WEBVTT 00:00:00.780 --> 00:00:04.120 [Begin Recording] Dr. Samantha Hack: This series is made possible 00:00:04.120 --> 00:00:09.440 by the VA Office of Mental Health and Suicide Prevention, Psychosocial Rehabilitation and 00:00:09.440 --> 00:00:16.490 Recovery Section, and the VISN 5 Mental Illness Research, Education and Clinical Center [MIRECC] 00:00:16.490 --> 00:00:22.060 in partnership with the Employee Education System. The planning committee members for 00:00:22.060 --> 00:00:29.540 this Webinar series include: Daniel Bradford, Valerie Fox, Spencer Glipa, Catherine Lewis, 00:00:29.540 --> 00:00:37.620 Marty Oexner, Kathryn Peacock-Dutt, Donna Russo, Tim Smith, my co-host Ralf Schneider, 00:00:37.620 --> 00:00:44.320 and myself, Samantha Hack. Today’s Webinar is entitled, “The Role of VA Peer Specialists 00:00:44.320 --> 00:00:49.910 in Supporting Physical Health and Wellness”. Our presenter for today’s Webinar is Dr. 00:00:49.910 --> 00:00:55.739 Anjana Muralidharan. Dr. Muralidharan is a clinical psychologist and researcher at the 00:00:55.739 --> 00:01:01.840 VISN 5 MIRECC. The focus of her research is on aging with serious mental illness, peer 00:01:01.840 --> 00:01:08.420 support, and recovery oriented and person-centered care. She is currently testing a peer delivered 00:01:08.420 --> 00:01:13.729 coaching intervention to promote participation and supervised fitness training among older 00:01:13.729 --> 00:01:19.450 adults with serious mental illness. She is avid mindfulness meditation practitioner, 00:01:19.450 --> 00:01:25.039 and a believer in the power of compassion and human connection as an ultimate source 00:01:25.039 --> 00:01:30.409 of joy and healing. At this time, I’m happy to turn the Webinar over to our presenter. 00:01:30.409 --> 00:01:43.140 Dr. Anjana Muralidharan: Hello. Thank you Samantha. Welcome everybody. I see people 00:01:43.140 --> 00:01:49.870 are still streaming in, but I am going to get started, because I have a lot of material 00:01:49.870 --> 00:02:03.371 I want to cover. So, can everyone hear me clearly? Yes. Okay. Got some yeses. Okay, 00:02:04.161 --> 00:02:08.450 so anyway, please interrupt me if there is any issues with the sound, but I will go ahead 00:02:09.184 --> 00:02:14.750 and get started. So, yeah, my name is Dr. Anjana Muralidharan and I work at the VISN 00:02:14.750 --> 00:02:19.620 5 MIRECC with my colleagues Ralf and Samantha. I’m so excited to be here today and talk 00:02:19.620 --> 00:02:29.650 about one of my favorite topics, which his peer support. I don’t have anything to disclose. 00:02:29.650 --> 00:02:35.900 So, before I jump into the actual sort of outline of my presentation, and the meat of 00:02:35.900 --> 00:02:41.040 my presentation, I want to do a little clarification of terms of and definitions. I think people 00:02:41.040 --> 00:02:46.930 throw the term peer support around, and it’s not always clear what type of peer support 00:02:46.930 --> 00:02:52.590 they’re referring to or talking about. So, um, I want to start by saying that peer support 00:02:52.590 --> 00:03:01.239 has its roots in as a non-hierarchal practice of giving and receiving help in which individuals 00:03:01.239 --> 00:03:09.430 with mental health conditions support each other and um, historically speaking, this 00:03:09.430 --> 00:03:16.610 kind of support, mutual self help and support, was actually an act of resistance as part 00:03:16.610 --> 00:03:24.940 of psychiatric survivor and ex-patient movement. Individuals who, in the mid-1900’s, the 00:03:24.940 --> 00:03:30.300 60’s, 70’s, objected to the paradigm of mental health care that were available at 00:03:30.300 --> 00:03:37.680 the time, that were in ways, dehumanizing and, you know, denied folks with mental health 00:03:37.680 --> 00:03:44.970 conditions certain civil rights . These individuals, you know, said, “We don’t need these formal 00:03:44.970 --> 00:03:49.989 healthcare systems, we’re going to build our own sense of community and support outside 00:03:49.989 --> 00:03:55.750 of these systems, and we can take care of ourselves”. So, this was a very powerful, 00:03:55.750 --> 00:04:02.760 sort of active resistance out of which our modern and current paradigm of peer support has grown, 00:04:02.760 --> 00:04:09.531 and mutual self-help and mutual peer support is still alive and well out there in the community 00:04:09.531 --> 00:04:14.090 and it’s a very, very important form of peer support that I think we don’t always 00:04:14.090 --> 00:04:21.009 value and we sort of undervalue from within healthcare systems. So, I wanted to give a 00:04:21.009 --> 00:04:25.360 nod to this paradigm with peer support. I included a link there if you’re interested 00:04:25.360 --> 00:04:31.630 in finding out what this symbol means, you can check that out. Some interesting history. 00:04:31.630 --> 00:04:39.470 So, with that, I’ll move on, to say that’s not the kind of peer support I’m going to 00:04:39.470 --> 00:04:44.900 be talking about in my presentation. I’m going to be focusing instead of peers providing 00:04:44.900 --> 00:04:50.590 services and supports in the context of formal community or healthcare organizations. And 00:04:50.590 --> 00:04:55.419 so I’ll probably use the term peer providers a lot because they sort of mean people who 00:04:55.419 --> 00:05:01.500 are embedded in these organizations and when they work with service users there kind of 00:05:01.500 --> 00:05:06.819 is a little bit of hierarchy where one person is a helper and the other is the person being 00:05:06.819 --> 00:05:13.870 helped. So, it’s not quite as mutual or reciprocal as other models of peer support. 00:05:13.870 --> 00:05:18.460 More specific than peer providers is the term Peer Specialist – these are individuals 00:05:18.460 --> 00:05:23.520 who are certified, they have specialized training to use their recovery story to support that 00:05:23.520 --> 00:05:29.009 of others. Frequently they are paid employees, and sometimes they work as volunteers. And 00:05:29.009 --> 00:05:35.220 then of course, even more specific than that are VA Peer Specialists who are Veterans and 00:05:35.220 --> 00:05:42.060 work in a VA setting. So, I’ll probably be using the term peer providers quite a bit. 00:05:42.060 --> 00:05:49.669 I’ll try to be specific about who I’m talking about when I’m talking about the 00:05:49.669 --> 00:05:56.229 research. So, what’s the point of this presentation? Well, historically speaking, in mental health, 00:05:56.229 --> 00:06:02.319 when you have mental health peers, they’re people with a mental health condition who 00:06:02.319 --> 00:06:06.380 are in recovery from the mental health condition, and they traditionally support others around 00:06:06.380 --> 00:06:12.100 mental health recovery. As they’ve been incorporated more and more into the healthcare 00:06:12.100 --> 00:06:16.690 system, they’re increasingly being asked to support physical health and wellness among 00:06:16.690 --> 00:06:21.949 individuals with mental illness. And this is, for really good reason, because among 00:06:21.949 --> 00:06:26.639 folks with mental illness, they are really high levels of medical comorbidities, as well 00:06:26.639 --> 00:06:32.190 as health disparities around access to care and access to high quality care. So, there’s 00:06:32.190 --> 00:06:40.419 a great need in this area of promoting physical health and wellness in this group and so, 00:06:40.419 --> 00:06:44.670 in a way it make sense that we’re excited about peers and we’re excited about having 00:06:44.670 --> 00:06:50.069 them as colleagues in our system, you know, could they help us with this very important 00:06:50.069 --> 00:06:58.520 and pressing problem. I think in our eagerness though, to incorporate peers and kind of see, 00:06:58.520 --> 00:07:06.699 you know, kind of test out and see everything that they can do. Sometimes we don’t think 00:07:06.699 --> 00:07:11.460 quite carefully enough about whether this is an appropriate role for mental health peers. 00:07:11.460 --> 00:07:17.780 And also, what does it mean to be a peer if we are now focusing on a physical health outcome. 00:07:17.780 --> 00:07:22.449 So, for example, you know if we have Peer Specialists who are working with folks with 00:07:22.449 --> 00:07:28.639 mental illness on weight management, is the mental health lived experience still relevant. 