Examination of Adaptations to the Evidence Based Supported Employment Model: Individual Placement and Support.

Individual Placement and Support (IPS) is a long-standing and innovative employment service for individuals with mental illness with dozens of clinical trials demonstrating effectiveness. Little is known, however, about intentional adaptations to IPS, especially those outside of the context of research studies. Using an implementation science framework, we conducted an exploratory study to better understand the characteristics of stakeholder-reported adaptions to IPS, the impetus for their development, and perceived impacts. We conducted qualitative interviews to analyze and describe these adaptations. Numerous adaptations of IPS were found that address the needs of new and underserved populations both within and outside of the mental health field. Programs reported adapting IPS because of the dearth of other evidence-based employment services, to serve diverse populations in need, and based on financial incentives. Benefits of adaptations were weighed against impacts on fidelity. As evidence-based practices (EBPs) are adapted, developers of EBPs should determine how fidelity of a program or service can be assessed or preserved in light of adaptations. This is critical with the increase in different service delivery methods, new populations, new service recipient needs, and new settings in need of EBPs.

Peer Support Specialist Work and Experiences During the COVID-19 Pandemic: A National Longitudinal Study.

OBJECTIVE: The study followed up with peer support specialists (PSSs) responding to an earlier survey to assess the pandemic's continued employment and personal effects. METHODS: A December 2020 online survey was conducted with respondents to a May 2020 survey. Items on employment status, work tasks, challenges, support, and benefits were included. Responses were analyzed with descriptive and inferential statistics. RESULTS: A total of 496 PSSs completed both surveys. Unemployment remained at 7%. The proportion with full-time employment increased by December, but financial instability also increased. Tasks involving individual support and group facilitation, which had decreased significantly, rebounded somewhat by December, when nearly all PSSs (86%) reported having some new tasks. Job satisfaction remained stable and high. In both surveys, about 75% reported pandemic-related benefits. Symptoms and housing instability among clients increased. CONCLUSIONS: Pandemic-related PSS unemployment was relatively stable, and work tasks evolved. Respondents reported increasing needs among clients, as well as pandemic-related work benefits.

Impact of COVID-19 on Peer Support Specialists in the United States: Findings From a Cross-Sectional Online Survey.

OBJECTIVE: Peer support specialists (PSS) are an integral part of the mental health workforce. The purpose of this study was to better understand how the COVID-19 pandemic affected their employment status and day-to-day work. METHODS: A cross-sectional, online survey was conducted (May-June 2020). Recruitment occurred through the National Association of Peer Specialists and additional snowball sampling. Closed- and open-ended questions sought information about employment status, work tasks, challenges faced by PSS and by individuals they supported, and positive impacts they experienced. RESULTS: A total of 1,280 surveys were analyzed. Nine percent of respondents reported having lost their job as a result of COVID-19. Of these, 65% reported a length of employment of 2 or more years, and 61% reported working 35 hours or less per week. Job tasks changed dramatically, with 73% reporting engagement in new tasks, including increased reliance on technology (N=717), increased coordination of resources (N=123), and COVID-19-related tasks (N=142). Engagement in some support tasks decreased significantly from prepandemic levels, including individual support provision (p<0.001) and group facilitation (p<0.001). Respondents reported significant challenges among individuals they supported, including increased isolation (92%), substance use (67%), housing instability (38%), and food insecurity (64%). Although respondents also reported challenges, satisfaction with organizational and supervisory support was high. Most respondents (73%) reported positive impacts or benefits from the pandemic. CONCLUSIONS: The changing roles and tasks identified in this study have implications for hiring, training, supervising, and supporting peer staff. The peer workforce demonstrated flexibility and commitment to meeting increasing needs.

Barriers to and Facilitators of Implementing Peer Support Services for Criminal Justice-Involved Individuals.

