Document 448453

Table of Contents
General Introduction
Our Process
Part 1 – Key Websites
Part 2 – Key Articles
Appendix 1
On our cover, we have chosen the image of a lighthouse at dusk to evoke what Peer
Support means to consumer/survivors. Just as its beacon provides a guiding light to
land, so does a network of caring friends assist the individual in viewing life positively
even in his or her darkest hour.
This body of work was the collaboration of members and staff of the Ontario Peer
Development Initiative (OPDI). OPDI supports Consumer/Survivor Initiative (CSI)
organizations and affiliates towards maximizing individual opportunities and retaining
their full rights as citizens within their communities. Peer Advisors provide tailored
workshops in cooperation with CSIs’ self-identified needs in their organizational
development and capacity building. OPDI furthers networking opportunities to promote
a strengthened consumer/survivor provincial voice, while working within the context of
the healthcare reform process.
The primary purpose of this paper is to enable the exchange of knowledge about Peer
Support. In compiling these resources, we have sampled from a wide and varying
continuum of evidence and beliefs about mental health from governments, agencies,
researchers, and individuals. We have brought these ideas and thoughts, wherever
possible in their own words. Please note that their inclusion in this paper does not imply
any endorsement by OPDI. As well, certain links and articles in this document connect
to other websites maintained by third parties over whom OPDI has no control. OPDI
makes no representations as to the accuracy or any other aspect of information
contained in other websites.
Ontario Peer Development Initiative
1881 Yonge Street, Suite 614, Toronto, Ontario M4S 3C4
Phone: 416y484y8785 Fax: 416y484y9669 Toll Free: 1y866y681y6661 Email: [email protected]
OPDI acknowledges the financial support of the Government of Ontario
General Introduction
Peer Support is seen as a driving force in recovery because it speaks to the values of
community, citizenship and the right to choice of alternative models of care in a
reformed mental health system.
In 2003, the OPDI Board of Directors made a commitment to advance the development
of Peer Support and set Peer Support Day as a priority for 2004/2005. As a result, the
Conference and AGM Committee of OPDI ensured that a workshop focusing on Peer
Support was included in the 2004 Creative Directions Annual Conference.
There was an outstanding response and participation with over 60% of the conference
participants attending the workshop. The outcome of this workshop identified the
commitment of OPDI’s membership toward the development of Peer Support as the
fundamental value of consumer/survivor organizations. Participants recommended that
additional information and supportive resources were needed. As well, OPDI was
encouraged to continue its efforts in establishing a celebration honouring the work of
Peer Support (see Appendix 1).
In a follow up survey sent to CSIs in November 2004, responses from the field centered
on the need to raise awareness of the benefits of Peer Support among
consumer/survivors, service providers and external stakeholders in the community.
OPDI therefore took the needs of CSIs into consideration when deciding to research the
topic of Peer Support. Our goal was to identify a sampling of Peer Support programs
along with directives in planning and implementing consumer-driven mental health
policies from the context of Ontario, Canada and other jurisdictions. Further to this, the
report was to provide links to web sites and academic literature that present self-help by
and for consumer/survivors as a model delivering beneficial outcomes.
OPDI understands that knowledge exchange among the consumer/survivor community
is critical to the ongoing development of Peer Support. Moreover, the transfer of
knowledge serves to offer relief to, and to empower consumer/survivor organizations
who feel socially isolated within a credential-driven formal healthcare system. We have
set out to achieve a balancing act: develop a report that can be used as a guide
providing relevant empirical evidence and research supporting the work of
consumer/survivors, and to find them on the Internet for you to freely access.
Purpose of this Report
The purpose of this report is:
To share findings regarding Peer Support.
To highlight a user-friendly collection of resources.
To empower consumer/survivors and their organizations.
To serve as a guide for future development of Peer Support in Ontario.
To support ongoing knowledge transfer and exchange.
By sharing this paper with the broader community, OPDI intends:
To promote Peer Support to its rightful position among the best practices available
in community mental health supports and services.
To strengthen the capacity of consumer/survivors in their partnership towards the
evolution of a reformed and recovery-driven mental health system in Ontario.
To generate funding, policy, and training recommendations for Peer Support based
on information and resources found.
Our process
Gathering of Information and Resources
The information and resources were retrieved through seven strategies:
1. OPDI in-house library and files.
2. Online search engine for websites (Google).
3. Online search engine for academic references (Google Scholar).
4. Online search engine for media citations (Google News).
5. Guest privileges using paid database ( of media articles and peerreviewed journals.
6. Site visits to York University and Centre for Addiction and Mental Health Libraries
(ProQuest database of online peer-reviewed journals).
7. Informal discussion and reflection with general members of OPDI, Board of Directors
and staff regarding Peer Support and the current context of provincial health care
system, for example, the recent Kirby Senate Committee on Mental Health Interim
Reports released in November 2004.
Senators Kirby and Keon, Chair and Deputy Chair of the Senate Committee, have
also shared their thoughts on funding Medicare in this article.
The schedule (listing affiliations of speakers including a number of
consumer/survivors) and the transcripts of their testimony at the Committee hearings
in Toronto on February 15-17, 2005 are available at:
We also took note of the Empowerment Council’s collaborative work at CAMH and
the ensuing celebration of the Client Bill of Rights.
Preliminary Findings
A preliminary search using the search engine GOOGLE ( found
potential areas of interest that led to highlighting specific elements which defined the
value and promising future of Peer Support.
Specific elements considered for this report emerged through our discussion and
reflection and the strategic gathering of our information and resources. The focus of the
research was identified in the following five areas:
1. Peer Support organizations
2. Operating guidelines
3. Education and training
4. Databases and bibliographies of articles and writings
5. Published academic literature of research findings
With a vast array of potential data available it was necessary to focus on fewer but
critical key search words. Consequently, the following report is limited to a rich, yet
limited sampling.
Structure of this Report
The report is constructed into two broad categories of Peer Support resources and
1. Key websites
2. Key articles
Each broad category includes a description of the search strategy used and is outlined
in its respective section. This includes details such as:
Procedure Used for retrieving and gathering
Sampling of Information and Resources from the array of information
Brief Description, wherever possible the information was taken directly from the
source in the form of a direct quote
PART 1 – Key Websites
The search engine GOOGLE ( was used with the following combination
of keywords to yield the following number of results from the Web:
Table 1
Keywords used
“peer support”
“peer support” and “mental health”
“peer support” and “consumer”
# of
“peer support and “survivor”
“peer support” and “consumer” and
“peer support” and
peer support
Too general
Too general
Too general
Useful references browsed using
secondary search terms
Useful references browsed using
secondary search terms
Useful references browsed using
secondary search terms
Line-by-line review to retrieve best
These secondary search terms included such key words as “self-help”, “mutual aid”,
“resilience”, “self-determination”, and “recovery”. Some references were located by
following web links.
