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Running head: HIRING YOUTH LIVED-EXPERTISE 1 First time hires of youth lived-expertise employees: An exploration of theory and application Lacy K. B. Dicharry Louisiana State University Author Note Submitted to LHRD 7575: Managing Change in Organizations

HIRING YOUTH LIVED-EXPERTISE 2 Table of Contents First time hires of youth lived-expertise employees: An exploration of theory and application .... 5 Definition of Change Experience .................................................................................................... 5 Role that I Play ............................................................................................................................ 5 Model or Pattern of Change ......................................................................................................... 6 Theory of Change ............................................................................................................................ 7 Stage 1: Establish a Sense of Urgency ........................................................................................ 7 Stage 2: Forming a Powerful Guiding Coalition ......................................................................... 7 Stage 3: Creating a Vision ........................................................................................................... 7 Stage 4: Communicating the Vision ............................................................................................ 8 Stage 5: Empowering others to Act on the Vision ...................................................................... 8 Stage 6: Planning for and Creating Short Term Wins ................................................................. 8 Change Analysis ............................................................................................................................ 12 Implications for Change ............................................................................................................ 12 Conclusion ..................................................................................................................................... 12 References ...................................................................................................................................... 13

HIRING YOUTH LIVED-EXPERTISE 3 First time hires of youth lived-expertise employees: An exploration of theory and application INTRODUCTION Definition of Change Experience The type of change I’d like to discuss is an emerging role in the workforce. While there has been an overarching evolution in the workforce of human services as persons with lived-experience in receiving services have become increasingly valuable in systems change and delivery, there is an acute or episodic change that occurs within this evolution when organizations decide to establish and hire their first lived-expertise role. Language used to describe this phenomenon is varied across health and human service sectors. A broadly accepted term across human serving systems is lived-experience (Burk et al., 2013). The field of mental health frequently uses the terms peer support services (Optum, 2016), peer workers, (Gagne, Finch, Myrick, & Davis, 2018), peer providers, peer support provider, youth peer support provider, youth peer provider (Delman, & Klodnick, 2017), user/survivor or consumer (Lived Experience Research Network, 2014) and lived-experience (Gopalan et al., 2017). Child welfare uses terminology such as foster care alumni (Geiger & Beltran, 2017) and peer advocate (CWS Stakeholder Group, 2003). Other recovery systems utilize terms like self- help groups and mutual support (Repper & Carter, 2011), and in medical systems, particularly diabetes and cancer, peer educator services is a frequently used term (Liu et al., 2018). The military simply uses peer support (Hom, Stanley, Schneider, & Joiner, 2017). Simons et al. (2016) offer the definition of the service of youth peer support as “youth with ‘lived experience’ who have personally faced the challenges of coping with serious mental health conditions, either as a consumer or a caregiver” (p. 4). Burk et al. (2013) offer an expanded definition of lived experience, “past participation in human-serving systems receiving services as

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HIRING YOUTH LIVED-EXPERTISE 4 a child, youth, or young adult (including but not limited to mental health, child welfare, juvenile justice, and/or special education) or currently or formerly living with a mental health or substance abuse diagnosis” (p. 20). For this purposes of this paper, and for future use in the field, I propose the following comprehensive definition of lived-expertise: the application of lived- experience as a professional skillset, including insight, knowledge, skills and competencies gained from lived-experience. For the purposes of this paper, peer support and lived-expertise will be used interchangeably. Role that I Play For the purposes of this assignment, I would like to offer my perspective from two different time points in the process of hiring lived-expertise. First, I’ll offer my perspective as being a ‘participant in the change’ as one of two first lived-expertise hires for a leading national organization. Second, I’d like to offer my perspective as a consultant supporting organizations going through this change, and what I’m seeing collectively across the nation as others work to implement this same change in their organization. The National Resource Center for Youth Development (NRCYD) was a training and technical assistance center funded through the HHS / ACF / Children’s Bureau to support state child welfare systems in implementing best practices in serving transition aged youth in foster care. I was hired as a Youth Consultant in 2005 to serve in a consultant capacity to model youth adult partnership and utilize my lived-experience as a youth leader on youth advisory boards in assisting other youth advisory boards to grow and develop. Upon graduation from undergraduate college in 2008, myself and another ‘youth’ were hired to fill the first full time employee role, whose primary purpose was to infuse the experience of being in foster care into the work of NRCYD. While this change was anticipatory, and internal values aligned with engaging and

