Early Experiences of Employing Consumer-Providers in the VA

The three-day conference, "Evolving Roles of Peers in VA Mental Health," was designed to provide training to newly hired CPs and their supervisors. Held in Chicago in August 2007, it provided information about the recommendations of the President's New Freedom Commission and the VA MHSP, skills important for CPs (recovery-fostering skills, group facilitation, role modeling, appropriate self-disclosure, and use of supervision), and issues of incorporating CPs into clinical teams (navigating dual relationships, developing relationships with existing staff, and conducting appropriate hiring practices).

Data were gathered about CPs' and supervisors' experiences through four focus groups held as part of the official conference. A standard-question guide was used in all groups ( 36, 37, 38 ). Focus groups were used because they encourage exploration of the uniformity of group opinion ( 39 ), allow participants to interact, and help identify outliers ( 40 ). Ninety-three individuals—59 recently hired VA CPs and 34 supervisors—attended the conference. All were randomly assigned to a group. Thus it is assumed that there were roughly equivalent numbers of CPs and supervisors in each group. The groups were not mandatory, but on the basis of group leaders' reports, it is assumed that all CPs and supervisors attended. All groups were held at the same time. Each individual participated in only one group.

Each group was led by one VA CP and one traditional VA staff person. Groups lasted 90 minutes and included 20 to 25 participants. In each, a note taker created the data by taking detailed notes on the entire session, including responses to questions, discussions, interactions, and group dynamics ( 41 ). This study was exploratory and designed to yield only information for program improvement within VA's CP initiative, not conclusions generalizable to all CPs. Therefore, written consent and institutional review board approval was not obtained. However, all participants were informed that their participation was voluntary and anonymous.

Group leaders guided the focus groups according to a protocol based on one used in a previous study that investigated stakeholder attitudes toward the future use of CPs ( 4 ). That protocol was then adjusted to ask about actual experiences rather than expectations. The five main questions for each group were related to positive and negative impacts of a CP's services, CPs' experiences in joining a team, duties and roles of CPs, supports that were or would be helpful for CPs, and barriers to current or future CP implementation.

Data analysis consisted of organizing the typed notes to summarize participant responses to the focus group questions and allowing additional categories to emerge consistent with grounded theory analysis ( 42, 43 ). First, for each group two doctoral-level researchers independently organized the notes according to the five main questions. We then compared and discussed our respective sortings. A few passages had been put under different topics. We discussed our respective rationales and decided together where each of these notes (line or phrase) belonged. A few cases were resolved by putting the passage under multiple topics. Second, one researcher collapsed the sorted notes across groups to make one document containing all data, sorted by the guide's questions and subquestions. Then the other reviewed and further refined this overall data document, grouping some specific points under broader ones to streamline the data.

We discussed these revisions, and there were no disagreements with the changes. In addition, all group leaders reviewed and held discussions about a summary of the results and suggested edits to improve the accuracy and reliability of the data. Finally, as is customary in focus group analysis, this data summarization was shared with participants ( 42 ). All conference participants were invited to attend one of two conference calls; 12 participated in the first and another 14 in the second. During each call, participants were invited to comment on the summary's completeness and accuracy. Minor revisions were suggested and then made by the two coders. The results presented here are a summary of the final document.

Many participants stated, on the positive side, that CPs helped the entire team become more patient centered and that most patients trusted and related to CPs more readily than traditional staff, which facilitated patient engagement and satisfaction. In addition, some said that CPs organized and led new services, such as peer support and illness management groups. Some also observed that CPs empowered patients to be more outspoken about pursuing their own goals. Finally, participants said that CPs were often role models to patients and traditional staff, encouraging both groups to be hopeful and action oriented in regard to recovery. One CP said, "We don't just bring the hope, we bring the proof that it [recovery] works."

Participants said that the CP's perspective was often educational for staff and motivating for patients. Some reported that CPs had suggested useful, veteran-oriented coping strategies and tools to patients and had facilitated increased patient engagement in services. Participants commented that the mixed role of peer and employee allowed CPs to act as liaisons between staff and patients, helping each to better understand the other. Finally, some participants commented that CPs often have a better understanding than traditional staff of community resources that are not part of VA.

