Delineation of the job role.

Both the Veteran's Affairs Action Agenda Work Group (2003) and the National Consensus Statement on Mental Health Recovery (Substance Abuse and Mental Health Services Administration, 2004) endorsed the concept of peer support and peer provided services as an important component of mental health transformation endeavors. Peer provided services are considered an indicator of a recovery oriented service delivery system (Dumont, Ridgeway, Onken, Dornan, & Ralph, 2005). The belief that a person living with a mental illness can provide services to others with similar mental health problems appears to be growing in acceptance within the traditional mental health system. The addictions field has a long tradition of viewing persons in recovery as providers or counselors. The mental health peer provider, like the peer addictions counselor, brings a unique perspective based on 'life experience' that is believed to enhance the peer provider's sense of empathy, insight, and offers hope for recovery.

Peer providers are persons who identify that they are living with a mental illness and provide services to assist others in their recovery. Peer providers typically work in one of two service settings: consumer operated or traditional mental health programs. Consumer operated programs are organized, administered, and managed by consumers of mental health services. Traditional mental health programs in contrast are operated and administered primarily, by non-consumers (Solomon, 2004; Mowbray & Moxley, 1997). There are two broad types of peer roles within the traditional mental health system: 1) peer or consumer designated positions and 2) conventional positions. Peer specialist positions are generally designated for a person living with a mental illness who is considered further along in their recovery than those to whom they will be providing services. An example is the peer advocate role on an assertive community treatment team. Persons in recovery may also occupy traditional mental health positions, for example, case manager, staff psychologist or social worker. These individuals, while recovering from mental illness, may or may not have disclosed their personal experience. In either case, the person is paid a competitive wage for their services.

There is a small but evolving body of research indicating that consumer providers (1) (CPs) can be as effective as or more effective than traditional providers in professional settings. Since the mid 1990's there have been a series of research endeavors examining the impact of services delivered by CPs. There have been at least three randomized control trials (Clarke et al., 2000; O'Donnell et al., 1999; Solomon & Draine, 1994; 1995a; 1995b; 1995c) and three quasi-experimental studies (Chinman, Rosenheck, Lam, & Davidson, 2000; Chinman, Weingarten, Stayner, & Davidson, 2001; Felton et al., 1995; Klein, Cnaan, & Whitecraft, 1998) comparing outcomes of CPs' services to traditional non-consumer provider services. The studies with CPs assigned to an intensive case management team tended to show outcomes favoring consumer providers.

Rowe and associates (2007) demonstrated that early in treatment CPs may possess distinctive skills in communicating positive regard, understanding, and acceptance to clients, and a facility for increasing treatment participation among the most disengaged. These findings suggest that peer providers serve a valued role in quickly forging therapeutic connections with persons typically considered to be among the most alienated from the health care service system. The hastened establishment of this relationship may lead to greater motivation for further treatment and use of peer-based community services. Schmidt and her colleagues (2008) recently demonstrated that consumers with life experience but little formal training can work together successfully with professionals to provide case management services for people with a serious mental illness. This research adds to the growing body of evidence that consumers can deliver services as effectively as other providers within conventional case management programs (Schmidt, Gill, Solomon, & Pratt, 2008).

Peer Services within the VA

In 2003 the VA developed a plan to implement the recommendations of the President's New Freedom Commission. The Veterans Administration Mental Health Strategic Plan endorsed the use of peer support within the VA. The goal was to hire veterans as peer mental health paraprofessionals, referred to as CPs. In 2005 funding became available for CP positions and by April 2008, 123 had been hired (Chinman et al., 2008). Peer providers in the VA deliver services "from orienting new patients entering programs, to providing support for emotional and social needs, to teaching skills and knowledge necessary to manage symptoms in order to live, work, learn, and socialize in the community" (Chinman et al., p. 1315).

