Consumers as mental health providers: first-person accounts of benefits and limitations

Certified Peer Support in the Field of Homelessness: Stories Behind the Work

Certified peer support specialists (CPSS) are used as a paraprofessional workforce to engage hard-to-reach populations, including people experiencing homelessness. Thematic analysis was used to explore with CPSS (N = 7) what contributed to their effectiveness when working with this population. Participants were recruited at a HUD lead organization in the southeastern United States. Open-ended semi-structured questions were used in online, synchronous interviews. Themes related to three areas, experience, competence, and the organization, contributed to participants being effective. Specifically, interviewees observed that their lived experiences and abilities to speak a common language with clients contributed to their effectiveness. They identified how personal qualities and unique skillsets suited them for the work. Participants also valued the training they received; certification helped them to develop competencies and to balance vulnerability, empathy, and connection. Finally, participants attributed their effectiveness to clarity about their roles within the organization, supervision, attention to self-care, and co-worker support. Findings from this study may have implications for the value of lived and learned knowledge coexisting in organizations serving those who experience homelessness.

A combined intervention strategy to increase linkage to and retention in substance use treatment for individuals accessing hospital-based services: study protocol

Background

In 2020, New Mexico had the highest alcohol related death and the 11th highest drug overdose rate in the U.S. Towards the long-term goal of addressing this public health problem, we are implementing and evaluating an multi-level intervention designed to identify adults at risk of substance use disorder (SUD) and encourage linkage to and retention in treatment. The first level includes equipping the ED and medical inpatient units of a safety-net hospital with a method to screen individuals at risk of a SUD. The second level includes Seeking Safety (SS), a trauma-specific treatment for PTSD and SUD; and pharmacotherapy for SUD. Motivational Interviewing (MI) is used throughout both levels. Using the SPIRIT guidelines and checklist, this study protocol describes the multi-level intervention and the methodology we are using to assess feasibility and effectiveness.

Methods

We are using a Type 1 hybrid implementation design with a non-randomized approach (ISRCTN registration # ISRCTN33100750). We aim to enroll 110 adults ( ≧ 18 ) who screen positive for unhealthy use of alcohol, prescription medications (used nonmedically) and/or illicit drugs. Peer support workers are responsible for screening, using MI to increase engagement in screening and treatment and delivery of SS. Pharmacotherapy is provided by addiction clinical specialists. Treatment is provided post hospital discharge via telehealth to increase access to care. Participants are identified through (1) review of electronic health records for individuals with a chief or secondary complaint or mental health condition relating to alcohol and/or other drug use, (2) referrals from clinical staff and (3) screening in the ED and medical inpatient units. Feasibility is being measured through process data. Effectiveness will be determined by changes in two primary outcomes: (i) PTSD symptom severity; and (ii) substance use.

Discussion

Our study will expand on research related to the implementation of treatment strategies for patients presenting at EDs and admitted to medical inpatients units wherein there is a significant window of opportunity to link patients with follow-up behavioral and clinical services for alcohol and/or drug misuse. The challenges associated with implementation and strategies that have been helpful to address these challenges will further inform the field.

"Teaching somebody else makes you a better person:" A phenomenological exploration of the importance of informal peer support for individuals with spinal cord injury

BACKGROUND

Peer support is widely recognized as an important aspect of health promotion for individuals with spinal cord injury (SCI). Reports indicate positive effects for the recipients of either informal and formal peer support. The experience can also be meaningful to the person(s) providing support, although the value to providers is not well studied.

OBJECTIVE

This study examines the experience of provision of and receipt of informal peer support for individuals with SCI through semi-structured interviews.

METHODS

Data were analysed using a qualitative phenomenological approach. 16 participants with SCI participated in the study.

RESULTS

Three main themes were developed, each describing different benefits of peer support from the perspective of both members of the peer support dyad. First, participants found personal satisfaction from using their own experiences to help others adjust to their disability. Participants also noted that they learned how to complete activities of daily living as well as how to be autonomous in travel from others with SCI. Finally, participants spoke of the intrinsic benefit in teaching others with SCI.

