Moderator: Jane Tobler
September 21, 2010
2:00 pm CT

Coordinator: Welcome and thank you for standing by. At this time all participants are in a listen only mode until the question and answer session of today's conference. Today's conference is being recorded. If you have any objections, you may disconnect at this time.

The PowerPoint presentation, PDF version, the audio recording of the teleconference and a written transcript will be posted to the SAMHSA ADS Center web site at http://www.promoteacceptance.samhsa.gov/teleconferences/archive/default.aspx.

Our presentation today will take place during the first hour and will be followed by a 30 minute question and answer session at which time you may press star 1 to ask a question.

I would now like to turn the call over to Jane Tobler. Thank you. You may begin.

Jane Tobler: Hello and welcome to Peer Support and Peer Providers: Redefining Mental Health Recovery. Today’s teleconference is sponsored by the Substance Abuse and Mental Health Services Administration Resource Center to Promote Acceptance, Dignity and Social Inclusion Associated with Mental Health also known as the SAMHSA ADS Center.

SAMHSA is the lead federal agency on mental health and substance abuse and is located in the U.S. Department of Health and Human Services. The views expressed in this teleconference do not necessarily represent the views, policies and positions of the Center for Mental Health Services, SAMHSA, or the U.S. Department of Health and Human Resources.

Today we are joined by three people with extensive experience and knowledge on the topic of peer support and peer providers. Our first speaker is Dr. Jean Campbell, a Research Associate Professor in the Department of Psychiatry at the University of Missouri, School of Medicine in Columbia. She is also the director of the program in consumer studies and training at the Missouri Institute of Mental Health.

She co-developed a consumer operated service programs evidence based practices kit for SAMHSA with the principle investigator of a consumer operated services program multi-site study and has written more than 40 articles and reports on the development and use of management information systems and service system improvement, shared decision making, privacy of health records and peer support programs.

She is also the creator of the vivid works of art that grace some of her slides. Today Dr. Campbell will give us an introduction to consumer-operated service programs. Welcome Dr. Campbell.

Dr. Jean Campbell: Well good afternoon everybody. You know, I am so pleased to be part of this important Webinar on peer support and recovery. Today I'm going to talk briefly about the development of consumer operated service programs and research regarding their effectiveness in promoting mental health recovery.

So to persons with mental illness, recovery has always implied having hope for the future. We have always thought of recovery as living a self-determined life, maintaining our personhood or self-esteem, self-efficacy and achieving meaningful roles in society. And this is the meaning of recovery that's really rooted in the rich history of the mental health consumer, survivor, ex-patient movement and its development of organized peer support services.

My story today is going to begin in the early 1970s when large numbers of psychiatric patients were discharged from the psychiatric hospitals only to find themselves really adrift in an uncaring community that feared and shunned them. So in response persons with psychiatric conditions organized small groups for their mutual support and began to develop self-help approaches in addition to advocating for social justice.

By the 1990s persons with mental illness began to more formally organize on a national level championing our motto, “nothing about us without us.” And at that same time many of these smaller self-help groups began to bundle together as what we call COSP or consumer operated service programs. And for my presentation that is an umbrella term for programs that are administratively controlled and operated by persons with mental illness and programs that emphasize self-help as their operational approach.

So by the turn of the twenty first century, the push for recovery and the use of peer support services had really expanded across the United States as these COSPs matured and they diversified and they increased in numbers. This was really a time of growth.

And what we see today is a wider range of peer support services that are available through six primary COSP service delivery models that most of you are familiar with. Those include self-help groups, drop in centers, which I would call the mother of peer support programs, specialized peer services; and that would include programs like crisis respite, housing support, supported employment, fiscal literacy programs and health coaching to name a few specialized services.

Also multi-site, multi-service agencies like case management, they would offer case management, help with local and federal benefits and provide referrals; also peer educator and advocacy programs and peer phone services or warm lines.

So these are all models of COSP or consumer operated service programs. So while many of the details of these models are different when you look at them, how are these all to be under the same concept of being a COSP? That's because at the heart of all of these programs is a common set of peer structures, beliefs and practices.

From the very beginning in the 1970s these practices evolved to recognize and nourish our personal strengths and personhood and began to support us in achieving a quality of life. And these commonalities, these common set of peer structures, beliefs, and practices are called COSP common ingredients and they're really composed of 46 items common to peer support programs regardless of the service model.

These common ingredients have been incorporated into a rating system called the FACIT, fidelity assessment common ingredients tool, to determine how faithful a peer run program is to the structures, beliefs and practices of peer support.

And today that FACIT has been implemented in Missouri and New Jersey and soon Ohio as a tool to improve cost, their quality and their mission and direction and assure that they are following the practices that will promote recovery.

And here's an example of some of the practices of COSP common ingredients and their structure and beliefs. Under structure you would have things like these programs are consumer operated. And they're also participant responsive and that would mean that members or participants have decision making input into programming and rules, hiring, policies to give you a few examples.

They generally operate in an informal setting, settings that are - make the participants feel comfortable and these programs are dedicated to maintain member safety from harm and coercion. They all operate with beliefs in consumer choice and hope, empowerment, recovery, diversity, spiritual growth and self-help meaning that they practice the peer principle and the helper principle.

And in terms of their practices, they encourage the participants to tell their stories of illness and recovery. They have and engage in formal peer support and informal peer support. People are encouraged to mentor - to receive mentoring and to become mentors to others.

They learn self-management and problem solving strategies and express themselves creatively in the search for meaning and purpose in life. And finally, advocate for themselves and for their peers and to change the mental health system to becoming recovery based.

So until the last ten years mental health services research has focused primarily on the effectiveness of traditional mental health services that treat mental illness. And most mental health services research didn't really do that much research on COSPs as programs that could produce positive outcomes leading to recovery for persons with mental illness.

That really changed in 1998 when the Center for Mental Health Services funded the large consumer operated services program multi-site research initiative. And that was composed of eight COSPs; four drop in centers, two peer support organizations and two education and advocacy programs throughout the United States and their local traditional mental health agencies.

I was very proud to be the principle investigator of the coordinating center for that study. It's been over a decade of research and analysis on over 1800 persons. And the study has established that when adults with mental illness participate in a COSP as an adjunct to their traditional mental health services there is a significant increase in their positive subjective well being in comparison to those that are in traditional mental health services only.

And here is a chart that actually shows you what that looks like over the year that we collected data from these programs. The red line illustrates the consumer operated service programs that people attended as an adjunct to traditional mental health services and the lower line, the blue line, showed those that went to traditional mental health services only.

