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Team Approach to Addiction Treatment
- 1. Team Approach to Addiction Treatment Joey Grenage Addiction Facility patient Hey, I’m Joey. I am.. well … I was a sophomore at Grenage High School before I was suspended for bringing drugs to school. My dad was killed in a car accident on my 10th birthday. My addiction started with Marijuana, but I've been doing some harder drugs since then. If only I hadn’t told my dad how important it was to come to my birthday party… Rebecca Addictions counselor Hi there. My name is Rebecca and I’m an addictions counselor. I first met Joey a little over a month ago when his mother admitted him to our facility. He wasn’t cooperative the first week of his sessions, but he has been opening up more and more since then. He wants to get better but he is still learning how. That’s where I come in. I can help monitor his mental and emotional progress
- 2. during treatment, while also teaching him ways to cope with the loss of his father. I will aim to engage him in learning healthier coping skills versus using alcohol and drugs to numb his feelings Dr. Roesan Doctor Hi, my name is Dr. Roesan, and I’ve been seeing Joey weekly to assess his health and to monitor his detox treatment. I do this by discussing his progress, not only with Joey himself, but also consulting with other treatment team members as well. He’s a bright kid— he’s just had a rough time in the past few years. I really want to make sure Joey succeeds in this early part of the recovery process. Steve Nurse Hello, my name is Steve, and I’m a nurse who has been treating Joey during his inpatient detox treatment program. I help him with his inpatient detox needs and also make sure that he receives his medication on time. Joey is a sweet kid, but he can put up a really big fight sometimes with his meds. Joey has shown a lot of anger that impacts him physically
- 3. and emotionally. That comes with the territory, though. We don’t hold it against him. Tamara Facility support staff member Hi, I’m Tammy. I’ve been working in this treatment center for two years now, and I’ve seen a lot of people come in and out, including Joey. He seemed like just a shy 15-year-old at first. Once we started seeing him each day and he saw that we were there to help him, he opened up a lot more. Joey seems to know now that everyone here—including the support staff—can be trusted. Joey knows that we will help him in any way we can, whether it be with his paperwork, making sure that he knows where his next appointment is, or just a friendly person to fill him in on the final score of the big soccer game last night. With Joey—and many of our other patients—we just have to earn their trust before they will let us help them. Critical Review of Dual Diagnosis Training for Mental Health Professionals
- 4. Pernille Pinderup1 & Birgitte Thylstrup2 & Morten Hesse2 Published online: 19 May 2016 # Springer Science+Business Media New York 2016 Abstract To review evidence on the effects of training programs in dual diagnosis treatment for mental health professionals. Three databases were searched. Included studies were evalu- ated by an adapted version of Kirkpatrick’s Training Evaluation Model, which evaluates participant perception of training, the effect on professional competencies, transfer of training, and the effect on the patients. Overall findings from the eleven included studies suggested that participants valued the training, increased some professional competencies, and that some transfer of training occurred. The effect at the patient level showed mixed results. Training mental health professionals in dual diagnosis treatment may have a positive effect on profes- sional competencies and clinical practice. Any conclusion regarding the overall training effect is premature due to limitations in study designs. Future studies on the effects of dual diagnosis training programs for mental health professionals should involve control groups, validated measures, follow-ups, and patient outcomes. Keywords Dual diagnosis . Training . Comorbidity. Mental illness . Substance use disorder The term dual diagnosis (DD) describes the coexistence of one or more mental illnesses (MI) and substance use disorders (SUD) (Todd et al. 2004). DD is often associated with early onset,
- 5. beginning in youth, and a chronic course (Di Lorenzo et al. 2014), and is associated with higher rates of relapse, poorer compliance to treatment, and more psychiatric symptoms, compared to MI (Archie and Gyomorey 2009; Zammit et al. 2008). Furthermore, DD is associated with higher risk of re-hospitalizations (Archie and Gyomorey 2009; Haywood et al. 1995; Schmidt et al. 2011), increased suicide risk (Soyka et al. 2001), violence/delinquency Int J Ment Health Addiction (2016) 14:856–872 DOI 10.1007/s11469-016-9665-3 * Pernille Pinderup [email protected] 1 Competence Centre for Dual Diagnosis, Mental Health Centre Sct. Hans, Mental Health Services – Capital Region of Denmark, Boserupvej 2, 4000 Roskilde, Denmark 2 Centre for Alcohol and Drug Research, Aarhus University, Artillerivej 90, 2nd Floor, 2300 Copenhagen, Denmark http://crossmark.crossref.org/dialog/?doi=10.1007/s11469-016- 9665-3&domain=pdf (Soyka 2000), incarceration (McNiel et al. 2005), unemployment (Laudet et al. 2002), homelessness (Olfson et al. 1999), and greater risk for infections such as HIV and hepatitis (Rosenberg et al. 2001). DD occurs at rates that exceed chance by far. For instance, the
- 6. Epidemiological Catchment Area (ECA) study found that the rate of lifetime SUD in general population was 17% compared to 48% for patients with schizophrenia and 56% for patients with bipolar disorder (Regier et al. 1990). Also, the National Comorbidity Survey (NCS) from 1996 found that 41.0–65.5% of individuals with a lifetime SUD suffers from at least one MI, and that 50.9% of individuals with an MI have at least one SUD (Kessler et al. 1996). In Denmark, a recent study found that the prevalence of any lifetime SUD among patients with MI to be 37% for schizophrenia, 35% for schizotypal disorder, 28% for other psychoses, 32% for bipolar disorder, 25% for depression, 25% for anxiety, 11% for OCD, 17% for PTSD, and 46% personality disorders (Toftdahl et al. 2015). Failure to identify and treat cases of DD has severe consequences for both the patient and society. Despite the evidence for using an integrated treatment approach, where both the MI and SUD are treated as primary disorders (Drake et al. 2004; Mangrum et al. 2006; Mueser et al. 2003), many patients often receive treatment for one disorder only (Drake and Mueser 2000). One of the reasons is that SUD can be difficult to differentiate from MI symptoms because of the acute or chronic effects (Hansen et al. 2000). Another reason is that mental health professionals often lack appropriate clinical competencies to detect and treat DD (Barry et al. 2002; Cleary et al. 2009; Griffin et al. 2008; Morojele et al. 2012), which has also been associated with negative attitudes towards the patient group (Adams 2008; Richmond and Foster 2003).
