Ethics, Values, and Boundaries in Peer Recovery Support Work

January 12, 202110:00-5:00pm Eastern

(9am Central, 8am Mountain, 7am Pacific)

Strengthening the Field of Recovery Support Services

Peer Recovery Center of Excellence

Housekeeping Details

• Technology

• Questions or Comments

• Participant Feedback - evaluation

Ethics, Values, and Boundaries in Peer Recovery Support

Work

Presented byJoseph Hogan-Sanchez

Faces & Voices of Recovery

info@facesandvoicesofrecovery.orgfacesandvoicesofrecovery.org

10 G Street, Suite 600, Washington, DC 20002

Learning Objectives

Participants will be able to:

• Describe terms that apply to delivering ethical peer recovery support services

• Identify how values, morals and boundaries apply to ethical peer recovery support delivery

• Apply a process for ethical decision making• Recognize the need for organizational framework that is

supportive and appropriate for ethical peer recovery support service delivery

Welcome and Introductions

Welcome and Introductions

• Name• Pronouns (he/him, she/her, they/them)• Where are you from (city, state)• Your favorite part of your job• Why you feel ethics are important to your work

Terms and Definitions

Ethics

• Behaviors based on values and a moral philosophy• Code of morals and informed by laws and boundaries• Practiced by a person or group of people.• Examples:

• Peer Support Specialists respect the privacy and confidentiality of those they serve

• Not divulging information received from others

Laws

• A set of rules that is legislated and enforced by government.

• Example• It is illegal for anyone receiving federal funds for

providing services to individuals with substance use disorder to disclose information about that individual to others without permission of the person receiving the services. (CFR 42 Part 2)

What is CFR Part 2

• What is 42 CFR (code of federal regulations) Part 2 and what does it do?

• Protects the privacy of substance use disorder (SUD) patient records by prohibiting unauthorized disclosures of patient records

• Why is Part 2 important to people living with substance use disorders?

• Frequently a top concern for individuals entering treatment for SUD

• As a result of stigma and legal penalties, people often experience discrimination and negative consequences such as:

• Arrest, prosecution, incarceration, loss of housing, employment barriers

(Reid et al., 2020)

Confidentiality Regulations

• Vary from state to state• Always follow the strictest regulation relative to your

situation• State (least strict) vs federal (most strict) = follow federal• Federal (least strict) vs state (most strict) = follow state

• Constantly changing, stay up-to-date• Seek counsel with experts in your area, and within your

organization• Regulations require ethical decision-making

Morals

• A set of beliefs that guide or dictate behaviors and conduct towards others

• Usually derived from family, community, religion and ethnic or social background

• Examples:• Peer support specialists will never intimidate,

threaten, harass, use undue influence, physical force, verbal abuse, or make unwarranted promises of benefits to the individuals they serve.

• I believe that violence is wrong in all situations, so I will never strike or threaten anyone.

Values

• Basic and fundamental beliefs • Guide or motivate attitudes or actions• Help determine what is right and what is wrong.

Boundaries

• Limits on what is acceptable and unacceptable in life• Examples

• Peer specialists will never engage in sexual/ intimate activities with those they serve.

• I don’t engage in intimate or sexual relationships with people I provide services to or work with because it can create too much confusion in the workplace.

Identifying Your Core ValuesSolo Exercise

Identify and write down at least 5 of your Core Values• Think about experiences or situations informed those

Core Values• Ask yourself if these Core Values are reflected in

• Your work relationships?• With your Supervisor?• With those you serve?

• How are they reflected or not?• When you are done raise your virtual hand

Breakout - 15 min

Discuss• An area where you feel your Core Values are in

alignment with your organization• How this impacts the work that you do• Go around your virtual room making sure that

everyone who would like to participate has a chance to share.

Debrief

• How was the discussion?• Write a reflective word on that experience

Ethics(Behaviors)

Laws (Govern Behaviors)

Boundaries (Govern Behaviors)

MORALSVALUES

15 MinuteWellness Break

Core Competencies, Principles, and Values

Core Competencies, Principles, and Values -SAMSHA

• In 2015, SAMHSA led an effort to identify the critical knowledge, skills, and abilities

• Convened diverse stakeholders from the mental health consumer and substance use disorder recovery movements.

• Conducted research to identify Core Competencies for peer workers in behavioral health.

