C4 Innovations

Community & Behavioral Health | Recovery | Social Change

Peer Supervision in Health and Human Services

An episode of the “Changing the Conversation” podcast

Cheryl Gagne shares strategies for supervising peer support workers with host Kristen Paquette.

July 20, 2020

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Erika Simon, Producer: [00:01] Hello, and welcome to Changing the Conversation. While we take a brief hiatus from producing new episodes, we are re-releasing this fan favorite for your listening pleasure. We will be back soon with new episodes.

Erika: [00:13] Before we get started, we want to acknowledge that as our communities respond to the COVID-19 outbreak, this is a difficult time for everyone, especially for people who are marginalized and those providing health and human services. We are deeply thankful to all the health and human service providers and community leaders who are working tirelessly to keep people safe and well and to help folks who are sick to recover. We appreciate you beyond measure. Please email us at info@c4innovates.com if we can support you or your programs in any way. All of us at C4 wish health and strength to you, your families and friends, and the people you work with.

Kristen Paquette, Host: [1:00] Hello, this is Kristen Paquette, CEO at C4 Innovations, and your host today for Changing the Conversation as we talk about the supervision of peer roles in health and human service settings. I’m joined today by my colleague, Dr. Cheryl Gagne. Cheryl is a senior associate at C4, providing expertise, training, and technical assistance to advance substance use and mental health recovery support locally and nationally. In this role, Cheryl developed skills based curricula for providers and supervisors, including peer workers and led a team that described core competencies for peer workers for SAMHSA. Her professional skills are influenced by her experiences as a person in long-term recovery. Cheryl, thanks for being here with me today.

Dr. Cheryl Gagne, Guest: [1:42] Thank you, Kristen.

Kristen: [1:44] Cheryl, maybe we can start off with you sharing a little bit more with our listeners about who you are and how you’ve come to focus so much of your work on the support and supervision of peers.

Cheryl: [1:53] Sure. Thank you. I first got introduced to the concept of peer support quite naturally. I am a person in recovery from both substance use disorder and mental illness and found, even before I had a word for it, that that connection with someone who’s been there made a big difference for me.

Cheryl: [2:15] Early in my career, I worked at Boston University Center for Psychiatric Rehabilitation. And Bill Anthony, the leader, had a real vision for people with lived experiences of mental illness in leadership roles. In fact, he was quoted to say, “Be very nice to the clients you work with, they could be your boss someday.” And that was a vision that he had, that people with lived experiences of mental illness would fill multiple roles in the mental health system, including the role of peer support worker.

Cheryl: [2:54] And so I came to it kind of naturally and then professionally. We began with people with lived experiences to offer peer support in our recovery education program. While at Boston University, I supervised a number of people who were in the role of peer support specialist, as what we called them then. I also supervised people with lived experience, people with mental illness, in recovery from mental illness who were filling other roles as research assistant or one was an intern in an occupational therapy program. So, a peer support role is one that is necessarily filled by a person with lived experience who offers direct assistance to another person who is going through recovering from a behavioral health condition. But people with lived experience fill more than peer roles within the mental health and substance use disorder system. I think it’s important to make that point. We are focusing on peer support today, but people with lived experience fulfill other roles.

Kristen: [4:08] That’s great. Thank you so much for sharing all that, Cheryl. We’re so lucky at C4 to have folks like yourself who bring your own personal lived experience of recovery, your experience working in direct surface roles and in supervisory roles, and now bringing your expertise to us as a national expert and researcher and trainer in so many different ways. Perfect for today’s conversation.

Kristen: [4:31] Before we talk more about supervision specifically, it’d be great to talk a little bit more about the history of peer roles to offer that context for our listeners. So you touched on the fact that part of what’s so important about the peer role is that experience of having been there. But the peer workforce has also changed and evolved a lot in recent decades and is becoming increasingly professionalized, increasingly formalized, and a lot of roles that are explicitly peer based and not just roles that are filled by people with lived experience. Could you talk us through a little bit of that evolution and what’s changed and maybe specifically what you’ve seen change over the course of your career?