HIRING YOUTH LIVED-EXPERTISE 5 supporting young people in this type of lived-expertise position, there were still tuning and adaptive changes that needed to occur due to unanticipated reactions to this change. In organizations where central organizational values align with hiring a lived-expertise role, a more significant reorientation or even re-creation change is required. Model or Pattern of Change The decision to hire is episodic, however the process, reactive or anticipatory, of adjusting workflows, policies and procedures, reasonable accommodations, communication and clarification of the role to other colleagues on what a “lived-expertise” role is, professional development approaches, and re-orienting an organizational culture to accept lived-experience as a professional skillset (lived-expertise) requires transformational shifts in the way people think about and engage professional skillsets and expertise. The classification into alpha, beta, gamma depends on the starting point of an organization. If an organization’s values, processes, and culture are aligned well with lived-expertise, then an alpha change in adjustment to HR and other processes (e.g. reasonable accommodations for mental health) may be all that is necessary. However, if an organization is not already aligned with valuing lived-expertise, a gamma(B) change may be necessary if the endeavor is to be implemented successfully (e.g. ‘delivering services to consumers’ to ‘consumer delivered services’). Assessment of an organization’s orientation to lived-expertise is paramount to determine the type of change needed to be inclusive of lived-expertise roles in service and program delivery. There are several barriers to implementing a change in the workforce addressed by Deming’s Fourteen Points of Management (Swanson & Holton, 2001), the greatest of which, in my experience, is fear. I have seen fear from the traditional professional roles that they will be replaced by these new roles, when in reality both are necessary to collaborate to produce good

HIRING YOUTH LIVED-EXPERTISE 6 outcomes for consumers. Fear also exists when working in intergenerational contexts (Rudolph, Rauvola, & Zacher, 2018). My biggest fear I’ve encountered along the way aligns with imposter syndrome – that I am not good enough or have the right skillsets for this position, despite consistent over-delivery and well-developed skillsets necessary for the job. Primary Theory of Change Kotter’s Stages of Change Theory (2007) supports the needed change process for integrating lived expertise roles into human service delivery organizations. Kotter (2006, p. 23) offers the following stages of change ( see Table 1 ). Table 1: Stages of Change, (Kotter, 2007, p. 4)

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HIRING YOUTH LIVED-EXPERTISE 7 Application of Theory Stage 1: Establish a sense of urgency. In this stage, Kotter (2007) recommends examining market and competitive realities and identifying crises and major opportunities. Youth peer advocates across the country have been effective in sharing the need and opportunity for lived-expertise employees. In the competitive landscape of human services, organizations are always seeking to increase outcomes for their clients, which can result in more accolades and more opportunities for funding (Ramey, Lawford, & Rose-Krasnor, 2017). We know that youth relate more readily to their peers, but there is evidence to show that “peer-delivered interventions can decrease mental health symptoms and stigma, reduce psychiatric hospitalizations, and enhance consumers ability to manage their illness” (Gopalan, 2017, p. 89). Additionally, when clients receive services from trained peers, they are more likely to experience “greater hope and belief that recovery is possible, expanded social networks, increased self-esteem, empowerment, self-efficacy, self- management of difficulties, and treatment engagement” (Gopalan et al., 2017, p. 89). Many states are now billing Medicaid for Youth Peer Support, lending additional urgency to hire youth peer workers (Simons et al., 2014). Stage 2: Forming a powerful guiding coalition. Here Kotter (2007) recommends two things: Assemble a powerful group and encourage the group to work together. Several efforts have been led in the mental health and military sectors to establish leading national organizations and workgroups whose charges were to develop national standards, competencies, and certifications for lived-expertise roles. While these efforts are a necessary part of leading a significant change, strong coalition efforts such as these have not trickled down to state agencies and community centers who will actually be