(Substance Abuse and Mental Health Services Administration (SAMHSA), 2015)

Core Competencies

1. Engage peers in collaborative and caring relationships

2. Provides support3. Shares lived experience of recovery4. Personalizes peer support5. Supports recovery planning6. Links to resources, services, and supports

(Substance Abuse and Mental Health Services Administration (SAMHSA), 2015)

Core Competencies (continued)

7. Provides information about skills related to health, wellness, and recovery

8. Helps peers to manage crises9. Values Communication10.Supports collaboration and teamwork11.Promotes leadership and advocacy12.Promotes growth and development

(Substance Abuse and Mental Health Services Administration (SAMHSA), 2015)

Fundamental Principles

• Recovery-oriented• Person-Centered• Voluntary• Relationship-focused• Trauma-informed

(Substance Abuse and Mental Health Services Administration (SAMHSA), 2015)

How Are These Competencies to be Used?

• Promote best practices in peer support. • Guide peer training programs• Provide standards for peer certification• Inform job descriptions and performance evaluations• Organizations can use them to build career ladders for

peer workers• Supervisors can use to appraise peer workers’ job

performance • Provide peers with a clear sense of the expectations of

their roles.

(Substance Abuse and Mental Health Services Administration (SAMHSA), 2020)

Practice Guidelines – INAPS

1. Peer support is voluntary2. Peer supporters are

hopeful3. Peer supports are open

minded4. Peer supporters are

empathetic5. Peer supports are

respectful6. Peer supporters facilitate

change

7. Peer supporters are honest and direct

8. Peer support is mutual and reciprocal

9. Peer support is equally shared power

10.Peer support is strengths-focused

11.Peer support is transparent

12.Peer support is person-driven

(National Association of Peer Supporters, 2013)

For you to consider

State, City, and County Laws

Certification

Organizational

Personal

How Are you setup for Success

• Organizationally – Do they know what you do and don’t do?

• Does your Job Description speak to that role?• Is supervision adequate, supportive, educational• Are policies and procedures informed by Peer

competencies, guidelines, laws and ethics

Role Clarity

• Sponsor• Perform AA/NA or other

mutual aid group services work in your peer role

• Guide someone through the steps or principles of a particular recovery program

• Therapist/Counselor• Diagnose• Provide counseling or refer to

their support activities as “counseling” or “therapy”

• Focus on problems, “issues”, trauma rather than recovery solutions

• Nurse/Physician• Suggest medical diagnoses• Offer medical advice

• Priest/Clergy• Promote a particular

religion/church• Interpret religious doctrine• Offer absolution/forgiveness• Provide pastoral counseling

You are moving beyond the boundaries of PRSS if you:

(White, 2006)

Breakout Discussion – 20 min

• Role Clarity/Integrity: George, who is a salaried Peer, has a practice of linking those he coaches to recovery communities by taking them to, and participating with them, in particular recovery support meetings. A complaint has come to the agency about George’s “getting paid” for the time he is in meetings, with the charge that this constitutes accepting money for Twelve-Step work.

• What are the ethical issues here? • How might George more clearly delineate his paid

activity from his Twelce-step service work?

(Ethical Guidelines for the Delivery of Peer-based Recovery Support Services)

Exercise Debrief

The values of stewardship require that the Peer carefully allocate his or her time. George should be careful to separate PRSS hours from hours spent in recovery support meetings so as not to receive payment for meeting time. The Peer function stops at the doorway of recovery support meetings: George should introduce his client to other recovery support group members and “hand him off” for Twelve Stepping.

(Ethical Guidelines for the Delivery of Peer-based Recovery Support Services)

After Lunch Preview

• More definitions• Boundary management• Ethical Arenas • National Standards for PRSS Service Delivery

LUNCH!

Welcome Back

• How was lunch?• Additional questions from this morning?• Housekeeping Reminders

Terms and DefinitionsPart 2

Iatrogenic

• Meaning:• Treatment caused unintended harm

• Application:• In the 40’s recommending a lobotomy was

considered a treatment not a harmful procedure. The purpose was to help patients with mental health conditions

• Peer service breach example:• Peer recommends 12 step programs as the only

way to sustain recovery because it has worked for them

Fiduciary

• Meaning:• Term used to describe a relationship in which one

person has assumed a special duty and obligation for the care of another.

• Application:• Peer Specialists are designated people for others to

approach for help. We have different roles. • Peer Service Breach Example:

• A Peer is going through a hard divorce and goes into a lengthy discussion with a peer about how marriage is a joke.

Boundary Management

• Meaning:• Encompasses the decisions that increase or

decrease intimacy in a relationship• Application:

• Your home organization will have specific boundaries that you need to uphold while working for them

• Peer Service Breach Example: • The organization does not allow for sharing

cigarettes with those you serve. The Peer does not agree and thinks smoking with participants is a way to bond, so regularly smokes with participants outside the facility.