- 7. One way to overcome these difficulties is to offer mental health professionals training in DD and DD treatment. In this context, training can be understood as a planned and systematic effort to modify or develop knowledge, skills, and attitudes through learning experience, in order to achieve effective performance (Buckley and Caple 2007). Renner (2004) suggests that training in DD should focus on enhancing professionals’ knowledge of MI and SUD, improve the clinical skills, and reduce counterproductive attitudes, and studies have highlighted the necessity of offering training in DD treatment to mental health professionals (Grella 2003; O’Gara et al. 2005; Ralley et al. 2009). Furthermore, mental health professionals also frequently request DD training (Happell et al. 2002; Howard and Holmshaw 2010; Ryrie and McGowan 1998; Schulte et al. 2010; Siegfried et al. 1999) that involves identifi- cation of substance withdrawal, management of alcohol and substance detoxification (Happell et al. 2002), interactions between alcohol, drugs, and prescribed medications (Ryrie and McGowan 1998), and therapeutic techniques (Howard and Holmshaw 2010). Accordingly, the British National Institute for Health and Care Excellence recommends that mental health professionals should receive continuous training in DD and DD treatment in the clinical guidelines on psychosis and co-existing substance use (NICE 2011). Despite these recommendations, a critical review of the effect
- 8. of DD training programs has, to our knowledge, not yet been conducted (Schulte et al. 2010; Siegfried et al. 1999). Such critical review is important for several reasons. Firstly, training programs for mental health professionals on SUD and co-morbidity issues have been criticized for being patchy and inadequate in a number of countries (Munro et al. 2007), and there is therefore a need to develop DD training programs that are more suitable than the current training programs. The present review will provide an overview of the research on DD training programs, which could help improving current and future DD training programs. Secondly, there is a need to explore Int J Ment Health Addiction (2016) 14:856–872 857 which effects DD training programs have on mental health professionals’ competencies, their clinical practice, and their patients. If time and resources invested in training mental health professionals do not have an effect on these outcomes, it might be more useful to improve DD treatment in other ways. The primary aim of this paper is to conduct a critical review of the literature on DD training programs for mental health professionals. A secondary aim is to examine whether the training programs result in professional competencies that could be put into practice and improve patient outcomes, such as diminishing psychiatric symptoms
- 9. and substance use. Conceptual framework for the analysis One of the most widely used models to evaluate training programs is Kirkpatrick’s Training Evaluation Model (O’Neill et al. 2004). The model specifies four levels of evaluation criteria that measure separate but related impacts of training (Kirkpatrick 1998), and it has been adapted slightly for this review (see Fig. 1). The first level, reaction, describes the participants’ perception of the DD training program. This level is fundamental, since participants might not be motivated to learn if they do not react favorably to the content and delivery of the training program (O’Neill et al. 2004). The second level, learning, refers to the participants’ improve- ments in professional knowledge, skills, and abilities. We have added attitudes to this level because attitudes toward patients with DD play a central role for quality of treatment. The third level, behavior, refers to transfer of training in the form of changes in professional work practices and behaviors. The fourth level, results, refers to organizational outcomes, which in this context is operationalized as improvements in patients’ psychiatric symptoms and sub- stance use. It is recommended that an evaluation strategy should start at the first level and move up through the levels in sequence (Kirkpatrick 1998; O’Neill et al. 2004). 4. Evaluation of results
- 10. (changes in patient outcomes) 3. Evaluation of behavior (changes to work practices and behaviors) 2. Evaluation of learning (improvements in knowledge, skills and attitudes) 1. Evaluation of reaction (perception of the training) Fig. 1 The adapted version of Kirkpatrick’s training evaluation model (Kirkpatrick 1998) 858 Int J Ment Health Addiction (2016) 14:856–872 Methods The review was conducted in accordance with relevant items from the PRISMA (The Preferred Reporting Items for Systematic Reviews and Meta- analyses) guidelines, which consists of a 27-item checklist and a four-phase flow diagram
- 11. (Moher et al. 2009). Literature search The electronic databases Web of Science, PsycINFO, and SCOPUS were searched using a pre- defined search string (see Appendix A for the full search string). Preliminary searches were conducted in all three databases prior to defining the search string. The search string included terms related to 1) SUD, 2) MI, 3) training outcomes, 4) training programs, and 5) DD, in order to ensure that records contained at least one search term from each category. The search terms had to occur in the title, abstract, keywords, or identifiers. In order to increase the number of relevant records, a proximity search was added to the string, such that records containing ‘professionals’ training’ was obtained while records containing ‘physical training’ were eliminated. A range of possible training outcomes (attitude, perception, knowledge, stigma, satisfaction etc.) was included in the string to ensure identifying relevant records. The search was restricted to English language studies, published between January 1990 and September 15, 2014. The year 1990 was chosen because the DD concept was established in the 1980s (Drake et al. 1996). Additionally, searching in subject-related journals, bibliogra- phies, and citation records, as well as searching Google Scholar, were used to identify relevant studies. Selection of studies
- 12. The review only included studies that examined training programs on DD for mental health professionals. Since different target groups require different training programs that might not be comparable, we focused exclusively on studies of training programs for professionals working in mental health settings, and not training programs for professionals working in substance use settings, students, patients with DD, or caregivers. Finally, this review was restricted to training programs targeting adult patients, as the assessment and treatment of children and adolescents might require other competencies compared to those needed for adults. Studies that fulfilled the following criteria were included in the review: 1) Involving a training intervention on treatment of both MI and SUD in adult patients; 2) involving professionals from mental health settings; 3) examining training effects such as changes in professional competencies of mental health professionals. Results The original search retrieved 988 database and 14 non-database records (see Fig. 2). After duplicates were removed, 767 records remained for initial screening. Of these, 731 records were excluded because their titles or abstracts indicated that the studies did not meet the inclusion criteria. The remaining records (N = 36) were examined in full-text to assess whether the inclusion criteria were met, and whether they addressed a
- 13. minimum of one of the research Int J Ment Health Addiction (2016) 14:856–872 859 questions. Studies were included only when there was agreement between all three authors. In total, 16 records originating from 11 studies were finally included in the review (see Table 1). The excluded full-text articles (N = 20) and the reasons for their exclusion are listed in Appendix B. Data from the included papers were extracted and analyzed within the four levels of the adapted version of Kirkpatrick’s Training Evaluation Model. Characteristics of the included studies The included studies differ in terms of geographical origin, study design, and training interventions (see Table 1). The studies were conducted in Australia, England, Ireland, Scotland, and in the US, and half of them used a repeated measure design. The remaining studies were randomized controlled trials (RCT), longitudinal studies, mixed methodology studies, or evaluation studies. Three studies used control groups. The training interventions ranged from 3 hours of training to 12 training days distributed over 10 months. In all studies, professionals conducted the training, but one study also involved lectures by patients. Records identified through database searching