And you can see that both lines go up a little bit. The traditional - everybody got a little bit of well being. But consumer operated service - those that attended consumer operated service programs got a significant amount of positive subjective well being over those that didn't attend consumer operated service programs.

So the greatest - we also found out that the greatest gains in well being were found for participants who use the peer support services the most that was one finding that was important. Another one was that variations in well being, findings of well being across the program models, didn't seem to be related to the model that the program had whether it was a drop in center or a peer - a peer support self-help group or an education advocacy program.

It didn't - all of the programs performed in the same way, which led us to discover that most important analysis of the COSP common ingredients that we talked about earlier and outcome results that really establishes strong relationship between those practices that I gave you some of the examples of that support inclusion and peer beliefs and self expression really have a strong relationship with well being outcomes.

So - and here's an example on this chart of the red line are those that went to the COSP the most and you can see they certainly got the most well being. And those that had really low attendance at the COSP, you can see it's quite a bit less. And then of course those that never attended the COSP got the least amount of well being. So the more that people attended these peer support programs, the greater their well being was.

So what we find is that this study confirms a growing body of evidence that COSPs are evidence-based practices. And within the next two months SAMHSA is going to be releasing for general distribution the evidence based practices kit for COSP. In other words, peer support services promote participant positive subjective well being.

When offered as an adjunct to the treatment of mental illness, they promise mental health consumers recovery of a life in the community. And study results have really advanced the capacity of researchers and peer providers and mental health administrators to promote evidence based peer practices in developing COSPs and inviting quality improvements within COSPs that are already operating.

And that leads us to what are the policy implications of these findings for our peer support programs. Well as a nation - as our nation really adopts an integrated recovery based approach to providing mental health services and support, the evidence of the effectiveness of COSPs will encourage policy efforts to expand peer support services and you can read the word fund peer support services there within the community of - within the continuum of community care.

One example would be that as an evidenced based practice that gives us leverage to really get a greater proportion of block grant funding and other funders will be more directed to support programs that can definitively say that they produce well being leading to recovery. And finally, there's some resources I encourage you to check out to learn more about what I discussed today. Thank you all.

Jane Tobler: Thank you Dr. Campbell for that excellent overview and introduction to consumer operated services programs. Our next presenter is Shery Mead Managing Director of Shery Mead Consulting.

Shery is the past Director of three New Hampshire peer support programs including a peer run hospital alternative. Shery is a nationally and internationally known speaker and trainer on the topics of alternative approaches to crisis, trauma informed peer services, system change and the development and implementation of peer-operated services.

She's authored several articles, manuals and books about recovery and peer support. Today Shery joins us to address intentional peer support. Welcome Shery.

Shery Mead: Thank you. Thanks for inviting me to this presentation. Today I hope to talk a little bit about intentional peer support, a philosophy in practices being taught around this country and in other parts of the world as well.

As a way of framing the discussion I would like to open with the following statement. Instead of more mental health services, our vision is that peer support becomes part of everyday culture and simply good community practice.

What I mean by that is that peer support is really no different than the kinds of relationships we should be able to expect from our peers but also our friends, our colleagues and our neighbors. In other words, peer support isn't just about mental health systems change but about social change as well.

Let's start with what makes intentional peer support different than some other mental health models. Where traditional mental health focuses on helping, we'll pay more attention to learning from each other. While services focus their attention on individuals where one person is there to help the other, we pay attention to relationships or what we can learn through the process of building mutuality.

Instead of reacting out of our own fear of what someone else is doing, we'll talk more about negotiating discomfort so we don't find ourselves in coercive roles.

Is it about health or is it about learning? Health assumes there's a problem to be solved. When we assume that our role is to help the other person, we are often actively looking for problems we can help with. While that's not a bad thing to do, it can get us stuck seeing a person as simply a basket of problems. Health tells us the other person - health tells the other person that you have some kind of expertise creating a potential power imbalance.

If we assume that we're there to help, we automatically put ourselves into a position of power and into the role of expert even if we don't feel like experts. If we find ourselves in this role, even sharing our own stories may come across like there's only one way to do things. One of the things we've learned from the international aide or health community is that if we just send the kinds of aide we think are needed, we forget that what we assume about others needs may not be correct.

And example of this is after the tsunami in Indonesia, a group of people from the United States sent books to replace the books in Indonesia that had been destroyed. But they were books written in English, which was not their first language. How helpful was that? While the intentions were good, the help was not very helpful.

So what's different about a focus on learning? Learning doesn't necessarily assume there's a problem. When we're focused on learning, we're not actively looking for problems to solve and therefore less likely to fall into any kind of assessment. Learning doesn't assume a mental health context.

When we assume that our task is to learn together, there's no assumption that we'll just focus on mental health. Learning from each other may even open up conversations that take us in completely new directions. For example asking someone, "what's new," may lead to some unexpected topics whereas asking, "how have you been feeling," is a direct line to getting a list of mental health problems thrown your way. Learning together doesn't assume that one of you is the expert.

The most obvious point is that when we spend time learning about and from each other neither one of us takes on the burden or role of expert and therefore there's naturally more of a power balance. It also leads to deeper trust and respect, which is the essence of mutual learning.

Finally, learning together may lead to possibilities that neither one of us had ever even dreamed of. While helping tends to focus on problems and solutions, learning is creative and opens new doors with no conditions or barriers to shared growth, therefore the sky's the limit.

When it's about the individual; if we're just paying attention to you making changes, I don't have to look at myself and my own changes. I also don't need to take responsibility or consider circumstances beyond the individual such as social or economic factors like poverty or discrimination or unequal access to resources.

Another subtle barrier is that when we believe that our job is to help another individual, we often come in with an agenda and then proceed to impose that on them. After all we're the ones who have done recovery, aren't we? Maybe that keeps us from doing our own learning.

Finally, when there are challenges in the helping relationship, I may see it as all your fault. How many times have you heard people talk about their quote "difficult clients?" Often we just don't see our own part in it. But when it's about the relationship. When we do work relationally, we both contribute to each other's learning and growth.

How freeing. You don't have to have the answers. It's also in these learning conversations that some of our more challenging situations can be negotiated with openness and honesty, which actually offers the possibility of understanding very different perspectives than our own.

Our relationship becomes a model for other relationships. How cool would it be if more of our relationships were like peer support? Outcomes are not pre determined. When we're not pushing our agenda or our expectations for particular outcomes, something totally unexpected may emerge.