Multi-Party Vulnerability

• Meaning:• A phrase that conveys how multiple parties can be

harmed by what a peer specialist does or fails to do• Application:

• Best practices in confidentially and ethical codes of conduct will protect not only the person being served but all those involved with that person

• Peer Services Breach Example:• A peer breaks confidentiality and shares concerns

with a family member of the participant receiving services.

Personal Boundaries

Types of Personal Boundaries

Skin

Words

Truth

Physical Space

Geographical Distance

Emotional Distance

Other People

Psychological Boundaries

Rigid, Porous, Healthy Boundaries

(What are Personal Boundaries? 2016)

Rigid Boundaries Porous Boundaries Healthy Boundaries

Avoids Intimacy and close relationships

Overshares personal information

Values own opinions

Unlikely to ask for help Difficult saying ‘no’ to the request of others

Doesn’t compromise values for others

Has few close relationships

Overinvolved with others’ problems

Shares personal information in an appropriate way

Very protective of personal information

Dependent on the opinions of others

Knows own wants and needs; can communicate them to others effectively

Keeps others at a distance to avoid the possibility of rejection

Fears rejection if they do not comply with others

Accepting when others say ‘no’ to them

Great Resource

(Selva, 2020)

Professional and Organizational

Boundaries in PRSS

The Balance: The Organization’s Role

• Professional boundaries are critical to a sustainable career in and the success of the organizations

• PRSS organizations can assist individuals in finding and operating in the zone of helpfulness through

• Training• Supervision• Code of Ethics

Common Challenges

• Dual Relationships• Value Conflicts• Compassion Fatigue• Playing the “Hero Role”• Poor Teamwork

Common Warning Signs

Begin referring to people as friends

Give or receive gifts

Significant personal

information is exchanged

Socializing outside of

parameters

Unable to sleep due to a person’s

situation

Work dominates all discussions

with friends and family

Providing assistance

outside of your role

Venting with person about

others on your team

Ask Yourself…

• When interacting with a peer you are providing services to, is it okay to

• Accept a gift from the peer or a member of their family?

• Engage in a sexual relationship with a member of their family member?

• Attend a mutual aid support group with them?• Give them a hug?

3 Words to Stick With

Establish… Communicate… Honor…

Your Boundaries.

Breakout Discussion - 20 min

• Pre-existing Relationships: Barry’s supervisor has assigned a new contact for Barry to visit in his Peer role. Barry recognizes the name as a person to whom Barry once sold drugs in his earlier addicted life.

• Who might be harmed in this situation? • What should Barry do? • Does Barry have a responsibility to report this pre-

existing relationship to the supervisor?

(Ethical Guidelines for the Delivery of Peer-based Recovery Support Services)

Barry: Case Study Debrief

Which of these terms could be considered in Barry’s situation?

• Answer 1: Iatrogenic• Answer 2: Multi-party vulnerability• Answer 3: Fiduciary• Answer 4: Boundary Management

Multiple parties may be at risk here: Barry, his contact, the contact’s family, and Barry’s agency. Barry should disclose the relationship and request another assignment. If the only alternatives are Barry or no services (e.g., a situation in which Barry might be the only Peer in the community), Barry and his supervisor should explore additional options or explore how they might ensure that these peer services are provided and still minimize harm to all parties. The most critical factor here is the need to maximize the comfort and safety of the individual/family receiving services. It is best if Peers are expected to declare immediately any pre-existing relationships with those to whom they have been assigned.

(Ethical Guidelines for the Delivery of Peer-based Recovery Support Services)

Ethical Decision-Making Worksheet

How to Use This Tool• Step One: Who is vulnerable to harm and what is the

potential degree of harm? What could go wrong?• Step Two: What core recovery values apply to this

situation and what action do they suggest?• Step Three: What laws, standards or historical practices

might guide our conduct in this situation?• Step Four: Where risk of injury is great to multiple

parties, document:• * What you considered, *Who you consulted, • * What you decided and did, *The outcome of your

decisions and actions

15 minuteWellness Break

Ethical Arenas

Ethical Arenas: Exploitation

A. Emotional B. SexualC. Financial

This Photo by Unknown Author is licensed under CC BY-NC-ND

A) EMOTIONAL

• Friendship: Raymond volunteers as a Peer for a recovery community organization (a freestanding organization, unaffiliated with any treatment organization, that provides recovery support services). Raymond shares a lot in common with Barry, a person to whom Raymond has been assigned to serve as a Peer. Over a period of months, Raymond and Barry have developed quite a friendship and now share some social activities (e.g., fishing) beyond the hours in which Raymond serves as Barry’s Peer.