Canadian Jurisdictions
1. "Bridge to Discharge" project was designed to assist with the discharge and
community integration of people diagnosed with schizophrenia. The documented
results are available here.
2. Mental Patients Association in Vancouver carrying out its mission to promote
the dignity and wellbeing of mental patients outlines the participation and
achievements of consumer/survivors in the mental health service delivery
3. Peer Support “working together to help each other to achieve harmony”
outlines the history of peer support in British Columbia and discusses integration
of peer support workers into the mental health system.
4. Psychiatric Patient Advocate Office provides advocacy services to individual
patients (instructed and non-instructed), addresses facility-based or provincial
systemic issues impacting on patients' rights, rights advice services, public and
health care professional education through speaking engagements, publishing
reports and media releases.
5. Self-Help Association of BC in British Columbia is dedicated to promoting peer
support approaches that build the capacity of individuals, and therefore
communities, to become healthy, responsive, and self-determining.
6. The Self Help Connection is a Nova Scotia-based group that offers a listing on
research into self-help in a downloadable PDF file.
7. Self-Help Resource Centre in Ontario has a searchable resources database,
education and training in self-help and mutual aid.
Other Jurisdictions
8. Alaska Mental Health Consumer Web's goal is to be an Internet resource for
mental health consumers, particularly ways to recover.
9. Behavioral Health Recovery Management (BHRM) project seeks to apply the
principles of disease management to assist individuals with chemical
dependency and/or serious mental illness to engage in a process of recovery
from these illnesses. The list of online clinical guidelines includes one for “Best
Practice Guidelines for Consumer-Delivered Services”.
10. BrolgaNet is a resource library containing web links relevant to mental health
consumer research with a focus on Australian mental health research carried out
by consumer/survivors in collaboration with professionals.
11. Center for International Rehabilitation Research Information and Exchange
(Cirrie Database) currently contains over 25,000 citations of international
rehabilitation research published between 1990 and the present.
12. Center for Psychiatric Rehabilitation Catalogue of Publications Books,
videos, training curricula, tools and articles that have been authored by research,
training and services staff.
13. Center for the Study of Issues in Public Mental Health is dedicated to
developing and conducting research within the context of a rigorous research
program that is strongly influenced by the requirements of a public mental health
system and, in turn, influences the development of policy and practice in this
14. Clearinghouse for the Community Living Exchange Collaborative is an
infrastructure of resources for people with disabilities and older adults.
15. The Community Living Exchange Collaborative (The Exchange) is a joint
effort of ILRU (Independent Living Research Utilization), a program of The
Institute for Rehabilitation and Research (TIRR), and Rutgers Center for State
Health Policy (CSHP). The Exchange is funded by the Centers for Medicare and
Medicaid Services (CMS) through grants awarded under the Systems Change
Community Living Initiative launched in September 2001. It serves as a
searchable clearinghouse for American national and state policies. Key words
such as “mental health” and “peer supports” are applicable.
These two retrieved PowerPoint presentations further identify peer supports as
integral to a recovery-based mental health system.
16. Consumer Organization and Networking Technical Assistance Center
(CONTAC) is part of the West Virginia Mental Health Consumers Association
providing resources and technical information as well as consumer/survivor
history and the recovery movement.
17. Consumer Resources Page of the South Carolina Department of Mental
Health includes information on how to become a peer support specialist.
18. Depression and Bipolar Support Alliance in the United States hosts its own
It sponsors the Peer-to-Peer Center website.
Its Peer Specialist Certification Training Program has been reviewed by an
outside third party.
19. Hamilton County Mental Health Board of Cincinnati, Ohio hosts this website
that features many online peer support references.
20. Independent Living Research Utilization hosts a website with resources
including a clearinghouse database and a collection of newsletters. This
newsletter reports on Consumer/Survivor-Operated Mental Health Services.
21. International Journal of Psychosocial Rehabilitation a web based peer
reviewed publication for mental health practitioners, consumers and applied
22. Kansas Consumer Run Organizations offers a central website that celebrates
the culture of recovery, and comes with resources such as a management
handbook and suggested codes of conduct for consumer agencies.
23. Mary Ellen Copeland’s Mental Health Recovery Self-Help Strategies are
offered along with the WRAP (Wellness Recovery Action Plan) catalogue of
publications; as well, there are many links to other resources.
24. National Association of State Mental Health Program Directors (NASMHPD)
is a non-profit organization dedicated to serving the Needs of the Nation's Public
Mental Health System through policy development, information dissemination,
and technical assistance. This NASMHPD/NTAC e-Report on Recovery
features a collection of essays and information from a variety of national experts
on psychiatric rehabilitation.
25. Mental Health Client Action Network of Santa Cruz, California has a
consumer-run practices research biography posted.
26. Mental Health Net is the home of the American Self-Help Clearinghouse
Of interest is a section on research into self-help.
27. Mental Health Statistics Improvement Group has developed a Consumer
28. National Empowerment Centre offers online resources linked to recovery and
consumer/survivor activism.
29. National Mental Health Association’s National Consumer Supporter
Technical Assistance Centre (NCSTAC) was established in 1998 by a grant
from the Centre for Mental Health Services to strengthen consumer organizations
by providing technical assistance in the form of research, informational materials,
and financial aid.
30. National Rehabilitation Information Centre is a searchable database with over
67,000 references.
31. The National Research and Training Center (NRTC) on Psychiatric
Disability is a five-year program of research, training, technical assistance and
dissemination activities designed to promote self-determination among people
with psychiatric disabilities. It publishes “Self-Determination Among People with
Psychiatric Disabilities: An Annotated Bibliography of Resources.”
32. People Who is a California-based online peer support organization with an
interesting index of articles.
33. Policy Information Exchange (PIE) matches keywords with an extensive
literature collection and is searchable by year as well as author.
34. Psychological Self-Help an online book for the individual perspective on selfhelp is easy to read, has a searchable index, and is accompanied by a
35. Recovery Institute State of Connecticut recovery-driven mental health system
offers a series of training opportunities, resources for recovery and related links.