Peer versus hope. Too often when we've had some challenging times even people with the best intentions have tried to help but mostly have ended up reacting out of their own fear. They've tried to calm us down. It makes me wonder did we really need to calm down or do they just need us to?

Is it more comfortable for them to fall into the helper role so that things will just go back to the way they were? Unfortunately when people do take over for us, we may even learn to believe that we're out of control and a need of someone else to control us?

But with a hope-based response, we're saying really what we need is for others to sit with their own discomfort and not be afraid to talk about it. We need connection and honesty so that instead of coming to rely on them we can work things through together.

It's in these kinds of conversations that new options open up and we don't keep coming back to the same old crisis over and over. In the safety of a mutual relationship we learn to see things differently and to take more risks and more responsibility for changing our lives.

Now let's switch gears and talk about some of the how tos. I've developed this framework called the four tasks. I hope it will give you some ideas about the practice. The first task is connection. This is the obvious first step in any relationship but it doesn't just come from assuming there's a connection because we have something in common. It actually takes courage, openness and vulnerability and a willingness to be affected or changed.

The second task is worldview. This is about developing awareness. Awareness of what we bring to the table and an awareness of what others bring to the table. That's us to remember that our beliefs and assumptions have come out of our own life experience and may actually get in the way of understanding someone else's way of seeing the world.

In the process of self-reflection we might ask ourselves, "what are my biases and assumptions about this situation? How have I learned to think or see things in this way?" I might ask similar questions of you including, "what is it that you really want me to hear?"

The third task is mutuality or mutual responsibility. The combination of connection and worldview plus dialogue sometimes create what we call light bulb moments. When you find your - when you find each of yourselves saying "wow, I never thought about it that way." This then leads to a bigger picture understanding while building more trust and depth in the relationship.

The fourth task is called moving towards. What's possible with our new learning? Who else can we bring into the dialogue? Moving towards is the energy that comes from a great conversation. It leads to a desire to try out new ideas and new practices and creates hope and courage for this kind of conversation with other people in your life. At its best moving towards is the social change snowball effect of peer support.

Here's a short conversation to illustrate the four tasks connection, worldview, mutuality and moving towards. (Mary) and (Sue) have been getting together for peer support for several weeks and (Mary) the peer specialist is feeling kind of stuck because it seems that the same old problems just keep coming up over and over again.

(Sue) says, "Hi (Mary). I wonder if you can help me with my anxiety. It's still really bad and I don't know what to do." If (Mary) says something like, "Well when my anxiety gets bad I usually go for a walk." We see (Mary) quickly falling into fix it mode and not really making much of a connection with (Sue).

If instead she says, "I'm sorry to hear that. It feels lousy to feel like you're not getting anywhere doesn't it." (Sue) will more than likely feel heard and validated leading to the beginning of a trusting connection. If (Mary) goes on to ask something like, "What does anxiety actually mean to you" gets out of the assumption that there's only one understanding of anxiety and opens the door to a conversation that can lead to different understandings.

(Sue) might say, "Well I just feel overwhelmed by things and then feel like I'm just spinning my wheels." Now (Mary) can bring in her own experience as well as provide another framework.

She might say, "That's so interesting. I used to think I was just kind of wound up but didn't think about it too much. Then my doctor told me that I had an anxiety disorder so I started to see myself as sick, which left me feeling out of control. It took me a while to realize that perhaps seeing myself as sick was much more the problem then simply feeling wound up."

This offers (Sue) a chance to see that there are many other ways of understanding her experience and she might say, "Yeah I guess maybe the worrying about the worrying is keeping me kind of stuck." (Mary) now has the opportunity to own her own part in the relationship and could deal with her own frustration without alienating (Sue). She could say, "Yeah I've been kind of wondering about that. It seems like we talk about it a lot and then I fall into trying to fix it for you."

Hopefully this opens the conversation up so that (Sue) sees things from a new angle and gives both of them a chance to reflect on the purpose of their relationship. (Sue) might say, "And for my part I've guess I've gotten used to people trying to fix me. What do you think we should do differently with peer support?"

Although this may or may not be the way the conversation goes, it shows an effective connection and sharing of worldviews. Instead of talking about what's wrong and how to fix it, they get to know each other better and can move the relationship into new territory.

So let's take a final minute to think about what we're doing here. Being curious about our own discomfort. Consider what we're learning together rather than what we're providing to one another. Seeing things as possibilities rather than problems to be solved.

Seeing mental health more broadly to include the health of the world or the planet. Is it possible that peer support might even change the world? Thanks so much for your time and commitment to peer support.

Jane Tobler: Thank you Shery for sharing that important information on intentional peer support and I think getting all of us thinking. And thank you for including the resources on Slide 36.

Our final presenter today is Steve Harrington, Founder and Executive Director of the National Association of Peer Specialists. Steve is a lawyer, mental health advocate and mental health organizational and curriculum consultant. Steve has been diagnosed with two psychiatric disorders and received mental health services.

He's the author of 12 books on a variety of topics including The Depression handbook, You Can Recover and his newest book, Trees of Hope, which is drawing critical acclaim from leaders in business, government and healthcare. Today, Steve joins us to talk about peer support, challenges and possibilities. Welcome Steve.

Steve Harrington: Thank you Jane. It is such a pleasure to be here as part of this Webinar. Dr. Campbell and Shery have done a wonderful job of presenting background and a vision. In this portion of the presentation we'll be looking at some of the issues and opportunities associated with peer support.

It is important to recognize that peer support can be paid or voluntary. When it is paid the individual may be referred to as a peer specialist or a peer advocate or one of many other titles. But it is also important to recognize that volunteer efforts are very meaningful and help a great many people on their recovery journeys. Peer supporters are needed wherever there's a need for hope. Thus the roles are quite varied.

Once peers join the workforce, there are issues to consider. The first issue as Shery discussed is often a function of fear among employers. But education and positive experiences are quickly overcoming this barrier. The other three are key issues we will examine in more detail.

Unfortunately the number of hours and wage levels are often minimal for paid peer supporters. Many peer supporters report that employers believe they are doing them a favor by not providing a real work experience because they don't want to interfere with social security or other benefits. This means peers in the workforce are still living in poverty for the most part.

Low wages and few hours also cast peer supporters in a subordinate role as compared to other mental health workers. This can effective self esteem and ultimately how well peer support is delivered. Some tasks assigned to peer supporters are simply inappropriate because they don't allow the peer to use his or her recovery experience to inspire and encourage others on their recovery journeys.