One of the programs developed early on in the implementation of peer services within the VA that is described in the literature is the Vet-to-Vet program. The Vet-to-Vet program is a consumer-professional partnership in which veterans who have a psychiatric diagnosis facilitate weekly psychoeducational and support group meetings (Resnick, Armstrong, Sperrazza, Harkness, & Rosenheck, 2004). The program is an adjunct to the existing mental health services provided by the VA and was initially developed in 2002 in partnership with Moe Armstrong, a combat veteran who lives with a diagnosis of schizophrenia (Resnick & Rosenheck, 2008). The 45-minute weekly meetings are structured in a read-and-discuss format with each weekday focused on one of the following topics: "Disability Awareness, Disability Pride: Recovery Workshop; Writers' Meeting; Wellness; and Mental Illness Anonymous (MIA)" (Resnick et al., p. 186). The group meetings are egalitarian, with conversations loosely organized around books written by CP mental health experts. Veterans participating in the Vet-to-Vet program explore issues such as taking personal responsibility for mental illness, learning to combat depressive cycles, and developing mutual support and feelings of hope. The CPs for the Vet-to-Vet program are nominated by their peers and approved by supervisory staff. All new CPs receive training based on a curriculum designed by peers, co-facilitate groups while in training, and are observed and provided with feedback. CPs participate in mandatory weekly group supervision co-led by a professional and a peer supervisor (Resnick et al.).

Resnick and Rosenheck (2008) compared the effectiveness of the Vet-to-Vet program to standard care without peer support on measures of recovery orientation, confidence, and empowerment. This study revealed that participation in the Vet-to-Vet peer support and education condition enhanced participants' sense of empowerment and self-efficacy in terms of dealing with common life challenges (Resnick & Rosenheck). Chinman and associates (2008) conducted a study to explore the challenges of CP implementation beyond Vet-to-Vet into roles in "mainstream" mental health services within the VA. Through a series of focus groups, they explored questions related to the impact of CP services, including the duties, roles, and early experiences of CPs on the team, and barriers to and supports for CP implementation. The results of these focus groups were similar to reports from CPs outside of the VA. Additionally, there were three findings that are pertinent to the current study. First, participants reported that the role of the CP was often loosely defined or unclearly communicated: second, participants wanted more supervision and training regarding their job, including the issues of self-care and professional/personal boundaries; and third, participants identified poor salaries and lack of an obvious path for professional development as problematic (Chinman et al.).

Role Delineation and Job Analysis

How does one define the role of peer providers? What do they actually do and how can they learn to do it? In order to delineate any work role or conduct a job analysis, role delineation method logy is available. This type of methodology is used in the establishment of job titles, personnel descriptions and the enumeration of job responsibilities (US Office of Personnel Management, 2007). Subject matter experts, meaning expert workers in the job role and their supervisors describe what tasks are involved in the position. They then are asked to delineate the knowledge and skills that are needed for an employee to be minimally competent in the workplace. Once a role delineation study is completed it can be used as the basis to construct a thorough job description and develop a valid professional examination that tests relevant knowledge and skills. One relevant example is the Certified Psychiatric Rehabilitation Practitioner exam (Gill, 2005)

Role Delineation methodology can be used as the first step in developing a content-valid training curriculum. A widely used methodology in this area is "DACUM", an acronym for "developing a curriculum" (California Resource Center for Occupational Design and Evaluation, n.d.). For example, the California Association of Social Rehabilitation Agencies (CASRA; n.d.) applied DACUM methodology to develop its introductory psychosocial rehabilitation curriculum.

This study employed role delineation methodology to specify the tasks of the peer specialist role in the New Jersey VA system and identify the associated knowledge and skills to implement those tasks. The identification of the knowledge and skills required was completed through gathering input from persons directly familiar with the jobs and tasks involved, both peer support specialists themselves and their supervisors. From their input, an analysis of the new job role was completed. The tasks of the role were enumerated and ranked by importance, frequency of implementation, and urgency of acquisition. In this manner, the peer specialist role was delineated and the empirical basis for the development of a relevant training curriculum was established.