36. Repository of Recovery Resources has a range of information from the Boston
University Centre for Psychiatric Rehabilitation which builds on the knowledge
base of recovery.
37. Self-Help Nottingham has an international listing of self-help organizations and
research links on this topic.
38. STAR Centre's primary focus is the area of Cultural Outreach and Self-Help
Adaptation, to ensure that self-help approaches are available and accessible to
various cultural groups.
39. Shery Mead Consulting offers training, books and articles about peer support
and peer run crisis alternatives in mental health.
40. “The Kit: A Guide to the Advocacy We Choose to Do” is an Australian online
resource kit for consumers of mental health services and family caregivers.
41. The United States Department of Health and Human Services oversees
SAMHSA (Substance Abuse and Mental Health Services Administration). Centre
for Mental Health Services in turn supports research, training, and technical
assistance centres, which are listed below.
PART 2 – Key Articles
We used the ProQuest online information service accessed through York University’s
Ross Library, Google Scholar and the Centre for Addiction and Mental Health Library.
By this method, peer-reviewed articles were sourced using the same key words as
outlined in Part 1 of the Website search. The results of the search will be found in the
following three categories:
1. Abstracts with accompanying articles available online
2. Abstracts available online (links have been provided for additional
information to obtain the article)
3. Other articles available through databases or print journals
Abstracts with Accompanying Articles Available Online
1. Cook, J.A., and Jonikas, J.A. (2002). Self-Determination Among Mental Health
Consumers/Survivors: Using Lessons from the Past to Guide the Future.
Journal of Disability Policy Studies, 13 (2), 87-95.
It is well known that people with psychiatric disabilities lack self-determination in their
lives. A number of studies have demonstrated the high rates of poverty experienced
by many of these individuals, leading them to confront a variety of barriers to a
higher quality of life. Moreover, concepts of self-determination and client control
have not yet proliferated in the public mental health system. In spite of this,
consumers/survivors have organized to demand their civil rights and full inclusion in
making decisions regarding their own treatment. This article traces the history of
self-determination for citizens with psychiatric disabilities, describes major barriers to
self-determination, presents several theories of self-determination with potential
relevance for mental health consumers/survivors, and offers ways in which selfdetermination and consumer control might be achieved both within and outside of
service systems.
Abstract and article at:
2. Corrigan, P.W. (2004). Enhancing Personal Empowerment of People with
Psychiatric Disabilities. American Rehabilitation, 28 (1), 10-21.
For most of recorded history, people with psychiatric disabilities have struggled with
maintaining personal power over their lives. The centuries-old battle against stigma
is the best example of this struggle. The ancient Greeks first gave voice to the
concept of stigma noting that those who were marked with mental illness were often
shunned, locked up or, on rare occasions, put to death (Simon, 1992). During the
Middle Ages, people with mental illness were viewed as living examples of the
weakness of humankind, what goes wrong when people are unable to remain
morally strong (Mora, 1992). This kind of attitude led families to hide away those with
psychiatric disabilities from public view. Not until the 18th century did asylums and
treatment centers emerge for mental illness. Before that time, those with serious and
persistent mental illness were often locked up with criminals. Although the struggle
for personal power has vastly improved during the last century, people with mental
illness still encounter stigma and disempowerment. The recently released report by
President George W. Bush's New Freedom Commission for Mental Health (2003)
issues a clarion call for practices that facilitate consumer empowerment.
The goals of this paper are threefold:
1. Provide a working definition of empowerment as applied to the lives of people
with psychiatric disabilities.
2. Identify community and service systems barriers to empowerment.
3. Describe guidelines and other system enhancements that facilitate personal
Abstract and article at:
3. Everett, B. (1994). Something is Happening: The Contemporary Consumer and
Psychiatric Survivor Movement in Historical Context. The Journal of Mind and
Behaviour, 15, (1 and 2, 55-70).
Despite three major reform movements over the last 300 years, the mental health
system has been remarkably resistant to change. Today, another period of reform is
underway, only this time, new players - dissatisfied ex-psychiatric patients - are
organising to affect the process of change. This paper discusses characteristics of
previous movements and examines their similarity to and difference from the present
consumer and psychiatric survivor movement. It appears that the new participants
have shaped the rhetoric of reform but it remains to be seen if they can affect the
Abstract and article at:
4. Health Systems Research Unit, Clarke Institute of Psychiatry (1997). Best Practices
in Mental Health Reform: Review of Best Practices in Mental Health Reform.
Prepared for the Federal/Provincial/Territorial Advisory Network on Mental Health
Article at:
Health Systems Research Unit, Clarke Institute of Psychiatry (1997). Best Practices
in Mental Health Reform: Situational Analysis. Prepared for the
Federal/Provincial/Territorial Advisory Network on Mental Health.
Article at:
5. Hodges, J.Q., and Segal, S.P. (2002). Goal advancement among mental health
self-help agency members. Psychiatric Rehabilitation Journal, 26 (1), 78-85.
Objective: Goal advancement is critical to mental health clients' reintegration into the
community. This research considers factors likely to contribute to goal advancement
among members of four consumer-run mental health self-help agencies (SHAs) who
responded to questions about their goals at baseline and six-month follow-up.
Method: Type of goals, demographics, psychiatric disability, agency characteristics,
and members' attitudes toward professionals were used to predict goal
advancement. Results/Discussion: Surprisingly, faith in the psychiatrist as the
source of responsibility for treatment decisions was associated with goal
advancement. This is contrary to SHA ideology, which emphasizes peer-driven help.
Other findings are also discussed.
Abstract and article at:
6. Jacobson, N., and Curtis, L. (2000). Recovery as policy in mental health
services: Strategies emerging from the states. Psychiatric Rehabilitation Journal,
23 (4), 333-341.
The concept of recovery has emerged as a significant paradigm in the field of public
mental health services. This paper outlines how the concept is being implemented in
the policies and practices of mental health systems in the United States. After a brief
overview of the historical background of recovery and a description of the common
themes that have emerged across the range of its definitions, the paper describes
the specific strategies being used by the States to implement recovery principles.
The authors conclude by raising key questions about the implications of adopting
recovery as system policy.
Abstract and article at:
7. Kelley, M. (2004). How Empowerment Changed My Life. American Rehabilitation,
28 (1), 2-9.