Responses about negative impacts of programs focused on disruptions of usual work patterns, because adding CPs meant that team operations needed to be reorganized to some degree. Some described CPs as not having a work space, desk, telephone, or computer access. Traditional staff told of not knowing how to "fit in" the CP at first. Further, some staff described fears of or experiences with CPs working "beyond their job" by intruding onto other staff's professional ground, overstepping their roles, or portraying their own recovery as the only blueprint to recovery. Participants said that their initial concerns largely dissipated once the CP was on staff and became a familiar coworker. However, some supervisors noted that some "traditional-minded" staff had ongoing difficulty accepting CPs. They found that discussing the benefits associated with CPs and having CPs trained and certified has helped these individuals understand and accept the CPs' role.

All stakeholders—CPs, traditional staff, and patients—experienced initial discomfort and challenges when CPs joined the teams. Many CPs reported that the role was initially ambiguous, which made them anxious about demonstrating their value. Many wanted more guidance, role definition, and time with good supervisors when they started. Several CPs said that they were "walking on eggshells" at first, consciously working hard to counteract staff's initial fears. Most said that being the team's only CP made entrée more stressful. When more than one CP was on a team, they provided peer support to each other.

Many CPs found the transition from "patient" to "staff" challenging, especially if they were working at the same facility from which they had received or were currently receiving services. CPs said the role change complicated their relationships with other patients; for example, friends had unrealistic expectations about what the CP's new position could do for them or resented the CP's success. Also, CPs sometimes became coworkers with a former or even current mental health provider. Several had to change providers to avoid these boundary problems. Some CPs, especially those in rural areas, said that alternative providers were sometimes unavailable. Finally, disclosure of one's mental illness also complicated the transition; it is private information, but it also is what makes one a "peer."

A few CPs reported experiencing overt wariness, paternalism, and even insensitive comments from a few co-workers or patients. One focus group discussed the fact that when a CP calls in sick, traditional staff often mistakenly conclude that the CP had had a psychiatric relapse. Another CP reported that some staff were afraid that the CP would "take away" their patients. Some CPs reported that some patients were nervous about working with "a crazy person," questioning the CP's abilities because most don't have formal training. Despite occasional skepticism from patients, most CPs and supervisors said that patients usually embraced CPs as veterans who "know what it's like" to have mental health problems.

Despite initial anxieties, most CPs came to be valued with time, familiarity, and better definition of their niche. For example, one CP said that when she recently applied for vacation time, colleagues joked that she could not be spared for even a week. Several other CPs reported being sought out when other staff had difficulty assisting a patient. Only a few CPs reported that they did not feel like a team member or that staff continued having unrealistic expectations of their role.

Because focus group participants hailed from diverse programs, the CP roles that they discussed varied. Many were involved in direct patient services with a recovery focus. These services included assisting with or conducting new patient orientation; leading many types of groups (support, illness management, 12 step, and social or quality of life); completing intakes, screenings, and treatment planning with patients and staff; helping patients find housing; and accompanying patients to community activities. Many CPs mentioned advocating on behalf of patients to get needed services. Some CPs described less clinical duties, such as providing patient transportation, assisting patients with basic daily needs, or being a "clerk" for the program. In all the focus groups, participants emphasized the CP role as loosely defined or unclearly communicated. One person even said that the CP's job was "anything anyone asks us to do." Some said that the flexibility this fuzziness afforded was beneficial and empowering, but most CPs and supervisors alike called for more role definition.

CPs said that they would have liked more training, supervision, and discussion about the content and process of their jobs and about self-care and role and boundary issues. Supervisors concurred. Both said that it would be helpful for CPs to shadow existing staff and to be told that it is OK to make and learn from mistakes. They also felt that teams with CPs should discuss difficult situations ahead of time ("What should we do if… ?") and have access to the experiences of other CPs and sites employing CPs, including resources, policies, procedures, and lessons learned.