- 14. (n = 988) (PsycInfo = 221, SCOPUS = 473, Web of Science = 294) Additional records identified through other sources (n = 14) Records after duplicates removed (n = 767) Records screened (n = 767) Records excluded (n = 731) Full-text articles assessed for eligibility (n = 36) Full-text articles excluded for not meeting the inclusion criteria (n = 20) Studies included in the review (n = 11) Articles meeting the inclusion criteria (n = 16),
- 15. these originated from 11 studies Fig. 2 Four-phase flow diagram 860 Int J Ment Health Addiction (2016) 14:856–872 T ab le 1 S tu dy ch ar ac te ri st ic s In cl ud ed st ud ie s
- 67. en t S ca le Int J Ment Health Addiction (2016) 14:856–872 861 Kirkpatrick’s level 1: perception of DD training programs Seven of the included studies examined participants’ reactions to a DD training program (Cooper et al. 2006; Hughes et al. 2008a, b; Munro et al. 2007; Rani and Byrne 2012; Saxton et al. 2011; Tobin and Boulton 2009). All reported that a substantial proportion of the participants valued the training (see Table 2). Three of the studies examined participant evaluation more closely (Hughes et al. 2008b; Rani and Byrne 2012; Tobin and Boulton 2009). Rani and Byrne (2012) found that the majority of the participants preferred group work, demonstration of skills, discussions, lectures, and the involvement of patients, compared to vignettes, role plays, video recording, and Powerpoint presentations. Hughes et al. (2008b) found that the training participation from work colleagues from drug and alcohol services enhanced the learning experience for many of the mental health professionals, who also valued the work materials provided at the training. Tobin and Boulton (2009) found that the participants considered several areas relevant to their work, and would implement it in clinical
- 68. practice, including motivational interviewing and using a stage approach to change (Drake and Table 2 Results Study Level 1: perception of the training Level 2: effect on skills, knowledge and attitudes Level 3: transfer of training Level 4: effect on patient outcomes Craig et al. (2008); Hughes et al. (2008a); Johnson et al. (2007) Satisfaction with the training - Increased knowledge - No sign. Effect on at- titudes - Reduced psychiatric symptoms - No sign. Effect on SU Clutterbuck et al. (2009); Copello et al. (2012); Graham (2004);
- 69. Graham et al. (2006) Satisfaction with the training - Increased confidence and skills, up to 10 years later Transfer of training occurred - No sign. Effect on psychiatric symptoms - No sign. Effect on SU Cooper et al. (2006) Satisfaction with the training - Increased skills Heslop et al. (2013) Satisfaction with the training - Increased knowledge Transfer of training occurred Hughes et al. (2008b) Satisfaction with the training - Increased confidence and skills
- 70. Munro et al. (2007) Satisfaction with the training - Increased knowledge - More positive attitudes Najavits and Kanukollu (2005) Satisfaction with the training - Increased knowledge Rani and Byrne (2012) Satisfaction with the training - Increased skills and confidence - Increased knowledge Transfer of training occurred Saxton et al. (2011) Satisfaction with the training - Increased knowledge - No sign. Effect on attitudes Sciacca and Thompson (1996) Satisfaction with
- 71. the training - Increased knowledge Transfer of training occurred Tobin and Boulton (2009) Satisfaction with the training 862 Int J Ment Health Addiction (2016) 14:856–872 Mueser 2000). All three studies found that the participants recommended longer training programs, in order to acquire the needed competencies. In the study by Tobin and Boulton (2009), the training program lasted 1 day, and in the study by Rani and Byrne (2012), training was delivered 1 day a week over a five-week period. In the study by Hughes et al. (2008b) the training took place once a month for 5 months, a time length that increased the risk of forgetting what had taken place in previous sessions. Kirkpatrick’s level 2: improvement in skills, knowledge, and attitudes Three studies examined changes in professional skills by using questionnaires that measured self-perceived changes (Cooper et al. 2006; Graham et al. 2006; Hughes et al. 2008b). All of these studies found that participants in general perceived having increased their skills after the training program. The study by Graham et al. (2006) involved a control group that did not
- 72. receive training initially, and changes in skills were only seen in the intervention group. The fact that the control group received training at a later stage and then increased their skills following this training, suggests that the training and no other factors was responsible for the change in skills. A few years after the training, a subgroup of the participants was interviewed, and a number of them stated that they felt more confident and skilled compared to 5 years earlier (Clutterbuck et al. 2009), and a follow-up study 10 years later also showed improve- ments in confidence and skills (Copello et al. 2012). Seven studies (Heslop et al. 2013; Hughes et al. 2008a; Munro et al. 2007; Najavits and Kanukollu 2005; Rani and Byrne 2012; Saxton et al. 2011; Sciacca and Thompson 1996) reported outcomes concerning whether participants increased their knowledge of DD and DD treatment. Two of the included studies used self-rated questionnaires (Rani and Byrne 2012; Saxton et al. 2011), and found that, on average, participants experienced an increase in knowledge following training. Two of the other studies (Hughes et al. 2008a; Najavits and Kanukollu 2005) used a multiple-choice questionnaire to assess their participants’ knowledge of DD treatment pre- and post-training. Najavits and Kanukollu (2005) found a high level of correct responses at baseline and a small increase in knowledge from pre-training to post- training. Since no other measures were included, it is not possible to establish whether the small difference in pre- and post-scores was due to a ceiling effect in the form of an initially
- 73. high level of knowledge, or whether the questions were too easy. The study by Hughes et al. (2008a) involved a control group that also completed the multiple-choice questionnaire. Improvements in knowledge were only seen in the intervention group, suggesting that training was responsible for the increased knowledge. Two studies (Heslop et al. 2013; Sciacca and Thompson 1996) included a combination of both self-rated questionnaires and objective knowledge tests, and found that the participants on average increased their knowledge, as measured by both, after the training. The study by Munro et al. (2007) included both a knowledge test with true/false questions and qualitative interviews, together with a control group. The intervention group responded more correctly both post- training and at the six-month follow-up, and the qualitative interviews conducted at a later stage supported the link between training and improvement in knowledge (Watson and Munro 2003). Three of the studies explored both changes in knowledge and changes in attitudes (Hughes et al. 2008a; Munro et al. 2007; Saxton et al. 2011). The only study that found an effect on attitudes was that of Munro et al. (2007). They found that attitudes in the intervention and control groups were rather negative before training, whereas the intervention group reported significantly more positive attitudes following the training and at the six-month follow-up. Int J Ment Health Addiction (2016) 14:856–872 863
