Positive Approaches Journal, Volume 9, Issue 1

Volume 9 ► Issue 1 ► 2020

Forensic Peer Support Services: A Personal Perspective

Jaclyn Mailloux, CPS/Certified Peer Specialist

Abstract

The purpose of this article is to provide an inside perspective about the differences between community peer support and forensic peer support. The article is written from the perspective of a Forensic Support Specialist (FPS) who is employed with Pennsylvania’s Torrance State Hospital-Regional Forensic Psychiatric Center and was tasked with developing/structuring their new peer support program. The FPS has also had many years of experience working within the community as a Certified Peer Specialist (CPS) so can give insight into what community CPS work entails as well. Additionally, while there has been research directly relating to how beneficial peer support programs can be within the community as well as within secured psychiatric settings, there are not many first-person perspectives that have been published for those who are seeking out more information pertaining to this subject matter. In this article one can ascertain the aforementioned benefits, as well as areas in which we can still work towards enhancing these evidenced-based programs.

I have worked as a Certified Peer Support Specialist (CPS) at Pennsylvania’s Torrance State Hospital- Regional Forensic Psychiatric Center (RFPC) for the past two years and subsequently as a CPS in the community setting for six years. I began my employment with the RFPC almost two years ago after working in the community at a private peer support agency. I had initially enrolled in college to earn a degree in criminal justice; however, I did not identify a specialization that I was interested in. As time passed, I found myself interested in Forensic Peer Support.

My company, at the time, eagerly sent me to the Forensic Peer Support (FPS) training in 2015 as my interest in the criminal justice system had increased greatly. While working with peers within the community I recognized a lack of support offered to justice-involved individuals within the jails/corrections system. I was able to clearly see that what we lacked most was assisting justice-involved individuals within the jails themselves. I am a staunch believer in and advocate for peer support services as I have been able to see so many life-changing experiences that peers have had by the time they are ready to be discharged from services.

Most people who are attempting to understand the nature and value of peer support are generally curious as to what the differences is between CPS as opposed to FPS. Peer support has been defined in many different ways, however the Substance Abuse and Mental Health Services Administration (SAMHSA) defines peer support as follows: “Peer Support encompasses a range of activities and interactions between people who share similar experiences of being diagnosed with mental health conditions, substance use disorders, or both. This mutuality - often called ‘peerness’- between a peer support worker and a person in, or seeking, recovery promotes connection and inspires hope. Peer support offers a level of acceptance, understanding, and validation not found in many other professional relationships.”¹ Peer support workers are able to lead by their own life experiences, which can immediately put a peer at ease. Just knowing that their peer worker has “been there” makes rapport building that much quicker, which helps to streamline the entire recovery experience. Moving on to the role of FPS: “FPS’s differ from CPS’s in that they exclusively engage a population of individuals with psychiatric disabilities who have had contact with the criminal justice system […] To meet the needs of either jail diversion or reentry programming initiatives, a number of state and local authorities have supported the development of new ‘forensic peer specialist’ workforce. This workforce is comprised of individuals with a history of mental illness and/or incarceration, who have achieved a reasonable degree of stability in their own lives and are now employed by local government and non-profit agencies to provide individualized support to others with psychiatric disabilities and criminal justice involvements.”²   It is important to note that one does not have to have a history of incarceration in order to become an FPS. As previously mentioned, the individual must have a history of mental illness while also having achieved a ‘reasonable degree of stability” in their lives. Many businesses and institutions require that the potential candidate for an FPS position have at least several years of recovery at the time of their interview and that they are able to actively model that recovery to peers that they will be working with.

The RFPC made the decision to incorporate FPS services into their programming at which time I was hired as the Forensic Peer Support Specialist. Coming into this position meant that I was tasked with developing/structuring a brand-new peer support program for patients within the RFPC. It was clear from the start of my employment that my prior work in the community was very different from the work that I would be embarking upon at this secured facility. Admittedly, I was very out of my element and so turned to researching similar facilities (that already had FPS programs in place) in order to gain more knowledge about how we could best provide support to our patients. I was encouraged and quickly gained approval from my supervisors to reach out and visit peer support staff at other facilities in order to gain the insight that I was seeking. Establishing connections with my new contacts would prove to play an important role in my efforts to understanding the inner working of the forensic environment, including the restrictions specific to RFPC and how those restrictions might allow for the type of goal setting that a community CPS would be accustomed to.

To best delineate peer support services being provided in these two very different types of settings I will explain my experience in the community while working as a CPS in addition to providing services in a locked-down state forensic psychiatric facility. Additionally, because the peer support program at RFPC is still in development I would like to share what some of my hopes are for the future regarding our new program.