Cheryl: [5:13] Sure. I have to believe that peer support is quite ancient. That it’s a very natural human urge to reach out and try to connect to another person who shares an experience with you. I think what they sometimes call small P peer support, the kind of unprofessional peer support is as ancient as humankind. The kind of the history of the modern peer support movement in, and that is big P, really started … People date it back sometimes to be 18th century in asylums in Paris. There was a doctor who very much felt that people who had recovered from a mental illness made the best attendance in his asylum and that they had more compassion, kindness, and were able to guide people to recovery better. So that’s pretty ancient. But in kind of the modern era, in mental health at least, peer support began very much as a political movement, a civil rights movement in the 1970s, alongside many other high profile, civil rights movements of black Americans, of native Americans, of women.

Cheryl: [6:34] And so it was very much a separatist’s idea that we will attend to ourselves. That was by and large, anti-psychiatry and separatist. They built their own program, they delivered their own service, they did not collaborate with the mental health system. And that was in the ‘70s. By the 1990s, there had begun conversations. There have been changes in the mental health system, lots of conversations between people who are using services. People were more empowered to share their voices. In fact, there were more options offered in the 1990s in terms of where services were offered. And so beginning then, some programs began to hire peer support workers. And these were people with their own lived experience whose job was to guide and support people who are participating in programs.

Cheryl: [7:37] It happened a little differently in the substance use disorder world. I think again, there was a deep history of mutual support amongst people with substance use disorders. It wasn’t yet a national movement until the early 20th century, but there were efforts to mutual support, help each other to recover from addiction.

Cheryl: [8:02] And then informal treatment services, which really didn’t start until the 1970s. There was a workforce that was pretty much peer based. Most people who went into the profession of addiction counselor, people with their own experience of recovery. And over the 1980s, ‘90s, and forward, there was a real professionalization, a move toward professionalization of substance use disorder workforce, the treatment workforce. In some ways, they lost a bit of a flavor of peer support. Since the late 2010, there have been programs that are really looking to hire peer recovery coaches. They began getting back to that sharing lived experience as a way to enhance each other’s recovery from substance use.

Kristen: [8:59] Great. And bringing us up to present day, we focus a lot on issues of how best to hire, retain, integrate, supervise, and support peers in a range of roles. It feels to me like supervision is increasingly a huge part of that conversation, probably because there are more and more folks who are hiring peers and supporting peers who may not even be peers themselves. So it’s a really important conversation for us to talk about today.

Kristen: [9:29] When we think about supervision, generally, of course, it’s an important function for any employee in any organization, but often it feels like it could be kind of an afterthought. Like you have a boss, someone’s making sure you’re doing your work, that supervision, right? But especially when we talk about people working in direct care settings, there’s just such a high risk for burnout and overwhelm given all of the issues that folks are facing as they try to help people who are in crisis in different ways. So we know supervision is really important in a direct service setting. And then today, we’re here to talk about specifically, what role does supervision play in the development of peer workers and what should that look like?

Cheryl: [10:11] Well, you’re right, Kristen, that and human services supervision is critical and high-quality supervision. It’s really an investment that the organization makes in its workforce. Supervision, benefits the employees, the employers in terms of reduction of burnout and turnover. And certainly the goal is to improve services for service participants.

Cheryl: [10:35] Some of the challenges have been though that supervising peer workers, because they’re still kind of a relatively new role and a unique role in behavioral health program, supervisors may not understand the role. They may actually have a clinical background and supervise as if the peer support worker were a clinician, which is a very different role. So kind of really clarifying roles and having supervisors who fully understand what the peer role is and is not, is critical.

Cheryl: [11:13] Many programs too, don’t invest in supervision. You become a supervisor once you’ve been there long enough, once you know where all the keys are, or after you’ve been there a while. People may not have gotten good training in supervision. It’s not a priority for every organization. I think organizations that have a number of entry level workers or one set higher peer workers who may be new to the workforce need to have a high quality program of supervision.