OBJECTIVE: This study sought to examine perceived barriers to and facilitators of the adoption, implementation, and sustainability of community-based mental health peer support services for criminal justice-involved individuals, also known as "forensic peer support" (FPS). METHODS: Qualitative interviews were conducted with stakeholders (N=14) and peer specialists (N=37) to better understand delivery of peer support services for justice-involved individuals in Pennsylvania. Thematic analysis followed by directed content analysis was used to identify factors in three a priori implementation categories based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model: initial facilitators (adoption), barriers (implementation), and facilitators (maintenance) to long-term sustainability. RESULTS: Initial service adoption was facilitated by buy-in from recovery-oriented gatekeepers in the criminal justice system. Unique implementation barriers included the chasm between the orientations of the two systems (recovery vs. punitive) and formal and informal limitations on the employment of individuals with criminal justice system exposure. For services to be sustainable and have an impact over the long term, FPS advocates and workers must develop rapport with on-the-ground employees of the criminal justice system. Funding barriers specific to the criminal justice system limited the adoption, implementation, and maintenance of FPS services. CONCLUSIONS: Although many of the factors that affect FPS service implementation were similar to those identified in the broader peer support literature, important differences must be addressed for successful FPS service delivery. Within the criminal justice system, both policies and norms presented barriers to the expansion of peer support services for justice-involved individuals.

Prevalence and Predictors of Limited Literacy in Public Mental Health Care.

Literacy is an important predictor of health care utilization and outcomes. We examine literacy among people seeking care in a state funded mental health clinic (Site 1) and a safety-net hospital clinic (Site 2). Limited literacy was defined as literacy at or below the 8th grade level. At Site 1, 53% of participants had limited reading literacy and 78% had limited aural literacy. At Site 2, 72% had limited reading and 90% had limited aural literacy. Regression analyses examined associations among limited literacy and psychiatric, neurocognitive and sociodemographic characteristics. Few associations among psychiatric and neurocognitive factors, and literacy were found. At Site 2, black and "other" race participants had higher odds for limited literacy compared to white participants suggesting that limited literacy may be an under-examined mechanism in understanding racial disparities in mental health. Work is needed to understand the relationships among literacy, mental health and mental health care.

Unintended consequences of institutionalizing peer support work in mental healthcare.

The widespread shift towards recovery-oriented mental healthcare has led to the extensive growth of peer-delivered services. Peer support workers draw on lived experience of mental health challenges and service use to provide non-clinical support services. As peer support services have grown, they have also formalized. This mixed-methods study of peer support work in Pennsylvania (USA) explores how peer support has been institutionalized, and identifies the intended impacts and unintended consequences associated with that process. In Pennsylvania, the inclusion of peer support services as a Medicaid reimbursable service, in addition to county level mandates regarding peer support service availability, have served to institutionalize the field. Data include 49 semi-structured interviews conducted with peer support workers (n = 35) and stakeholders (n = 14) in 2016. Qualitative analyses reveal changes to the scope and nature of peer support work, the peer workforce, peer client relationships, and to stigma in the workplace. Despite these changes, peer workers frequently remain underpaid and unable to advance professionally. The institutionalization of peer support serves as a barrier to worker entry and retention and highlights tensions between the consumer-driven origin of the recovery field and the current mental healthcare system. The institutionalization of roles defined by experiential expertise, such as peer support, has the potential to reduce the very centrality of experiential expertise, reproduce social inequalities, and paradoxically impact stigma.

Forensic peer specialists: Training, employment, and lived experience.

OBJECTIVE: Despite calls for increased peer support services for individuals involved with the criminal justice system, little is known about the training, employment, and characteristics of forensic peer specialists (FPSs). Pennsylvania developed the nation's first FPS program and remains at the forefront of the field. This paper responds to three research questions regarding forensic peer support in Pennsylvania, assessing: (a) employment patterns and demographic characteristics; (b) work tasks and sites; and (c) challenges and benefits of working as an FPS. METHOD: Data are drawn from a larger mixed-methods study of forensic peer support in Pennsylvania, including a detailed online survey of 117 FPS-trained workers, followed by 16 qualitative interviews with a subset of survey respondents. RESULTS: While all survey respondents completed forensic peer support training, only 36% (n = 44) have been employed as FPSs. 96% of survey respondents report having used mental health services, compared to 55% reporting past incarceration. FPSs spend the majority of their work time providing individual support to peer clients and work in multiple settings. Additionally, FPSs report both benefits and challenges related to their work. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Study results suggest that FPS characteristics, practices, and work settings simultaneously align with and differ from nonspecialized peer support services. Program developers and advocates should focus attention on expanding employment opportunities, and FPSs with lived experience should be prioritized for these positions. Despite significant implementation barriers, FPSs are passionate about this work and promote the expansion of the field. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Meaning and Management of Multiple Medications Among Public Mental Health Service Users.