“I don’t have to live in my car anymore.”
It is through my personal and professional experience that I write this article on
empowerment. I have thought about empowerment a lot throughout the years. I
have researched it, lived with it and lived without it. I have shared empowerment
with others. Without it, I have been utterly alone. Empowerment is simple, yet
complex. It pertains to people with psychiatric disabilities and to people with any
disability. I learned this through working at a center for independent living. People
with disabilities face many obstacles that can be disempowering. It is evident that
when the disability community unites and rallies behind a cause, we become more
empowered citizens.
Abstract and article at:
8. Kyrouz, E.M., Humphreys, K., and Loomis, C. (2002). A review of research on the
effectiveness of self-help mutual aid groups. In White, B. J., and Madara, E.
(Eds.), J. American Self-Help Clearing house Self-Help Group Sourcebook (7th
It's not easy to capture the value of self-help groups through empirical studies. But
some researchers have partnered with self-help groups to find appropriate ways. For
those with interest, here are some studies. Several professionally run support group
studies are included. Teachers at all levels might note that the personal stories
which people tell within and about mutual help groups can often convey more
understanding of their value - consider adding it to the curriculum.
Article available at:
9. Leung, D. & DeSousa, L. (2002). A vision and mission for peer support stakeholder perspectives. International Journal of Psychosocial Rehabilitation,
7, 5-14.
Peer support has been described as a key component to the recovery process of
mental illness (Mead & Copeland, 2000); a message that mental health consumer
groups have been highlighting since the 1970s (Petr, Holtquist & Martin, 2000). Peer
support has been defined as a form of social network therapy in which stigmatized
persons interact with each other, feel self-acceptance, and strive to be valued
members of a community (Schubert & Borkman, 1991). This paper describes the
process that the Canadian Mental Health Association (CMHA) - Metropolitan Branch
initiated to decrease social isolation through peer support for consumers within the
agency. The process began with a systematic literature review of different models of
peer support. It also incorporated interviews with key stakeholders that described a
vision, mission, gaps, and future direction for peer support.
Abstract and article at:
10. McLean, A. (2003). Recovering Consumers and a Broken Mental Health
System in the United States: Ongoing Challenges for Consumers/ Survivors
and the New Freedom Commission on Mental Health. Part I: Legitimization of
the Consumer Movement and Obstacles to It. International Journal of
Psychosocial Rehabilitation, 8, 47-57.
Since its anti-psychiatry beginnings, the consumer/survivor movement has
succeeded in promoting its self-help recovery perspectives and gaining legal rights
for patients. On July 22, 2003, the U. S. President’s Freedom Commission on Mental
Health advocated a consumer-driven and recovery-oriented mental health system -a major coup for consumers/survivors. At the same time countervailing forces began
blocking their efforts, challenging their accomplishments and promoting opposing
agendas. This article is the first of a two-article series that examines how multiple
counteracting forces have situated the psychiatric consumer movement today, either
propelling it or trying to reverse its achievements in shaping the production of mental
health services. This part of the series describes how professionals came to
embrace consumer/ survivor perspectives as well as attempts of oppositional forces
to de-legitimize its gains early in federally funded initiatives of consumer run
demonstration projects.
Abstract and article at:
11. McLean, A. (2003). Recovering Consumers and a Broken Mental Health
System in the United States: Ongoing Challenges for Consumers/ Survivors
and the New Freedom Commission on Mental Health. International Journal of
Psychosocial Rehabilitation, 8, 58-70.
This article is the second in a two-part series that examines multiple forces that have
situated the psychiatric consumer movement today, either propelling it or trying to
reverse its achievements in shaping the production of mental health services. Since
its anti-psychiatry beginnings, the consumer/survivor movement has succeeded in
promoting its self-help recovery perspectives and gaining legal rights for patients. On
July 22, 2003, the U. S. President’s Freedom Commission on Mental Health
advocated a consumer-driven and recovery-oriented mental health system -- a major
coup for consumers/survivors. At the same time countervailing forces began
blocking their efforts, challenging their accomplishments and promoting opposing
agendas. This article examines the impact on consumer initiatives resulting from a
restructuring of behavioral health services in the United States under managed
care. It also considers the oppositional economic, political and economic forces that
have attempted to erode consumer gains in recent years. Last, it examines
recommendations of the Freedom Commission, and considers their implications for
the future production of mental health services in a political environment where
consumers/ survivors have recently lost legal ground.
Abstract and Article at:
12. Mead, S., and Copeland, M.E. (2000). What recovery means to us: Consumers'
perspectives. Community Mental Health Journal, 36 (3), 315-328.
In this article two consumer leaders use their own experiences to explain the
meaning and significance of recovery. They emphasize the importance of hope,
personal responsibility, education, advocacy, and peer support. They also address
controversial issues, such as the nature of the therapeutic relationship, the place of
medications in symptom control, and the need for attitudinal changes in mental
health professionals.
Abstract at:;jsessionid=59j7l58b6kfbj.victoria?pu
Article at:
13. Mead, S., and Hilton, D. (2003). Crisis and connection. Psychiatric Rehabilitation
Journal, 27 (1), 87-94.
Psychiatric interventions for crises care lie at the center of the conflict between
forced treatment and recovery/wellness systems in mental health services. Though
crisis can mean completely different things to people who have the experience, the
general public has been taught a unilateral fear response based on media
representation. More and more this has led to social control but is erroneously still
called treatment. This does nothing to help the person and in fact further confuses
people already trying to make meaning of their experience.
This paper offers a fundamental change in understanding and working with
psychiatric crises. Rather than objectifying and naming the crisis experience in
relation to the construct of illness, people can begin to explore the subjective
experience of the person in crisis while offering their own subjective reality to the
relationship. Out of this shared dynamic in which a greater sense of trust is built, the
crisis can be an opportunity to create new meaning, and offer people mutually
respectful relationships in which extreme emotional distress no longer has to be
pathologized. The authors, who have had personal experience with psychiatric
crises, have provided this kind of successful crisis counseling and planning and have
designed and implemented peer support alternatives to psychiatric hospitalizations
that support this model.
Abstract and article at:
14. Parkinson, S. (2003). Consumer/Survivor Stories of Empowerment and
Recovery in the Context of Supported Housing. International Journal of
Psychosocial Rehabilitation, 7, 103-118.