00:07:28.639 --> 00:07:34.310 Is it more important that the person has experience with managing their own weight, for example. 00:07:34.310 --> 00:07:40.270 Does it matter if they’re successful in managing their own weight? Um, what sort of 00:07:40.270 --> 00:07:44.759 the essential “peerness” or the characteristics that are important for the peer to have and 00:07:44.759 --> 00:07:51.550 bring forward. So that’s what I’m going to dig into and talk about a little bit today. 00:07:51.550 --> 00:07:58.759 So, here’s my outline. I’m gonna talk a little bit about what mental healthcare 00:07:58.759 --> 00:08:05.680 providers typically do, just in a mental health kind of setting. And then we’ll talk some 00:08:05.680 --> 00:08:11.229 about the broad overview of the literature on how peer providers are supporting physical 00:08:11.229 --> 00:08:16.490 health and wellness outcomes among folks with mental illness. And then I’m going to dig 00:08:16.490 --> 00:08:22.229 into a little qualitative work to see what we know about “peerness” in these contexts 00:08:22.229 --> 00:08:26.910 and what it is that peers are doing in these health and wellness interventions, what’s 00:08:26.910 --> 00:08:33.650 the peer role. We don’t really know. We don’t have that much information on that, 00:08:33.650 --> 00:08:37.560 but we’re going to, I’m hoping, at the very least, what I talk about today will be 00:08:37.560 --> 00:08:47.040 thought provoking and spur some ideas for future research and investigation. So, we’ll 00:08:47.040 --> 00:08:57.230 start with what mental healthcare peer providers typically do. So, there’s been quite a bit 00:08:57.230 --> 00:09:04.860 written about this. In a general sense, peer providers are a source of social support. 00:09:04.860 --> 00:09:09.850 So, they are another person that the service user can turn to for support, including emotional 00:09:09.850 --> 00:09:15.450 support and validation, instrumental support like goods and services, and informational 00:09:15.450 --> 00:09:21.290 support. And this social support might be particularly powerful coming from a peer because 00:09:21.290 --> 00:09:26.950 the service user perceives the peer as like themselves, have been there, and really understands 00:09:26.950 --> 00:09:32.600 and knows that they are talking about. This brings us to what peers uniquely bring to 00:09:32.600 --> 00:09:38.640 the table which is their experiential knowledge. Peers self-disclose regarding their own experiences 00:09:38.640 --> 00:09:44.321 and per social learning and social comparison theories, when a person perceives another 00:09:44.321 --> 00:09:49.670 person as like themselves, they are more likely to perceive them as credible role models, 00:09:49.670 --> 00:09:54.740 and credible role models enhances self-efficacy, which is your confidence that you can engage 00:09:54.740 --> 00:10:01.760 in certain behaviors, and it also encourages hope and upward social comparison, which is 00:10:01.760 --> 00:10:06.780 a process where you see another person who you perceive to be just like you, and you 00:10:06.780 --> 00:10:10.930 see that they’ve accomplished certain things and you think to yourself maybe I can do that 00:10:10.930 --> 00:10:19.170 as well. Right. So that gives folks something to strive towards and enhances motivation 00:10:19.170 --> 00:10:24.030 and hope. Another interesting construct that has been written up about, by Larry Davidson 00:10:24.030 --> 00:10:30.020 and colleagues, about the role of peers is the concept called conditional regard. So, 00:10:30.020 --> 00:10:38.120 I think this is a really interesting concept. I think it’s a play on what many mental 00:10:38.120 --> 00:10:44.270 health providers on this call have probably been exposed to, the term, unconditional positive 00:10:44.270 --> 00:10:51.621 regard, right, where you always work with a patient, a service user, with warmth, with 00:10:51.621 --> 00:10:58.670 empathy in an unconditional kind of way. The concept of conditional regard is the idea 00:10:58.670 --> 00:11:08.140 of empathy paired with a very strong accountability that can be drawn from the Peer Specialist’s 00:11:08.140 --> 00:11:12.940 own lived experience and credibility. So, a Peer Specialist might say to someone, “Look, 00:11:12.940 --> 00:11:17.450 I’ve been where you are and I know that you can do better than this because I was 00:11:17.450 --> 00:11:21.700 there.” And so, they’re able to maybe have even a higher level of accountability, 00:11:21.700 --> 00:11:27.020 hold people to even a higher level of accountability because of the credibility that they bring 00:11:27.020 --> 00:11:44.100 to the table. A little bit more about what Peer Specialists do uniquely. This is from 00:11:44.100 --> 00:11:49.280 a literature review from 2016 that kind of pulled together a list of things that Peer 00:11:49.280 --> 00:11:55.610 Specialists do. So, a lot of really great things right? Promoting hope, serving as a 00:11:55.610 --> 00:12:03.110 role model, sharing your story, reducing isolation, being flexible in terms of where and when 00:12:03.110 --> 00:12:11.370 they meet, engaging clients in treatment, increasing patient activation, helping link 00:12:11.370 --> 00:12:20.280 folks to resources, serving as a liaison between staff and client, helping to increase access 00:12:20.280 --> 00:12:27.690 to services, running groups, having a strength focus, being empathic, promoting empowerment, 00:12:27.690 --> 00:12:33.220 having a trusting and friendly relationship and teaching skills. And then the last thing 00:12:33.220 --> 00:12:38.830 on here is helping their clinical team be recovery oriented and focus on recovery. So, 00:12:38.830 --> 00:12:44.830 this is a lot, right? This is a lot of really valuable things that peers are bringing. And 00:12:44.830 --> 00:12:50.921 so, it’s really important to think about, okay, given that this is what peers can bring 00:12:50.921 --> 00:12:58.610 to the table, how can this, how is this working when we shift the target outcome to physical 00:12:58.610 --> 00:13:09.820 health and wellness? So, I’ll review some of the literature in this area now. As a caveat, 00:13:09.820 --> 00:13:15.300 most studies of peer providers delivering health and wellness interventions for individuals 00:13:15.300 --> 00:13:21.020 with mental health conditions are small, single group, pre-post studies. There are some pilots, 00:13:21.020 --> 00:13:25.720 RCTs with a couple of, you know, with two groups. But most of them are small. There 00:13:25.720 --> 00:13:33.280 are a very few randomized controlled trials, and so I’m going to try cover the RCTs today, 00:13:33.280 --> 00:13:37.370 and I’ll cover some of the smaller studies, but it won’t be an inclusive review because 00:13:37.370 --> 00:13:41.890 this is a growing area and there’s a lot of new and exciting work out there that I 00:13:41.890 --> 00:13:47.760 couldn’t possibly cover in one presentation. So, the intervention target that I’ll discuss 00:13:47.760 --> 00:13:53.590 include medical illness self-management, getting connected to healthcare, health lifestyle 00:13:53.590 --> 00:14:02.360 interventions like weight management, and smoking cessation. One thing I won’t really 00:14:02.360 --> 00:14:08.660 touch on very much is this growing literature around incorporating a technology component 00:14:08.660 --> 00:14:13.060 to peer support. So, there’s this really cool, cutting edge kind of area called digital 00:14:13.060 --> 00:14:20.660 peer support where, you know, there’s evidence to support the idea that peers can help service 00:14:20.660 --> 00:14:26.130 users engage with technology to support their recovery. And so, there’s, you know, generally 00:14:26.130 --> 00:14:31.540 a lack of large trials to establish clear efficacy of this, but it’s becoming increasingly 00:14:31.540 --> 00:14:37.100 clear that this is something that is feasible and that people like. So, if folks are interested 00:14:37.100 --> 00:14:44.250 in this area of work, I suggest you see a recent systematic review written by a colleague 00:14:44.250 --> 00:14:48.830 of mine, Karen Fortuna, that I was a co-author on, and it’s listed in the reference section. 