by Jim Hajny, Executive Director
November 27, 2024
(Some information collected via AI)
This is one topic I am very familiar with and have spent years advocating in Montana. Our website has specific information on various demonstration projects MPN have operated over the years. It is one of the most asked questions I get when it comes to the implementation of peer supporters. This article will attempt to provide resources, and the “how to” for implementation of peer supporters into your crisis program.
One of the earliest presentations I am aware of was one in which SAMHSA invited me to join a panel of other peers to discuss the role of peer support as providers. Each of panelists were providing some type of support around crisis response. From warms lines, peer respites, emergency rooms to our project in the community. Leah Harris was the moderator, and I remember the overwhelming response we got. I received so many emails afterwards with follow up questions. It was so popular, we had to do the webinar twice because we overloaded the SAMHSA server, and it crashed for many people. Over the years I have been asked about our work in this area. Just last summer I did a consultation with another state that was implementing peer supporters into their crisis response system. The SAMHSA webinar Peers as Crisis Service Providers was presented on August 7, 2015, and discussed the benefits of peer specialists in crisis services. The webinar was sponsored by SAMHSA and presented by the National Coalition for Mental Health Recovery. (https://www.ncmhr.org/) If you would like to review it. Today there are many other webinars on this topic. One really good one is “Providing Peer Support Services in Crisis Service” by Cheryl Gagne which goes in depth to the Crisis Now model.
Ten years ago, the idea of implementing non college credentialed people in recovery was a new concept being promoted within the recovery movement in an effort to change the status quo. The way in which we did things back then and by in large the way in which we operate the crisis system today is ineffective. Peer Support in crisis response was supported by SAMHSA then and is today. A great document to review is SAMHSA’s Crisis Services Meeting Needs Saving Lives. by Debra A. Pinals. This document is built upon a handful of other documents on the subject of crisis response and on the title page it says, “behavioral health best practices toolkit”. Peer Support is mentioned at every level of response in this document. It states specifically, “Best practices call for peer support (i.e., those with direct experience with the behavioral health system and who are trained to support individuals in crisis) as part of the mobile crisis team to decrease engagement of law enforcement.” There is an over reliance on law enforcement. I worked directly with the Gallatin County Sheriff’s office for 4 years on a peer support pilot project and in the vast majority of crisis calls there was no need for law enforcement. Yes, there were times when law enforcement involvement was necessary. (i.e. someone has a gun) My experience was one in which people needed someone to talk to, not a pair of handcuffs. An effective peer supporter can deescalate and support not just in the moment of crisis but ongoing. Many people need ongoing support not just a one time shot. Law enforcement is insufficiently trained and quite frankly it is not their job to respond to people in mental health crisis. Now before all the law enforcement people cry out, “We have CIT training!” I am a graduate from CIT. Crisis Intervention Team (CIT) training is a 32–40-hour course developed in Memphis, TN that teaches law enforcement officers how to respond to people with mental illness in crisis. We have a very active CIT Montana organization here in Montana. CIT is the best we have right now, but very inadequate in the long term. I would term the training as an “introduction” or a level I course in crisis intervention. Again, it is all we have for now. The time has come for level II. I am not aware of this being available today but maybe in the future.
If this is the case then what do we do with so many individuals with untreated mental illness, substance use, and homelessness?
That is not a simple answer. It will require many changes to improve the current situation. Let’s start with the responsibility of the community and the behavioral health system to address mental health crisis. The behavioral health system is always short staffed and underfunded and untrained in crisis response. (As is law enforcement) The behavioral health system overly relies on government funding which ebbs and flows. Licensed counselors get very little education at the college level on mental health crisis. The community has a responsibility to fund and appropriately staff crisis services. Would communities not fund fire fighters? Or EMTs? This should be the same for crisis response. Fund it locally. Government officials in Montana have been dancing around the behavioral health system for years. Relying on old models and even older beliefs about mental health. Pull yourself up by the bootstraps. That is until it is one of their loved ones. DPHHS has more than enough funds to address crisis response across the state. Look up the Montana budget, it comes in around $2 billion, give or take a little either way. We only have 1.2 million people statewide. We have been operating with a surplus for years, but we somehow don’t have enough funds for mental health services. This is why we must shift the responsibility to communities to create new models for crisis response. The current system should be replaced by one that provides care, ongoing support and does not rely on government funding.