Public mental health service users frequently manage multiple health conditions, and are often prescribed multiple medications. While medications are useful tools in treating diagnosed mental illnesses, they bring management challenges and also can carry complex meanings for the individuals taking them. This study utilized a qualitative methodological approach to examine the experience and meaning of polypharmacy among public mental health services users. This sample of service users (n = 26) who were prescribed multiple medications described three distinct types of challenges they faced in managing medications: related to information, material tasks, and self-stigma. Nevertheless, respondents reported creative and resilient strategies to manage these challenges. Findings build on previous literature and reflect the increasing need to focus on challenges related to polypharmacy. Furthermore, findings indicate that low levels of literacy and high levels of material disadvantage, which are common among public mental health service users, complicate the management and meaning of multiple medications.

'The problem here is that they want to solve everything with pills': medication use and identity among Mainland Puerto Ricans.

Taking medications are complex symbolic acts, infused with diverse meanings regarding body and identity. This article focuses on the meanings of medications for older Puerto Ricans living on the United States mainland, a population experiencing stark health disparities. We aim to gain an understanding of the way multiple cultural and personal meanings of medications are related to and integrated in identity, and to understand how they are situated within Puerto Rican culture, history and circumstance on the US mainland. Data is drawn from thirty qualitative interviews, transcribed and translated, with older Puerto Ricans living on mainland United States. Thematic Analysis indicated four prevalent themes: embodiment of medication use; medications redefining self through the fabric of daily life; healthcare experience defined through medication; and medicine dividing the island and the mainland. While identity is impacted by experience of chronic illness, the experience of medication prescription and consumption is further related to the construction of the sense of self in distinct ways. For these individuals, medication use captures the dilemma of immigration. While cultural belonging and well-being remains on the island of Puerto Rico, the mainland hosts both easier access to and excess reliance on medication.

Puerto Rican Victimization and Crime on the Mainland: The Role of Acculturation.

This study addresses criminal victimization and contact with police among older Puerto Ricans living in Northeastern United States. Framing their experiences within the context of immigration, we assess the role that acculturation and perceived stress play on Puerto Rican crime and victimization. Data from the Boston Puerto Rican Health Study (BPRHS; N = 1,504) were analyzed using multiple logistic regressions. The experience of criminal victimization by Puerto Ricans is associated with higher educational attainment, increased perceived stress, and also with psychological acculturation. Contact with police is associated with linguistic, but not psychological, acculturation. Our findings give strength to the argument that exposure to crime and the criminal justice system increases with acculturation and that this argument is relevant to Puerto Ricans. Thus, the association between acculturation, criminal victimization, and police contact depends on the conceptualization of acculturation used. The relationship between stress, acculturation, and crime among Latinos is complex and warrants further assessment.

Gratitude and longing: Meanings of health in aging for Puerto Rican adults in the mainland.

Puerto Rican adults in the United States mainland live with socioeconomic and health disparities. To understand their contextual experience of aging, we interviewed participants in the Boston Puerto Rican Health Study. Through a Thematic Analysis we identify themes and tensions: normalization and acceptance of aging; gratitude; the importance of aging within social networks; longing to return to Puerto Rico at older age. We address the tensions between 'acceptance' and fatalismo as a cultural belief, and a function of structural barriers. The experience of aging is discussed in the context of Puerto Rico's history and continued dependence on the United States.

The cellular generation and a new risk environment: implications for texting-based sexual health promotion interventions among minority young men who have sex with men.

African American and Latino young men who have sex with men (YMSM) are at the forefront of the U.S. HIV epidemic. As members of the "cellular generation," these youth are very likely to use text messaging; yet, relatively little research has explored use of text messaging as a tool for sexual health promotion, particularly among racial ethnic minorities who are also sexual minorities. We report on the results of ten focus groups conducted among African American and Latino YMSM, aged 18-25, regarding their current texting practices and the feasibility/acceptability of text messaging as a means of conducting sexual health promotion. Our analyses revealed four main themes around their texting behaviors, texting preferences, perceived advantages/disadvantages of texting, and the "etiquette" of texting. We consider implications of these findings for the development of texting-based sexual health promotion interventions, particularly in conjunction with other existing interventions operating in a new risk environment.