Kristen: [11:51] You mentioned the real distinction between clinical supervision and peer supervision. Can you talk a little bit more about what makes peer supervision unique?

Cheryl: [12:01] Well, one of the most unique things about peer supervision is the attention to how the person, how the peer worker is sharing his or her, their experience with the person they’re helping. A peer role is one that is kind of future … Helps people with the future. It helps people think positively. It is strength based. It’s not deficit based. It does not address pathology, but rather attends to strengths and builds on strengths. Peers support recovery oriented values and practices such as, choice, offering choice, individualization, having full participation, full partnership with the person that they’re helping or that they’re meeting with. I think the unique thing about peers is to be able to reflect on their own lived experience and begin to share that with the person they’re assisting.

Cheryl: [13:05] Now, peers fill other roles beyond peer support. And many peer workers have become involved in case management like activity, linking people to services and supports and resources in the community. Some peer staff have been also work in residential settings, providing assistance in the home. And so while the role isn’t exactly peer support, the peer workers still need to sort of align with their own code of ethics in terms of what peer support is and is not.

Cheryl: [13:47] For example, there may be a policy in some house, a residential setting that somebody must do something that they’re not … Let’s say it’s a randomized drug test, and that’s not a role for a peer staff. Peer staff are not the enforcers or the … It is contrary to the code of ethics to force the person to give a urine test, for example. To force a person to take medication, to participate in anything like seclusion and restraint. A peer worker, if that’s their credential, needs to follow a code of ethics, even if they work within a program or an organization that may not be fully aligned with sort of recovery oriented values and principles. And that’s challenging.

Kristen: [14:53] It really is. These are such great examples of where there might be some tension in an organization where perhaps a program is just hiring its first or second peer, and maybe the supervisor is not well versed in the kind of spirit and function of peer support in its truest form. I’m curious, your thoughts on situations like that, what does it take to do peer supervision well?

Cheryl: [15:19] Well, I think that you know, one thing is to be open and willing to learn about what peer … If you’re not a peer support specialist yourself, if you’ve never received training to be very open to other ways of doing things. For example, there is some controversy about whether or not peer specialists do documentation. Most programs do require some documentation and yet it would be against the code of ethics to write about deficits or to write something about the person that the person didn’t know about. And so a supervisor needs to be open to, let’s try another way. Yes, there’s a demand for documentation, but let’s think about ways in which you can document and still be true to your code of ethics, and maybe even educate the rest of the staff through reading your documentation. You can influence the sort of attitudes and beliefs of the rest of the staff.

Cheryl: [16:24] Peer specialists will often do co-documentation after meeting with somebody, sitting down and say, “Okay, let’s write the note. What did we do today? What should we highlight?” And write that together. Before, the person may need to go back and put it into the electronic record. A supervisor needs to be willing to, not cast boundaries, but really try things other ways. Policies and procedures have been in place, they do work, but they don’t all align with a recovery orientation or a peer support worker or a peer recovery coach. So it’s important that a supervisor have a vision and have the sort of, I think, bravery to stretch and change things within the organization.

Kristen: [17:20] I love that guidance of first be open, be curious. I think that’s such important go-to advice for us all whenever we find ourselves in unknown situations. And at the same time, there really are some kind of core standards and features of peer roles. You’ve been a part of leading an effort nationally to identify some of those core competencies for peer workers. Can you talk a little bit about this, and I’m thinking especially, why was this needed? Why do we need to define core competencies and how can the competencies even help the supervision process?

Cheryl: [17:47] Sure. The competencies were written a couple of years ago, developed by a large team of people who both work currently in a peer role or supervise peer workers. We tried to delineate what are the actions, what are the real core foundational behaviors or competency skills that the person needs to be able to do. Now, no one person has all of them to a high degree. We can assess our own competency. I think for me, that was the biggest motivation, was to give something to people working in the role for them to be able to assess, am I doing a good job or not? In the absence of sort of declared competencies or standards, it’s hard to know, it’s hard to sort of gauge your own performance. And so for me, that was the primary reason.