These tasks - a few of the inappropriate tasks are listed here. Again cast the peer in a subordinate and even demeaning role. As Dr. Campbell noted, the trend to expand peer support is founded on positive experiences and research that demonstrates meaningful outcomes. Meaningful tasks help support the reality of the power of peer support and as a result expansion of these kinds of services.

Conflicts arise in every workplace but because peer support is relatively new many of these conflicts appear to be fear driven. Here are some of the questions traditional co-workers may be asking themselves. Peer workers often find themselves reassuring their co-workers that although there may be some workplace changes, fears are generally unfounded. We all want the same thing and that's important to keep in mind. We all want effective services for those in need.

If conflicts are not addressed, what happens? Here we can see some of the reported results. Communication and effective supervision especially where the supervisor addresses the fear issues of incumbent staff can go a long way in avoiding these results.

Peer workers may react to workplace pressures and cultures by behaving more like traditional mental health workers than peers. They may adopt behaviors that reflect an "us versus them" attitude. In this case peer supporters lose their peerness and with that loss the ability to meaningfully help peers on their recovery journeys.

Why does this happen? Well here's some of the reasons. Perhaps the most common are the effects of the existing workplace culture. Being surrounded by people who work and have worked in a certain way for a very long time, it can be a little contagious.

Less effective services. We have to remember that as peers we bring a special set of skills to the workplace. And if we fail to use those skills, it is those who need our services the most who will suffer. We all want the same thing. We all want recovery.

So what are the possibilities? Peer workers are creative. Some are considering forming associations that act as contractors for mental health agencies. In this way peer workers may be able to have more control over wages and hours. More Medicaid reimbursement means more jobs. And the number of states with Medicaid reimbursement is growing. And more peers in the workforce is likely to mean more change toward true recovery oriented systems.

There are other possibilities as well and some of these possibilities are becoming reality. Peer workers are increasingly being seen as the recovery experts and at least informally educating the incumbent workforce. Research such as that performed by researchers such as Dr. Campbell can help us form persuasive arguments for acceptance of peer workers and the systems.

It is important to consider that the skills peers develop in the mental health workplace can be used elsewhere such as in business and government. We can look beyond mental health systems for employment opportunities. I do not fear storms for I am learning to sail a ship. One of the skills we learn is that challenges can be real learning opportunities. And that skill often helps us not just in our personal lives but can be very important in other contexts such as business.

The National Association of Peer Specialists is now working to develop peer support in the workplace. Previously the association focused solely on getting peers employed. Now the organization is looking at ways to create career paths and make peer workers even more meaningful and effective.

The Recovery to Practice project, which is funded by SAMHSA, is exciting because we are identifying recovery knowledge gaps and will be addressing those gaps. This project will result in a curriculum that will benefit not only peer specialists but all mental health occupations because we're collaborating with these other professions.

Peer supporters are developing networks in a variety of ways. These networks help us learn from other's experience and collaborate so that we're not duplicating efforts and resources. One of the most important ones that's evolving as a social media like the Google groups and Facebook.

Yes we have many challenges but we have come very far and it's easy to lose sight of that. The challenges before us though are great but we have great people working to address those challenges and that is exciting. But we also need more leaders. That is an important issue we must address today to ensure that there's a tomorrow with effective peers in mental health work.

In our recovery journeys we have learned to be persistent and creative. Those and other skills will help us overcome the challenges before us. Reach high for stars are hidden in your soul. Let's dream and dream big. We won't know what we can accomplish until we stretch our minds, imaginations and hearts.

Here are just a few key resources that you may find valuable. I strongly advise people to access those particular resources especially if they're looking for ways to persuade employers that peer support is indeed important. Okay Jane.

Jane Tobler: Yes. That was great. Thanks Steve for sharing that information around challenges and possibilities in peer support. And I love the images as well as I'm sure many people on today's call do. On the next slide you see resources and now I would like to go back to our first speaker Jean and ask you what is your vision?

Dr. Jean Campbell: You know, I really dream of a future where treatment and services are empowering and hopeful and we end all forced interventions. And I also really hope for peer support services to become a vital force for well being and carry the message of recovery around the world. Carrying the vision of hope and empowerment and goal attainment and self-esteem and social connectiveness and the belief in recovery for everyone.

Jane Tobler: Thanks Jean. Shery what is your vision?

Shery Mead: I guess I hope that the kinds of good peer support relations that we have with each other begin to influence our other relationships. Like I love it when I hear people say, you know, "I'm doing peer support with my father or my partner or my brother, my employer." And that to me is what's it about; spreading the more practice more widely.

I hope that people become more open to very diverse views and hold all kinds of different truths equal. It increases the tolerance of our own ability to sit with discomfort and it increases our ability to have meaningful dialogue.

But most important I think that peer support is really something quite a bit bigger than mental health. And it helps us begin to think more internationally. We can't separate out what we do from the issues of poverty and international conflict even things like global warming. So my hope is that peer support and the kinds of relationships that we have with one another begin to contribute to some of these global issues that just are so significant in our lives.

Jane Tobler: Thanks Shery. And finally Steve, what is your vision?

Steven Harrington: My vision is similar to Shery's. I want to see a world where peer support is part of how we live our lives. Acts of kindness become the norm and not the unusual. I was at a conference one time and had a psychologist say, "You know, peer support can really change the world." And that made me stop and think and the more I thought, the more I thought he's really right.

As a person with a psychiatric condition I don't want to be just accepted or tolerated. I want to be embraced for what I have to offer in the workplace and to society as a whole. You know, we've all learned a lot from our mental health experiences and we do have an awful lot to offer and I think we should be embraced for overcoming and dealing with those challenges. It costs a candle nothing to light another candle. We can do this. That's my vision.

Jane Tobler: Thank you Steve. We will take listeners' questions soon. So if you have a question please press star 1 to go into the queue. But before we move onto questions, I want to point out there are additional resources on Slide 63 and Slide 64 including some that were written by today's experts.

For the questions, please dial star 1 on your telephone keypad to be placed in the queue and give the operator your name, which will be announced before your question. If you would prefer to only have your first name announced today, then only give the operator your first name.

Once the operator calls your name, please ask your question and then your line will be muted allowing the presenters an opportunity to respond. If you have additional questions beyond the time of the call, you're welcome to follow up with the presenters whose contact information is listed on Slide Number 66 or you can contact the SAMHSA ADS center at promoteacceptance@samhsa.hhs.gov. The address and contact information for the ADS Center are listed on Slide 72.