CONCLUSIONS

This study provides a novel understanding of the importance of informal peer support for individuals with SCI. Practitioners should provide opportunities for individuals with SCI to develop informal peer relationships with others who have sustained SCI.

'I Will Fight for People to Not Have the Experience I've Had': A Thematic Analysis of the Experiences and Perspectives of Chronic Pain Lived Experience Advocates

Navigating the healthcare system with chronic pain, alongside navigating the experience of the chronic pain itself, is recognised to be highly challenging. Frequently available interventions do not fully meet the needs of people with chronic pain. This study aimed to explore the perspectives of people who have been through these experiences and now support and campaign for improved approaches to chronic pain management. Semi-structured interviews of 10 participants who independently support others through some form of chronic pain advocacy or support were conducted online. Data were digitally recorded, transcribed, and analysed using reflexive thematic analysis, through a critical realist and constructivist lens. Data were interpreted to represent a journey into chronic pain advocacy, represented by three overarching themes. Advocacy as healing incorporates sub-themes of pain trauma, gaining knowledge, and using my experience for good. Unequal partnership includes respect and unmet needs from institutions. The final theme, evolution, relates to two sub-themes of pushing boundaries and personal growth. Participants talked about the dual benefit of their contribution to pain advocacy, both in terms of helping others and also their own personal benefit. Overall findings indicated that pain advocacy can take multiple and various forms. Commonly, our participants who took on the role of pain advocacy were motivated by their own early difficult experiences, both navigating their pain and healthcare systems, and by a wish for others to not have similar difficult experiences. Having taken on the role, despite its challenges, rewards can include recognition and personal growth.

Support, care and peer support for gay and bi men engaging in chemsex

The objective of this research was to explore how gay men use drugs in their sex lives, colloquially called "chemsex". This paper reports on a sub-theme within the research about support, care and peer support. Longitudinal interviews were conducted with 20 gay and bi men between April 2017 and July 2019. Participants were recruited via geolocated dating apps (n = 17) and snowball sampling (n = 3). The main findings of this research are that medicalised forms of support for gay and bi men engaging in chemsex are often tardy in their responses to need, and whilst helpful for cessation of drug use, fail to address the holistic needs of the participants. A wide variety of peer support was practiced amongst the sample which often echoed previous forms of peer support practiced in the LGBT+ community. It was offered by both people who engaged in chemsex and those who did not and was highly beneficial to people who experienced problems with chemsex. However, peer support was also limited by factors such as shame and the instability of those offering support. In conclusion, we suggest that medicalised forms of chemsex support could benefit from more rigorous and rapid forms of assessment for problematic chemsex, and also provide infrastructure and training to peer support initiatives. We also suggest that medical services could learn from patients and their peers about what support needs remain unaddressed by professional services, and engage in collaborative approaches to practice development.

Peer involvement in service provision: how US human service nonprofit organisations include sex workers as organisational staff

Human service non-profit organisations (HSNPs) looking to improve the representation of clients in the work of their organisation may decide to hire people with lived experience as peer providers. This paper looks at how HSNPs that provide services to sex workers make decisions about hiring those with lived experience of sex work as staff. To address the issue, the following questions were asked: 1) how do HSNPs make the decision to hire sex workers as staff members; and 2) if hired, how are individuals actually involved in the organisation? The study aimed to answer these questions using open-ended interviews with 64 staff in HSNPs in the US Midwest that indirectly or directly provide services to sex workers. Findings indicate that while many organisations hire individuals with lived experience in sex work, the expectations placed on these individuals vary considerably depending on the perceptions other HSNP staff have about sex work. When HSNPs hire individuals with lived experience to further their organisational agendas with respect to sex work, they should include sex workers in a substantive and inclusive way to minimise organisational bias and ensure sex worker views are accurately represented.