• Are there any ethical issues raised by this friendship?

(Ethical Guidelines for the Delivery of Peer-based Recovery Support Services)

B) SEXUAL

• Sexual Exploitation: You supervise a Peer for a local recovery advocacy and support organization. It comes to your attention that Joshua, one of your Peers, is sexually involved with a person to whom he is delivering recovery support services.

• What are the ethical issues involved in this situation? • How would these issues differ depending on:

• age or degree of impairment of the person receiving services? • whether this was a person currently receiving or a person who

had previously received recovery support services? • the time that had passed since the service relationship was

terminated? • Would you view this situation differently if the relationship were not

with the primary “client” but with a family member or friend who was involved in the service process?

• Could the Peer or the agency face any regulatory or legal liabilities related to this relationship?

(Ethical Guidelines for the Delivery of Peer-based Recovery Support Services)

C) FINANCIAL

• Gifts: Marie works as a Peer in an addiction treatment unit within a local community hospital. Her job is to provide recovery support services to those discharged from addiction treatment. She serves a predominately Native American population and conducts most of her work via home visits on two reservations. When she arrives for one of her visits today, the family she is visiting presents her with an elaborate, culturally appropriate gift as a token of their appreciation for her support. The problem is that Marie works in a hospital whose personnel code prohibits any staff member from accepting a personal gift. Marie is concerned about the consequences of accepting the gift but is also concerned that refusal of the gift could harm her relationship with the family and the tribe.

• What are the ethical issues here? • What should Marie do?

(Ethical Guidelines for the Delivery of Peer-based Recovery Support Services)

In Service Relationships

• Choice/Autonomy: Roberto has been assigned as a Peer for Oscar, but four weeks into this process, Oscar requests a change in Peer provider on the grounds that he is having difficulty relating to Roberto.

• Do those receiving peer recovery supprot services have the right to select their own Peer?

(Ethical Guidelines for the Delivery of Peer-based Recovery Support Services)

Service with other Service Providers

• Representation of Credentials: Samuel works as a Peer, doing post-treatment telephone monitoring. In his interactions with the larger community, Samuel has represented that he is working as a “counselor.” He also makes periodic mention of his plans to “get back” to graduate school,” but Samuel has only completed two years of college and has not been in school for more than ten years.

• What ethical issues does this situation raise?

(Ethical Guidelines for the Delivery of Peer-based Recovery Support Services)

Local Communities and Agencies

• Predatory Behavior: Felicia works as a Peer for women who are just entering intensive outpatient treatment and living in a women’s recovery home. One of Felicia’s responsibilities includes linking these women to local recovery mutual-aid meetings. Many of the women Felicia works with have histories of sexual victimization as well as long histories of toxic intimate relationships. Felicia is aware that predatory behavior (“Thirteenth Stepping”) is common in some local recovery meetings.

• To what extent is Felicia responsible for preparing the women she refers for such behavior or protecting them by linking them to meetings with a strong group conscience?

(Ethical Guidelines for the Delivery of Peer-based Recovery Support Services)

3 Question Poll

• In your Peer role with your employer do you have a clear job description that reflects your responsibilities and duties as a Peer?

• Do you feel you have adequate supervision? • Did your onboarding experience cover the

organizations ethics and policies and procedures in case ethics were breached?

National Standards for Ethics in PRSS

National Standards

Developed by and for ...

Peers Providing

PRSS

Organizations Providing

PRSS

Ethical Framework for Service Delivery

EFSD-1.0 Code of Ethics The program has guidelines, policies, procedures, and practices related to ethics that are consistent with peer values, protecting both providers and recipients of peer services.

EFSD-2.0 Ethics Training and Support The program ensures that training and guidance are provided on the implementation of ethical guidelines.

EFSD-3.0 Confidentiality The program has guidelines, policies, procedures, and practices related to maintaining confidentiality of personal information.

EFSD-4.0 Boundary Setting The program provides supervision, support, and learning opportunities to address boundary-related conflict before, during, and and after conflict happens.

Peer Leadership Development

PLD-1.0 Recruitment The program uses efficient and effective processes to recruit quality peer leaders.

PLD-2.0 Selection and Orientation The program has clearly defined processes for screening, selecting, and orienting peer leaders to the peer recovery support program and position

PLD-3.0 Training and development The program provides peer leaders with training to help them gain the knowledge and skills necessary for their assigned job to help them develop within the organization

PLD-4.0 Retention The program has clearly defined methods for increasing peer leader retention

Peer Supervisor Development

PSD-1.0 Recruitment The program uses efficient and effective processes to recruit quality peer supervisors.