Cheryl: [18:51] I think supervisors can use them really wonderfully in terms of partnering with the person they’re supervising in identifying competencies that are necessary. The ones the person wants to improve and to really develop a plan for the development of that competency. I think it organizes our professional growth as peer workers. And I do use the word “professional.” I know it makes some people cringe.

Cheryl: [19:25] While peers can have a professional role, when they’re paid, it’s a profession, it’s not a clinical role. It’s different, it’s very different, but we can become much more competent, much more skilled in our delivery of support. That’s really the spirit of the competencies that were really written with a recovery lens, that thinking that there is continued growth and we can set a goal for ourselves. Many supervisors are using it. It’s not meant to be a checklist that a supervisor … Like a report card, someone goes down the list and gives you a grade on. That’s not the spirit of it at all, but really as a tool where you can meet together and assess together your own peer worker’s strengths and then an area or two that they want to develop.

Kristen: [21:29] That’s such a great point because the competencies are so comprehensive in what they cover. But what I’m hearing you say is that there’s still room for it to be a person-centered, strength-based way of getting supervision and honing your own professional development in ways that are most meaningful to you, and giving some information to supervisors and organizations about what this role is really supposed to look like. That’s fantastic.

Kristen: [20:58] I do have one more question on my mind before we wrap up, Cheryl. As we record this podcast today, you and I are both in our home offices, which have now turned into our home recording studios because we’re at home here in Massachusetts, like folks in many states, in response to the COVID-19 outbreak. You and I are lucky working at C4 because we’re able to do a lot of our work from home. But of course, for folks working in service settings and those providing peer support, that may not be the case. I’m curious what you’re seeing happening right now in the world of peer support as we navigate this pandemic, and if you have any advice for supervisors on how to support peer workers, especially during this time.

Cheryl: [21:38] Yes. Thank you, Kristen. I’m happy to answer that. Peer support is alive and well in the era of COVID-19. Of course, it’s all happening through the telephone. Sometimes through meeting rooms. Certainly with a 12-step programs closed, virtual meetings are happening. The technology gap does come alive here in terms of not everybody having access to internet. Everybody does have access to phones, so peer support workers are reaching people via telephone. And if possible, through other means. Peers may need additional funds to pay their phone bill at the end of the month. These are not high paying jobs. And if you’re doing peer support virtually full time, then it’s going to cost you a lot money. So my hope is they’re negotiating with their employers about this.

Cheryl: [22:44] The other thing too is if your program may need to help a peer worker obtain internet so that they can connect with people through meeting rooms. I do encourage supervisors to keep the rhythm of supervision going, that if you’re meeting once a week that you continue that. If you’re not meeting once a week, that maybe you increase to more frequently. I think everybody, all of us, myself included, needs more support during this time and outreach. Yeah, outreach and support is key. So work with the supervisor, yes, check in, check in about the financial burden of doing peer support virtually. Work with your organization to find those resources for your peer specialists and recovery coaches because this is probably going to last for a while. In terms of supervision, keep it going, make sure supervision is happening as it had been.

Kristen: [23:52] That’s a wonderful advice, Cheryl, and important reminders for all of us that we all need support and will continue to need support as we face this.

Kristen: [24:03] Cheryl, thank you so much for taking the time to be here with me today, and more importantly, for all of your leadership to advance roles and supports and supervision for the peer workforce. Thank you.

Cheryl: [24:15] Thank you, Kristen. I’m happy to be here.

Kristen: [24:17] And to our listeners, thank you for taking the time to join us today on Changing the Conversation.

Erika: [24:22] Visit c4innovates.com and follow us on Twitter, Facebook, and LinkedIn for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Our hosts are Jeff Olivet, Kristen Paquette, and Regina Cannon. Join us next time on Changing the Conversation.

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