HIRING YOUTH LIVED-EXPERTISE 8 leading the change effort in their organizations. Additionally, in local organizations, leadership sets the tone and has significant impact on employees’ well-being, and leading through change is no different (Inceoglu, Thomas, Chu, Plans, & Gerbasi, 2018). Well-being of all employees is important, but because lived-expertise employees are often hired BECAUSE they have lived experience with health and mental health issues, stewardship of well-being of lived-expertise employees is especially imperative throughout change. Stage 3: Creating a vision. Kotter (2017) offers two strategies for creating a vision: creating a vision that helps direct the change and develop strategies that can be implemented to achieve the vision. The challenge with creating a broad vision is that a vision needs to be specific – and organizations look very different. A vision for a peer support led drop-in center in Kentucky will look very different than an urban setting peer support unit in Alleghany county (Simons, 2014). The challenge presented in this step is that in order to have an authentic vision, youth with lived experience must be at the table and have an integral role in defining the vision – however this is challenging when the people with authority don’t believe that youth are assets and shouldn’t be at the table, creating a difficult catch-22. A stronger national vision needs to be created to make this stage effective. Stage 4: Communicating the vision. Advocates for lived-expertise roles and increasing youth voice in systems change have been working to communicate the vision of having a lived-expertise workforce for more than a decade through many channels, as Kotter suggests (2007). Advocates have presented at conferences, given keynote speeches, written guides (Burk et al., 2013; Delman & Klodnick, 2017), and advocated at state administration and capital levels. These activities are commendable and inspirational, but because many of these advocates are grassroots youth leaders, there isn’t as

HIRING YOUTH LIVED-EXPERTISE 9 much authority to create the vision for decision makers who have the power to implement a significant change in the workforce. While the Substance Abuse and Mental Health Services Administration (SAMHSA) has been supportive and has mandated hiring of youth lived- expertise roles in Systems of Care, Healthy Transitions, and other grant initiatives, there has been little guidance on what the ideal change would look like. States and organizations are left to ‘figure it out’ and are failing many times before they succeed, leading to burnout and a quick dissolution of the vision of a youth lived-expertise workforce in many situations. Stage 5: Empowering others to act on the vision. Key steps to empowering others include eliminating obstacles, changing systems or structures. Having been a consultant with several states and organizations implementing this change, I feel that the field collectively is in Step 5– again people are beginning to see the vision, some are able to communicate the vision, but because step 1 wasn’t thoroughly addressed in many cases, organizations are now spending much more time and energy in removing obstacles in Step 5. This also prevents success in gaining short term wins in Step 6, resulting in extensive spending due to turnover, a diminishing belief in the vision, and a desire to halt efforts at hiring and supporting youth lived-expertise roles altogether in some organizations. Stage 6: Planning for and creating short term wins. This is the stage where the field as a whole is still in development. Despite a few exceptions of organizations who have been able to successfully hire and grow a youth lived- expertise workforce, there are much more numerous accounts of organizations who are attempting to build in the youth lived-expertise role into their organizations and are failing, resulting in re-structuring or outright elimination of the youth lived-expertise role despite growing evidence that lived-expertise roles aid in positive mental health outcomes and

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HIRING YOUTH LIVED-EXPERTISE 10 significantly increase cost savings across medical and mental health sectors (Optum, 2016; Rossiter, Louise & Socho, 2018; Johansson, Keller, Sönnichsen, Weitgasser, 2017; Delman, & Klodnick, 2017; Gopalan et al., 2017; Repper & Carter, 2011). Stage 7: Consolidating improvements and producing still more change. Kotter (2007) suggests utilizing credibility to “continue to change systems, structures and polices that don’t fit the vision, hiring, promoting, and developing employees who can implement the vision, and reinvigorating the process” (p. 4). The organizations in the field who have had the most success with implementing large scale changes in workforce are the few who have aligned values of youth engagement with the vision of developing a youth lived-expertise workforce, primarily Alleghany County and Youth MOVE Oregon (Simons, 2014). When organizations can focus primarily on building the new workforce rather than changing old policies and workplace cultures, they can more effectively and efficiently implement the necessary supports to continue to develop the lived-expertise workforce. Stage 8: Institutionalizing new approaches. There is a call to action to continue developing leadership and succession in youth lived- expertise workforce, as referenced in Kotter’s eighth step (2007). Once organizations have successes with hiring lived-expertise individuals, there is a strong precedent to continue and grow this workforce. Take me for example. After I was hired as the first youth at the NRCYD, I went on to go to grad school, and 4 full time lived-expertise staff have followed. My successors have built upon my work to expand the Young Adult Consultant Network, a network of more than 30 youth consultants with lived-experience from foster care, who are now professional colleagues alongside other state review teams. This practice has continued to grow and spread to other national initiatives, with new lived-expertise young professionals being hired every day.