We examined the stories of empowerment and recovery of five psychiatric
consumer/survivors who participated in supported housing programs. Interviews with
these five participants and members of their social networks were used to gather
qualitative data on their lives prior to supported housing, their experiences with
supported housing, and the impacts/changes that they experienced through
supported housing. Changes in personal empowerment, community integration, and
access to valued resources were reported in each of the five stories. The qualities of
the supported housing programs that were reported to contribute to individuals’
empowerment and recovery included individualized and consumer-controlled
support, diverse sources of support, and assistance with accessing basic resources.
The implications of these findings for research and practice were discussed.
Abstract and article at:
15. Pomeroy, E., Trainor, J., and Pape, B. (2002). Citizens shaping policy: The
Canadian Mental Health Association's framework for support project. Canadian
Psychology, 43 (1), 11-20.
Fifteen plus years of work in mental health policy development from a community
development perspective under the aegis of the Canadian Mental Health Association
are described. The evolution of a model de-emphasizing formal mental health
services and emphasizing partnerships between consumers, family members, the
community at large, and the mental health service providers is presented. Particular
attention is paid to the value of re-investing in natural support systems both through
the diversion of funds to such groups and the recognition of such systems as integral
components of the cultural response to serious mental illness.
Abstract and article at:
16. Resnick, S.G., Armstrong, M., Sperrazza, M., and Rosenheck, R.A. (2004). A model
of consumer-provider partnership: Vet-to-Vet. Psychiatric Rehabilitation Journal,
28 (4), 185-187.
Recently, there has been increased interest in consumer-provided mental health
services. Two models have been proposed: One emphasizing full independence
from professional services, and one in which consumers work within the mental
health system. In this paper we describe Vet-to-Vet, a consumer-professional
partnership model in which consumer services are embedded in a mental health
system. We describe the advantages of this approach and barriers to
implementation of other models. Vet-to-Vet has several unique elements, developed
and implemented by consumers with professional consultation and supervision. We
believe that consumer-partnership models of consumer-provided mental health
services have potential for minimizing implementation barriers and for maximizing
long-term sustainability.
Abstract available at:
PDF article available at:
17. Ridgway, P. (2001). Restorying psychiatric disability: Learning from first
person recovery narratives. Psychiatric Rehabilitation Journal, 24 (4), 335-343.
This qualitative study examines first person accounts of recovery from psychiatric
disability. Common themes and patterns are identified and findings are linked to
narrative and resiliency theories. Implications for policy, practice, and research are
Abstract and article at:
18. Solomon, P. (2004). Peer support/peer provided services: underlying
processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal,
27 (4), 392-401.
The article defines peer support/peer provided services; discusses the underlying
psychosocial processes of these services; and delineates the benefits to peer
providers, individuals receiving services, and mental health service delivery system.
Based on these theoretical processes and research, the critical ingredients of peer
provided services, critical characteristics of peer providers, and mental health
system principles for achieving maximum benefits are discussed, along with the
level of empirical evidence for establishing these elements.
Abstract and article at:
19. Williamson, T. (2004). User Involvement - A Contemporary Overview. The Mental
Health Review, 9 (1), 6-12.
There has been a dramatic shift from passive recipient to active participant among
mental health service users over the last 20 years in the UK. The article presents an
overview of what user involvement actually means in relation to the modern mental
health system, and people's experiences of having contact with that system. It
identifies a number of unresolved issues, particularly relating to the question of how
much user involvement can actually achieve and for whom?
Abstract at:
Article at:
Additional articles available online
1. A selection of papers on self-determination is available online.
2. Self-determination tools and resources are also updated here.
Abstracts Available Online
Note: The links to abstracts listed in this portion of the report provide additional
information to obtain the article.
1. Bjorklund, R.W. and Pippard, J.L. (1999). The mental health consumer
movement: Implications for rural practice. Community Mental Health Journal 35
(4), 347-359.
Developing consumer-oriented programs for rural areas presents a major challenge
for practitioners and policy makers. The mental health consumer movement, a
successful urban creation, has yet to fully impact rural practice and be of benefit to
individuals with severe and persistent mental illness. Rural mental health
professionals face unique challenges and opportunities in utilizing rural strengths to
foster consumer participation in the design and implementation of service delivery.
The authors address the unique barriers facing rural communities and propose a
self-help model as a service delivery alternative.
Abstract at:
2. Burns-Lynch B., and Salzer, M.S. (2001). Adopting innovations--lessons learned
from a peer-based hospital diversion program. Community Mental Health
Journal, 37 (6), 511-521.
Moves to bridge the gap between research and practice have heightened interest in
how service innovations are adopted. This paper reports on a peer-based hospital
diversion program that provided short-term respite care, clinical monitoring,
connection or re-connection to other mental health services, and peer support. The
program was successful in providing services to the target population and was
viewed as highly desirable by service recipients and clinical agencies. However, full
adoption of this innovation was not realized and it closed barely a year after opening.
Lessons learned from both the life and death of this program are offered.
Abstract available at:
3. Carlson, L.S., Rapp, C.A., and McDiarmid, D. (2001). Hiring consumer-providers:
Barriers and alternative solutions. Community Mental Health Journal, 37 (3), 199213.
The hiring of consumers as providers of mental health services has steadily
increased over the last decade. This article, based on the literature and two round
table discussions, explores three prevalent barriers (i.e., dual relationships, role
conflict, and confidentiality) and proposes alternative solutions to each.
Abstract at:
4. Chinman, M.J., Weingarten, R., Stayner, D., and Davidson, L. (2001). Chronicity
reconsidered: Improving person-environment fit through a consumer-run
service. Community Mental Health Journal, 37 (3), 215-229.
In the past, the term “chronic” referred to people who had serious mental illness and
who typically received long-term care in a state mental hospital. Although this term
recently has fallen out of favor, we resurrect the term here, not to revive a
demeaning euphemism, but rather to redefine it as the result of a poor personenvironment fit between the complex and challenging needs of those with serious
psychiatric disorders and a community-based service system that often is illequipped to treat them. Previous research indicates that recurrent acute
hospitalizations and an inability to establish or maintain tenure in the community may
be due to a disconnection from community-based services and supports, social
isolation, and demoralization. One promising approach to addressing these issues is
that of peer support. To illustrate the potential utility of peer support in improving
person-environment fit and decreasing the chronicity of the subsample of people
who continue to have difficulty in establishing viable footholds in the community, we
describe a peer support-based program, the Welcome Basket, developed, staffed,
and managed entirely by mental health consumers. Preliminary analyses that
evaluate Welcome Basket's effectiveness are included, and we discuss the
implications of these data for future research and program development in this area.