Practising critical resilience as an advanced peer support worker in London: A qualitative evaluation of a peer-led hepatitis C intervention amongst people experiencing homelessness who inject drugs

BACKGROUND

Peer support has been used as a mechanism to facilitate active engagement with healthcare amongst underserved populations. The HepCare project upskilled experienced peer support workers (PSWs) to become equal members of a service provider team, taking on advanced clinical roles normally carried out by medical or nursing specialists.

METHOD

A participatory case study approach was taken to the study following the methodological guidance of Merriam (1998). The subject of the case in our study is the advanced peer support workers (APSWs) functioning in the HepCare project as service providers. The object of the case is an exploration of their transition to service provider in the HCV screening and treatment support service. Five peer led in-depth interviews with APSWs were supplemented by a survey of health professionals, interviews with service users, documentary evidence in the form of job descriptions, observational notes and a blog from the field. Thematic analysis of the data was conducted, refined and finalised in a workshop with the research team and APSW participants.

RESULTS

Three themes were generated from the data that explore the peer support worker's transition to APSW in the programme: Transition to Integration, Retaining 'Peerness', and Practising Critical Resilience. The advocacy and support enacted by the APSWs through the HepCare project, offer purpose and meaning alongside integration into a new social group. This is buffered by the supportive context of the programme and facilitates a motivating sense of worth.

CONCLUSION

The programme offers policy guidance for the structured career development of APSWs and a platform for enactment of critical resilience as they transition to their advanced role, in the healthcare provider team.

Using Peer Support to Strengthen Mental Health During the COVID-19 Pandemic: A Review

Background: The coronavirus (COVID-19) pandemic has had a significant impact on society's overall mental health. Measures such as mandated lockdowns and physical distancing have contributed to higher levels of anxiety, depression, and other metrics indicating worsening mental health. Peer support, which is peer-to-peer provided social and emotional support, is an underutilized and effective mental health resource that can potentially be used to ameliorate mental health during these times. Objective: This review aims to summarize the toll that this pandemic has had on society's mental health as found in peer-reviewed literature from October 2019 to March 2021, as well as suggest the utility of peer support to address these needs. Methods: References for this review were chosen through searches of PubMed, Web of Science, and Google Scholar for articles published between October 2019 and March 2021 that used the terms: "coronavirus," "COVID-19," "mental health," "anxiety," "depression," "isolation," "mental health resources," "peer support," "online mental health resources," and "healthcare workers." Articles resulting from these searches and relevant references cited in those articles were reviewed. Articles published in English, French and Italian were included. Results: This pandemic has ubiquitously worsened the mental health of populations across the world. Peer support has been demonstrated to yield generally positive effects on the mental health of a wide variety of recipients, and it can be provided through numerous accessible mediums. Conclusions: Peer support can overall be beneficial for improving mental health during the COVID-19 pandemic and may be an effective tool should similar events arise in the future, although the presence of a few conflicting studies suggests the need for additional research.

The Experiences of Youth Mental Health Peer Workers over Time: A Qualitative Study with Longitudinal Analysis

Peer work is a rapidly growing part of the mental health workforce, yet few studies explore the implementation of peer work in youth mental health. Qualitative focus groups were conducted with eight youth peer workers at the commencement of their employment, then at 3-months and 6-months after this time. Data were transcribed verbatim and analysed using thematic and trajectory analysis. The three main findings included: (1) there was a trajectory from fear to hope; (2) there was an improved understanding of benefits and role definition over time; and (3) there was an evolving concept of understanding shared experiences as a primary asset. Known barriers to implementing peer work are likely to occur in youth mental health settings as well. Ensuring that adequate training, change management and tailored support strategies are important to maximise the chances of successful youth peer work programs.