HIRING YOUTH LIVED-EXPERTISE 11 For the organizations who have maintained and grown the youth lived-expertise positions, the demand has shifted to ensure appropriate professional and leadership development opportunities for these young professionals (Solomon, 2004). Secondary Theories of Change Two additional change theories support the adaptation of the lived expertise workforce development change. Rogers (2003) Innovation Adoption Curve applies to the landscape of how organizations adopt the change (early innovators). Organizations like NRCYD when I was hired, and Alleghany County Peer Support Unit, have led the innovation in establishing an entire peer support workforce in Pittsburg (Simons, 2014). These innovators allow for a model to be established, a vision to be realized, and offer a roadmap forward for the early adopters to establish an evidence base and work out ‘the bugs’ in order for the early majority to follow. Table 2: Rogers (2003) Diffusion of Innovation Curve Garvin & Roberto (2005) offered phases of a persuasion campaign (Table 1) that could lend itself well to incorporating a new role of lived-expertise in the workforce. When intergenerational collaboration is utilized (Rudolph, Rauvola, & Zacher, 2018), and with the right engagement techniques with the rest of the workforce in an organization, and when fears, questions, and concerns are heard and addressed, the current workforce would likely be much

HIRING YOUTH LIVED-EXPERTISE 12 more open to accepting and supporting the changes in hiring youth lived-expertise workers across systems (Ramey, & Rose-Krasnor, 2015). Table 3: Four Phases of a Persuasion Campaign Change Analysis While Kotter’s theory of change provides an excellent overlay of the change implementation process, and I believe can effectively be applied, I do feel there are some areas that are lacking in order to be the most effective change model for hiring youth-lived expertise employees. Developmental, contextual, and cultural considerations need to be made at each phase of the model, particularly in complex systems (Yawson, 2012). Because hiring youth lived-expertise employees engages two very different groups to be effective, this change requires the preparation and support of three separate entities: the adults and colleagues with whom the new employees will be working; the youth lived-expertise employees themselves; and the organizational policies, practices, and environment. Because each of these is significantly complex, Kotter’s change theory fails to account for preparing individuals, and only focuses on communicating and engaging in the vision of change.

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HIRING YOUTH LIVED-EXPERTISE 13 Kotter’s model also does not account for change resistance strategies. Ford, Ford, & D’Amelio (2008) discuss the ‘resistors’ to change might actually be informative and could be a key to effectively implementing changes, if engaged in the correct way. Rogers (2013) does provide for social influences and means for ‘persuading’ the early and late majorities to accept and eventually implement changes that individuals might be hesitant to embrace. This process does, however, take a long time to work through the innovators proving the concept, and the early adapters developing the evidence base required for the early majority to adopt the practices. This, in combination with Kotter’s vision communication strategies, and delivered through Garvin & Roberto’s (2005) persuasion campaign strategy could prove a powerful motivational approach to effectively implement youth lived-expertise across all services and sectors which serve young people. Conclusion While the engagement of lived-experience voices, often through acute activities (i.e. focus groups, CQI processes, advisory boards, consultants, coordination/collaboration with consumer led organizations, etc.) has been an evolution, an effective change process of hiring lived-expertise, I believe, can be addressed in the scope of this term’s paper. There is wide variation in basic understanding, even in finding a common language that accurately captures this phenomenon across systems and sectors. Consistency in role, competencies, and certifications is widely varied. There is even more work to be done to identify necessary antecedents for first time hires of lived-expertise roles, and even more to capture an evidence base of successful strategies to ensure a smooth change process for organizations throughout the implementation stages of this change. Kotter’s theory of change can be applied as a framework from which to build these effective practices and offers stages through which to apply

HIRING YOUTH LIVED-EXPERTISE 14 incremental and transformational change. There is much to be learned from innovators and early adapters that could ensure a smoother transition for the early and late majorities, ensuring organizational effectiveness and better outcomes and states of well-being for the lived-expertise employees and their supervisors. One thing that is common across sectors is that when lived- expertise employees are utilized correctly and effectively in their roles, outcomes of service recipients are better than clinical treatment alone. I hope that benefit will outweigh resistance to change as we continue to serve our client populations to the best of all our collaborative abilities.