Abstract at:
5. Corrigan, P.W., Calabrese, J.D., Diwan, S.E., Keough, C.B., et al. (2002). Some
recovery processes in mutual-help groups for persons with mental illness; I:
Qualitative analysis of program materials and testimonies. Community Mental
Health Journal, 38 (4), 287-301.
Outcome research is beginning to suggest that mutual-help programs lead to
significant improvements in the quality of life and related factors of members who
have serious mental illness. This paper is the first in a series that examines recovery
processes that may account for these positive outcomes. In Study 1, a content
analysis was completed on one dimension of the written program for GROW, a
mutual-help program with more than 40 years of experience. Thirteen reliable
recovery processes emerged from this analysis; most prominent among these was
to "be reasonable" and to "decentralize from self by participating in community." In
Study 2, the recovery processes that emerged from this analysis of one aspect of
GROW's written program were applied to 22 written testimonies made by Growers.
Results of this analysis again showed being reasonable and decentralizing from self
by participating in community were essential processes in this mutual-help program.
Analysis of the personal testimonies also showed accepting one's personal value as
an important element in the GROW program.
Abstract at:
6. Drake, R.E., Green, A.I., and Mueser, K. T. (2003). The history of community
mental health treatment and rehabilitation for persons with severe mental
illness. Community Mental Health Journal, 39 (5), 427-440.
The authors review the evolution of the treatments for persons with severe mental
illnesses over the past 40 years in three areas: pharmacological and other somatic
treatments, psychosomatic treatments, and rehabilitation. Current treatments are
based on a much stronger evidence base, are more patient-centered, and are more
likely to target autonomy and recovery.
Abstract at:
7. Francis, L.E., Colson, P.W., and Mizzi, P. (2002). Beneficence vs. Obligation:
Challenges of the Americans with Disabilities Act for consumer employment in
mental health services. Community Mental Health Journal, 38 (2), 95-110.
Involvement of mental health service consumers in the provision of mental health
services is a growing model in community mental health. It is, however, a
complicated issue, made ever more so by the passage of the Americans with
Disabilities Act. In this ethnographic case study, the authors seek to explore the
changes one social services agency has made to adjust to the requirements of the
ADA and the impact of these changes on their consumer employees. Their results
indicate potential for positive progress as a result of the ADA, but also unexpected
pitfalls as organizational cultures change as well.
Abstract at:
8. Hardiman, E.R., and Segal, S. P. (2003). Community membership and social
networks in mental health self-help agencies. Psychiatric Rehabilitation Journal,
27 (1), 25-33.
This article explores community membership among self-help agency (SHA)
participants. It is suggested that SHAs foster the enhancement of peer-oriented
social networks, leading to the experience of shared community. Social network
analysis was used to examine the structure of support mechanisms, and to assess
levels of community membership through peer inclusion. Results indicate that both
individual and organizational characteristics play roles in predicting peer presence in
social networks. Organizational empowerment is a key factor, with the SHA
emerging as a promising locus for peer support development through enhanced
social networks. Implications for the organization of consumer-based services are
Abstract at:
9. Holter, M.C., Mowbray, C.T., Bellamy, C.D., MacFarlane, P., and Dukarski, J.
(2004). Critical Ingredients of Consumer Run Services: Results of a National
Survey. Community Mental Health Journal, 40 (1), 47-63.
In this article, the authors describe steps used to develop and operationalize fidelity
criteria for consumer-run (CR) mental health services: articulating and
operationalizing criteria based on published literature, then revising and validating
the criteria through expert judgments using a modified Delphi method. According to
the authors, respondents rated highest those structural and process components
emphasizing the value of consumerism: consumer control, consumer choices and
opportunities for decision-making, voluntary participation, and respect for members
by staff.
Abstract at:
10. Linhorst, D.M., Eckert, A., Hamilton, G., and Young, E. (2001). The involvement of
a consumer council in organizational decision making in a public psychiatric
hospital. The Journal of Behavioral Health Services & Research, 28 (4), 427-438.
This article describes a consumer group within a public psychiatric hospital that
serves primarily a forensic population. Some barriers to participation included the
severity of some clients' mental illness, an organizational culture that does not fully
support participation, the lack of clients' awareness of problems or alternative
actions, and inherent power imbalances between clients and staff. Despite these
barriers, the consumer group has made improvements for facility clients. Some
factors associated with this success included strong administrative support, the
allocation of a highly qualified staff liaison to work with the group, and the integration
of the group into the facility's formal decision-making structure. Lessons are offered
for the development of similar groups within public psychiatric hospitals and
community-based mental health agencies.
Abstract at:
11. Lord, J., Ochocka, J., Czarny, W., and MacGillivary, H. (1998). Analysis of Change
Within a Mental Health Organization: A Participatory Process. Psychiatric
Rehabilitation Journal, 21 (4), 327-339.
This article documents the process of change of a mental health organization, using
a case study that illustrates a shift in philosophy and practice based on the concepts
of empowerment and community integration. The case study includes the context
and motivation for change, planning and implementation, evaluation and outcomes
of the change process.
Abstract at:
12. Mowbray, C.T., Moxley, D.P., and Collins, M.E. (1998). Consumer as mental
health providers: First-person accounts of benefits and limitations. The Journal
of Behavioral Health Services & Research, 25 (4), 397-411.
Community support programs are increasingly establishing paid service positions
designated exclusively for consumers. Project WINS (Work Incentives and Needs
Study), a hybrid case management-vocational program for individuals with severe
mental illness, used consumers as peer support specialists (PSSs) to supplement
professional roles. Semi structured interviews were conducted with PSSs about 12
months after their employment ended. They identified substantial personal benefits
specific to consumer-designated roles (e.g., a "safe" employment setting with
accommodations) and general benefits from employment. Problems described were
just as numerous, encompassing attitudes toward assigned peers and costs to their
own well-being. Critical commentary addressed program operations (structure,
supervision, and training needs) and problems in the mental health system. The
authors discuss the changed sense of self that service provider roles can create for
consumers and suggest that mental health administrators provide anticipatory
socialization for this service innovation throughout their agencies and ongoing
supports for consumers in their new roles.
Abstract at:
13. Mowbray, C.T., Robinson, E.A.R., and Holter, M.C. (2002). Consumer drop-in
centers: Operations, services, and consumer involvement. Health & Social
Work, 27 (4), 248-261.