- 74. Kirkpatrick’s level 3: transfer of training Whereas Level 2 evaluates the short-term effect of a training program in terms of acquired competencies, information on the longer-term outcomes of the training after participants have returned to their workplace is evaluated at Level 3 (O’Neill et al. 2004). Four of the studies investigated whether the acquired competencies from training were transferred into clinical practice (Graham et al. 2006; Heslop et al. 2013; Rani and Byrne 2012; Sciacca and Thompson 1996). All four studies found that the participants had changed some of their work practices after the training. Rani and Byrne (2012) used focus group interviews 8 weeks after training, and found that some of the participants reported a change in their work practices regarding providing psychoeducation to their patients, and that participants who had not changed their practices explained this by lack of time, current work load, or poor patient attendance. In the three other studies, the training was part of the implementation of a new treatment method (Graham et al. 2006; Heslop et al. 2013; Sciacca and Thompson 1996). In the study by Heslop et al. (2013), a screening instrument and brief interventions were to be implemented, and the authors reviewed medical records before and after participants completed the training program. Significant improvements were found in the number of drug and alcohol assessments
- 75. at patient admission, and in the inclusion of drug and alcohol issues in the patients’ manage- ment plan following training, suggesting that some professional work practices had changed as a result of the training program and the implementation process. In the study by Sciacca and Thompson (1996), a new treatment model was to be implemented. Following the training, all the participants led at least one DD treatment group for the first time, suggesting a positive effect of the training and the implementation of a new treatment model. In the study by Graham et al. (2006), changes in teams’ practice were observed following their participation in a training program and the implementation of integrated DD treatment. Post-training involved more attempts to apply the intervention appropriately, improved incorporation of information on substance use into clinical medical case notes, more psychoeducation provided to the patients, and improved therapeutic practices. Kirkpatrick’s level 4: effects of training on patient outcomes Only two studies investigated whether training professionals in DD and DD treatment had an effect on patients’ psychiatric symptoms and substance use. In the first study, patients to mental health professionals in an intervention group who received training and supervision were compared to a control group (Craig et al. 2008; Johnson et al. 2007). Patients in the intervention group had significantly lower symptom levels at follow-up compared to patients in the control group, but there were no significant reductions in substance use in either group (Craig et al.
- 76. 2008). In the second study, results indicated that the training did not affect the patients’ psychiatric symptoms (Graham et al. 2006). There was a reduction in outcomes related to substance use at follow-up, but this was found in both the intervention and control group. Discussion Research on the effect of training mental health professionals in DD treatment is an important field that calls for more attention and development, since training mental health professionals often is expensive and takes time from the clinic and the patients. 864 Int J Ment Health Addiction (2016) 14:856–872 Using Kirkpatrick’s Training Evaluation Model, we were able to identify both key findings and areas that require substantial further research. Seven studies reported that DD training programs were positively evaluated by the participants (Cooper et al. 2006; Hughes et al. 2008a, b; Munro et al. 2007; Rani and Byrne 2012; Saxton et al. 2011; Tobin and Boulton 2009), and three of these studies suggested that training programs should involve a wider range of teaching methods, last more than one training day, involve patients as lectures, and that the training should not be spread over a lengthy period of time (Hughes et al. 2008b; Rani and Byrne 2012; Tobin and Boulton 2009). However, the absence of standard measures regarding
- 77. participants’ reaction to the DD training limits the interpretation of these findings, and more research is needed to determine how to design a suitable training program. Three studies found that training programs enhance the professional skills of mental health professionals (Cooper et al. 2006; Graham et al. 2006; Hughes et al. 2008b), and seven studies found that training enhanced their professional knowledge (Heslop et al. 2013; Hughes et al. 2008a; Munro et al. 2007; Najavits and Kanukollu 2005; Rani and Byrne 2012; Saxton et al. 2011; Sciacca and Thompson 1996). However, the three studies on changes in attitudes towards patients with DD found mixed results (Hughes et al. 2008a; Munro et al. 2007; Saxton et al. 2011). The effect of training on these three outcomes can be evaluated by two types of measurement tools (O’Neill et al. 2004). One approach involves direct measures, e.g. tests, observations, program-specific questionnaires, role play, job and task simulation, and log books, while the other approach involves less direct measures, e.g. self-report questionnaires. The studies that measured changes in skills or attitudes used less direct measures, however, and the relations between experienced gains and clinical gains are yet to be established, since experienced gains do not necessarily mean that the participants improved their clinical skills or adopted more positive attitudes. Two of the studies that investigated changes in knowledge also used indirect measures (Rani and Byrne 2012; Saxton et al. 2011), and could only show that participants felt more knowledgeable following training,
- 78. and not whether they actually gained more knowledge. An actual gain in knowledge could have been measured by using a knowledge test or questionnaire (O’Neill et al. 2004), which was done in two of the included studies (Hughes et al. 2008a; Najavits and Kanukollu 2005). However, such studies may be limited due to the use of tests or questionnaires that are too simple, or due to re-test effects. This limitation can be overcome by combining direct measures with less direct measures, which three studies did (Heslop et al. 2013; Munro et al. 2007; Sciacca and Thompson 1996). These studies showed both that the participants perceived a gain in knowledge and that they actually gained more knowledge. Only four studies examined transfer of training, and all found that professional competen- cies acquired from training were transferred into clinical practice (Graham et al. 2006; Heslop et al. 2013; Rani and Byrne 2012; Sciacca and Thompson 1996). However, the training was part of a broader implementation process in three of the studies, and it is therefore unclear whether the effect was caused by the training program, the implementation process, or the combination of the two. Moreover, in the same three studies, the researchers or the consultants visited the workplace regularly to measure adherence to the new treatment method, or to support the implementation process, and it is likely that these regular meetings supported the transfer of training. Transfer of training can be measured both by direct measures,
- 79. e.g. observations, log books, and diaries, and by less direct measures, e.g. self-reports on behavior change (questionnaires, interviews, diaries, and focus groups), and reports of behavior as observed by peers and/or supervisors (O’Neill et al. 2004). Of the four studies measuring transfer of training, Rani and Int J Ment Health Addiction (2016) 14:856–872 865 Byrne (2012) relied solely on results from focus group interviews, which is a less direct measure that only shows that participants believed that they had changed their practices following training, but not whether changes in clinical practices had actually occurred. The remaining three studies that assessed the transfer of training used direct measures. Heslop et al. (2013) reviewed medical records before and after the training and found that the assessment of drug and alcohol issues improved, and Sciacca and Thompson (1996) observed that the professionals led more DD treatment groups after the training. However, both studies are limited by the use of one single measure. The third study by Graham et al. (2006) involved a range of measures, including observations, observers’ ratings, and interviews which strength- ened the results of their study. Still, none of the studies used validated tests or questionnaires to evaluate the first three levels, whereas Level 4, the effect on patient outcomes, was primarily measured by validated instruments.