00:14:48.830 --> 00:14:53.510 But yeah, some of these, this is for peer support across the board, but some of the 00:14:53.510 --> 00:14:59.300 studies look at supporting physical health and wellness outcomes by connecting service 00:14:59.300 --> 00:15:09.950 users to like mHealth and apps like that, that support health. Okay, so let’s start 00:15:09.950 --> 00:15:15.390 with medical illness self-management. This is where we have the strongest support in 00:15:15.390 --> 00:15:23.370 terms of the research evidence. So, medical illness self-management, as a model, promotes 00:15:23.370 --> 00:15:28.670 proactive health behaviors among individuals with chronic health conditions. And it’s 00:15:28.670 --> 00:15:35.020 based on the idea that across various chronic health conditions, there are common tasks 00:15:35.020 --> 00:15:38.670 that everyone has to engage in. So whether you have diabetes, whether you have heart 00:15:38.670 --> 00:15:44.680 disease, whether you have arthritis, you do need to think about managing your medicine, 00:15:44.680 --> 00:15:49.880 making good use of your healthcare, staying physically active, eating a healthy diet and 00:15:49.880 --> 00:15:55.800 managing your stress. So, medical illness self-management focuses on teaching key self-management 00:15:55.800 --> 00:16:08.660 skills to support this broad self-management of chronic health conditions. The most well 00:16:08.660 --> 00:16:13.810 studied self-management intervention is Chronic Disease Self-Management. The Chronic Disease 00:16:13.810 --> 00:16:19.180 Self-Management program, or CDSMP, this is a group-based intervention delivered by individuals 00:16:19.180 --> 00:16:22.130 with chronic health conditions. So, it is a peer delivered intervention, but it’s 00:16:22.130 --> 00:16:29.360 not in the mental health world, it’s among folks with chronic medical conditions. It 00:16:29.360 --> 00:16:35.410 has been adapted for individuals with mental illness. There are two versions, that both 00:16:35.410 --> 00:16:41.380 have good research evidence behind them. One is the Health and Recovery Peer Program and 00:16:41.380 --> 00:16:48.450 the other is Living Well. Just to orient you, so I have a lot of slides, and they unfortunately 00:16:48.450 --> 00:16:55.120 have a lot of text on them, so to help orient you to the main points on these slides, I’ve 00:16:55.120 --> 00:17:03.040 done a little formatting, so, when you see the text that is italicized and underlined, 00:17:03.040 --> 00:17:10.090 that explains who the peers were and what “peerness” was in those particular interventions. 00:17:10.090 --> 00:17:14.640 And then the bold text are the things that were positive outcomes. I’m hoping that 00:17:14.640 --> 00:17:26.010 will help orient folks to the slides, which have a lot of information on them. Okay, so 00:17:26.010 --> 00:17:35.531 yeah, so both of these interventions are group-based interventions, co-facilitated, well, the Health 00:17:35.531 --> 00:17:39.580 and Recovery Peer Program is co-facilitated by two peers who have comorbid mental health 00:17:39.580 --> 00:17:45.330 and chronic medical conditions, where as Living Well has the option to be facilitated by two 00:17:45.330 --> 00:17:53.190 peers, or by a peer and non-peer provider. In both cases, “peerness” is defined as 00:17:53.190 --> 00:17:58.250 somebody who has both a mental health and a chronic medical condition. And there are 00:17:58.250 --> 00:18:03.310 positive outcomes in both of these studies for self-management behaviors, self-efficacy 00:18:03.310 --> 00:18:07.790 and quality of life, testing in large randomized controlled trials [inaudible 18:06]. I’m 00:18:07.790 --> 00:18:12.870 going to talk more about Living Well later, because that was actually a study that we 00:18:12.870 --> 00:18:19.670 did here at our MIRECC and we’ve done some interesting qualitative analysis of the data, 00:18:19.670 --> 00:18:25.430 that I think will be, you know interesting to kind of dig into around the question of 00:18:25.430 --> 00:18:32.250 “peerness” and what the peer role is. Um, I can say now that the, the, this was 00:18:32.250 --> 00:18:38.560 a VA study, we tested it in our RCT in VA and the participants really connected with 00:18:38.560 --> 00:18:44.300 the peer facilitators, around many different aspects of identity. Especially Veteran identity, 00:18:44.300 --> 00:18:54.520 so that was a major reason or way that people felt connected to the peer providers, as well 00:18:54.520 --> 00:19:09.300 as other aspects of identity like mental health and medical issues. That was medical illness 00:19:09.300 --> 00:19:13.340 self-management, I want to talk a little about connecting to healthcare now. So, there’s 00:19:13.340 --> 00:19:19.330 a handful of studies looking at if mental health peers can help individuals with mental 00:19:19.330 --> 00:19:25.010 illness connect to healthcare. We know that there are, like I said, there are health disparities 00:19:25.010 --> 00:19:32.030 among folks with mental illness. They tend to have poor access to healthcare, you know, 00:19:32.030 --> 00:19:39.160 less likely to get good preventive primary care. So, in a study where individuals were 00:19:39.160 --> 00:19:46.290 admitted to the psychiatric ER, were randomized to receive a primary care navigator, or usual 00:19:46.290 --> 00:19:51.760 care for one year. They were also offered the opportunity to connect with a mental health 00:19:51.760 --> 00:19:56.880 peer. So, the peers in this study were individuals with a mental health condition who worked 00:19:56.880 --> 00:20:03.640 at peer run organization and had formal training as peers. So, the randomization component 00:20:03.640 --> 00:20:07.660 was not around the peers for this study, so it’s not actually a randomized control trial 00:20:07.660 --> 00:20:13.670 for this research question. However, it was found that the participants who were connected 00:20:13.670 --> 00:20:19.330 to mental health peers, were more likely to follow through with primary care. So, it’s 00:20:19.330 --> 00:20:26.400 not as strong as if it was a randomized trial around the peer, but it still provides a little 00:20:26.400 --> 00:20:37.550 bit of evidence that peer support can be helpful with this construct. Another study is the 00:20:37.550 --> 00:20:42.680 Bridge intervention. So, this was a randomized controlled trial that, in which services users 00:20:42.680 --> 00:20:49.560 were randomized to either the Peer Navigator intervention or a waitlist control. And 00:20:49.560 --> 00:20:59.810 the Peer Navigator intervention is a six month intervention that consisted of coaching, motivational 00:20:59.810 --> 00:21:06.320 interviewing, goals setting, patient activation, the peers actually attended medical appointments 00:21:06.320 --> 00:21:12.320 with the participants and helped them advocate for themselves, they reviewed what the doctor 00:21:12.320 --> 00:21:16.070 said after the medical appointment, and then there was a kind of fading out of support 00:21:16.070 --> 00:21:21.100 over time, over the six months. And so, the Peer Navigator intervention was associated 00:21:21.100 --> 00:21:27.230 with improvements in access and use of primary care, as well as other health outcomes at 00:21:27.230 --> 00:21:33.230 six months. So, it’s cool, it’s pretty promising. What’s really interesting about 00:21:33.230 --> 00:21:38.100 this study is that the peers were either people who have lived experience of their own of 00:21:38.100 --> 00:21:44.470 mental illness or had a loved one with this experience. So, in this case the “peerness” 00:21:44.470 --> 00:21:52.130 is experience navigating the healthcare system either for yourself or on behalf of someone 00:21:52.130 --> 00:21:56.650 with a mental health condition. So, it’s just an interesting definition of “peerness” 00:21:56.650 --> 00:22:02.901 and individuals all got a training and received ongoing supervision and feedback. So, you 00:22:02.901 --> 00:22:08.430 can see already just in this handful of studies that “peerness” is defined totally differently 00:22:08.430 --> 00:22:14.270 depending on the context, and there’s a lot of variability and how people are trained 00:22:14.270 --> 00:22:23.860 and things like that . Very important to keep an eye on those things. Last set of studies 00:22:23.860 --> 00:22:30.290 in the connecting to healthcare category is the Peer Navigator Program that came out of 00:22:30.290 --> 00:22:34.550 Pat Corrigan’s work. So, this was based on community-based participatory research, 00:22:34.550 --> 00:22:42.471 so the