In addition to the needs discussed above, participants mentioned three barriers to further incorporating CPs within VA. First, many said that human resources personnel at their site did "not know what to do with a CP position," leading to lengthy challenges getting positions approved, posted, and filled. Second, some said that administrators at their site "seem to find recovery … a new concept" and so were less able to help with administrative challenges related to CPs. Third, a number of CPs stated that they were poorly compensated. Many participants speculated that this might be because the CP role is new or not fully valued or that human resources personnel are unclear how the position fits into VA. Others felt that CPs do not have a clear path for professional growth or promotion. Participants also noted that professional competencies some CPs bring with them (such as being a social worker) are not factored into grade and salary levels because, although valuable for CP roles, they are not part of the job requirements.

On the basis of these data and the CP literature ( 4 ), the following recommendations are offered to improve the process of employing CPs in new places. First, CPs, traditional staff, and administrators need to be adequately prepared. Staff should be prepared to address potential dual roles and to incorporate CPs within their team's mandated mission. Training and actively involving staff in establishing the parameters of the CP's role has demonstrated some success in preparing traditional staff and thereby reducing their concerns and resistance ( 44 ). A readiness assessment of the team that the CP would join—via focus groups, surveys, or informal discussions with staff and leadership—could be conducted to better plan training and specific preparation steps needed. Previous research has recommended assessing and improving readiness conceptualized in this manner ( 12 ). Although hiring CPs has been viewed as making the care around them more recovery oriented ( 8 ), several authors have commented that part of becoming ready to accept CPs involves changing the entire culture toward a recovery orientation in which the utilization of CPs is one component ( 7, 12, 13, 45 ).

Second, although many authors have commented that training is critical ( 4, 10 ), the best training package for CPs must be determined. The types of training available for CPs inside and outside VA vary greatly, ranging from 30 hours to 28 weeks ( 46 ). Given the nascent state of evidence of the effectiveness of CPs, it is difficult for those who need training to know which training package would lead to the best outcomes. Reviewing the most effective topics, formats, and duration for CP training across existing sites—for example, through expert panels—would begin to shed light on this area.

Third, it would be prudent for systems contemplating use of CPs to establish a system of continuous quality improvement. This infrastructure would serve two purposes simultaneously. It would provide organizations with a system for evaluating how well CPs are performing and influencing patient outcomes. It would also allow standardized data to be aggregated to further develop a knowledge base regarding best practices in CP employment, including hiring, training, service delivery, supervision, and outcomes. These findings could be systematically disseminated though a variety of mechanisms, including practice collaboratives ( 47 ), brief reports, and conferences.

Some limitations of the current study should be noted. First, focus groups yield exploratory data, not conclusive results, and thus these findings should be interpreted with caution. Second, use of the conference as the vehicle for data collection resulted in groups that were larger than traditional focus groups and use of multiple facilitators. However, the opportunity to hear the experiences of 65% of all VA-employed CPs from across the United States and their supervisors outweighed the drawbacks of deviating from usual focus group procedures. Related to that limitation, sampling of traditional staff (that is, supervisors) was not as representative as was the CP sample and may reflect some bias; those who traveled to the conference more likely had favorable attitudes toward CPs than those who were not in attendance. Fourth, patients were not involved in the groups. Doing so could have provided additional insights into the use of CPs in these settings.

In addition to research on services that CPs currently provide, more prospective research is needed in which key aspects of CP services are purposefully tested. For example, prospective studies should assess different training options, different CP roles, placement of CPs in different settings, whether the CP is also a veteran (with or without combat experience), and the impact of these variations on patient outcomes. Also, although there is a small amount of literature that suggests positive impacts on CPs themselves—enhanced self-esteem, social approval, interpersonal competence, employment, and recovery ( 48, 49, 50 )—much more can be done in this area. Finally, research should provide additional opportunities for providers to describe the challenges they experience employing CPs. CPs should not be looked upon as a panacea that will address all the challenges of facilitating recovery within public-sector mental health care but as one more resource to accomplish that goal. More research can help to elucidate the parameters within which CPs can be most effective.