Working in the community, CPSs are able to spend (billable) time with peers that have already been assigned to the CPS by supervisors who had already completed a Strength Based Assessment (SBA) in addition to developing an Initial Service Plan (ISP) with the peer. The CPS is permitted to spend up to four hours per day, five days per week with a peer if the justification for services was present in the CPS’s documentation of the session. During the time that a peer and CPS spend with one another establishing boundaries and building rapport, the pair would also clarify which goals listed on their treatment plan would take the most priority. Common goals addressed with peers within the community setting include, but are not limited to, Wellness Recovery Action Plan (WRAP), the development of Mental/Physical Advance Directives, educational goals, and employability. The goals that each peer has are very individualized and the peers oversee their own recovery process—they are strongly encouraged to take the lead in this process.

One who is employed as a CPS should ultimately develop an extensive knowledge of community resources, as this is a huge part of what a CPS is able to assist a consumer with. There are often many resources and/or benefits that a consumer might be eligible for that they are not yet aware of. When building a network of contacts, it is important that the CPS is willing to reach out to their colleagues so they can continue growing their knowledge of the various community resources.

While peer support in the community does continue to grow, it also appears that it has been very slow-moving in regards to FPS being available to mental health consumers at each of the points of potential intercept. Because of this we continue to see mental health consumers who would benefit from actual treatment rather than incarceration moving in and out of our criminal justice system frequently. To further clarify, mental health consumers can become involved in the criminal justice system if they are experiencing a mental health/substance abuse related crisis. One potential point of intercept would be within the community, a point where a crisis usually begins for an individual. “Diversion” is incredibly relevant and important when it comes to individuals as it means that we are diverting them away from becoming justice involved. For example, a Crisis Team could be contacted by the local police department if they are aware that an individual is experiencing a mental health crisis. If the Crisis Team can assist the individual by either deescalating them or another solution-oriented result, then the individual will have been spared the painful and at times, traumatic experience of having to go to jail. Not only does diversion help individuals from becoming part of a viscous cycle of criminal justice-involvement, but it also spares the community the costs that are associated with housing individuals in jail.

Here is a brief account of the experience I have gained while being employed as a Forensic Peer Support Specialist. The patients that are served here at the RFPC have come from county jails to either receive treatment for their Serious Mental Illness (SMI) or to be found competent/incompetent to stand trial on whatever charges that they have been accused of.

A typical day at RFPC would include facilitating groups of patients that are interested in developing new tools/concepts relating to coping skills, Cognitive Behavioral Therapy, establishing boundaries, social skills training, and a continuing of topics relating to mental health recovery. What occurs during an individual session varies depending on the peer that I am having a session with. For example, there are many times that an individual will be experiencing anxiety (which could have a variety of sources, including fear that stems from being around other patients who might also be experiencing mental health symptoms or fear of the unknown, which could stem from the fact that the patient is not allowed to know their discharge date under any circumstances). When someone is experiencing anxiety, I want to be able to sit down with them and just listen if that is what is needed in that moment by the patient. The peer is still encouraged to take the lead and direct their CPS to provide the level of support they need. I make it a point to model recovery to my peers rather than to preach it, as actions truly speak louder than words.

Being in a secured environment may mean that a patient is restricted in many areas of their lives; however, it does not indicate a lack of significant opportunity for personal growth and recovery. “Forming a supportive, professional relationship takes time, perseverance, and skill. Sometimes it involves just being ‘ordinary’: listening, keeping a conversation going, saying very little sometimes, not avoiding tricky subjects, and laughing together.”³ When sitting down with peers, I ask questions of them as we begin our session, for example starting with, “How are you doing right now or since we have last seen each other?” As the patients and I discuss their everyday means of coping within the facility it not only helps the patient assess where they are at with their own feelings/state of mind, but also to build rapport.

Once rapport has been established, a patient and I are truly able to begin speaking about their lives in an honest way, so the patient is best able to benefit in their recovery. “Working together to create a culture of safety means supporting people to understand how their life experiences have contributed to their risk and the impact that this has had upon their safety and the safety of others”⁴ The patient and I will discuss very intimate details of their lives; such as what their upbringing was like, if they suffered trauma, and how that trauma might still be impacting them. Additionally, the patient must eventually come to terms with their own choices, some of which have most likely led them to where they are today.