Interest in involvement of consumers in mental health and psychiatric rehabilitation
services delivery has expanded in recent years, encompassing self-help
approaches, consumers employed as providers in formal agencies, and consumers
operating their own services. This study reports results from in-depth phone surveys
conducted with 32 consumer drop-in centers in Michigan. Results indicate that
centers operate in many ways like other human services businesses, albeit with
much smaller budgets. Funding levels, salaries, and services showed great
heterogeneity among the centers and in comparison with reports in the literature.
Centers autonomously run by consumers and centers with consumer involvement
(operated by a non-consumer agency) were found to differ significantly on several
variables, including consumer control, funding and service levels, and challenges.
Implications for the growth and increased use of consumer drop-in centers are
Abstract at:
14. Mowbray, C.T., and Tan, C. (1993). Consumer-operated drop-in centers:
Evaluation of operations and impact. Journal of Mental Health Administration, 20
(1), 8-19.
Research on self-help for consumers of psychiatric services has focused on the
operation of voluntary groups and largely ignored service programs operated by
consumers. This evaluation study focused on six consumer-operated drop-in
centers, each established for at least two years. These centers served a combined
total of 1,445 consumers and were funded as demonstration projects by the
Michigan Department of Mental Health. Structured interviews of consumer-users of
these centers indicated that the program was meeting its funding intents of serving
people with serious mental illness and of creating an environment promoting social
support and shared problem solving. Levels of satisfaction were uniformly high;
there were few differences across centers. Issues that emerged for future policy and
research considerations included funding constraints, enhancing accessibility
(particularly for women and people needing frequent hospitalization), variable levels
of support from catchment area community mental health agencies, and determining
the long-term benefits of drop-in center participation.
Abstract at:
15. Pudlinski, C. (2001). Contrary themes on three peer-run warm lines. Psychiatric
Rehabilitation Journal, 24 (4), 397-400.
Peer-run warm lines are relatively new precrisis services, designed for providing
social support. Participant observation of three warm lines revealed them to be
complex entities, consisting of three contrary themes. Site 1 emphasized
connectedness: build peer support networks and establish relationships. Site 2
emphasized nondirectiveness: actively listen and respect boundaries. Site 3
emphasized problem solving: make sure callers are safe for the night.
Abstract at:
16. Reeve, P., Cornell, S., D’Costa, B., Janzen, R., and Ochocka, J. (2002). From our
perspective: Consumer researchers speak about their experience in a
community mental health research project. Psychiatric Rehabilitation Journal, 25
(4), 403-408.
People who have experienced the mental health system were hired and trained as
researchers in a community mental health research project. Throughout the course
of the project, these consumer researchers reflected on what they learned about
their research experience. This article is a window into this learning process and
offers an opportunity to see research through the eyes of consumer researchers. We
begin by giving an overview of the research project and introducing the research
team. Then the consumer researchers in our project share their experiences and
insights about involving mental health consumers in research projects. We hope that
our project's experiences will help other projects that involve consumers in ways that
are empowering for the consumer and beneficial to the research.
Abstract at:
17. Salzer, M.S., and Shear, S.L. (2002). Identifying consumer-provider benefits in
evaluations of consumer-delivered services. Psychiatric Rehabilitation Journal 25
(3), 281-288.
Consumer-delivered services are different in many ways from traditional mental
health services and require unique approaches to how they are studied. This
includes attending to benefits to both consumer-providers as well as to program
participants. A qualitative study was conducted to systematically examine consumerprovider benefits. A thematic analysis of interviews with 14 peer providers from
Friends Connections, a peer-support program for persons with recurring mental
health and substance use disorders, was conducted. Responses indicate that peer
providers benefit from their roles as helpers, a finding consistent with the helpertherapy principle. Implications for research and policy are discussed.
Abstract at:
18. Segal, S. P., Silverman, C., and Temkin, T. (1997). Program environments of selfhelp agencies for persons with mental disabilities. The Journal of Behavioral
Health Services & Research, 24 (4), 456-464.
Leaders of self-help agencies (SHAs) aspire to develop program environments that
are different from community mental health agencies (CMHAs). This article
addresses two questions. Do consumers' perceptions of SHAs approximate the
characteristics leaders think ought to typify such agencies? Do SHA and CMHA
consumers differ in their program perceptions? Using the Community-Oriented
Program Environment Scale, leader expectations of ideal SHA environments were
obtained from a national survey of 189 consumer-run agency heads, perceptions of
actual environments from interviews with 310 SHA consumers, and perceptions of
CMHAs from questionnaire responses of 779 consumers in 54 programs. SHA
reality conforms to ideology in offering opportunities for consumers to experience
involvement, support, and autonomy in the receipt of needed service. While showing
only modest differences from CMHAs on relationship and treatment characteristics,
SHA consumers differ in their perceived control over program rules, a fact previously
found significant in promoting positive outcomes.
Abstract at:
19. Solomon, P. and Draine, J (2001). The state of knowledge of the effectiveness of
consumer provided services. Psychiatric Rehabilitation Journal, 25 (1), 20-27.
There is a mixed record of research on consumer delivered services. There has
been a great deal of descriptive work that supports the feasibility of consumer
provided services. Only a limited number of studies have been reported that focus
on outcomes for people who receive services from consumers. This new literature is
at a critical juncture. This paper examines the state of research on three types of
consumer provided services, consumer operated services, consumer partnership
services, and consumers as employees. All these service types include consumers
as paid providers who deliver mental health services to others, not primarily for their
own benefit. This excludes self-help programs. Research resources need to be
focused less on consumer provided services as adjunctive to professional services
and more on determining the effectiveness of stand-alone consumer provided
services in order to develop evidence to influence policy decisions.
Abstract at:
20. White, H., Whelan, C., Barnes, J.D., and Baskerville, B. (2003). Survey of
consumer and non-consumer mental health service providers on assertive
community treatment teams in Ontario. Community Mental Health Journal, 39 (3),
Reflecting the increasing trend of consumers as providers in mental health services,
the standards for Assertive Community Treatment (ACT) teams in Ontario, Canada
require the hiring of at least 0.5 full-time equivalent consumers as a service provider.