folks who were sort of the targets of intervention were very involved in the 00:22:42.471 --> 00:22:47.571 actual development of the intervention. This program was tested in two randomized control 00:22:47.571 --> 00:22:53.100 trials, two different versions – one version was for homeless African Americans with serious 00:22:53.100 --> 00:22:57.960 mental illness, and the other was for Latinx individuals with serious mental illness. And, 00:22:57.960 --> 00:23:03.460 of course, the peers were, you know, matched on all those different characteristics respectively, 00:23:03.460 --> 00:23:10.430 so racial identity, ethnic identity, language, and experience of homelessness. Great, so, 00:23:10.430 --> 00:23:17.140 this is an example where there’s so many intercepting identities along which the peers 00:23:17.140 --> 00:23:21.650 are connecting to people, but it’s unclear, you know, which aspect of identity is really 00:23:21.650 --> 00:23:26.980 doing the heavy lifting and even in Pat Corrigan’s paper he talks about how, you know, we’re 00:23:26.980 --> 00:23:32.020 just really not sure about which of these is most important, or even if they can be 00:23:32.020 --> 00:23:37.400 parsed out in that way, right, because, you now, our identifies are intersect, so… . I 00:23:37.400 --> 00:23:43.280 think again, it’s just really important to, that when we think of peer, even within 00:23:43.280 --> 00:23:49.400 mental health it can mean so many different things. So anyway, in this study the, the, 00:23:49.400 --> 00:23:55.450 in both RCT’s, the Peer Navigator Program was connected to, associated with increase 00:23:55.450 --> 00:24:03.970 scheduling and attendance of healthcare appointments compared to usual care. So, you know, some 00:24:03.970 --> 00:24:10.520 decent evidence that having a mental health peer can help you make better use of primary 00:24:10.520 --> 00:24:18.450 care and preventive care. So, I’m gonna talk a little bit about healthy lifestyle 00:24:18.450 --> 00:24:22.010 interventions now. So, these are the types of interventions that are focused on diet, 00:24:22.010 --> 00:24:31.320 exercise, and weight management. So, I want to talk about the webMOVE Study. So, this 00:24:31.320 --> 00:24:37.040 is a study that some of us at the VISN 5 MIRECC were involved in, along with collaborators 00:24:37.040 --> 00:24:44.730 of ours out in California. This is a little bit complicated so I will talk you through 00:24:44.730 --> 00:24:50.210 it. Probably folks on the call are familiar with the VA Move Weight Management Intervention. 00:24:50.210 --> 00:24:56.190 Our center took that intervention and created a manualized version, specifically for folks 00:24:56.190 --> 00:25:02.980 with mental illness. And then, that version was adapted further to become a computerized 00:25:02.980 --> 00:25:08.320 version that was delivered as computerized modules. So that’s WebMOVE, these computerized 00:25:08.320 --> 00:25:13.410 modules with education and opportunities for monitoring and goal setting around weight 00:25:13.410 --> 00:25:19.500 management that are delivered on a computer. webMOVE was supplemented with weekly phone 00:25:19.500 --> 00:25:25.080 calls from a peer coach to promote engagement. So, they’d call every week and say, “Hey, 00:25:25.080 --> 00:25:28.420 you know, did you do your module, did you have any questions, did you set your goal, 00:25:28.420 --> 00:25:34.110 how did it go”, that kind of thing. And in this case, peers were Veterans with mental 00:25:34.110 --> 00:25:40.670 health condition. This was a three-arm study, so webMOVE was compared to an in-person version 00:25:40.670 --> 00:25:47.270 of MOVE as well as the usual care, and it was a large trial with 276 Veterans who were 00:25:47.270 --> 00:25:50.890 randomized to one of those three conditions. I mean, you can see the outcomes there that 00:25:50.890 --> 00:25:56.990 webMOVE was associated with in terms of decreases in weight, increases in weight related self-esteem, 00:25:56.990 --> 00:26:06.680 and increases in physical activity. So, again, some evidence to show that peer coaching and 00:26:06.680 --> 00:26:14.900 in this case, interacting with a tech delivered intervention, can have positive impacts, albeit 00:26:14.900 --> 00:26:24.900 modest, but positive impacts on healthy lifestyles. We did some qualitative work around the participant’s 00:26:24.900 --> 00:26:30.300 perceptions of the peer coaches and what they said, and generally the participants remarks 00:26:30.300 --> 00:26:34.750 about the peer coaches were really positive, but they involved the program in general, 00:26:34.750 --> 00:26:40.280 so they were happy about peer coaches helping them review content, remind them of their 00:26:40.280 --> 00:26:46.370 goals, and offering accountability, motivation and support, and only secondary to that was 00:26:46.370 --> 00:26:54.309 things around specific recommendations for physical activity, tech support, etc. So, 00:26:54.309 --> 00:27:06.910 connecting to folks more around, broadly helping them engage in the program as opposed to specific 00:27:06.910 --> 00:27:15.950 lifestyle recommendations. Okay, the other intervention I want to briefly mention is 00:27:15.950 --> 00:27:22.760 an intervention called Peer-led Group Lifestyle Balance (PGLB). So, this is a peer delivered 00:27:22.760 --> 00:27:25.880 healthy lifestyle program that was delivered in supportive housing, which I think is a 00:27:25.880 --> 00:27:34.310 really cool model, right, like bringing it to folks right where they live. So, the paper 00:27:34.310 --> 00:27:40.270 I cited here is the protocol paper, so they talk about the methods, but I have not been 00:27:40.270 --> 00:27:43.750 able to find the results, I do not think they are yet published, though I look forward to 00:27:43.750 --> 00:27:47.380 seeing them because I think that it would be really interesting. But the reason I share 00:27:47.380 --> 00:27:54.341 it is that this group has done some really cool qualitative work around how this intervention 00:27:54.341 --> 00:27:58.710 is working. So, I’m going to share that towards the end of the presentation, so I 00:27:58.710 --> 00:28:07.650 wanted to prep you all for it now. So, basically this is a group, a peer-led group, delivered 00:28:07.650 --> 00:28:16.940 in supportive housing and the peers – um, this is one study where the peers are actually 00:28:16.940 --> 00:28:22.620 trained as Peer Specialists. Very few studies actually specify that. So, I think that’s 00:28:22.620 --> 00:28:29.470 important to know. So, these are people who have completed a Peer Specialist training 00:28:29.470 --> 00:28:42.360 program. Okay, um, lastly, I’ll talk about smoking cessation. So, as I’ve gone through 00:28:42.360 --> 00:28:47.679 each of these categories, right from medical illness self-management on down, the evidence 00:28:47.679 --> 00:28:53.750 has gotten weaker and weaker from what we know in the literature. In the area of smoking 00:28:53.750 --> 00:28:59.210 cessation, what we’ve got are uncontrolled studies. So, I’ll just share them because 00:28:59.210 --> 00:29:09.750 I think it’s an interesting example of “peerness”. So, for example, in one study that involved 00:29:09.750 --> 00:29:15.880 peer to peer tobacco education and advocacy, peers were nonsmoking individuals with mental 00:29:15.880 --> 00:29:21.140 health conditions who had one-on-one sessions, brief, with folks providing information about 00:29:21.140 --> 00:29:26.559 tobacco and, you know, talking to folks about whether they want to quit and how they want 00:29:26.559 --> 00:29:32.590 to quit. Among 102 people, there was a decrease in the number of cigarettes they smoked at 00:29:32.590 --> 00:29:38.050 one-month follow-up. So, generally with these studies we don’t see significance around 00:29:38.050 --> 00:29:44.660 actually quitting. Some people will quit, but it’s not a significant number, so, but 00:29:44.660 --> 00:29:51.850 they do see a decrease in the number of cigarettes smoked. Another study, which was a large study 00:29:51.850 --> 00:29:57.500 done in Australia, it was a multifaceted smoking cessation program that was implemented at 00:29:57.500 --> 00:30:03.601 community mental health centers all across, I think southern Australia. It included, you 00:30:03.601 --> 00:30:09.330 know, access to a quit line, it included access to nicotine