Method

Participants

Two categories of subject matter experts (SMEs) were sampled in this study, peer specialists (n = 7) and their supervisors (n = 2). The peer specialists were all African-American, six were men, and all served during the Vietnam or Gulf War eras. All the peer providers currently employed by the VA in New Jersey in Psychiatry and Behavioral Sciences participated, thus representing 100% of the individuals in these positions.

Job Task Identification

SMEs were asked to identify tasks that are completed as part of the peer specialist position. After these tasks were identified the SMEs were asked to rate these tasks in terms of their importance, acquisition and frequency (see Appendix 1). Importance refers to the significance or meaningfulness of the task and was rated from not at all to extremely important. Acquisition asked the respondents to indicate the time until competent performance of the task is expected; identified because if the task is not done competently it could result in harm. The acquisition ratings included: never needs to be acquired, must be acquired before hiring, must be acquired by end of probationary period, must be acquired before X months (respondent indicated what X was equal to) in position, expected only of senior personnel in position for X (specify length of time). Frequency asked respondents to identify how often a task is completed or how much time a task requires. The frequency ratings ranged from not at all to more than once per day.

Two meetings were held with the peer specialists to gather data regarding tasks related to their positions. During the first meeting, the peer specialists were surveyed, using a focus group format, to identify the tasks that they considered most critical, important, and frequent in their own jobs. Participants provided written responses and then discussed their responses with the group. The group then provided comments and honed the concepts. Focus group facilitators served as discussion recorders. During the second meeting the peer specialists were presented with a listing of the tasks identified during the initial meeting and asked to rate them according to their importance, acquisition, and frequency (as described above). The peer specialists were also asked to identify any additional tasks that were not identified during the initial meeting. Peer specialists were provided with these additional tasks (as well as additional tasks from the supervisors, described below) at a later date for rating.

Peer specialist supervisors with knowledge of the functions of the peer specialists' jobs, tasks, and associated knowledge and skills were also surveyed. Reviewing those tasks identified by the peer specialists, two direct supervisors rated them according to the degree of their importance, acquisition, and frequency. Following their review of the identified tasks, the supervisors were given the opportunity to add any tasks they did not feel were adequately covered. The supervisors were provided with these additional tasks at a later date for rating.

Categorization of Tasks into Domains

After the SMEs identified the tasks that are performed as part of the Peer Specialist position two research assistants (AM and BBL) arranged the tasks, grouping them by similarity. Titles were then created for each grouping that encompassed the tasks contained therein. The P.I. (KG) reviewed the assignment of individual tasks to each overarching domain and made adjustments as needed. Additional clarification of nine tasks was required from the SMEs before proper categorization could occur.

Computation of Values for Competencies and Tasks

A composite weight score was computed for each task based on the peer specialists and supervisors' ratings. The score was computed by equally weighing both the importance and acquisition (importance + acquisition / 2) and then multiplying this intermediate result by the frequency of the task. The result was a score potentially between 0 (no value to job role) and 20 (highest value to job role).

Results

Based on the tasks named by peer specialists and their supervisors, 85 specific tasks and skills were identified and categorized into eight domains. During the initial meeting the peer specialists identified 61 specific job related tasks. During a second meeting with the peer specialists another 14 tasks were reported. A meeting with the peer specialists' supervisors resulted in the naming of 10 additional tasks and the clarification of two tasks previously identified by the peer specialists. Peer specialists and supervisors rated the complete list of 85 tasks within these domains in terms of their importance, acquisition, and frequency. Means were computed by the average individual rating regarding each task within each of the eight domains. The eight areas in terms of their frequency, importance, and acquisition and the overall combined weighted scores or values are presented in Table 1. Counseling skills, professional development, and professional documentation and communication are weighted as most valuable. A full listing of the domains and specific tasks is available from the authors.

[FIGURE 1 OMITTED]

Results from Specific Domains

The four domains with the highest mean values will be described in more detail below.