Although this call may have brought up personal stories that we would all like to share, we do ask today that you limit yourself just to asking one question so we may get to as many of the callers that we can. Operator, we will now take our first question from a caller.

Coordinator: Thank you. Our first question comes from (Diane Lickmen). Go ahead, your line is open.

(Diane Lickmen): Hello. I 'm wondering if Mr. Harrington could speak to the other possibilities of say a little bit more perhaps about peer supporters finding career development outside mental health; what that would look like? If you could give some examples please?

Steven Harrington: Well that's a question that's near and dear to my heart. There's a book recently published. It was written by Robert Thomas. It was called Crucibles of Leadership. And Robert Thomas had interviewed a number of business leaders and he found out that what made them good leaders was having overcome a serious life challenge.

And that got me to thinking about what could be more challenging then dealing with a psychiatric condition. And as a result of what we learned, I think that we're in a position to really enter and really affect the business community in a positive way.

You know, and other areas we're seeing - for instance, we're dealing with a law firm that is interested in hiring peer specialists because they find that their defendants or people they're representing whether it be a civil case or a criminal case, quickly lose hope as part of the legal system. And they're seeing that peers specialists, peer supporters may be a way to inspire hope.

But those skills that we've learned, those skills of being persistent and creative, they can be applied in government and other context as well.

Jane Tobler: Excellent Steve. Thank you very much. And (Diane) that was a great question. Operator, do we have another question?

Coordinator: Our next question comes from (Joy Torres). Go ahead, your line is open.

(Joy Torres): Hi. My question is for Shery. I am looking at, you know, looking at, you know, tackling poverty. And what would be some of the ways that we could get our own services to show how to go from SSI to a full time or part time job without being in the poverty section? What would be some advice to do that?

Shery Mead: Is your question more about how to deal with poverty in general or how to work with getting off benefits?

(Joy Torres): Well like how to get off benefits without setting yourself up if you're on housing and SSI or...

Shery Mead: Yeah. Probably there are other people on the call who know more about benefits than I do. But there's - I know there's a lot of resources about how to get off benefits in a way that, you know, maintains your Medicaid and housing and so forth. Is there anybody else on the call who would like to answer that question?

Steve Harrington: I know the Social Security Administration is a wonderful resource in that regard and they can help people with programs that make that transition.

Jane Tobler: Excellent. Thank you Steve. Steve, one of our email questions that have come in is for you. What peer support options are available for consumers without Medicaid?

Steven Harrington: That is becoming an increasing challenge. But at the same time we're also seeing, like I say, peer supporters are creative. And we're seeing a move to where in some states they can actually provide peer support on a private pay basis. They can do that in some states. Peers support can also be found in support groups. We're seeing an increasing number of churches offering support groups for mental health issues, which to me is just a wonderful evolution to see that.

So there are resources in the community such as those. Also I would suggest NAMI groups. Belonging to NAMI can be really powerful. And there are also state wide or even local consumer groups as well. And anywhere you're making connections with a peer whether it's intended or not, you're likely to find peer support.

Jane Tobler: Excellent.


Dr. Jean Campbell: I would also like to add to that.

Jane Tobler: Sure, please do.

Dr. Jean Campbell: This is Jean and I'd like to add that, you know, we're facing a tremendous fiscal crisis right now and many people aren't - are losing their Medicaid benefits at the state level because of not - the states not being able to make the matches.

And actually consumer operated service programs are really becoming the safety net within our communities to help support people that have lost Medicaid benefits or can't receive Medicaid benefits and don't have any other ways to get resources.

And in many - we've talked about the services that have been offered by peer run models. But just to remind you that many programs now are having health coaches so you can get some screening for health conditions and having food banks is another service. There are multiple resources that these programs provide in a time of real crisis and poverty.

Jane Tobler: Okay. Thanks a lot. Operator, could we go to our next question please?

Coordinator: Our next question comes from (Rosalyn Garner). Go ahead, your line is open.

(Rosalyn Garner): Yes, hello. A fair number of mental health consumers have criminal backgrounds, which makes seeking employment problematic. And when you talk about peer support, what kind of guidelines are used in regards to criminal backgrounds?

Jane Tobler: Steve, could you answer that please?

Steve Harrington: I'd love to. What we're seeing is that actually a criminal background can actually be an asset. We're seeing peer specialists specializing in what's called forensic peer support. And that's where peers are going to jails and to prisons and even in courtrooms and they're able to use their own criminal experience as a way to connect with peers in a similar situation even more effectively.

This came up several years ago and it can be an incredibly powerful tool. Turning that detriment in peer support can be a powerful, powerful asset.

Dr. Jean Campbell: The consumer-operated programs here in Missouri for example require a background check for both volunteers and for paid staff. But what we've discovered is it's only certain kinds of crimes that really eliminate people from working within one of these programs. Plus there is a process of appeal and getting waivers. So it depends also on the individual context.

Jane Tobler: That's a great point. Thank you. Jean, this question is for you that came in via email. Are there other research studies currently occurring right now around peer support and what are they measuring or what should they be measuring?

Dr. Jean Campbell: I am not familiar with any ongoing studies but that doesn't mean that they're actually not occurring. There are many studies operating at different levels like local and community studies, qualitative studies in which a small group is going out in the field to find out information.

So that being the case, I will tell you that funding is certainly available for recovery studies and also participatory action research studies in which people within these programs actually participate. They may not be studying directly consumer operated service programs but the focus on recovery and the focus on organized groups of the recipients of care I think can lead one to write a proposal that could involve a consumer operated service program.

Shery Mead: Just wanted to throw in a couple of my two cents. There's a couple of research projects going on in different parts of the world actually studying mutuality in peer support. You asked about what kinds of things we should study. I think that's kind of the essence of peer support and what makes it different. And I think that kind of thing is unique and really contributes to the literature a great deal.

Dr. Jean Campbell: I think one area where there isn't enough study going on is really understanding what outcomes that peer run programs and peer support produce because it's my understanding that we need both the treatment of illness through traditional mental health services and the promotion of wellness through consumer operated services to get to recovery. And I don't think that there is enough research showing that dynamic and the importance of the promotion in wellness.

Jane Tobler: Thank you.

Steve Harrington: Just briefly...

Jane Tobler: Sure.

Steve Harrington: ...I'd like to contribute. There is a study of peer support underway at Kansas State University and (Matt Shinman) and (Mark Salzer) in Pennsylvania are working on some studies that focus on outcomes to support the work of Dr. Campbell. And also the Center for Psychiatric Rehabilitation at Boston University is studying ways to help improve peer support such as developing a curriculum for vocational rehabilitation and then testing how well that curriculum works.