replacement therapy, a lot of 00:30:09.330 --> 00:30:15.160 different components, but it also included a 10-week peer and non-peer co-facilitated 00:30:15.160 --> 00:30:21.700 smoking cessation group. And, interestingly in this case, folks had mental health conditions 00:30:21.700 --> 00:30:27.210 and quit experience, so they had to have been successfully quit smoking, and be comfortable 00:30:27.210 --> 00:30:34.220 nonsmokers. So, again another sort of very specific aspect that folks were looking for. 00:30:34.220 --> 00:30:38.610 Again, this was associated with a decrease in the number of cigarettes smoked at the 00:30:38.610 --> 00:30:49.050 end of the program of around 844 folks. Okay, and then one last study I’ll share about 00:30:49.050 --> 00:30:54.000 smoking cessation is a small study. It’s carried out by some of my colleagues here 00:30:54.000 --> 00:31:01.831 at the MIRECC and at our academic affiliate, where peers were individuals with mental health 00:31:01.831 --> 00:31:06.810 conditions and quit experience, and they were trained to provide a smoking cessation group, 00:31:06.810 --> 00:31:12.840 as well as individual coaching to smokers with mental illness. So, this was a small 00:31:12.840 --> 00:31:18.080 study, just 30 folks. There was a decrease in the number of cigarettes smoked. The reason 00:31:18.080 --> 00:31:23.830 I share it is that the group published some interesting qualitative data around the experiences 00:31:23.830 --> 00:31:30.770 of the peer mentors and what they shared is that more salient than mental illness, or 00:31:30.770 --> 00:31:37.960 psychiatric illness experience, smoking and quitting smoking was more a focus of self-disclosure 00:31:37.960 --> 00:31:48.809 in this. Yeah. So, as you can see from this brief sort of review, what is “peerness” 00:31:48.809 --> 00:31:54.070 in these contexts that really seems to differ right? So in the smoking cessation studies, 00:31:54.070 --> 00:31:59.179 it seems like at least with that last one, but, you know, the ability to quit to smoking, 00:31:59.179 --> 00:32:03.430 the fact that you were a former smoker, and now you’ve stopped is very important. Um, 00:32:03.430 --> 00:32:07.860 in our VA studies, Veteran identity always comes up as a major component, as well as 00:32:07.860 --> 00:32:14.809 experience navigating the VA healthcare system, right? Because that’s a whole lived experience 00:32:14.809 --> 00:32:23.950 and wisdom in itself. In connecting to healthcare world of stuff, it’s often a person in recovery 00:32:23.950 --> 00:32:31.110 from mental illness who have experience navigating the healthcare system as a person with a mental 00:32:31.110 --> 00:32:37.090 health condition, but it can also be a loved one and it really seems like it might depend 00:32:37.090 --> 00:32:43.330 on the context of the intervention, right? Like, um, with some of Pat Corrigan’s work, 00:32:43.330 --> 00:32:47.690 they are kind of carrying out these studies in communities that have certain racial or 00:32:47.690 --> 00:32:54.360 ethnic identities that are really important. So, I just think it’s a really fascinating 00:32:54.360 --> 00:32:58.920 question that, you know, we need to be keeping our eye on as we continue to do work in this 00:32:58.920 --> 00:33:05.400 area. So, I’m gonna try to dig into this question a little bit more with the time I 00:33:05.400 --> 00:33:13.150 have left, sharing some of the qualitative research that we’ve done and then some qualitative 00:33:13.150 --> 00:33:22.620 research from another group as well. So, let’s talk about the peer role right…, what the 00:33:22.620 --> 00:33:27.309 peer even doing in these health and wellness interventions, and is it similar or different 00:33:27.309 --> 00:33:31.150 from what they’re doing in mental health, when the outcome is focused on mental health. 00:33:31.150 --> 00:33:37.559 So as a reminder, Living Well is an illness self-management intervention for folks with 00:33:37.559 --> 00:33:42.860 serious mental illness. We tested here at the VA with the Veterans in a large RCT with 00:33:42.860 --> 00:33:50.679 good outcomes and the groups were co-facilitated by a peer and non-peer. And the peers were 00:33:50.679 --> 00:33:58.160 folks with medical and mental health conditions, Veterans. So, we did qualitative interviews 00:33:58.160 --> 00:34:02.370 with 15 participants in Living Well and we asked them about a whole bunch of different 00:34:02.370 --> 00:34:06.300 things related to their experience with Living Well. The analyses I’m going to talk to 00:34:06.300 --> 00:34:12.490 you a little bit about today are focused on what were their perceptions of the peer co-facilitation 00:34:12.490 --> 00:34:23.840 model in terms of having both the peer and non-peer be involved, and how that worked. 00:34:23.840 --> 00:34:31.600 And then I’ll talk just a little bit about how they reported that Living Well led to 00:34:31.600 --> 00:34:41.919 processes of change and changed behaviors for themselves. Um, so, let’s first talk 00:34:41.919 --> 00:34:51.369 about peer and non-peer co-facilitation. So, this is a figure that we came up with. Um, 00:34:51.369 --> 00:34:58.790 so I’ll talk us through it. I want to start with Box 1, Group Atmosphere, right there 00:34:58.790 --> 00:35:04.970 in the middle. So, this was the most salient theme that came up. People spoke very, very 00:35:04.970 --> 00:35:11.350 positively about the group atmosphere. The participants said that it was warm, supportive, 00:35:11.350 --> 00:35:17.950 kind, folks were caring and it felt like an atmosphere where everyone was equal, on an 00:35:17.950 --> 00:35:23.120 equal playing field and no one was better than anyone else, very non-hierarchical, and 00:35:23.120 --> 00:35:28.350 also interactive and participatory, where everyone spoke up, everyone shared their experiences 00:35:28.350 --> 00:35:35.480 and everybody got to share. This was very important. Then I will bring your attention 00:35:35.480 --> 00:35:43.350 to Box 2 on the left, Diverse and Complimentary Perspectives. So, what people said about the 00:35:43.350 --> 00:35:48.770 peer and non-peer co-facilitation model was they really appreciated the complimentary 00:35:48.770 --> 00:35:54.030 perspectives of these two facilitators. They said it was great to have the peer with their 00:35:54.030 --> 00:35:58.960 kind of been there kind of experience, or lived experience, their wisdom, sharing their 00:35:58.960 --> 00:36:05.170 own anecdotes, etc. It was also great to have the non-peer facilitators, which in our case 00:36:05.170 --> 00:36:12.730 was typically a master’s level person with a background in psychology, bring what they 00:36:12.730 --> 00:36:17.850 termed as sort of their book smarts, as well as kind of a diverse or different perspective 00:36:17.850 --> 00:36:25.869 on the same topics. So, they really, the folks really appreciated having both, and a very 00:36:25.869 --> 00:36:33.200 important reason why having both worked was because of how well they worked as a team. 00:36:33.200 --> 00:36:38.050 So, people really talked about that, the facilitation between the peer and the non-peer was really 00:36:38.050 --> 00:36:44.660 seamless. They worked together in a very collegial way, very respectful. It didn’t seem like 00:36:44.660 --> 00:36:49.300 one person was really in charge, and the other was like supporting them, but really the two 00:36:49.300 --> 00:36:54.710 worked together very well on goal splitting. And so that those two things, the fact that 00:36:54.710 --> 00:37:02.920 they work well together and brought complimentary perspectives, significantly contributed to 00:37:02.920 --> 00:37:09.910 the positive group atmosphere. Okay, so I think that’s very important, and I will 00:37:09.910 --> 00:37:17.410 talk about that more later. But I also want to draw your attention to box 6, at the bottom, 00:37:17.410 --> 00:37:21.500 Self-Disclosure. So, participants talked about how peer self-disclosure was really important 00:37:21.500 --> 00:37:28.970 in getting the other participants to self-disclose and share their experiences. And I’ll share 00:37:28.970 --> 00:37:33.570 some quotes that say it better than I ever could. But that that was a very important 00:37:33.570 --> 00:37:40.290 part of facilitating a positive group atmosphere that was interactive. And then both self-disclosure 00:37:40.290 --> 00:37:47.420 and the group atmosphere contributed to an atmosphere that was conducive to social learning 00:37:47.420 --> 00:37:54.240 which is a really important part of health behavior change models, though, you know in 00:37:54.240 --> 00:37:58.609 groups, one of the active ingredients was that you hear from other people, and you hear 00:37:58.609 --> 00:38:03.520 their ideas and you brainstorm with them and you get, you know, that helps you figure out 00:38:03.520 --> 00:38:09.280 how you want to move forward with your health and wellness, or whatever the topic of the 00:38:09.280 --> 00:38:15.030 group is. And so you can see here that a major thing, that peers are bringing to the table, 00:38:15.030 --> 00:38:21.130 in group-based health and wellness intervention is promoting and enhancing this process of 00:38:21.130 --> 00:38:29.109 social learning by self-disclosing, by bringing their lived experience, they’re contributing 00:38:29.109 --> 00:38:36.660 to group cohesion, which helps to promote an atmosphere of social learning. Really, 00:38:36.660 --> 00:38:43.369 really valuable and it’s very key and it fits right in with health behavior change 00:38:43.369 --> 00:38:53.980 models. So, I will share some quotes now. So, “you had peer on one side, you had non-peer 00:38:53.980 --> 00:38:57.210 on the other side, so those were two different perspectives than what they’re gonna throw 00:38:57.210 --> 00:39:02.470 out there to you. What non-peer might not understand, peer would – you know, especially 00:39:02.470 --> 00:39:06.070 with the mental health issue, I mean, unless you’ve been there and done that, you don’t 00:39:06.070 --> 00:39:11.120 have a clue.” “You got to have a peer facilitator to help egg the group a long and 00:39:11.120 --> 00:39:16.241 get participation out of the group members.” “I’ve learned over the years that a lot 00:39:16.241 --> 00:39:21.340 of times the people who are supposed to be teaching you about stuff don’t have a clue. 00:39:21.340 --> 00:39:24.820 Peer brought some very, very, very personal anecdotes to the class, which she didn’t 00:39:24.820 --> 00:39:29.310 have to and that really made the group a more cohesive group because she ripped a veil, 00:39:29.310 --> 00:39:34.170 for lack of a better word, she ripped a veil and allowed us to kind of open ourselves up 00:39:34.170 --> 00:39:40.180 because she put her stuff on the table too.” “Peer helped by the things he would say 00:39:40.180 --> 00:39:44.710 about himself and his problems – he had back problems and he some mental problems, 00:39:44.710 --> 00:39:53.380 he had stuff, would instantly group us all together as a group.” And then finally, 00:39:53.380 --> 00:39:57.400 “you know some people go in there, the group, with a little lack of confidence and self-esteem, 00:39:57.400 --> 00:40:01.040 and you know they’re a little bit reserved, so when you have a peer like that they’re 00:40:01.040 --> 00:40:05.860 discussing things, and it kind of opens them up a little bit more. Peer would, every, every 00:40:05.860 --> 00:40:10.310 discussion that was started, the first example was always peer. He gave us his example to 00:40:10.310 --> 00:40:14.700 relate to whatever we were talking about, whether it was physical or eating better or 00:40:14.700 --> 00:40:19.930 whatever, and then they started around the table, so I think that helped out a lot.” 00:40:19.930 --> 00:40:24.170 You can see how powerful this is, right, this peer self-disclosure and how much it contributed 00:40:24.170 --> 00:40:31.670 to the group atmosphere. You can also see that people talked about the peer sharing 00:40:31.670 --> 00:40:40.550 both medical and mental health examples. Based on this analysis, we came up with some recommendations 00:40:40.550 --> 00:40:45.170 for peer and non-peer co-facilitated groups. I just want to draw your attention to a couple 00:40:45.170 --> 00:40:52.400 of them. So, #3, fostering a respectful collegial relationship between the peer and non-peer 00:40:52.400 --> 00:40:56.570 facilitator. I feel like that’s really important. I think what we saw in our analysis is kind 00:40:56.570 --> 00:41:02.010 of a parallel process, where there’s this really great respectful and collegial relationship 00:41:02.010 --> 00:41:06.760 between the peer and non-peer, and that served as a signal to the rest of the group members 00:41:06.760 --> 00:41:11.512 that, hey, like this is the space where we all on equal footing, we are all equal, all 00:41:11.512 --> 00:41:18.770 of our opinions and our perspectives are valued. And I think that was really powerful. So, 00:41:18.770 --> 00:41:25.300 in order to foster that relationship, I think 4, 5 and 6 kind of help, maybe as concrete 00:41:25.300 --> 00:41:30.130 things to help foster that. So, you now, one is setting aside time to really talk about 00:41:30.130 --> 00:41:38.359 what’s my role and what’s your role, right. Um, it could be, as per #5, that the non-peer 00:41:38.359 --> 00:41:44.099 is more focused on tasks – keeping the group on task, covering the material, etc. That 00:41:44.099 --> 00:41:49.910 sort of seemed to be what participants were saying was helpful from the non-peer facilitator 00:41:49.910 --> 00:41:58.540 and the peer facilitator might be much more focused on process, so eliciting participation. 00:41:58.540 --> 00:42:04.470 And lastly, explicitly creating space for peer self-disclosure, both structure on spontaneous 00:42:04.470 --> 00:42:09.190 during the group session is really, really important. I think we often, you know, give 00:42:09.190 --> 00:42:13.880 these manuals or we give intervention to peers and we say “hey man, you know, self-disclose, 00:42:13.880 --> 00:42:18.530 you know how to do that, like do your thing.” Um, but I do think working collaboratively 00:42:18.530 --> 00:42:24.330 with peers we can say “hey, where in this session would you like to self-disclose” 00:42:24.330 --> 00:42:32.290 and then, in a more structured way. And then also, I know spontaneous self-disclosure as 00:42:32.290 --> 00:42:35.960 it comes up it feels right to you, is really important, so how can we make sure to make 00:42:35.960 --> 00:42:40.470 space for that, like how will I know that you want to or, you now, that kind of thing. 00:42:40.470 --> 00:42:47.359 I think it’s really important to consider. I’ll talk briefly about out processes of 00:42:47.359 --> 00:42:54.300 change findings. So, this is a separate qualitative analysis we did with the same interviews. 00:42:54.300 --> 00:42:58.869 So we wanted to see what people said were the most important active ingredients of Living 00:42:58.869 --> 00:43:07.700 Well that led to, you know, behavior change, and so in this Living Well box, the two bullets, 00:43:07.700 --> 00:43:11.030 actually the three bullets – I’ll draw your attention to the last three bullets. 00:43:11.030 --> 00:43:15.320 So, the first is learning from others, which is basically the same as social earning, which 00:43:15.320 --> 00:43:20.920 I already talked about, which the peers were like key to making that happen. The third 00:43:20.920 --> 00:43:26.320 bullet is real world practice, so um, the structure of Living Well was that folks would 00:43:26.320 --> 00:43:32.130 assign, I’m sorry, would set goals in one group, go practice the goals and then come 00:43:32.130 --> 00:43:37.250 back the next group and talk about how it went. And people really appreciated that opportunity 00:43:37.250 --> 00:43:40.540 for real world practice, they said that that was a very important active ingredient of 00:43:40.540 --> 00:43:46.450 the group. And then, the last bullet, that I’ll highlight, is the kind support and 00:43:46.450 --> 00:43:54.150 a push to go further. So this was a, it was something that all the participants talked 00:43:54.150 --> 00:44:02.270 about where a blend of being really caring, nonjudgmental, respectful, but also holding 00:44:02.270 --> 00:44:07.570 you accountable that you set a goal last week so what did you do this week… It was really, 00:44:07.570 --> 00:44:12.040 really important. And I actually think it sort of maps on a little to the conditional 00:44:12.040 --> 00:44:16.650 regard construct that I talked about earlier, where peers are able to hold people at a certain 00:44:16.650 --> 00:44:24.170 level of accountability because of their own experiences. So, you can see that these