Although our FPS program at RFPC is running along quite smoothly, there are plans for future positive additions to the program to ensure that we are utilizing best practices and offering our patients the best care possible. Suggestions for continued development of FPS services would include a step-down program, patient orientation, and peer crisis support. Having a step-down program prior to discharge from an inpatient psychiatric setting would assist in lowering the recidivism rate and prepare patients for their transition into the next level of care. “Psychiatric (including forensic) patients who received this overlapping contact with support providers and peer support were discharged after a shorter time in hospital and, a year post-discharge, reported improved quality of life in terms of social relations compared to patients receiving treatment as usual, although there was no group difference in global quality of life.”⁵ In a step-down program, patients who are being released back into the community would go through a skills development based peer support program. Skills included would be coping skills, activity of daily living/personal hygiene, medication management, anger management, emotion regulation, etc. Although peers are coached on some of these skills at one time or another during their stay on the forensic unit, the specific type of coaching received in a step-down unit would be very individualized, more detailed, and have fewer restrictions in place. To clarify, in a locked down setting, patients have very limited abilities in their movements and having items in their rooms with them (such as writing utensils and books). Fewer restrictions on a step-down unit could include a patient working their way towards community outings with their FPS so the patient is able to better prepare for their discharge back into the community. This could include the patient actively being involved in their own care by ensuring connection with mental health support, career counseling, substance abuse counseling, housing matters, navigating transportation concerns, etc. By working their way towards community outings, the patient can actively practice needed social skills when they go to their local drop-in centers and meet other peers.

Another future addition to the program would be a type of patient orientation. Upon admission to the hospital, a peer support specialist would meet with the patient right away. This could be beneficial to patients because the admissions process can be very unnerving for some individuals, but especially for those who have never been to a hospital that functions like RFPC. In the many discussions I have engaged in with patients, I have consistently been told that the addition of an orientation program upon initial admission would be appreciated. I have also experienced fear upon being admitted to a hospital before and it was due to a lack of patient-centered care at the facility. When fear and anxiety kick in, it can magnify the symptoms those of us with mental health issues experience. Having another individual present at the beginning of a process who discloses that they, too, suffer from mental health and/or substance abuse challenges could serve to really put a patient at ease. The orientation would ultimately make for a much smoother admissions process for both the patient and the members of the treatment team who take part in that process. During moments where the patient must wait in silence for the next phase of the admissions process, the FPS would have the ability to answer any questions that the patient might have. Additionally, if the patient is actively experiencing mental health symptoms, the FPS can assist the patient with utilizing coping skills in order to lessen/cease these symptoms. This addition could also prove helpful to patients who struggle with mistrust/animosity towards authority figures. This specific type of distrust can sometimes lead to a negative start to the process, resulting in an individual becoming downright defiant, violent or acting out behaviorally.

FPSs have the appropriate training and understanding regarding how to best approach an individual who needs assistance with getting through such a challenging situation (being admitted to an inpatient facility). The CPS attempts to develop rapport with as many patients as possible to provide the most benefit when an individual is in troublesome circumstances such as a crisis. It would also be helpful to patients and staff if the CPS assisted the patient by going over minor grievances when appropriate, as this could assist with developing a more transparent understanding of the complaint/grievance process. This could be a great opportunity for the patient to practice advocating for themselves in a way that is productive and healthy.

Moving forward in the RFPC, FPS staff envision many additions to the Peer Support Program that will continue to benefit our patients. While the restrictive environment can prove to be an additional challenge in developing this evidenced-based program, there have been other facilities that have proven it is possible. As research of our forensic facilities continues, we will persist in enhancing our programs and learning from forensic partners so we may continue to provide stellar care to the peers we serve.

References

1. Chinman M, Weingarten R, Stayner D, Davidson L. Chronicity reconsidered: Improving person-environment fit through a consumer-run service. Community Ment Health. 2001; J37: 215–229. https://doi.org/10.1023/A:1017577029956.
   
2. Baron R. Policy brief: Forensic peer specialists: An emerging workforce. Center for Behavioral Health Services & Criminal Justice Research. http://www.pacenterofexcellence.pitt.edu/documents/Policy_Brief_Jun_2011%20Forensic%20Peers.pdf. Published June 2011. Accessed April 16, 2020.
3. Drennan G, Woolridge J, Aiyegbusi A, et.al. Making recovery a reality in forensic settings. Centre for Mental Health and Mental Health Network NHS Federation. https://www.nhsconfed.org/-/media/Confederation/Files/Publications/Documents/making-recoveryreality-forensic-settings.pdf.  Published September 2014. Accessed April 20, 2020.
4. Boardman J, Roberts, G. Risk, safety, and recovery. Centre for Mental Health and Mental Health NHS Federation. https://somersetwlc.co.uk/wpcontent/uploads/2019/09/IMROC-Guidance-Risk-Safety-Recovery-Briefing.pdf. Published June 2014. Accessed April 20, 2020.
5. Cherner, Rebecca. Transitioning into the community: outcomes of a pilot housing program for forensic patients. International Journal Forensic Mental Health. 2014; 13(1): 62-74. doi:10.1080/14999013.2014.885472.