Dr. Jean Campbell: Well Steve, you jogged my memory actually. I'm involved here through our transformation grant here in Missouri. We were required to be involved in a study of proof of concept. And we chose the concept of peer specialist. So we are right now studying peer specialist and in particular the outcomes of well being is primary.

Jane Tobler: Excellent. Well, that was a very, very good answer. Operator, could we have the next caller please?

Coordinator: The next question comes from (Pametha Davis). Go ahead, your line is open.

(Pametha Davis): Yes. I'm a peer support specialist here in Kentucky. And I work with other consumers in many capacities. But I'm most passionate about advocating. I give both educational as well as inspirational speeches. I have many opportunities to speak for consumer groups but my problem is that I'm very limited on opportunities to speak to state government or provider groups and about any changes that, you know, need to be made in the system.

And what I was - my question was if you all had any contact here in Kentucky or had any suggestions on how I could gain a broader platform here in Kentucky.

Shery Mead: One of the ways that I got going was to do little presentations at schools. And I think that can be really powerful if you go to a social program or a nursing program or even a medical department; it's great to be able to bring that kind of story to people just coming out into the field.


Steve Harrington: There's still much power in the personal story. And it seems like it's a question of marketing and if the caller would contact me -- my contact information is on that slide -- I can provide some information.

Jane Tobler: Excellent. Thank you. Next caller please operator.

Coordinator: The next question comes from (Clint Riner). Go ahead, your line is open.

(Clint Riner): Thank you so much for taking my question all three of you. This is probably going to go to Jean but I'd like to hear from the other two speakers though, Shery and Steve. As we push for employment with our certified peer specialists who are vetted and who are certified and who go through really more background research and have to become more of a professional. We call them peer professionals in the state of Florida.

We've identified two barriers with our providers and they are the human resource directors and the risk management teams that once someone is a particular successful applicant for an employee's position, when they get into that provider status, that's the two barriers, they run into either someone at risk management or with HR.

And my question is have you - and Jean and you may have done this when you've done some of your research. Are you seeing that - are we seeing this across the country number one? And number two is there an effort that's being directed towards these two specific groups of people that we can get them to understand that there's, you know, they're hiring quality people who really have been more vetted probably than the average employee. Thank you.

Dr. Jean Campbell: I think that actually this question should go to Steve rather than me.

Steve Harrington: Okay. Well (Clinton), it's good to hear from you.

(Clint Riner): (You too Steve).

Steve Harrington: This is an issue that has come up as we've talked to peer specialists across the country as part of the Recovery to Practice project. And it will be part of the new curriculum, recovery curriculum that will result. Is it common across the country? Unfortunately it is. It seems to be a barrier and in my view it's really a false barrier.

We found that very often when you get that first or second peer specialist into a particular agency they become comfortable with that individual and understand the roles. These kinds of barriers become irrelevant.

We have also found that if there is even just a basic training about ethics and boundaries that that helps a great deal to ally those fears. So that's really what we're looking at is education for the peer specialists but also for those administrators who have that fear of what could happen. It really seems a legal liability issue is really not a real issue from experience.

Jane Tobler: Thank you Steve. The next question comes from email and this question is from Jean. What tool was used to measure the change and well being over time?

Dr. Jean Campbell: It was a composite tool that was composed of many established scales that composed well - that composed well being which included hope - a scale on hope called the Herth Hope Index; a scale on empowerment primarily the making decisions scale developed by Judi Chamberlin and others at BU.

A subscale on goal attainment, how well people attain their goals, which is part of a recovery assessment; a scale that was developed. A scale on self-esteem, self-efficacy, that it is one that's been used a lot; and another scale on social connectedness. So we used all of those scales to show the different aspect or dimensions of well being.

Jane Tobler: Excellent. Operator can we go for the next caller question please?

Coordinator: Thank you. Our next question comes from (Linda Simpson). Go ahead, your line is open.

(Linda Simpson): Hi. I'm calling from Arizona where we have lots of activity at the local level. One of the - and I know there was a lot of energy and creativity that led to this call. And my question is where can - let's see. There's system change that we need at all levels and local efforts as well as national efforts.

And I'm curious about what are things that are moving forward that maybe need some more momentum or that are poised and ready to go where we can channel our interest and energy that's generated from this event?

Dr. Jean Campbell: Well I can speak to one thing is that, you know, as I mentioned before that soon there will be the release of the evidence based practice kits for consumer operated service programs and also the rollout of the cost study is going to occur. So there's going to be articles published on the effectiveness of consumer operated programs.

And this can be a real - apply real leverage to get funding for consumer operated service programs which are facing now even though they're a safety net. They're really facing cuts at the state level. So being involved in - on the planning committees for state budgeting and really advocating that these programs get funded under block grant funding.

Those two efforts being part of the planning committee for the state budget and advocating for block grants funding based on this becoming an evidenced based practice I think is really, really key to the survival and the future of peer run services.

Jane Tobler: Excellent. Thank you. This is another question that came in via email. And I'm going to ask Steve and Shery to think about this one. So since licensed marriage and family therapists as well as licensed clinical social workers have an ethical code regarding not participating in dual relationships, how do clinicians and peers handle this when working side by side? Steve. Do you want to answer first? And if you're talking, you're still on mute so you need to star 6 yourself.

Steve Harrington: I'm sorry. Yes. I was on mute.

Jane Tobler: That's okay. No problem. It was on the licensed married and family therapist...

Steve Harrington: Yeah.

Jane Tobler: ...and the LCSWs and the ethical code...

Steve Harrington: Yeah.

Jane Tobler: ...regarding not participating in dual relationships. So how...

Steve Harrington: Right.

Jane Tobler: ...do you suggest this is handled?

Steve Harrington: We're seeing ethical guidelines being developed by each state because each state is handling their certifications. This is a real difficult issue because the relationship between peers and the power that shared experience and the trust part really makes it different than other professions.

And to just apply the ethical standards I believe that govern other professions and just directly apply them to peer supporters is really not practical; it could be counterproductive. There does need to be protections of course for both the peer supporter and for the peers who are being served.

Exactly how that's going to shake out, I don't know. We are seeing some much more discussions on this very issue. And ethical issues is another one, like I said, was raised in the Recovery to Practice project. And we will be looking at these kinds of debates.

Shery Mead: And I guess I hear two questions in that one is possibly that they're asking about family therapists and social workers and such becoming peer support workers and what do they do in that case where they have two ethics statements. And I think that knowing which hat you're wearing at any given time is really important.