active 00:44:24.170 --> 00:44:29.740 ingredients from Living Well, that the peer involvement really enhances them in a lot 00:44:29.740 --> 00:44:39.099 of ways. So, you might say, well okay, that’s one study, that’s 15 people, you know, who 00:44:39.099 --> 00:44:45.080 cares. I was really delighted to find some qualitative work from this group that is conducting 00:44:45.080 --> 00:44:50.490 the Peer Group Lifestyle Balance Study that really very closely mirrored a lot of our 00:44:50.490 --> 00:44:54.720 findings. I don’t know if anyone from this group is on the call, but, you know, call 00:44:54.720 --> 00:44:58.600 me, send me an E-mail – this work is so interesting, and I’d love to figure out 00:44:58.600 --> 00:45:05.440 how we could collaborate. So, they did qualitative interviews with 28 participants in this Peer 00:45:05.440 --> 00:45:10.010 Group Lifestyle Balance which, as a reminder, the peer led group lifestyle intervention 00:45:10.010 --> 00:45:18.000 delivered in supportive housing and they, again, they compared, just like we did, perspectives 00:45:18.000 --> 00:45:23.940 of the peers who led the group with their participant perspectives of non-peer providers 00:45:23.940 --> 00:45:32.710 that they also had, and they found that peers were more process oriented, emphasizing hope 00:45:32.710 --> 00:45:37.520 and change and relating through self-disclosure and shared experience, where as non-peer providers 00:45:37.520 --> 00:45:43.369 were more task oriented, they emphasized consequences of non-action, like, if you don’t start 00:45:43.369 --> 00:45:47.780 eating better, if you don’t start, you know, exercising, these are the bad things that 00:45:47.780 --> 00:45:54.840 could happen. And that they related more through shared treatment goals. So, participants appreciated 00:45:54.840 --> 00:45:59.070 the contributions of each, and so this is really important, right? Like when we’re 00:45:59.070 --> 00:46:02.940 trying to focus on health and wellness in this group, we can all be person-centered, 00:46:02.940 --> 00:46:09.300 we can all be, we can all empower people, but we might have slightly different roles 00:46:09.300 --> 00:46:24.369 because of, you know, what our discipline is, right? Okay. Um, so some other really cool 00:46:24.369 --> 00:46:34.130 qualitative work that came out of this was they also wanted to explore a little bit how 00:46:34.130 --> 00:46:40.530 it was that peers contributed to the intervention. So they did qualitative interviews, but they 00:46:40.530 --> 00:46:47.210 also did this really card sort exercise, where they provided participants with 15 statements 00:46:47.210 --> 00:46:53.630 and said can you pick the top three statements that describe the Peer Specialist that you 00:46:53.630 --> 00:46:58.480 work with. The first choices that were most often selected were Peer Specialists were 00:46:58.480 --> 00:47:02.140 someone I felt comfortable with, who provided me with encouragement and support and that 00:47:02.140 --> 00:47:08.090 helped me feel hopeful. And then the most common second choices was the Peer Specialist 00:47:08.090 --> 00:47:11.610 knew what they were talking about in terms of a healthy lifestyle, understood what I 00:47:11.610 --> 00:47:16.170 was going through, shared their story, and put things in words I was able to understand. 00:47:16.170 --> 00:47:21.920 So, I felt like this is so powerful and it really helps us understand, you know, what 00:47:21.920 --> 00:47:25.920 are the main things that people are connecting to the peers around in these healthy lifestyle 00:47:25.920 --> 00:47:32.430 interventions. And so, another thing that came out of that qualitative analysis was 00:47:32.430 --> 00:47:39.530 this really beautiful figure that I feel kind of jealous of. I think it’s a really lovely 00:47:39.530 --> 00:47:44.260 figure and captures a lot. It is not my work, so I’m going to do my best to talk through 00:47:44.260 --> 00:47:54.530 it. But, as I said, if there are folks from this group on the call, give me a call. So, 00:47:54.530 --> 00:48:01.940 interestingly what they found in their qualitative analysis was that the shared experience of 00:48:01.940 --> 00:48:07.370 SMI, serious mental illness, which you see all the way on the left, was sort of foundational 00:48:07.370 --> 00:48:15.540 at the beginning to help with building rapport and engagement in the first place. So, you 00:48:15.540 --> 00:48:20.380 know, your credible because you’ve been through mental health issues and you, you’re 00:48:20.380 --> 00:48:24.570 figuring it out, and in that way you can connect with people on the front end, so they start 00:48:24.570 --> 00:48:32.099 feeling engaged and like they can trust you. Then, a little bit later, a shared experience 00:48:32.099 --> 00:48:36.450 of the healthy lifestyle became more salient, you know, now that I trust you, that we’re 00:48:36.450 --> 00:48:42.859 sort of similar on this foundational way, I feel like you’re a credible role model 00:48:42.859 --> 00:48:48.130 around other aspects of healthy lifestyle as well. So, people shared about, you know, 00:48:48.130 --> 00:48:53.490 diets, physical activity and all these other things. If you look at the other three circles 00:48:53.490 --> 00:49:00.320 that sort of surrounding that middle triangle, there’s a lot of overlap with what we found 00:49:00.320 --> 00:49:06.839 in our work, so um, for example, the top circle, feeling comfortable, that seems to map on 00:49:06.839 --> 00:49:13.650 a lot to what we found around a group atmosphere that’s warm, where everybody is equal, nonjudgmental, 00:49:13.650 --> 00:49:20.790 right? Friendly, it’s genuine. So that was really interesting to see. If you move down 00:49:20.790 --> 00:49:27.240 to the support and encouragement circle, um, again, also seems to map on to our warm group 00:49:27.240 --> 00:49:33.859 atmosphere where people were caring, you know, consistent, supportive and providing that 00:49:33.859 --> 00:49:40.760 kind support like we talked about as well. And then the hope and motivation bubble, this 00:49:40.760 --> 00:49:47.660 is also very interesting, seems to map on to our construct around a push to go further, 00:49:47.660 --> 00:49:54.200 right? That accountability as well as real world practice, so being able to set goals, 00:49:54.200 --> 00:49:59.380 try them, normalizing slips – this is very, very important so, you know, it’s totally 00:49:59.380 --> 00:50:06.599 okay if you don’t, you know do the whole goal that you set out to do, that’s normal 00:50:06.599 --> 00:50:11.970 and that happens to everybody and it’s not a linear process of change and recovery. It’s 00:50:11.970 --> 00:50:17.130 a very, very important thing that peers bring to the table because, again, they can share 00:50:17.130 --> 00:50:27.820 their own experiences around slips. So, you know, that’s, that’s it, that’s what 00:50:27.820 --> 00:50:34.099 we’ve got in terms of how it is that peers are contributing to health and wellness intervention. 00:50:34.099 --> 00:50:39.280 So, I’ll give a little summary now and then I’ll stop, and we’ll have some time for 00:50:39.280 --> 00:50:43.720 questions – not as much time as I hoped but that’s all right. So, from what we know 00:50:43.720 --> 00:50:48.780 it seems like the peer role in health and wellness overlaps with the peer role in mental 00:50:48.780 --> 00:50:55.950 health quite a bit in terms of providing social support, hope, motivation, self-efficacy; 00:50:55.950 --> 00:51:05.690 in terms of providing respectful, friendly, and non-hierarchical relationships, and what 00:51:05.690 --> 00:51:10.540 I italicized is it seems like, what’s really important about what peers do, is they can 00:51:10.540 --> 00:51:17.410 skillfully self-disclose across a variety of experiences, right? So, I don’t, I don’t 00:51:17.410 --> 00:51:23.570 think that the literature supports the idea that, you know, a person who is gonna provide 00:51:23.570 --> 00:51:29.109 support around weight management, for example, is someone who has lost ton of weight. Right? 