- 80. Only two studies explored the effect on patient outcomes. The study by Craig et al. (2008) suggested that training was associated with reduction in psychiatric symptoms, while the study by Graham et al. (2006) found no effect on psychiatric symptoms. None of these studies found an effect on substance use. Since only two studies included patients’ outcomes, it is premature to draw any conclusions regarding the effect at the patient level. Long-term effect of training Participation in training programs costs both money and time, and it is therefore important to consider the long-term gains of the training. If competencies acquired during training are forgotten few months later, it might be more useful to qualify mental health professionals in other ways. Only two of the identified studies (Graham et al. 2006; Munro et al. 2007) included a follow-up, and one of them showed that gains in skills remained 10 years after the training (Copello et al. 2012; Graham et al. 2006). Control groups Intuitively, it is hard to imagine that training mental health professionals in DD treatment would have no effect on their knowledge, skills, or attitudes. A critical question is therefore what a specific training program requires, in order to increase these competencies. None of the included studies compared different training programs, and the lack of control groups was a general problem in most of the studies. Without control groups, it cannot be ruled out that other
- 81. factors could account for any observed effect, for instance that participants might simply have become more interested in the DD field as a result of their participation in a study. Greater interest in DD could in turn have led the participants to seek more information, resulting in increased skills, knowledge, and attitudes. Another factor that could account for the results is the so-called Hawthorne Effect (Mayo 1933) whereby receiving attention from researchers during study participation may cause participants to feel more competent at the end of the study, regardless of whether they had been through training or not. Conceptualization The review found considerable challenges with the conceptualization of the outcome skills. The three studies that explored changes in skills used a questionnaire which measured changes in perceived skills and confidence as a single construct. It is therefore not possible to 866 Int J Ment Health Addiction (2016) 14:856–872 distinguish between improvements in skills and confidence: participants might feel more confident after training without necessarily being more skilled. This argument is supported by the fact that five of the included studies (Heslop et al. 2013; Hughes et al. 2008a; Munro et al. 2007; Rani and Byrne 2012; Saxton et al. 2011) found that
- 82. the participants’ professional confidence increased after the training program, suggest- ing that specialized training enhances professional confidence. However, again the effect on skills is still unknown. Future research There are several areas that require further research, and researchers and practitioners need to work together to develop reliable and valid measures of the key constructs that DD training aims to address. Future research on training effects should combine direct and indirect measures, and focus on changes in professional skills, in knowledge, and in attitudes. Moreover, future research should include control groups, or at least some type of relevant comparison group. Randomization of individual practitioners may often not be feasible, but cluster-randomized studies could be a pragmatic solution in many mental health settings. Ideally, such studies should involve training with various contents and intensities, in order to improve knowledge of what are the important elements in training. Since only one study explored the long-term effects of training and only two studies examined patient outcomes, more research is needed on the long-term effects of DD training programs and the effect on patient outcomes. Limitations The literature search was only performed by the first author. However, the search was
- 83. performed twice to minimize errors, and at both stages, the included studies were agreed upon by all three authors. Another limitation is a possible publication bias, namely that studies with negative findings may not have been reported in the literature. Conclusion Mental health professionals have a positive perception of DD training programs, they consider that they gain knowledge from them, and some transfer of training to clinical practice occurs. Whether the professionals actually acquire more skills, change their attitudes, or whether their patients benefit from the training is still unknown. Because of the methodological limitations in the included studies, it would be premature to draw any firm conclusions regarding the effect of DD training programs. Future studies should include patient outcomes, control groups, follow-ups, and validated multiple measures. Compliance with ethical standards Funding No grants or financial support were received for this review. Informed consent No animal or human studies were carried out by the authors for this article. Disclosures Pernille Pinderup, Birgitte Thylstrup, and Morten Hesse declare that they have no conflict of interest. Int J Ment Health Addiction (2016) 14:856–872 867
- 84. Appendix A: Search string Search string Balcohol dependenc*^ OR Bdrug dependenc*^ OR Bdrug use disorder*^ OR Balcohol use disorder*^ OR substance* OR Bsubstance use disorder*^ OR Bdrug abus*^ OR Balcohol abus*^ OR addiction* AND psychiatr* OR mental OR psychos* OR psychot* AND attitude* OR perception* OR knowledge OR stigma OR satisfaction OR skill* OR view* OR confidence OR treatment outcome OR efficacy OR competence* OR abilit* AND (train* OR program* OR educat* OR workshop OR intervent* OR quiz) NEAR/4 (doctor* OR staff OR nurse* OR professional* OR manager* OR psychiatrist* OR physician* OR psychologist* OR clinician* OR therapist* OR worker* OR personnel OR practitioner* OR co-existing OR coexisting OR cooccurring OR co-occurring OR co-morbidity OR comorbidity OR concurrent OR Bdual diagnosis^ OR Bdual disorder^) AND co-existing OR coexisting OR cooccurring OR co- occurring OR co-morbidity OR comorbidity OR Bdual diagnosis^ OR Bdual disorder^ OR concurrent Appendix B: Excluded studies Excluded studies Reason for exclusion Eden, T., & Hughes, L. (2009). Facilitating the dialogue
- 85. between service users and participants in a training situation. Advances in Dual Diagnosis, 2(3), 5–7. Harwood, H. J., Kowalski, J., & Ameen, A. (2004). The need for substance abuse training among mental health professionals. Administration and Policy in Mental Health and Mental Health Services Research, 32(2), 189–205. Manley, D. S. (2008). Acceptability and applicability of Cue Exposure Therapy as a relapse prevention intervention for individuals who have substance misuse and mental health problems. Mental Health and Substance Use, 1(2), 172–184. Maxwell, S. (2001). Care of people with dual disabilities in the mental health system: Education vs. attitude rehabilitation. Psychiatric Rehabilitation Skills, 5(1), 197–215. Moore, J. (2013). Dual diagnosis: training needs and attitudes of nursing staff: Jayne Moore explores nursing staff’s training needs and their attitudes towards patients who misuse substances in a large forensic mental health service. Mental Health Practice, 16(6), 27–31. Nehlin, C., Fredriksson, A., Gronbladh, L., & Jansson, L. (2012). Three hours of training improve psychiatric staff’s self-perceived knowledge and attitudes toward problem-drinking patients. Drug and Alcohol Review, 31(4), 544–549.