But the other response about peers and codes of ethics is that it's going to be tremendously important for us to define peer support by what makes it unique and different. And for me that's about mutuality and reciprocity. So being able to have more sort of natural, if you will, community type relationships with people is kind of the key to what makes peer support work and work differently than other services.

It's kind of a much more friendship oriented type relationship as opposed to professionalized. And so when we get really clear about what makes it different, then I think we can guide ourselves with ethics but also with good quality co-supervision where we're evaluating our actions by our set of values.

Jane Tobler: Excellent. Thank you to both of you. Operator, can we go to the next caller please?

Coordinator: The next question comes from (Dan Bader). Go ahead, your line is open.

(Dan Bader): Yes. Thank you for the interesting presentation. I was wondering if you could say something about the cost of programs or creating peer support specialists. I've been told that some of them are quite expensive.

Jane Tobler: (Dan), this is Jane. Can you give a little more - can you talk a little more about what you mean?

(Dan Bader): Well, to get the educational requirements to be a peer support specialist, someone was telling me that the cost could be as much as 950, $975 which would be prohibitive for so many people to be able to obtain that kind of educational input.

Jane Tobler: Okay. Steve, can you address that please?

Steve Harrington: Sure. In some states the way it's - the training is organized it can be very expensive. Even more than $1200 or $1500 which precludes people who would like to be peer specialists from getting that training. There are some options for funding. Some people are finding great luck explaining what a peer specialist is to community foundations or community groups like Lion's Clubs, Rotaries, getting support that way.

Usually it is an employer who pays for the training that's usually the way the models go but that's not uniform of course. The cost of training can be a barrier. I would just really encourage you to explore what options, what training options are out there.

In North Carolina for instance they ran into this barrier and peers themselves created a curriculum and got it approved and are teaching it themselves with great success at a much reduced cost.

Jane Tobler: Great. Thank you so much. This I want to share. It comes from one of our people on email. It's information about the question earlier about getting off of SSI, SSDI. And they suggest -- thank you (Mary) by the way -- a very good resource called "It Pays to Work, Are You Ready to Cash In?"

She said it's a very user-friendly book and you can get it by calling 412-325-1100. That's 412-325-1100. And it's published by the Allegheny Health Choices Inc. in Pittsburgh, Pennsylvania. If you go and Google Allegheny Heath Choices," it will - it should be one of the top ones and then you can also find it there.

So again, "It Pays to Work, Are You Ready to Cash In?" And that was for the earlier caller that asked about getting of SSI and SSDI. And we've had several questions also coming in via email about that. So again, thank you to (Mary) for sharing that.

And operator, we will go to our next question please.

Coordinator: Thank you. Our next question comes from (Latasha Jordan). Go ahead, your line is open.

(Latasha Jordan): Hello. My question is how and where do you go to become - apply to become a peer specialist?

Jane Tobler: That's an excellent question. Steve, do you want to tackle it?

Steve Harrington: Sure. It depends entirely upon the state. While a little more than half of the states have very meaningful powerful peer specialist programs, some states do not and are just working on getting there. I would look on the Internet and Google, "the State Department of Mental Health."

Try to find out from your Department of Mental Health where your program is if they have one. And they should also be able to provide some information regarding training and certification as well. So your state - you individual state is going to be the best resource on that.

Jane Tobler: Excellent. Shery, this question is via email for you. It says, "I know you do lots of international work. Can you share some of the leading edge intentional peer support or peer support programs and initiatives worldwide?"

Shery Mead: Well, there's different - different countries are doing different things. I think everybody always asks me what - who's doing the best work and I have to say everybody's doing their own bit of the best work. Australia is just starting to develop peer support for crisis programs. I think that's really exciting using intentional peer support.

And New Zealand is actually running an entire mental health center in all capacities. All of their workers including peer support workers use intentional peer support training. In England there's a lot of research - consumer run research that's quite interesting. Let me just think.

And Canada's been doing all kinds of interesting work particularly in Ontario towards developing a curriculum that's Canadian specific and they've done quite a lot with peer operated programs up there. So I hope that gives you some ideas.

Great. That was wonderful. Thank you. Operator, can we get our next question please?

Coordinator: Our next question comes from (Gayathri Ramprasad). Go ahead, your line is open.

(Gayathri Ramprasad): Hi. It's (Gayathri Ramprasad). Thank you. An incredible presentation. I'm so grateful to every one of our speakers and all the audiences that are asking great questions as well.

Just a suggestion and of course I'm going to reach out to each of the speakers via email also. In the last several years since I've started ASHA International, a non-profit organization in doing global outreach, it is a challenge and my dream to carry on the power of peers and help communities around the world start peer support groups within their communities.

But needless to say and of course there's many challenges. And just as an example in my home country of India there's still a cultural fear. The silence is our peers. And so from the chain and secrecy and as much as they would want to be hope bringers, they are terrified of disclosing about their illnesses and sharing about their journeys to recovery as well.

So my question really is how much global outreach has been done so far and what have we learned from it?

Jane Tobler: So your question is the - what have we learned from the research that's been done?

(Gayathri Ramprasad): Have any of you actually focused on peer support systems around the world? And if you have, what have you learned about them? What are the challenges faced or the successes that they have experienced? You mentioned Australia as an example but, you know, are you familiar with peer support programs around the world?

Jane Tobler: Well certainly both Dr. Campbell and Shery have lectured internationally. Dr. Campbell, can you address that?

Dr. Jean Campbell: Well, you know, and I can't address it directly. It's one of those things where I would have to do some research on this and check things. But, you know, in my own experience for example I've attended the World Congress of Mental Health, which has been held in many different countries. And the first one I went to was in Chile. And I went there with the idea of meeting other peers and finding out how peer support particularly in countries like Chile and in countries in Africa how peer support was done.

And, you know, I found out there was no peer support. And in most of those countries which really flabbergasted me. At one - one thing I also that I did find out as well over the years has been that the U.S. government as it promotes mental health services and our models of mental health services around the world, it mainly promotes from the traditional mental health services treatment system.

And for example, when they sent psychiatric support to Yugoslavia and Czechoslovakia and Bosnia, they didn't send any peers to help establish peer support services. And even in our own country when we've experienced disasters like Katrina in New Orleans and other southern states or in - when there was the great in 1993, the federal government called for volunteers - mental health professionals but not peers.

So I think that one avenue in order to spread the peers or the - would be to get that - to be in the system that provides psychiatric service models and teaching to be able to expand that to allow for even the concept of peer support in terms of global outreach.