00:51:29.109 --> 00:51:36.640 I think it’s more around a person who knows how to draw from their own experience and 00:51:36.640 --> 00:51:42.119 self-disclose in a way where the other person will feel engaged and motivated. This is a 00:51:42.119 --> 00:51:47.690 very important skill that our peers know how to do, but we don’t know how to do. This 00:51:47.690 --> 00:51:53.970 is an opportunity for us to learn from them about how to do this in a skillful way and 00:51:53.970 --> 00:52:01.740 I really think that this needs more exploration in the research. I’m getting some folks 00:52:01.740 --> 00:52:09.460 that agree with me in the chat, which I appreciate. So, what about “peerness”. So, it could 00:52:09.460 --> 00:52:12.650 be that a shared experience of mental illness is foundational at the beginning – we really 00:52:12.650 --> 00:52:17.010 don’t know we don’t have enough work on this. It may be that specific experience about 00:52:17.010 --> 00:52:23.450 health behaviors may come into play later. But more, more work is needed, and it might 00:52:23.450 --> 00:52:27.480 depend on context. So, I’m gonna see, I’m sure there are Peer Specialists on the call, 00:52:27.480 --> 00:52:32.770 but as a non-peer person I’m going to speak to the non-peers in the audience for a second. 00:52:32.770 --> 00:52:37.520 What can we do to further this work? I think, number one we need to include peer providers 00:52:37.520 --> 00:52:41.380 as collaborators in our research because they have the best understanding of what they do 00:52:41.380 --> 00:52:48.970 and what they bring to the table, especially around self-disclosure. And then, when we’re 00:52:48.970 --> 00:52:53.359 designing interventions to be delivered by peers, or thinking about having a peer deliver 00:52:53.359 --> 00:52:57.490 a particular intervention in your clinic, you have to think carefully about how to make 00:52:57.490 --> 00:53:01.941 space for the valuable lived experience that they bring to the table. So, does this engage 00:53:01.941 --> 00:53:09.020 this deep wisdom that peers have about mental health recovery, or is this just like something 00:53:09.020 --> 00:53:15.900 we’re asking them to do because they have availability? Right? Um, I want to bring up 00:53:15.900 --> 00:53:20.180 Whole Health groups really briefly, because Whole Health I think is a great intervention 00:53:20.180 --> 00:53:25.190 in the, you know, taking charge of my life and health group is a great group, but it 00:53:25.190 --> 00:53:29.280 can be delivered by anyone. It is not designed for peers, to be delivered by peers, to my 00:53:29.280 --> 00:53:34.860 understanding, and so, there’s actually not like explicit space for peers to self-disclose. 00:53:34.860 --> 00:53:39.790 I think they do it because they know how to do it and that’s their skills, but, you 00:53:39.790 --> 00:53:43.960 know, we could really think thoughtfully about, you know if want peers to be delivering these 00:53:43.960 --> 00:53:49.470 groups then how do you want to bring their lived experience with them into the room and 00:53:49.470 --> 00:53:53.020 put it on the table. And I think that’s something we brainstorm with peers about, 00:53:53.020 --> 00:53:59.109 you know, when and how should self-disclosure be used and how do we understand skillful 00:53:59.109 --> 00:54:05.830 self-disclosure that promotes engagement and recovery. And at the very, very basis of everything, 00:54:05.830 --> 00:54:10.880 we all need to work towards creating collegial respectful and non-hierarchal relationships 00:54:10.880 --> 00:54:17.730 with peer providers that we work with, to the extent that we can. I think we all pretend 00:54:17.730 --> 00:54:23.550 that, maybe in VA, that these, these relationships are non-hierarchal, but the truth is, that 00:54:23.550 --> 00:54:26.839 Peer Specialists don’t get paid as much as other clinicians. They don’t have as 00:54:26.839 --> 00:54:30.950 much power in the system, they have a lot of, you know, supervision and oversight, and 00:54:30.950 --> 00:54:37.621 I think we need to continue to work towards closing that gap and disparity so that they 00:54:37.621 --> 00:54:44.140 can really bring their wisdom to bare on this important work. Thanks to my collaborators…. 00:54:44.140 --> 00:54:53.090 Ralf Schneider: Great, we had a couple questions earlier on Dr. Muralidharan we can touch on 00:54:53.090 --> 00:55:00.020 those, and they’re about the three big different interventions, webMOVE, PGLB and Living Well. 00:55:00.020 --> 00:55:07.490 So, for webMOVE, do you recall, was that within Whole Health, or how was, or was webMOVE 00:55:07.490 --> 00:55:14.020 part of the MOVE program for that study? Dr. Anjana Muralidharan: Yeah, so webMOVE 00:55:14.020 --> 00:55:16.910 was tested in a research study. Ralf Schneider: Right. 00:55:16.910 --> 00:55:22.300 Dr. Anjana Muralidharan: So, to my knowledge, I don’t know if it has been disseminated 00:55:22.300 --> 00:55:24.950 or implemented in clinical care. Ralf Schneider: Right. Right. 00:55:24.950 --> 00:55:26.621 Dr. Anjana Muralidharan: If others know about that… 00:55:26.621 --> 00:55:31.430 Ralf Schneider: The next question, right, right, we don’t know that yet. And how about 00:55:31.430 --> 00:55:39.080 PGLB, I think the um, the research study was in a supportive housing setting, that’s 00:55:39.080 --> 00:55:45.720 where the peers delivered that – has it been used in other settings? And again, I’m not 00:55:45.720 --> 00:55:51.940 sure if that’s been used further yet, and um, that’s one question. 00:55:51.940 --> 00:55:58.810 Dr. Anjana Muralidharan: Yeah sure, I don’t even think there are, as far as I can find, 00:55:58.810 --> 00:56:03.470 I couldn’t find the published results from that study yet, so, um I don’t think it’s 00:56:03.470 --> 00:56:08.590 been rolled out anywhere else. I think it was an intervention, the Lifestyle Balance 00:56:08.590 --> 00:56:12.829 intervention that I think has been used in other settings and they sort of adapted it 00:56:12.829 --> 00:56:18.390 for folks with mental illness in supportive housing to be delivered by peers. So, hopefully 00:56:18.390 --> 00:56:25.120 the results from that come out soon and we might see steps to implement it in the future. 00:56:25.120 --> 00:56:32.000 Ralf Schneider: Right. And there was a similar question from Michelle Kelly about a curriculum 00:56:32.000 --> 00:56:36.329 for Living Well and I think your answer would be similar to that. 00:56:36.329 --> 00:56:40.820 Dr. Anjana Muralidharan: Yeah, exactly, we’ve published the results from Living Well, but 00:56:40.820 --> 00:56:45.530 at the moment it’s not implemented in the VA. 00:56:45.530 --> 00:56:54.460 Ralf Schneider: Right, so I guess we, our advice to folks is to look out for new developments 00:56:54.460 --> 00:57:02.680 about even limited roll-outs of some of these interventions. Although they certainly apply 00:57:02.680 --> 00:57:09.540 to the work that peers are doing already naturally. Dr. Anjana Muralidharan: Yes. Absolutely. 00:57:09.540 --> 00:57:14.619 Ralf Schneider: Great. Let me see if there were any other questions. In the meantime, 00:57:14.619 --> 00:57:20.079 though, just folks are just interested in more information and we want to draw their 00:57:20.079 --> 00:57:33.820 attention again to the slide set that we have in files to download. And, yes, the Living 00:57:33.820 --> 00:57:43.359 Well model was a peer and non-peer co-facilitated training to answer Eric Gary’s question. 00:57:43.359 --> 00:57:44.670 And I think… Dr. Anjana Muralidharan: Yes, it can be led 00:57:44.670 --> 00:57:47.830 by two peers… Ralf Schneider: It can be led by two peers. 00:57:47.830 --> 00:57:53.290 Dr. Anjana Muralidharan : Uh huh, uh huh. Ralf Schneider: Great. As you can see, a lot 00:57:53.290 --> 00:58:01.300 of thank yous for this. Thank you everyone for attending. So as a reminder, please go 00:58:01.300 --> 00:58:08.550 to TMS and complete the 10-item test and the Webinar evaluation within the next 30 days 00:58:08.550 --> 00:58:15.770 so you can receive a CE credit. This is a monthly presentation. Our next Webinar is 00:58:15.770 --> 00:58:25.480 on May 11th at 12:00 PM EST. Drs. Peeples, Hack and Muralidharan will present VA connection 00:58:25.480 --> 00:58:32.700 plans and Introduction in Clinical Training on a Social Connection Intervention for Veterans. 00:58:32.700 --> 00:58:37.920 So, we look forward to seeing you all back. And thank you again. 00:58:37.920 --> 00:58:43.770 Dr. Anjana Muralidharan: Bye everybody. Thank you. If you have any other questions you can E-mail 00:58:43.770 --> 00:58:45.250 me, my contact information is there. [End Recording]