- 86. Rassool, G. H. (2006). Professional Education in Co-occurring Disorders: Some Considerations towards Practice Development: Journal of Addictions Nursing, 17(3), 187–191. Schoener, E. P., Madeja, C. L., Henderson, M. J., Ondersma, S. J., & Janisse, J. J. (2006). Effects of motivational interviewing training on mental health therapist behavior. Drug and Alcohol Dependence, 82(3), 269–275. Wrong intervention Cameron, J., Lee, N. K., & Harney, A. (2010). Changes in attitude to, and confidence in, working with comorbidity after training in screening and brief intervention. Mental Health and Substance Use: Dual Diagnosis, 3(2), 124– 130. Caravella, K., Tod, L., & Brown, A.-M. (2012). Awareness into action: How communication skills training enhances traditional substance abuse treatment programs. Journal of Global Drug Policy and Practice, 6(1). Crowe, T. P., Kelly, P., Pepper, J., McLennan, R., Deane, F. P., & Buckingham, M. (2013). Service Based Internship Training to Prepare Workers to Support the Recovery of People with Co-Occurring Substance Abuse and Mental Health Disorders. International Journal of Mental Health and Addiction, 11(2), 269–280.
- 87. Wrong study population 868 Int J Ment Health Addiction (2016) 14:856–872 Excluded studies Reason for exclusion Hunter, S. B., Watkins, K. E., Wenzel, S., Gilmore, J., Sheehe, J., & Griffin, B. (2005). Training substance abuse treatment staff to care for co- occurring disor- ders. Journal of Substance Abuse Treatment, 28(3), 239–245. Lee, N., Jenner, L., Baker, A., Ritter, A., Hides, L., Norman, J., … Cameron, J. (2010). Screening and intervention for mental health problems in alcohol and other drug settings: Can training change practitioner behaviour? Drugs: Education, Prevention, and Policy, 18(2), 157–160. Roussy, V., Thomacos, N., Rudd, A., & Crockett, B. (2013). Enhancing health-care workers’ understanding and thinking about people living with co-occurring mental health and substance use issues through consumer-led training. Health Expectations, 18(5), 1567–81. Wenzel, S. L., Ebener, P., Hunter, S. B., Watkins, K. E., & Gilmore, J. M. (2005). Research-practice partners assess their first joint project. Science & Practice Perspectives, 3(1), 38–45.
- 88. Covell, N. H., Margolies, P. J., Smith, M. F., Merrens, M. R., & Essock, S. M. (2011). Distance Training and Implementation Supports to Scale Up Integrated Treatment for People With Co-occurring Mental Health and Substance Use Disorders. Journal of Dual Diagnosis, 7(3), 162–172. Davis, K., O’Neill, S., Devitt, T., Baerentzen, B., Little, N., & Wilkniss, S. (2012). Consulting in action: A case study of six community support teams sustaining integrated dual disorder treatment. American Journal of Psychiatric Rehabilitation, 15(4), 313–333. Lewis, T. (2008). Dual diagnosis education by distance learning. Advances in Dual Diagnosis, 1(2), 13–18. McKee, S. A., Harris, G. T., & Cormier, C. A. (2013). Implementing Residential Integrated Treatment for Co-occurring Disorders. Journal of Dual Diagnosis, 9(3), 249–259. http://doi.org/10.1080/15504263.2013.807073 Renner Jr., J. A., Quinones, J., & Wilson, A. (2005). Training psychiatrists to diagnose and treat substance abuse disorders. Current Psychiatry Reports, 7(5), 352–359. Wrong outcomes References
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- 99. Toftdahl, N. G., Nordentoft, M., & Hjorthøj, C. (2015). Prevalence of substance use disorders in psychiatric patients: a nationwide Danish population-based study. Social Psychiatry and Psychiatric Epidemiology, 1– 12. doi:10.1007/s00127-015-1104-4 Watson, H. E., & Munro, A. (2003). A study of staff training to promote effective care for clients with Bdual diagnosis.^. Glasgow: Caledonian Nursing & Midwifery Research Centre, Glasgow Caledonian University. Zammit, S., Moore, T. H. M., Lingford-Hughes, A., Barnes, T. R. E., Jones, P. B., Burke, M., et al. (2008). Effects of cannabis use on outcomes of psychotic disorders: systematic review. The British Journal of Psychiatry, 193(5), 357–363. doi:10.1192/bjp.bp.107.046375. 872 Int J Ment Health Addiction (2016) 14:856–872 http://dx.doi.org/10.1007/s00127-015-1104-4 http://dx.doi.org/10.1192/bjp.bp.107.046375 International Journal of Mental Health & Addiction is a copyright of Springer, 2016. All Rights Reserved. Critical Review of Dual Diagnosis Training for Mental Health ProfessionalsAbstractConceptual framework for the analysisMethodsLiterature searchSelection of studiesResultsCharacteristics of the included studiesKirkpatrick’s level 1: perception of DD training programsKirkpatrick’s level 2: improvement in skills, knowledge, and attitudesKirkpatrick’s level 3: transfer of trainingKirkpatrick’s level 4: effects of training on patient outcomesDiscussionLong-term effect of trainingControl groupsConceptualizationFuture
- 100. researchLimitationsConclusionAppendix A: Search stringAppendix B: Excluded studiesReferences 1 BRINGING RECOVERY SUPPORTS TO SCALE Technical Assistance Center Strategy (BRSS TACS) C o r e C o m p e t e n c i e s f o r P e e r W o r k e r s i n B e h av i o r a l H e a lt h S e r v i c e s OVERVIEW In 2015, SAMHSA led an effort to identify the critical knowledge, skills, and abilities (leading to Core Competencies) needed by anyone who provides peer support services to people with or in recovery from a mental health or substance use condition. SAMHSA—via its Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS) project— convened diverse stakeholders from the mental health consumer and substance use disorder recovery movements to achieve this goal. SAMHSA in conjunction with subject matter experts conducted research to identify Core Competencies for peer workers in behavioral health. SAMHSA later posted the draft competencies developed with these stakeholders online for comment. This additional input helped refine the Core Competencies and this document represents the final product of that process. As our understanding of peer support grows and the contexts in which peer recovery support services are provided evolve, the Core Competencies must evolve over time. Therefore, updates to these competencies may occur periodically in the future.
