Process Clear to all staff Many young adult peers would rather stop showing up to work instead 46 Slide 25 of discussing on-the-job struggles Toolkit pp. 77-78

8. Preparing and engaging non-peer staff 47 Educating and supporting non-peer staff Required trainings: The peer role, disclosure, boundaries, CPS code of ethics et al. Person-first language Myths of mental illness Person centered care and planning Shared decision making Interacting with peers, including protocol for asking personal questions Active role for people with lived experience Making referrals to YA peers TK Chapter 8

Management tools Meaningful Roles for Peer Providers in Integrated Healthcare manual Staff concerns self-assessment, which helps to identify staff training needs (page 98); Responses to staff on their concerns about the peer role (page 99); Discussion questions for staff and peers (page 107). 49

California Association of Social Rehabilitation Agencies (CASRA) 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 Workshop 1

SHARED DECISION MAKING IN FIRST EPISODE PSYCHOSIS Jonathan Delman, PhD, JD, MPH Assistant Research Professor, Transitions to Adulthood Research and Training Center, https://www.umassmed.edu/transitionsrtc, UMass Medical School Slide 51 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 ones consent to treatment, orally or in writing, at any time* Subject to capacity to provide consent- Rogers guardianship. *DMH Informed Consent Policy Slide 52 Shared decision making model Prescribers, recommendations, and decisions: Balancing risk and reward with young adults Factors Personal/clinical values Developmental stage Practical

Probability of effect(s) Intensity of effect(s) Short v. Long term View E.g., Wants to go off meds: *Prevention of further psychosis *Safety * Trust/alliance * Personal growth re developmental stage Critical competencies and best practices Psychiatric

competencies and practices oDemonstration of knowledge Relational o Openness to and/or direct interest in the clients perspective on treatment o Extend oneself beyond expected duties o Strategy for outside of office hours- triage o Client support oDecision

aids/support Formal Electronic E.g., Power statement Informal Internet, Social media oCoaching and instruction manuals oPeer specialist oOther providers oParents/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. Workshop 2 Boundaries and Dual Relationships in first episode programs: The value of strategic disclosure Jonathan Delman, PhD, JD, MPH Assistant Research Professor, Transitions to Adulthood Center for Research, https://www.umassmed.edu/transitionsrtc, UMass Medical School Slide 56 Integrate Team Building Activities Co-learning & cross training. Share:

Personal expertise Personal stories Employee mentorship Opportunities for informal interaction Organizational approach to support peers 1. Define and clarify the peer specialist role for all staff 2. Enhance capacity to recruit and hire peer specialists 3. Promote workplace culture that supports peers 4. Educate and support non-peer staff 5. Establish effective supervisory practices; 6. Address job difficulties using reasonable accommodation (RA) framework and health support access 7. Enhance positive psychological capital through employee self-help 8. Enhance critical elements of organizational infrastructure to

drive above 58 Peer specialists influencing policy and practice Peer specialists can have the most influence on organizational planning and learning when they: o Make up a significant portion of the service provider workforce; o Are educated on the best & evidence based practices; o Are active participants on committees and workgroups relevant to their work; o Are in organizational leadership roles. Peer specialists integration into organizational leadership o Centralize peer education o Peer specialist(s) in senior management o Build relationships with peer run organizations TK Pp. 95-98 Slide 59

Strong Organizational Communication Endorsing the Peer Role Internal messages Champions Trainers with direct experience o Peer specialists o Management and supervisors Internal publications Office walls and corridors Presence of peer specialists External messages Mission and policy statements Websites Newsletters Slide 60 References 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 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, 88-115 Gutheil, T. G., & Gabbard, G. O. (1993). The concept of boundaries in clinical practice: Theoretical and riskmanagement dimensions. The American journal of psychiatry. Reamer, F. G. (2003). Boundary issues in social work: Managing dual relationships. Social work, 48(1), 121133. Simmons, M. B., Coates, D., Batchelor, S., DimopoulosBick, T., & Howe, D. (2017). The CHOICE pilot project: Challenges of implementing a combined peer work and shared decisionmaking 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,

Slide 61 http://www.zurinstitute.com/selfdisclosure1.html. 10 Toolkit Takeaways 62 Toolkit Takeaways: Preparation for the YA Peer Provider Role 1. All staff should understand the purpose and unique qualities of the young adult peer role via orientation, training, teambuilding and supervision. [Chapters 1, 3, 8] 2. 3.

Agency staff must understand the unique developmental experiences of young adults in todays society. [Chapter 4] Organizational leadership must proactively address discrimination and prevent discrimination toward young 63 adult employees diagnosed with mental conditions. [Chapters 4, 8, 9] Toolkit Takeaways: Recruiting & Hiring 4. 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. 7.64Orientation and training for YA peers should clarify organizational policies, including those on communications, absences, accommodations, and health benefits. [Chapter 5] Toolkit Takeaways: Practice 8. 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 persons 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

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