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May 01, 2007

We both spend a lot of time traveling across the country training staff in various programs and systems about recovery. When we get to the part about how to actually transform a program into one that regularly uses recovery principles and practices, we suggest adding well-trained peers and family members to the workforce. We find this to be one of the single most effective ways to develop and sustain a culture that stays focused on recovery practices. This is not to say that a program without peers can't do the same thing. It's just more difficult.

The importance of adding peers and family members to the workforce was strongly reinforced by the President's New Freedom Commission on Mental Health. Federal funding often is linked to recovery programming and to adding peers and family members to the workforce. Many states, especially those that have received transformation grants, have followed suit, adding language to statutes and policies that recognize the value of including peers and family members in the workforce. Several training programs have sprung up across the nation that prepare peers and family members to work and contribute to the recovery process in behavioral health settings.

This all sounds pretty good, but there's a serious “glitch” when it comes to actually making it happen at an organizational level. You may not want to read this next part, but we feel compelled to discuss it with you because we need your help in addressing it. Here's the problem: In many places we see resistance to adding peers and family members to the behavioral health workforce. Even though well-trained peers and family members can expand and enrich our services; the federal government supports their inclusion; and many states have included this type of workforce integration in their strategic plans for behavioral health services, there is still a lot of resistance to actually making it happen.

Any major change involves some level of resistance. We human beings are just like that. While some of the resistance from professionals stems from the fear that peers could take their jobs, another theme runs deeper than this, and we suspect it is linked to prejudice associated with mental illnesses.

Did you know that prejudicial attitudes against people with severe mental illnesses are found among behavioral health service providers?1,2 Service providers are for the most part good folks trying to make a difference, so why would they be harboring stigmatizing prejudices against the very people they serve? We think it has to do with the fact that caregivers usually only see people when they are not at their best. If they haven't been practicing recovery principles, they probably are not seeing much change in the people they are serving. From this perspective they presume that people don't recover3 and, furthermore, that they can't make a worthwhile contribution in the behavioral health workforce. If you take into account this mind-set, you can see why they would resist having peers and family members join the behavioral health workforce.

As you probably know, prejudice and discrimination have been identified as two of the main culprits that interfere with the recovery process. Campaigns have been waged in most communities to extinguish stigma, and while much more research is needed, preliminary data suggest that campaigns against prejudice can change attitudes in a positive way.4 So maybe we need a stigma campaign that targets behavioral health professionals.

Perhaps the best way to overcome this “glitch” is to stay focused on the positive contributions peers and family members can add to the workforce. Below are some ways in which peers are extremely good at boosting a clinical team's performance and outcomes:

  • Peers (including family members) can reach out and engage people unwilling to use behavioral health services. This is especially important because only 15% of people with serious mental illnesses are estimated to receive minimally adequate treatment.5

  • Peers who work alongside professional staff provide living proof that recovery is possible. This can raise morale by providing evidence to service providers that people can and do recover.

  • Peers provide a living example of hope for others with mental illnesses. The “if I can do it, you can do it” message doesn't even have to be spoken—it's right before their eyes. This often allows peers to engage and bond with people who otherwise would be reluctant to trust and use clinical services.

  • Peers can free up professional staff to do other tasks that can be done only by professionals because of licensing issues and regulations.

  • The boundaries and ethics that guide most peer programs are very similar to those that guide professionals, but peers do have more latitude in being “real” people. By this we mean that they can share their own experiences of recovery because they are operating on a foundation of mutuality. This is a great asset that can be incorporated into a clinical team to improve overall engagement and trust.

  • Peers' personal experiences can be a valuable asset to the clinical team. When they add their first-person knowledge and their stories of recovery to the service mix, services are enhanced and extended, as well as infused with hope and self-determination.

Coming from the school of hard knocks, peers bring a special knowledge and skill set to the behavioral health workforce that complement and enrich our services. Let's not resist peers in the workforce, but rather welcome them with open arms and accept the gifts peers contribute to the recovery process of those we serve.

Peers should be a part of the team. Resist the temptation to turn peers into “junior” case managers, giving them menial tasks that don't capitalize on their most effective contributions. The best way to benefit from peers' talents is to employ them in positions in which they can engage people and give them hope of recovery.

Ask peers for their input; include their perspectives when making decisions. Give their ideas serious thought, especially when they differ from the organization's general thinking. Peers know things that people without recovery histories do not, and they can prevent professionals from making decisions that would set recovery back.

And remember, peer employees aren't here to take things away from professionals, but rather to enhance and expand what professionally run organizations have to offer.

Lori Ashcraft, PhD, directs the Recovery Education Center at META Services, Inc., in Phoenix.
William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University.


  1. Mirabi M, Weinman ML, Magnetti SM, Keppler KN. Professional attitudes toward the chronic mentally ill. Hosp Community Psychiatry 1985; 36 (4): 404-5.
  2. Lyons M, Ziviani J. Stereotypes, stigma, and mental illness: Learning from fieldwork experiences. Am J Occup Ther 1995; 49 (10): 1002-8.
  3. Nairn RG, Coverdale JH. People never see us living well: An appraisal of the personal stories about mental illness in a prospective print media sample. Aust N Z J Psychiatry 2005; 39 (4): 281-7.
  4. Corrigan PW, River LP, Lundin RK, et al. Three strategies for changing attributions about severe mental illness. Schizophr Bull 2001; 27 (2): 187-95.
  5. Wang PS, Demler O, Kessler RC. Adequacy of treatment for serious mental illness in the United States. Am J Public Health 2002; 92 (1): 92-8.
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