What does peer support in the crisis system look like?
Peer Supporters who have direct experience in crisis are particularly effective at providing support to others. This should be considered when developing your own program. SAMHSA recommends hiring credentialed peer support workers with direct lived experience. They also recommend that crisis services include a no-force-first approach and supportive environments. I would also echo this recommendation. Certification means public safety. It means training, supervision and continuing education. In June 2022 SAMHSA released a 17-page advisory entitled, Peer Support Services in the Crisis System. Here are the keys they listed.
- Peer support services are an integral component of the behavioral health continuum of care—from prevention and early intervention to treatment, recovery, and crisis services.
- Crisis care provides services to anyone, anywhere, at any time. Three essential elements comprise crisis care: crisis phone lines, mobile crisis teams, and crisis receiving and stabilization facilities.
- There are several benefits to including peers in crisis care, including strengthening engagement in treatment and improving outcomes for individuals experiencing a crisis who receive these services.
- Peers working in crisis service care settings provide opportunities for individuals in crisis to talk with someone who has similar experiences, embodies recovery, and can offer messages of encouragement and hope.
Peers may experience challenges related to role integrity, stigma from co-workers, and sustainable employment. They also face challenges unique to providing crisis care, including the complexity of managing crisis situations and, often, a lack of specialized crisis training. Another benefit worth noting here is that peer supporters are plentiful. Psychiatrists are not. There is a health care worker shortage across the US. In Montana 51 of the 56 counties are designated as “health professional shortage areas (HPSA).” For a variety of reasons, Montana lacks enough well-trained healthcare professionals to fill the gap.
Possible solutions
The inclusion of peer supporters into crisis response across the state. Including warm handoffs, peer respites, recovery residences and Drop in Centers. This is one piece, but the issues run much deeper than just the inclusion of people in recovery. Communities need to heal themselves; we have a “me first” mentality that has taken over society. Some of this is from unresolved trauma, some is from fear, some is the culture of drinking and pill popping to solve what ails us. Which is driven by relentless ads from pharmaceutical companies focused on profits rather than healing. (If you got an ill, we got your pill) A lack of care for one another. These issues are not going to be solved by peer support in crisis response. They also require additional articles or maybe even a book.
Might a starting point be communities developing wellness centers for healing, spiritual awakening, rejuvenating, education and support. Why wait for crisis? That’s what the system does now. We know someone is deteriorating mentally. But we don’t look to support the person with compassion. We wait until they commit a crime, and place them in jail or until they have deteriorated to the point where we take them in handcuffs for mental health evaluation fully knowing for weeks even months this individual was not in balance mentally, emotionally or spiritually. That is a broken system that needs to change. We all have smoke alarms in our homes, this provides an early warning system before the whole house is on fire. We should be promoting wellness centers as prevention for mental health issues and healthier communities. I would envision these are places to go to get everything from counseling, massage, acupuncture, yoga, meditation, peer support and spiritual growth. There could be naturopaths and healers available. There could be facilitators of Wellness Recovery Action Plan workshops.
We need to stop referring to practices such as Reiki as “alternative”. It is not an alternative if it has been utilized for a couple thousand years. None of this can happen if communities keep waiting on the government to solve their issues. Community recovery organizations should be supported by the community not the government alone. If you don’t know what community recovery organizations (RCO) are then check out Faces and Voices of Recovery.
I will end with this bit of history. The ancient Egyptians valued wellness centers they called them, temples. Not in a religious context as we might today but in a healing aspect. Some temple precincts had centers where patients could receive treatments and therapy. For example, the Temple of Hathor at Denderah used water from the temple's Sacred Lake to bathe patients. The Greeks copied the Egyptians with healing sanctuaries dedicated to the God of medicine and healing, Asclepius. The Sanctuary of Epidaurus, located on the northeastern coast of the Peloponnese, embodied a belief in the restorative qualities of nature. Central to Native American healing practices is the concept of balance and harmony. These cultures believe that when an individual's equilibrium is disrupted, whether physically, emotionally, or spiritually, it leads to ailments. Healing is seen as a restoration of this balance, and the land plays a crucial role in facilitating this process.