Mental Health Recovery: The Effectiveness of Peer Services in the Community

Peer recovery services are a community-based treatment option for people suffering from mental illness and/or substance use problems. Peer services provide an alternative to inpatient care and can help decrease costs associated with hospitalization or incarceration of the mentally ill. Yet, scant research has explored the effect of these services, particularly in rural communities. The current study assesses the impact of peer services on peer mentees' and mentors' recovery capital, quality of life, and general wellness. Consumers of peer services completed three surveys every three months for approximately 18 months. Quantitative analyses demonstrated that subjects had a marginal change in their recovery capital, but quality of life and general wellness were unaffected. Peer providers' experiences were also explored through interviews. Qualitative analyses revealed that providers have a positive outlook regarding peer services but would benefit from greater resources and additional training. Policy and community implications are also discussed.

Psychoeducation and Problem-Solving Therapy as an Integrative Model of Mutual-Help Groups for People with Severe Mental Disorders: A Report from Brazil

This case study describes the "Entrelaços" Peer Support Program, a psychoeducational program of a psychiatric institution in the city of Rio de Janeiro that admitted, between 2011 and 2019, 246 people comprising family members and patients to participate in eight educational seminars followed by multifamily problem-solving groups in cycles that were 18 months in duration. Ninety percent of the participants who completed the program decided to create 7 mutual-help groups in the community independent of technicians and the institution. Community groups have already served spontaneously more than 214 families. They have organized scientific, social and anti-stigma events, expanded their social support network and demonstrated empowerment by switching from service users to peer providers to receive new families. This work is based on a pioneering model in Brazil that integrates psychoeducation with problem-solving therapy, spreading the benefits of education and peer-support with lower cost and greater representativeness.

Using peer workers with lived experience to support the treatment of borderline personality disorder: a qualitative study of consumer, carer and clinician perspectives

BACKGROUND

Peer support is a recovery oriented approach where consumers and carers are introduced to people with lived experience of the disorder who have recovered. Paid roles within health services for such consumer peer workers and carer peer workers (or 'specialists') are increasingly common. To date specific studies on such peer support for consumers with borderline personality disorder (BPD) and their carers has not been conducted.

METHODS

This qualitative study used interviews to explore perceptions and models of peer support for BPD from the perspectives of 12 consumers, 12 carers, and 12 mental health professionals. Participant responses were analyzed using reflexive thematic analysis within a phenomenological methodology.

RESULTS

All groups described how consumer peer workers may provide hope, connection, and validation to a consumer's lived experience. Offering both traditional mental health treatment plus peer support, and giving consumers choice regarding a consumer peer worker was welcomed. Differences in opinion were found regarding the consumer peer worker's role in relation to the mental health team, including whether consumer peer workers should access medical records. Perspectives differed regarding the consumer peer worker and carer peer worker positions, highlighting potential role confusion. Carers discussed the value of receiving support from carer peer workers and consumer peer workers. Mental health professionals described how consumer peer workers can experience workplace stigma and problems with boundary setting, and acknowledged a need for peer workers to be valued by having a duty of care and confidentiality code to follow and be offered supervision.

CONCLUSIONS

Two models of peer support for BPD emerged: an integrated model where consumer peer workers work within the mental health team, and a complementary model where consumer peer workers are separate from the mental health team. Based on these findings we provide recommendations for services to help support such peer work for consumers with BPD and their carers.

Feasibility of peer support services among people with severe mental illness in China

BACKGROUND

Peer-delivered services potentially provide broad, multifaceted benefits for persons suffering severe mental illness. Most studies to date have been conducted in countries with well-developed outpatient mental health systems. The objective of this study was to examine the feasibility for developing a community-based peer service in China.

METHODS

Thirteen peer service providers and 54 consumers were recruited from four communities in Beijing. We initiated the program in two communities, followed by another two in order to verify and add to our understanding of potential scalable feasibility. Semi-structured face-to-face interviews were conducted 12 month after initiation at each site to measure satisfaction and perceived benefits from perspectives of peer service providers, and consumers and their caregivers.