Shery Mead: The other - there are many places that I've heard of peer run programs, not the least of which was Nepal and I know they're running on a shoestring. But they actually do quite a bit of advocacy. And I know there's quite a bit going on in India and some African nations. We've worked a fair amount in Japan which I know there's a lot of peer specialists coming to Japan. But they're doing some really interesting community work and that's been very exciting.

Steve Harrington: I've discovered like Shery that Japan has moved rather aggressively to really create what appears to be a substantial peer support network. And we've seen that of course in Australia, which was mentioned. Australia, New Zealand are pretty powerful in peer support and United Kingdom.

And what are we learning? It's interesting because in Australia for example it is peer supporters who talk to the peers and in their practices recognized that sexual health was a major issue for people. And they developed materials to help peers with these issues. And that was just one example. But we're seeing different things - different emphasis in different countries.

Jane Tobler: Excellent. Operator, we're going to ask one more question from one more caller please.

Coordinator: Our next question comes from (Tom) Tempe, Arizona. Go ahead, your line is open.

(Tom): Good evening or good afternoon everyone. Great job. Thank you very much. First I have a comment on the dual role relationship. And the social workers' code of ethics says that social workers shouldn't engage in dual or multiple relations in which there is a risk of exploitation or potential harm. The code does recognize that dual role relationships exist and that there's things that we as peer support specialists can do when dual roles are part of the process.

I have a question for Steve and my question is - and maybe Shery. Do we know of any work being done in the commercial or the private sector to start looking at developing and implementing peer support programs?

Steve Harrington: OptumHealth is a leader in looking in the - as far as in the mental health. Are you looking beyond mental health treatment?

(Tom): Yeah. I'm looking beyond the public mental health system. Magellan, Optimum, Value Options, Sympatico, we all have peer support that operates within the public behavioral health system. But within the traditional commercial employee assistance programs in, you know, private hospitals, in private insurance programs, in Blue Cross Blue Shield. Are there any of those agencies that you're aware of or Shery or even Jean that are looking to develop the role of the peer support specialist?

Steve Harrington: There is a - there is a fellow out in Colorado who is asking much the same question of me a few weeks ago and he was looking at employee assistance programs. How far he got so far I don't know. But I think employee assistance programs would be a natural entree for peer supporters. I do not know of any programs off the top of my head (Tom). My guess is there probably are some out there. It might take some sniffing to find them out.

(Tom): I think we've created the expertise and the evidence base and I think it's time that us folks who work in the public sector need to take this information to the private sector.

Shery Mead: Really to the public in general.

Jane Tobler: All right. We're going to ask - I'm going to ask each of our speakers if they would address this as our, you know, final question and then I have a few things I want to cover. The question is how do we develop more peer leaders? So in all the things we've covered today and all the things we've talked about, at the end of the day, how do we develop more peer leaders? Jean, do you want to start?

Dr. Jean Campbell: Well, you know, I try to make leadership development part of every single thing I do. In other words, not only mentoring other people and, you know, giving them skills but consciously emphasizing leadership development. I remember when I first started working with the programs here in Missouri that one of the programs felt that they were going to stop having their greeter, the person who took names at the door, you know, the sign in and greeted people when they came in.

And this was a program that had one person in charge and no other leaders. And I saw that as a key step for leadership development, empowering people, giving them important things to do. I mean when you see a person catch fire and become inspired to learn and to do, that is really one of the most important first steps.

Jane Tobler: Excellent. Thanks Dr. Campbell. Steve, will you go next please?

Steve Harrington: Sure. I agree with Dr. Campbell on a lot of issues. The leadership for me is a combination of mentoring. I think that as peer specialists, as peer supporters, we are often cast in a leadership role and we can take somebody along with us. And it's more than just having somebody along for the ride. It's more about actually discussing leadership skills and practicing those skills.

And that's the second point is that people have to have an opportunity to practice skills. And that as I think existing leaders have to be willing to share those leadership opportunities and sometimes that's - that can be difficult because it can be such - it is such an exciting time right now with transformation and so many wonderful things happening in mental health.

It can be difficult sometimes to give up some of those leadership opportunities but we have to do that if we're going to fill the pipeline - keep the pipeline full so that as existing leaders like me who are getting older, fade out of the picture that we've got fresh blood. And there's no shortage of issues that need leadership right now.

Dr. Jean Campbell: Yeah. The concept of passing the torch I think is really preeminent in a lot of our minds.

Jane Tobler: Thank you. Shery, any more thoughts on how to develop more peer leaders?

Shery Mead: I think teaching is often a really good way to get your head around the concepts and having to explain it to other people. So I mean I would encourage any of us who are going out presenting to bring somebody along to co-present or even set people up to offer a half an hour talk to a classroom or conference or whatever it is.

The other thing that I think is really important is - in building leadership is developing your own person skills. And I think having some kind of co-supervision group where we actually feed back to one another how we're practicing what we say we want to practice including, you know, how we work through conflict and power issues and so forth and so on because I think that what doesn't contribute to leadership is the isolation and, you know, some of the stuff that doesn't get talked about.

So having a forum for discussing how we practice what we say we want to be doing I think is really important.

Jane Tobler: Excellent. What a great question to end on. We do have some more people that were in the queue, so, and on email. So I just want to encourage you if you have an additional question or a question that we weren't able to answer today, please follow up with our presenters whose contact information is on the Slide 66 or us at the SAMHSA ADS Center at promoteacceptance@samhsa.hhs.gov. And our information is on slide 72.

And I especially want to thank Jean, Steve and Shery for your work on this important issue and also for spending your time today to share your insights and knowledge. I think it was a wonderful call. And I want to thank all of the listeners for caring about the topic so much that you took the time out of your afternoon to learn more and share some of your questions and comments with us.

In a few days you will receive an email about the anonymous online survey. And we'd like you to take a few minutes to fill it out. It should only take five minutes. We really encourage you to share your feedback with us. And we use the survey information to help determine what resources and topic areas we need to address in future training events. So please take a few minutes and fill it out.

This conference has been recorded and the audio recorded and transcription will be available in late September on the SAMHSA ADS Center Web site. And finally I just want to thank everyone once again for your work on this topic. I think we had a lot of people that came on the Web and that also called in. It's a very important topic. I feel like we're going in great places. So thank you so much for being involved. Thank you for filling out our survey. And, you know, until next time, goodbye.

Coordinator: Thank you. And that does conclude today's conference. Thank you for participating. You may disconnect at this time.