- 101. Core Competencies are intended to apply to all forms of peer support provided to people living with or in recovery from mental health and/or substance use conditions and delivered by or to adults, young adults, family members and youth. The competencies may also apply to other forms of peer support provided by other roles known as peer specialists, recovery coaches, parent support providers or youth specialists. These are not a complete set of competencies for every context in which peer workers provide services and support. They can serve as the foundation upon which additional competencies for specific settings that practice peer support and/or for specific groups could be developed in the future. For example, it may be helpful to identify additional competencies beyond those identified here that may be required to provide peer support services in specific settings such as clinical, school, or correctional settings. Similarly, there may be a need to identify additional Core Competencies needed to provide peer support services to specific groups, such as families, veterans, people in medication-assisted recovery from an SUD, senior citizens, or members of specific ethnic, racial, or gender-orientation groups. BACKGROUND What is a peer worker? The role of the peer support worker has been defined as “offering and receiving help, based on shared understanding, respect and mutual empowerment between people in similar situations.” Peer support has been described as “a system of giving and receiving help” based on key principles that include “shared responsibility, and mutual agreement of what is helpful.”1 Peer support workers engage in a wide range of activities,
- 102. including advocacy, linkage to resources, sharing of experience, community and relationship building, group facilitation, skill building, mentoring, goal setting, and more. They may also plan and develop groups, services or activities, supervise other peer workers, provide training, gather information on resources, administer programs or agencies, educate the public and policymakers, and work to raise awareness.2 1 Mead, S., Hilton, D. & Curtis, L. (2001). Peer support: A theoretical perspective. Psychiatric Rehabilitation Journal, 25(2), 134-141. 2 Jacobson, N. et.al. (2012). What do peer support workers do? A job description. BMC Health Services Research. 12:205 2 As mentioned previously, the development of additional Core Competencies may be needed to guide the provision of peer support services to specific groups who also share common experiences such as family members. The shared experience of being in recovery from a mental or substance use disorder or being a family member of a person with a behavioral health condition is the foundation on which the peer recovery support relationship is built in the behavioral health arena. What is recovery? SAMHSA developed the following working definition of recovery by engaging key stakeholders in the mental health consumer and substance use disorder recovery communities: Recovery is a process of change through which individuals improve their health and wellness, live self-directed lives, and
- 103. strive to reach their full potential.3 Throughout the competencies, the term “recovery” refers to this definition. This definition does not describe recovery as an end state, but rather as a process. Complete symptom remission is neither a prerequisite of recovery nor a necessary outcome of the process. According the SAMHSA Working Definition of Recovery, recovery can have many pathways that may include “professional clinical treatment; use of medications; support from families and in schools; faith-based approaches; peer support; and other approaches.” SAMHSA has identified four major dimensions that support a life in recovery: 1. Health—Learning to overcome, manage or more successfully live with the symptoms and making healthy choices that support one’s physical and emotional wellbeing; 2. Home—A stable and safe place to live; 3. Purpose—Meaningful daily activities, such as a job, school, volunteer work, or creative endeavors; and, increased ability to lead a self-directed life; and meaningful engagement in society; and 4. Community—Relationships and social networks that provide support, friendship, love, and hope Peer workers help people in all of these domains. What are Core Competencies? Core Competencies are the capacity to easily perform a role or function. They are often described as clusters of the knowledge, skills, and attitudes a person needs to have in order to
- 104. successfully perform a role or job or as the ability to integrate the necessary knowledge, skills, and attitudes. Training, mentoring, and supervision can help people develop the competencies needed to perform a role or job.4 5 This will be the first integrated guidance on competencies for peer workers with mental health and substance use lived experience. Why do we need to identify Core Competencies for peer workers? Peer workers and peer recovery support services have become increasingly central to people’s efforts to live with or recover from mental health and substance use disorders. Community- based organizations led by people who have lived experience of mental health conditions and/or who are in recovery from substance use disorders are playing a growing role in helping people find recovery in the community. Both the mental health consumer and the substance use disorder recovery communities have recognized the need for Core Competencies and both communities actively participated in the development of these peer recovery support worker competencies. Potential Uses of Core Competencies Core Competencies have the potential to guide delivery and promote best practices in peer support. They can be used to inform peer training programs, assist in developing standards for certification, and inform job descriptions. Supervisors will be able to use competencies to appraise peer workers’ job performance and
- 105. peers will be able to assess their own work performance and set goals for continued development of these competencies. 3 Substance Abuse and Mental Health Services Administration. SAMHSA’s Working Definition of Recovery. PEP12-RECDEF, Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 2012. 4 Henandez, R.S., O’Connor, S.J. (2010). Strategic Human Resources Management in Health Services Organizations. Third Edition. Delmar Cengage Learning. P. 83. 5 Sperry, L. (2010). Core Competencies in Counseling and Psychotherapy: Becoming a Highly Competent and Effective Therapist. Routledge. P. 5. 3 Core Competencies are not intended to create a barrier for people wishing to enter the peer workforce. Rather they are intended to provide guidance for the development of initial and on-going training designed to support peer workers’ entry into this important work and continued skill development. Core Competencies, Principles and Values Core Competencies for peer workers reflect certain foundational principles identified by members of the mental health consumer and substance use disorder recovery communities. These are:
- 106. RECOVERY-ORIENTED: Peer workers hold out hope to those they serve, partnering with them to envision and achieve a meaningful and purposeful life. Peer workers help those they serve identify and build on strengths and empower them to choose for themselves, recognizing that there are multiple pathways to recovery. PERSON-CENTERED: Peer recovery support services are always directed by the person participating in services. Peer recovery support is personalized to align with the specific hopes, goals, and preferences of the individual served and to respond to specific needs the individuals has identified to the peer worker. VOLUNTARY: Peer workers are partners or consultants to those they serve. They do not dictate the types of services provided or the elements of recovery plans that will guide their work with peers. Participation in peer recovery support services is always contingent on peer choice. RELATIONSHIP-FOCUSED: The relationship between the peer worker and the peer is the foundation on which peer recovery support services and support are provided. The relationship between the peer worker and peer is respectful, trusting, empathetic, collaborative, and mutual. TRAUMA-INFORMED: Peer recovery support utilizes a strengths-based framework that emphasizes physical, psychological, and emotional safety and creates opportunities for survivors to rebuild a sense of control and empowerment.