RESULTS

Key stakeholders reported that peer support services were satisfying and beneficial. Eleven of 13 peer service providers were willing to continue in their roles. Ten, 8, and 7 of them perceived improvements in working skills, social communication skills, and mood, respectively. Among consumers, 39 of 54 were satisfied with peer services. Improvements in mood, social communication skills, illness knowledge, and illness stability were detected among 23, 18, 13, and 13 consumers, respectively. For caregivers, 31 of 32 expressed a positive view regarding peer services. Caregivers reported improvement in their own mood, confidence in recovery of their family members, and reduction in caretaker burdens.

CONCLUSIONS

The findings highlight that peer-delivered services have promise in China for benefiting persons with severe mental illness and their family caregivers, as well as the peer service providers themselves.

From peer-based to peer-led: redefining the role of peers across the hepatitis C care pathway: HepCare Europe

BACKGROUND

HCV infection disproportionately affects underserved populations such as homeless individuals, people who inject drugs and prison populations. Peer advocacy can enable active engagement with healthcare services and increase the likelihood of favourable treatment outcomes.

OBJECTIVES

This observational study aims to assess the burden of disease in these underserved populations and describe the role of peer support in linking these individuals to specialist treatment services.

METHODS

Services were identified if they had a high proportion of individuals with risk factors for HCV, such as injecting drug use or homelessness. Individuals were screened for HCV using point-of-care tests and a portable FibroScan. All positive cases received peer support for linkage to specialist care. Information was gathered on risk factors, demographics and follow-up information regarding linkage to care and treatment outcomes.

RESULTS

A total of 461 individuals were screened, of which 197 (42.7%) were chronically infected with HCV. Referral was made to secondary care for 176 (89.3%) and all received peer support, with 104 (52.8%) individuals engaged with treatment centres. Of these, 89 (85.6%) started treatment and 76 (85.4%) had a favourable outcome. Factors associated with not being approved for treatment were recent homelessness, younger age and current crack cocaine injecting.

CONCLUSIONS

Highly trained peer support workers working as part of a specialist outreach clinical team help to identify a high proportion of individuals exposed to HCV, achieve high rates of engagement with treatment services and maintain high rates of treatment success amongst a population with complex needs.

International insights into peer support in a neonatal context: A mixed-methods study

Peer support is a widely used intervention that offers information and emotional support to parents during their infant's admission to the neonatal unit and/or post-discharge. Despite its widespread use, there are no comprehensive insights into the nature and types of neonatal-related peer support, or the training and support offered to peer supporters. We aimed to bridge these knowledge gaps via an international study into neonatal peer support provision. A mixed-methods study comprising an online survey was issued to peer support services/organisations, and follow-up interviews held with a purposive sample of survey respondents. Survey/interview questions explored the funding, types of peer support and the recruitment, training and support for peer supporters. Descriptive and thematic analysis was undertaken. Thirty-one managers/coordinators/trainers and 77 peer supporters completed the survey from 48 peer support organisations/services in 16 different countries; with 26 interviews undertaken with 27 survey respondents. We integrated survey and interview findings into five themes: 'background and infrastructure of peer support services', 'timing, location and nature of peer support', 'recruitment and suitability of peer supporters', 'training provision' and 'professional and emotional support'. Findings highlight variations in the types of peer support provided, training and development opportunities, supervisory and mentoring arrangements and the methods of recruitment and support for peer supporters; with these differences largely related to the size, funding, multidisciplinary involvement, and level of integration of peer support within healthcare pathways and contexts. Despite challenges, promising strategies were reported across the different services to inform macro (e.g. to facilitate management and leadership support), meso (e.g. to help embed peer support in practice) and micro (e.g. to improve training, supervision and support of peer supporters) recommendations to underpin the operationalisation and delivery of PS provision.