HIRING YOUTH LIVED-EXPERTISE 15 References Burk, L. K., Bergan, J., Long, J., Noelle, R., Soto, R., Richardson, R., & Waetzig, E. (2013). Youth Advocate to Advocate for Youth: The Next Transition. Portland, OR: Research and Training Center for Pathways to Positive Futures. Child Welfare Services Stakeholder Group. (2003). CWS redesign: The future of California’s child welfare services final report . Sacramento, CA. Retrieved from http://www.childsworld.ca.gov/res/pdf/CWSReport.pdf . Delman, J., & Klodnick, V. V. (2017). Factors supporting the employment of young adult peer providers: Perspectives of peers and supervisors. Community Mental Health Journal , 53 (7), 811–822. Ford, J. D., Ford, L. W., & D’Amelio, A. (2008). To change: Resistance the rest of the story. The Academy of Management Review , 33 (2), 362–377. Gagne, C. A., Finch, W. L., Myrick, K. J., & Davis, L. M. (2018). Peer workers in the behavioral and integrated health workforce: Opportunities and future directions. American Journal of Preventive Medicine , 54 (6S3), S258–S266. Garvin, D. A., & Roberto, M. A. (2005, February). Change through persuasion. Harvard Business Review , 104-112. Geiger, J. M., & Beltran, S. J. (2017). Readiness, access, preparation, and support for foster care alumni in higher education: A review of the literature. Children and Youth Services Review , 11 (4–5), 487–515. Gopalan, G., Lee, S. J., Harris, R., Acri, M. C., & Munson, M. R. (2017). Utilization of peers in services for youth with emotional and behavioral challenges: A scoping review. Journal of Adolescence , 55 , 88–115.

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HIRING YOUTH LIVED-EXPERTISE 16 Hom, M. A., Stanley, I. H., Schneider, M. E., & Joiner, T. E. (2017). A systematic review of help-seeking and mental health service utilization among military service members. Clinical Psychology Review , 53 , 59–78. Inceoglu, I., Thomas, G., Chu, C., Plans, D., & Gerbasi, A. (2018). Leadership behavior and employee well-being: An integrated review and a future research agenda. The Leadership Quarterly , 29 , 179–202. Johansson, T., Keller, S., Sönnichsen, A. C., Weitgasser, R. (2017). Cost analysis of a peer support programme for patients with type 2 diabetes: A secondary analysis of a controlled trial. European Journal of Public Health, 27 (2), 256-261. Kotter, J. P. (1996). Leading Change . Boston: Harvard Business School Press. Boston, Massachusetts. Kotter, J. P. (2007). Leading change: Why transformation efforts fail. Harvard Business Review, January, 1-9. Liu, Y., Xiong, S., Ma, Y., Zhang, W., Jin, C. (2018). Selection, training and supervision of breast cancer peer educators: A literature review. TMR Integrative Nursing, 2 (2), 61-67. Lived Experience Research Network. (2014). User/Survivor leadership & capacity-building in research. White paper from the Promoting Engagement Practices in Peer Evaluation/Research (PEPPER) project. Albany, NY: Mental Health Empowerment Project. Optum. (2016). Peer support services improve clinical outcomes by fostering recovery and promoting empowerment . Optum Inc.: Eden Prairie, MN. Retrieved from: https://www.optum.com/content/dam/optum3/optum/en/resources/white-papers/ PeersImproveOutcomes.pdf .

HIRING YOUTH LIVED-EXPERTISE 17 Ramey, H. L., Lawford, H. L., & Rose-Krasnor, L. (2017). Doing for others: Youth’s contributing behaviors and psychological engagement in youth-adult partnerships. Journal of Adolescence , 55 , 129–138. Ramey, H. L., & Rose-Krasnor, L. (2015). The new mentality: Youth-adult partnerships in community mental health promotion. Children and Youth Services Review , 50 , 28–37. Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health services. Journal of Mental Health, 20(4), 392–411. Rogers, E. M. 2003. Diffusion of Innovations (5th Edition). New York: Free Press. Rossiter, Louise & Socho, A. (2018). Workplace bullying and burnout: The moderating effects of social support. Journal of Aggression, Maltreatment, & Trauma , 27 (4), 386–408. Rudolph, C. W., Rauvola, R. S., & Zacher, H. (2018). Leadership and generations at work: A critical review. The Leadership Quarterly , 29 , 44–57. Simons, D., Hendricks, T., Lipper, J., Bergan, J., & Masselli, B. (2016). Providing youth and young adult peer support through Medicaid . Baltimore, MD. Solomon, P. (2004). Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal , 27 (4), 392–401. Swanson, R. A., & Holton, E. F. (2008). The nature of the change process. In Foundations of Human Resource Development, (First, pp. 284–316). San Francisco: Berrett-Koehler Publishers, Inc. Yawson, R. M. (2012). Systems theory and thinking as a foundational theory in human resource development: A myth or reality? Human Resource Development Review , 12 (1), 53–85.

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