Through a mail-out survey, we explored how the consumer position has been
integrated into these ACT teams. It was found that despite some variation in the
roles and degree of integration of the consumers on these teams, consumers were
generally well-incorporated team members with equal or better job satisfaction as
compared to other employees
Abstract at:
Other articles available through databases or print journals
1. Epstein, M., and Olsen, A. (1998). An introduction to consumer politics. Journal
of Psychosocial Nursing & Mental Health Services, 36 (8), 40-49.
2. Ferguson, T. (1992). Health in the Information Age: Patient, Heal Thyself.
The Futurist, 26, (1), 9-13.
3. Lehman, A. F. (2000). Putting recovery into practice: A commentary on "what
recovery means to us". Community Mental Health Journal, 36 (3), 329-331.
4. Lunt, A. (2000). Storytelling: How nonconsumer professionals can promote
recovery. Journal of Psychosocial Nursing & Mental Health Services, 38 (11), 4245.
5. Nicholls, S. (2001). Making connections: clients newly discharged from psych
hospitals gain support from their peers. The Journal of Addiction and Mental
Health, 4 (3), 5.
6. Towsend, E., Birch, D.E., Langley, J., and Langille, L. (2000). Participatory
research in a mental health clubhouse. The Occupational Therapy Journal of
Research, 20 (1), 18-44.
7. Trainor, J., Shepherd, M. Boydell, K., Leff, A., & Crawford, E. (1997). Beyond the
service paradigm: The impact and implications of consumer/survivor
initiatives. Psychiatric Rehabilitation Journal, 21, 132-140.
8. Turner, M., Korman, M., Lumpkin, and Hughes, C. (1998). Mental health
consumers as transitional aides: A bridge from the hospital to the community.
Journal of Rehabilitation, 64 (4), 35-39.
9. Walsh, J., and Connelly, P.R. (1996). Supportive behaviors in natural support
networks of people with serious mental illness. Health & Social Work, 21
(4), 296-303.
10. Wilson, M.E., Flanagan, S., and Rynders, C. (1999). The FRIENDS program: A
peer support group model of individuals with a psychiatric disability.
Psychiatric Rehabilitation Journal, 22 (3), 239-247.
This report is intended to provide a sampling from a broad range of accessible
Internet resources as well as academic literature on Peer Support.
With the following points in mind, one can envision the future directions of
Consumer/Survivor Initiatives in Ontario.
a) Peer support has received credible attention from a variety of healthcare
stakeholders (government, academic researchers, physicians, and the popular
b) Other jurisdictions (United States, United Kingdom, and Australia) have taken
consumer/survivor expertise further by integrating Peer Support as a cornerstone
of recovery in their mental health systems.
c) Empirical evidence has shown the credibility of Peer Support within the
continuum of services and supports. Studies have shown its role in decreasing
hospitalizations and increasing quality of life.
d) Systemically, CSIs are in a unique position to help the province with its
transforming healthcare agenda. In the midst of the mental health field, CSIs
retain a unique and distinct appeal. Their community-based and membershipdriven nature makes them responsive to local needs.
Peer Support creates a “win-win” situation for all partners in the mental health
¾ For CSIs, new healthcare dollars will improve availability of proven wellnessoriented strategies. Investments in training and education will lead to additional
research and capacity building.
¾ For the institutional sector, working with CSIs has been shown to reduce the rate
of hospitalizations for mental health system users. This fits with the provincial
transformation health agenda by freeing up hospital beds for mental health
consumers or other patients who are on waiting lists. Please see the
Connections website:
¾ For other community mental health providers, the individuals that they serve will
benefit from associating with Peer Support organizations. CSIs that offer Peer
Support increase the range and enhance the flexibility of mental health services
such as case management and assertive community treatment teams, enabling
individualized approaches to recovery. The complementary nature of CSIs
among other community mental health services has been documented in the
Community Mental Health Evaluation Initiative (CMHEI) report.
¾ The mental health system benefits from consumer/survivors who have advanced
in recovery to the point where they are employed in helping their peers. The
development of peer support specialists in the States is one striking example.
The legitimate acknowledgement of Peer Support is fundamental to a holistic vision of
mental health. CSIs need to achieve funding equity to sustain their momentum and
growth thereby strengthening the entire mental health sector.
Appendix 1
“Creative Directions” Peer Support Workshop (September 22, 2004)
Presenters: Donna Cross, Deborrah Sherman, Peggy Guiler-Delahunt
Peer Support: Who, What, When, Where, Why … and How???
Donna Cross: [email protected]
Deborah Sherman: [email protected]
Peggy Guiler-Delahunt: [email protected]
Consumer-members and non-members
Flow through money, ½ Transfer Payment Agency and ½ independent
Board or Steering committee (non consumer/survivors)
District Health Councils
Other funders
Community Mental Health & Local communities
is Peer Support?
is the goal?
do people need? Want ask for?
are the gaps?
funds are available?
resources do we have?
When should/shouldn’t Peer Support be “paid for”?
When is an organization ready to take on funding etc.?
When does Peer Support begin?
When is there enough to “give” or “receive” Peer Support?
When is it appropriate to diversify into specialties?
What can a supporter disclose?
When is it OK to disclose?
When to disengage?
When to draw lines between Peer Support & friendship/therapy?
When is Peer Support putting supporter themselves at risk (burnout)?
“Creative Directions” Peer Support Workshop notes cont’d
How to create a peer program in your CSI
Address issues like:
- Confidentiality
- Hope & Recovery
- Listening & Communication
- Suicide Intervention
- Community Resources (very specific to your area)
- Programs need measures in place to enforce certain boundaries (eg.
- Ability/access for peer supporter to “debrief” and “de-stress” should be built into
- “continuing” education via monthly meetings/or “levels” of achievement
- CPR/First Aid component?
- “Intimacy” boundaries and power imbalances for peer supporters
- Grief
- Self esteem
- Parameters needed re: what “level” or “responsibility” can people take on
- Any exclusionary criteria considered
- Offer certification? Level of activity/responsibility connected to level of
What activity = Peer Support?
- Volunteering at the CSI?
- Facilitating program/activity in the CSI
- Facilitate groups
- Hospital visits??
- 1 to1 matches
Working for peanuts
Pressure MOHLTC to support Peer Support!
Is this a direction OPDI can go? As long as there is accredited/ approved
More Training Possibilities
- History of your CSI
- Policy/procedures
- Body Language and “Attending” skills
- Abuse Issues/Anger
- Create a method or process to make 1:1 buddy matches
CSIs need to unify
- Via OPDI