Within Domain 3. Counseling Skills, several tasks were identified as highly valuable. Those with the highest endorsements are as follows:

* Share "we" experiences to create an environment of comfort, honesty, and trust Use reflective listening skills to encourage peers to come to a better understanding of themselves and their recovery

* Allow peer to talk with minimal interruption to obtain information

* Ask open ended questions

* Reflectively respond to content, feeling, and meaning

* The most highly endorsed nine items (out of 13) from the Counseling Skills domain are illustrated in Figure 1 below.

Within Domain 8, Continued Professional Role/Competency Development, several tasks were identified as valuable. The most highly endorsed of these tasks (out of 19) are the following:

* Manage one's time in order to prioritize ongoing tasks

* Be familiar with and adhere to VA policies and procedures

* Focus on personal wellness in order to maintain one's own recovery

* Manage time frame you have to work with individual veterans

[FIGURE 2 OMITTED]

In Figure 2 above are additional items that were highly valued by peer specialists and their supervisors within Domain 8.

The most highly valued tasks (out of 10) within Domain 5, Professional Documentation and Communication, were:

* Document all delivered services to peers according to VA program policies

* Enter encounter data into system

* Participate in briefing meetings

The most highly valued 5 items are illustrated in Figure 3 below.

Within the Peer Support domain, those tasks that were weighted most heavily (out of 25) were:

* Help peer to make a commitment to change towards sobriety

* Encourage peer to focus on personal wellness and recovery rather than trying to fix or change others

* Educate peers about the value of self-help and link to peer support and self-help groups

* Share personal experiences with mental health and/or drug and alcohol recovery to demonstrate that recovery is possible

[FIGURE 3 OMITTED]

In Figure 4 you will see the ratings for the top seven tasks of the Peer Support domain.

Discussion

In this study, implementation of the role delineation approach clarified the responsibilities of a peer specialist in the VA system in New Jersey. The complexity of the role identified makes apparent the need for specialized education and the importance of education that meets the needs of the CPs and their service recipients. While the VA recognizes the unique strengths that peer specialists possess, they also understand that formal training that is directly relevant to their work roles can enhance these strengths. In the role delineation study described in this report both peer specialists and supervisors identified a diverse and complex professional role that requires extensive knowledge and skills. These findings have significant implications, suggesting that general trainings in mental health would not be nearly as beneficial as trainings focused directly on the tasks and competencies required of these unique peer specialist positions.

Individual tasks that were weighted the heaviest were the: ability to prioritize one's own work followed by adherence to agency procedure. Whether these are specific to the VA and this peer role within that system is an interesting question. Anecdotally the prioritization challenge is raised by many employers about all mental health staff. Also, one of the authors of the current article, from a community -based, peer operated agency said knowledge of and adherence to procedure is a problem in that very different sort of agency. Another task, very specific to the peer specialist role that was also highly rated is very central to all peer provider roles: sharing the "we" experience of the common challenges of recovery.

The other highly weighted tasks are quite familiar to the helping professions and have been identified in a number of role delineation studies: These included: promoting open-ended questions, reflective responding, and listening with minimal interruptions.

[FIGURE 4 OMITTED]

Based on the findings described in this preliminary report educational curriculum is being developed and will be offered as part of an academic certificate tailored to the relevant knowledge and skill areas required of peer specialists in the VA system. Potential positive outcomes include an increased sense of competence among peer specialists, a significant impact on the larger VA system in terms of their views on recovery from mental illness, and improved individual outcomes for service recipients.

Limitations

Obvious limitations include the fact that the findings are generalizable solely to VA peer support specialist roles as implemented in New Jersey. While the methodology employed can be used to study peer specialist roles both throughout the VA system and state funded community mental health services, the specific findings of this study are not more broadly generalizable.