- 107. 4 C o r e C o m p e t e n c i e s f o r P e e r W o r k e r s i n B e h av i o r a l H e a lt h S e r v i c e s Category I: Engages peers in collaborative and caring relationships This category of competencies emphasized peer workers’ ability to initiate and develop on-going relationships with people who have behavioral health condition and/or family members. These competencies include interpersonal skills, knowledge about recovery from behavioral health conditions and attitudes consistent with a recovery orientation. 1. Initiates contact with peers 2. Listens to peers with careful attention to the content and emotion being communicated 3. Reaches out to engage peers across the whole continuum of the recovery process 4. Demonstrates genuine acceptance and respect 5. Demonstrates understanding of peers’ experiences and feelings Category II: Provides support The competencies in this category are critical for the peer worker to be able to provide the mutual support people living with behavioral health conditions may want. 1. Validates peers’ experiences and feelings
- 108. 2. Encourages the exploration and pursuit of community roles 3. Conveys hope to peers about their own recovery 4. Celebrates peers’ efforts and accomplishments 5. Provides concrete assistance to help peers accomplish tasks and goals Category III: Shares lived experiences of recovery These competencies are unique to peer support, as most roles in behavioral health services do not emphasize or even prohibit the sharing of lived experiences. Peer workers need to be skillful in telling their recovery stories and using their lived experiences as a way of inspiring and supporting a person living with behavioral health conditions. Family peer support worker likewise share their personal experiences of self-care and supporting a family-member who is living with behavioral health conditions. 1. Relates their own recovery stories, and with permission, the recovery stories of others’ to inspire hope 2. Discusses ongoing personal efforts to enhance health, wellness, and recovery 3. Recognizes when to share experiences and when to listen 4. Describes personal recovery practices and helps peers discover recovery practices that work for them 5
- 109. Category IV: Personalizes peer support These competencies help peer workers to tailor or individualize the support services provided to and with a peer. By personalizing peer support, the peer worker operationalizes the notion that there are multiple pathways to recovery. 1. Understands his/her own personal values and culture and how these may contribute to biases, judgments and beliefs 2. Appreciates and respects the cultural and spiritual beliefs and practices of peers and their families 3. Recognizes and responds to the complexities and uniqueness of each peer’s process of recovery 4. Tailors services and support to meet the preferences and unique needs of peers and their families Category V: Supports recovery planning These competencies enable peer workers to support other peers to take charge of their lives. Recovery often leads people to want to make changes in their lives. Recovery planning assists people to set and accomplish goals related to home, work, community and health. 1. Assists and supports peers to set goals and to dream of future possibilities 2. Proposes strategies to help a peer accomplish tasks or goals 3. Supports peers to use decision-making strategies when choosing services and supports 4. Helps peers to function as a member of their treatment/recovery support team
- 110. 5. Researches and identifies credible information and options from various resources Category VI: Links to resources, services, and supports These competencies assist peer workers to help other peers acquire the resources, services, and supports they need to enhance their recovery. Peer workers apply these competencies to assist other peers to link to resources or services both within behavioral health settings and in the community. It is critical that peer workers have knowledge of resources within their communities as well as on-line resources. 1. Develops and maintains up-to-date information about community resources and services 2. Assists peers to investigate, select, and use needed and desired resources and services 3. Helps peers to find and use health services and supports 4. Accompanies peers to community activities and appointments when requested 5. Participates in community activities with peers when requested 6 Category VII: Provides information about skills related to health, wellness, and recovery These competencies describe how peer workers coach, model or
- 111. provide information about skills that enhance recovery. These competencies recognize that peer workers have knowledge, skills and experiences to offer others in recovery and that the recovery process often involves learning and growth. 1. Educates peers about health, wellness, recovery and recovery supports 2. Participates with peers in discovery or co-learning to enhance recovery experiences 3. Coaches peers about how to access treatment and services and navigate systems of care 4. Coaches peers in desired skills and strategies 5. Educates family members and other supportive individuals about recovery and recovery supports 6. Uses approaches that match the preferences and needs of peers Category VIII: Helps peers to manage crises These competencies assist peer workers to identify potential risks and to use procedures that reduce risks to peers and others. Peer workers may have to manage situations, in which there is intense distress and work to ensure the safety and well-being of themselves and other peers. 1. Recognizes signs of distress and threats to safety among peers and in their environments 2. Provides reassurance to peers in distress 3. Strives to create safe spaces when meeting with peers
- 112. 4. Takes action to address distress or a crisis by using knowledge of local resources, treatment, services and support preferences of peers 5. Assists peers in developing advance directives and other crisis prevention tools Category IX: Values communication These competencies provide guidance on how peer workers interact verbally and in writing with colleagues and others. These competencies suggest language and processes used to communicate and reflect the value of respect. 1. Uses respectful, person-centered, recovery-oriented language in written and verbal interactions with peers, family members, community members, and others 2. Uses active listening skills 3. Clarifies their understanding of information when in doubt of the meaning 4. Conveys their point of view when working with colleagues 5. Documents information as required by program policies and procedures 6. Follows laws and rules concerning confidentiality and respects others’ rights for privacy 7 Category X: Supports collaboration and teamwork
- 113. These competencies provide direction on how peer workers can develop and maintain effective relationships with colleagues and others to enhance the peer support provided. These competencies involve not only interpersonal skills but also organizational skills. 1. Works together with other colleagues to enhance the provision of services and supports 2. Assertively engages providers from mental health services, addiction services, and physical medicine to meet the needs of peers 3. Coordinates efforts with health care providers to enhance the health and wellness of peers 4. Coordinates efforts with peers’ family members and other natural supports 5. Partners with community members and organizations to strengthen opportunities for peers 6. Strives to resolve conflicts in relationships with peers and others in their support network Category XI: Promotes leadership and advocacy These competencies describe actions that peer workers use to provide leadership within behavioral health programs to advance a recovery-oriented mission of the services. They also guide peer workers on how to advocate for the legal and human rights of other peers. 1. Uses knowledge of relevant rights and laws (ADA, HIPAA, Olmstead, etc.) to ensure that peer’s rights are
- 114. respected 2. Advocates for the needs and desires of peers in treatment team meetings, community services, living situations, and with family 3. Uses knowledge of legal resources and advocacy organization to build an advocacy plan 4. Participates in efforts to eliminate prejudice and discrimination of people who have behavioral health conditions and their families 5. Educates colleagues about the process of recovery and the use of recovery support services 6. Actively participates in efforts to improve the organization 7. Maintains a positive reputation in peer/professional communities Category XII: Promotes growth and development These competencies describe how peer workers become more reflective and competent in their practice. The competencies recommend specific actions that may serve to increase peer workers’ success and satisfaction in their current roles and contribute to career advancement. 1. Recognizes the limits of their knowledge and seeks assistance from others when needed 2. Uses supervision (mentoring, reflection) effectively by monitoring self and relationships, preparing for meetings and engaging in problem-solving strategies with the supervisor (mentor, peer)
- 115. 3. Reflects and examines own personal motivations, judgments, and feelings that may be activated by the peer work, recognizing signs of distress, and knowing when to seek support 4. Seeks opportunities to increase knowledge and skills of peer support Last Updated December 7, 2015