PSD-2.0 Selection The program has clearly defined processes for identifying needed qualifications, screening and selecting peer supervisors

PLDD-3.0 Training, Mentoring, and Support

The program provides peer supervisors with training and ongoing support to gain knowledge, skills, experience, attitudes and attributes necessary to effectively supervise peer leaders in a non-clinical context.

Your Takeaways

• Peer recovery support service (PRSS) programs require an ethical framework for service delivery.

• “Importing” a professional code of ethics is not effective. • The relationship of the peer worker and those served

warrant an ethical framework specifically tailored to PRSS.• From hiring practices, onboarding, and ongoing training;

Ethics should be systematically revisited and should reflect the work done in PRSS.

• Adequate supervision and support must be informed by the work we do and support the growth of the peer worker.

Post Event Reminders

• You will receive the slides and any materials within one week.

• Continuing Education links will be included.

• We value your feedback! Please share your thoughts on the Participant Feedback Evaluation.

For training information: Cindy Christy, Sr. Program Manager, christyc@umkc.eduFor general information: Callan Howton, Director, howtonc@umkc.edu

Upcoming Trainings!Training Focus Date(s)The Impact of Compassion Fatigue in Peer Support Work

January 26th & February 18th, 2021

For training information: Cindy Christy, Sr. Program Manager, christyc@umkc.eduFor general information: Callan Howton, Director, howtonc@umkc.edu

ReferencesNational Association of Peer Specialist (NAPS). (2013). National Practices Guidelines for Peer

Supporters [PDF]. Retrieved on December 21, 2020, from https://inaps.memberclicks.net/assets/docs/nationalguidelines_updated.pdf

Reid, D. A., Gueronniere, G. D., Khaikin, C., Marton, A. R., Friedman, S., & Seitz, J. (2020, October). Fundamentals of 42 CFR Part 2. Retrieved December 21, 2020, from https://lac.org/addiction-confidentiality-42-cfr-part-2-important/

Selva, J. (2020, October 16). How to Set Healthy Boundaries: 10 Examples + PDF Worksheets. Retrieved December 21, 2020, from https://positivepsychology.com/great-self-care-setting-healthy-boundaries/

Substance Abuse and Mental Health Services Administration (SAMHSA). (2015, December 7). Core Competencies for Peer Workers in Behavioral Health Services [PDF]. Retrieved December 21, 2020, from https://www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/core-competencies.pdf

Substance Abuse and Mental Health Services Administration (SAMHSA). (2020, April 16). Frequently Asked Questions for Core Competencies for Peer Workers. Retrieved December 21, 2020, from https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers/core-competencies-peer-workers-behavioral-health-services/frequently-asked-questions

References

What are Personal Boundaries? [PDF]. (2016). Therapist Aid LLC. Retrieved December 21, 2020 from https://www.therapistaid.com/worksheets/boundaries-psychoeducation-printout.pdf

White, W. L., & et al. (n.d.). Ethical Guidelines for the Delivery of Peer-based Recovery Support Services[PDF]. Retrieved on December 21, 2020 from https://facesandvoicesofrecovery.org/wp-content/uploads/2019/06/Ethical-Guidelines-for-the-Delivery-of-Peer-based-Recovery-Support-Services.pdf

White, W. L. (2006). Sponsor, Recovery Coach, Addiction Counselor: The Importance of Role Clarity and Role Integrity [PDF]. Philadelphia: Philadelphia Department of Behavioral Health and Mental Retardation Services. Retrieved on December 21, 2020 from https://facesandvoicesofrecovery.org/wp-content/uploads/2019/06/Sponsor-Recovery-Coach-Addiction-Counselor-The-Importance-of-Role-Clarity-and-Role-Integrity.pdf

Resources

• CFR Part 2 - https://www.samhsa.gov/about-us/who-we-are/laws-regulations/confidentiality-regulations-faqs

• https://www.samhsa.gov/sites/default/files/does-part2-apply.pdf• Personal core Values - https://scottjeffrey.com/personal-core-values/• SAMHSA Competencies -

https://www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/core-competencies_508_12_13_18.pdf

• INAPS National Guidelines -https://inaps.memberclicks.net/assets/docs/nationalguidelines_updated.pdf

• How to Set Healthy Boundaries - https://positivepsychology.com/great-self-care-setting-healthy-boundaries/

• How to Create Healthy Boundaries -https://www.uky.edu/hr/sites/www.uky.edu.hr/files/wellness/images/Conf14_Boundaries.pdf

• What are Personal Boundaries -https://www.therapistaid.com/worksheets/boundaries-psychoeducation-printout.pdf