Do personnel with lived experience cultivate public values? Insights and lessons from mental healthcare managers

Health organizations charged with addressing public problems sometimes employ persons with relevant lived experience in meaningful organizational roles. Because of their prior experience, these individuals have intimate knowledge of the subject matter that professional training and education cannot replicate. Mental health treatment facilities in particular have demonstrated a growing trend toward incorporating staff members with lived experience. This study conducted semi-structured interviews with senior-level managers of organizations in this field to gain insight into the public values associated with this practice. Findings reveal that several public values, including dialogue, social cohesion, sustainability, productivity, and altruism, are cultivated when treatment facilities incorporate staff members with lived experience into service delivery. This study concludes with lessons for mental health leaders seeking to address mental illness.

Beneficial effects of peer support in psychiatric hospitals. A critical reflection on the results of a qualitative interview and focus group study

Background: The implementation of peer support work in psychiatric hospitals is a relatively recent development. Consequently, the effects of peer support work on mental health professionals, patients and peer support workers (PSWs) are mostly unknown.Aims: To explore the beneficial effects of peer support work in detail and to reflect critically on potential sources of misunderstanding.Method: (1) Nine open-ended, semi-structured interviews with PSWs and (2) five focus groups with mental health professionals plus one focus group with PSWs. The data were analyzed using qualitative content analysis.Results: Our data show various beneficial effects on patients, such as the themes "less professional distance," "more time for one-on-one attendance" and "a role model for recovery." Themes that emerged for mental health professionals were, amongst others, "adding a new perspective," "improved continuity in treatment offers" and "preserving a respectful tone in meetings."Conclusions: It is necessary to minimize the risk of role confusion to achieve the beneficial potential of peer support work. A thorough education on what peer support work can and cannot deliver is essential and could help to foster its successful implementation.

[Models of peer support in psychiatric care]

In the past decades, psychiatric care has changed from the traditional medical model to a more person-centered and recovery-focused approach. In this process, peer support workers are essential, because with their lived experience of crisis and recovery they are able to spread hope.This article gives an overview of the recent literature describing the current change model of peer support, reporting the evidence of peer support, as well as the current stage of implementation of peer support in different psychiatric contexts.An overview of the current state of research, selected by the authors, based on repeated systematic literature searches in peer support research projects, is given. Additionally, some examples of user involvement from the Hamburg EX-IN Curriculum, trialogs between sufferers, relatives and professionals, as well as the so-called psychosis seminars are described in more detail.Peer support has shown promising results in one-to-one and group settings, case management, crisis interventions, and the reduction of coercive measures.Although there are promising results of peer support in various clinical contexts, multiple challenges in the implementation of peer support are reported. They need to be overcome by the inclusion of all staff members in the change process of the system in order to further develop user-oriented and recovery-oriented psychiatric care.

A Qualitative Study of an Employment Scheme for Mentors with Lived Experience of Offending Within a Multi-Agency Mental Health Project for Excluded Young People

The use of peer intervention schemes is increasingly popular within services for offending groups and there is growing evidence of their benefit for peers delivering the interventions. The current study explores staff and peer experiences of an employment scheme for peer mentors within a community project for young people involved in offending. Semi-structured interviews were conducted with full time staff (n=4) and peer mentors employed on the scheme (n=2). Thematic analysis revealed three themes of "Opportunity and Empowerment", "Supportive Processes" and "Role Definition and Structure". The results suggest that meaningful employment opportunities, with holistic support and processes for reflection and mentalisation of self and others, contribute to the personal and professional development of ex-offenders in peer mentoring roles.

Providing mental health peer support 2: Relationships with empowerment, hope, recovery, quality of life and internalised stigma

OBJECTIVE

Qualitative research has identified personal costs and benefits for peer supporters associated with their role; however, quantitative evidence is sparse. This study used quantitative methods to explore relationships in experiences of providing peer support with constructs of empowerment, hope, recovery, quality of life and internalised stigma. Differences were examined for those in statutory versus non-statutory services; who had themselves received peer support versus those who had not and who identified having had negative experiences in clinical teams versus those without such experiences.