Future Directions

Based on the role delineation results presented above, identified competencies can be translated into course objectives. Curriculum development and content is an issue that requires further exploration. It is often unclear how the content of many curricula have been developed and conceptualized. For example, Stoneking and McGuffin (2007) report the knowledge, skills and attitudes taught in the Arizona Recovery Support Specialist Institute, but it is not specified whether input is gleaned from the peer specialists to be trained or their intended service recipients. CP training programs vary widely with the length of trainings inside and outside of the VA ranging from 30 hours to 28 weeks (Katz & Salzer, 2006). Given this variation, the obvious question is what course content or training is essential. Role delineation or job analysis methodology is all the more necessary to provide the data upon which to proceed. As Schmidt and Bums-Lynch (in press) state:

Further refinement of the competencies necessary to promote empowerment and recovery will be gleaned by interviewing working peer providers and recipients of their support. Training strategies to enhance knowledge and skill levels of peer providers need to continue to be examined through more rigorous study designs and the publication of training content and processes (e.g., practicum experiences, on-the-job training, ongoing supervision, and continuing education). A direct comparison of training outcomes across training curricula would serve to identify best practices in teaching strategies and supports, and the underlying processes that enhance the subjective benefits of personal recovery.

Appendix 1--Rating Dimensions TASK

(Describe as behavior, actions, or solving problems as much as possible)

How frequently is this task done?

[] Never (0)

[] Several times per year (1)

[] At least once per month but less than once per week (2)

[] More than once per week but less than daily (3)

[] At least once per day (4)

[] More than once per day (5)

How important is this task?

[] Not at all

[] Of little importance

[] Moderately important

[] Very important

[] Extremely important

When must one acquire the ability to do this task?

[] Never needs to be acquired

[] Must be acquired before hiring

[] Must be acquired by end of probationary period

[] Must be acquired before--months in position

[] Expected only of senior personnel in position for--(specify length of time)

Note

Research was funded by the VA. Support for Drs. Swarbrick's and Gill's effort on this article is in part from the National Institute of Disability and Rehabilitation Research Grant #H133P050006.

References

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(1) The term consumer providers (CPs) will be used to refer to peer providers or peer specialists

Kenneth J. Gill

University of Medicine and Dentistry of New Jersey

Ann A. Murphy

University of Medicine and Dentistry of New Jersey

William Burns-Lynch

University of Medicine and Dentistry of New Jersey

Margaret Swarbrick

University of Medicine and Dentistry of New Jersey

Kenneth J. Gill, Ph.D., CPRP, Department of Psychiatric Rehabilitation and Counseling Professions, University of Medicine and Dentistry of New Jersey (UMDNJ), 1776 Raritan Road, Scotch Plains, NJ 07076. Email: [e-mail]

Table 1
Ratings of Domains of Peer Specialist Role

Domain                                    Mean     SD

1. Outreach (5 Tasks)                     7.06     (3.85)
     Frequency                            2.28     (1.02)
     Importance                           3.08     (0.86)
     Acquisition                          2.96     (0.54)
2. Peer Support Activities (25 Tasks)     7.51     (4.56)
     Frequency                            2.37     (1.26)
     Importance                           2.80     (1.09)
     Acquisition                          2.88     (.86)
3. Counseling Skills (13 Tasks)           10.63    (4.46)
     Frequency                            3.16     (1.22)
     Importance                           3.24     (.86)
     Acquisition                          3.24     (.76)
4. Skill Development (5 Tasks)            5.68     (3.51)
     Frequency                            1.84     (.85)
     Importance                           2.72     (1.02)
     Acquisition                          2.88     (.78)
5. Professional Documentation &
     Communication (10 Tasks)             8.99     (4.56)
     Frequency                            2.80     (1.33)
     Importance                           3.22     (1.08)
     Acquisition                          2.66     (1.00)
6. Crisis Intervention (3 Tasks)          6.38     (5.85)
     Frequency                            1.75     (1.55)
     Importance                           3.83     (.39)
     Acquisition                          3.42     (.52)
7. Knowledge of Resources (5 Tasks)       6.56     (4.23)
     Frequency                            1.92     (.95)
     Importance                           3.04     (.89)
     Acquisition                          3.32     (.48)
8. Continued Professional Role/
   Competency Development (19 Tasks)      9.52     (5.40)
     Frequency                            2.84     (1.37)
     Importance                           3.47     (.74)
     Acquisition                          2.98     (.71)