METHODS

A cross-sectional online and postal survey was undertaken in tandem with a linked consensus study. In all, 147 peer supporters were recruited from a variety of organisations across the United Kingdom. Validated questionnaires were used to examine constructs. Instruments created for the study measured peer support experiences, and personal costs and benefits involved. Correlations were calculated and results informed further regression analysis. Chi-square tests and independent samples t-tests tested group differences.

RESULTS

Peer supporters indicated they experienced almost twice as many role-related personal benefits than personal costs. Benefits included improvements to mental health and well-being, reduced use of services, increased social functioning and development of skills. Total number of personal costs experienced was significantly negatively related to peer supporters' empowerment and quality of life. There were no significant differences between the groups examined.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

An accumulation of personal costs may result in reduced quality of life; however, costs can be minimised by organisations. Limitations of the research are discussed and recommendations for future research are made including the need for longitudinal research.

Peer Education: Productive Engagement for Older African Americans in Recovery From Depression

Background and Objectives

Older adults who have personal experience with the mental health service delivery system gain unique and potentially valuable insight from their treatment experiences. Research suggests that incorporating trained individuals in recovery from a mental illness (i.e., peer educators) into mental health service delivery roles results in substantial benefits for current mental health consumers, particularly for older adults and racial and ethnic minorities who may feel disenfranchised from the traditional mental health service delivery system. However, little research has examined the impact of participating in these activities on the peer educators themselves.

Research Design and Methods

This mixed methods study examines the experiences of 10 African American older adults in recovery from depression currently working as trained peer educators. Peer educators reported feeling more positive, feeling their lives had significantly improved, and feeling better in general due to their peer educator roles.

Results

This qualitative investigation highlights four unique themes that can explain the benefit of serving in this capacity (i.e., Community Engagement, Life Long Learning and Education, Mental Health Recovery and Productive Aging).

Discussion and Implications

This study suggests that serving has a peer educator has a number of beneficial outcomes for African American older adults in recovery from depression.

Peer Workers in the Behavioral and Integrated Health Workforce: Opportunities and Future Directions

The growth of the peer workforce in behavioral health services is bringing opportunities to organizations and institutions that serve people living with mental and substance use disorders and their families. Peer workers are defined as people in recovery from mental illness or substance use disorders or both that possess specific peer support competencies. Similar roles are identified for families of people in recovery. Peer support has been implemented in a vast range of behavioral health services, including in the relatively new use of peer support in criminal justice and emergency service environments. Behavioral health services are striving to integrate peer workers into their workforce to augment existing service delivery, in part because peer support has demonstrated effectiveness in helping people with behavioral health conditions to connect to, engage in, and be active participants in treatment and recovery support services across all levels of care. This article describes the experiences that organizations and their workforce, including peer workers, encounter as they integrate peer support services into the array of behavioral health services. Specific attention is given to the similarities and differences of services provided by peers in mental health settings and substance use settings, and implications for future directions. The article also addresses the role of peer workers in integrated behavioral and physical healthcare services.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

A pilot training program for people in recovery of mental illness as vocational peer support workers in Hong Kong - Job Buddies Training Program (JBTP): A preliminary finding

OBJECTIVES

The present study reviews the delivery of a pilot curriculum-mentorship-based peer vocational support workers training in a Hong Kong public psychiatric hospital. The present paper reports (1) on the development of a peer vocational support workers training - Job Buddies Training Program (JBTP) in Hong Kong; and (2) preliminary findings from both quantitative and qualitative perspectives.

METHOD

The curriculum consists of 15-session coursework, 8-session storytelling workshop and 50-hour practicum to provide Supported Employment Peer Service (SEPS) under the mentorship of occupational therapists. Six trainees were assessed using three psychosocial assessments and qualitative methods.

FINDINGS

Compared to the baseline, the Job Buddies (JB) trainees showed an increase in awareness of their own recovery progress, occupational competence and problem-solving skills at the end of the training. Their perceived level of self-stigma was also lessened. In post-training evaluation, all Job Buddies trainees said they perceived positive personal growth and discovered their own strengths. They also appreciated the help from their mentors and gained mutual support from other trainees and from exposure with various mini-projects in the training.

CONCLUSIONS AND IMPLICATIONS

This pilot study provides an example of incorporating peer support and manualized training into existing work rehabilitation service for our JB trainees. Further studies on the effectiveness of service provided by peer support workers and for development on the potential use of peer support workers in other clinical and rehabilitation settings with larger subjects will be fruitful.

Peer mentoring for eating disorders: evaluation of a pilot program

Background

Eating disorders are serious psychiatric illnesses that are often associated with poor quality of life and low long-term recovery rates. Peer mentor programs have been found to improve psychiatric symptoms and quality of life in other mental illnesses, and a small number of studies have suggested that eating disorder patients may benefit from such programs. The aim of this study is to assess the efficacy of a peer mentor program for individuals with eating disorders in terms of improving symptomatology and quality of life.

Methods

Up to 30 individuals with a past history of an eating disorder will be recruited to mentor 30 individuals with a current eating disorder. Mentoring will involve 13 sessions (held approximately every 2 weeks), of up to 3 h each, over 6 months.

Discussion

This pilot proof-of-concept feasibility study will inform the efficacy of a peer mentoring program on improving eating disorder symptomatology and quality of life, and will inform future randomised controlled trials.

Trial registration

Australian and New Zealand Clinical Trials Registration Number: ACTRN12617001412325. The date of registration (retrospective): 05/10/2017.

Electronic supplementary material

The online version of this article (10.1186/s40814-018-0268-6) contains supplementary material, which is available to authorized users.

Peer workers in mental health services: literature overview

Peer worker roles are being introduced in mental health services in the UK and internationally, to support individuals in their recovery. There is substantial qualitative evidence that demonstrates benefits at an individual level and some evidence of impact on service use and costs, although there are currently few high-quality randomised controlled trials supporting these findings, especially from the UK. A growing body of research indicates that careful consideration of organisational issues regarding the introduction of peer worker roles – the distinctiveness and shared expectations of the role, strategic alignment, organisational support – might maximise their impact. Properly supported and valued peer workers are an important resource to the multidisciplinary team, offering experiential knowledge and the ability to engage patients in their treatment through building relationships of trust based on shared lived experience.

LEARNING OBJECTIVES

People with dementia as peer workers, challenges, and benefits: a thematic analysis and nominal groups study

BACKGROUND

There are national initiatives to involve service users in service delivery. However, programs employing people with dementia as peer support workers (PSWs) in memory services are in their infancy. This study is the first to explore the challenges and benefits to staff and peers involved in such a program.

METHODS

Focus groups, structured based on nominal groups (NG) methodology were run with PSWs and clinical staff from two memory services. In total, there were 12 participants, with three focus groups: PSWs alone (n = 3); staff members alone (n = 6); and PSWs and staff members combined (n = 6). Data were analyzed through thematic analysis of recorded session content and the ranking of themes inherent in an NG approach.

RESULTS

Perceived benefits of the PSW program were similar for staff and PSWs and included personal benefits for PSWS and stereotype reduction for staff. More challenges were reported by staff than PSWs, but both groups agreed that role definition and dealing with the cognitive deterioration inherent in dementia were key issues.

CONCLUSIONS

The PSW program does have benefits for involved staff and PSWs. However, the challenges identified highlight the need for careful and consensual setup and consideration of power dynamics, with agreed roles and clear guidelines to deal with cognitive deterioration.

'…it shows that there's no limits': the psychological impact of co-production for experts by experience working in youth mental health

Co-production is commonly conceptualised as a more equal sharing of power and decision-making between a dichotomy of service user and service provider, each bringing valuable and different assets to the process. Experts by experience lie in the overlap between this conceptually created duality, providing the services they now do by virtue of having once used services themselves. Previous related studies suggest that their involvement in co-production could impact positively on their social capital, self-esteem, self-efficacy and life skills. However, no studies have been explicitly psychological or phenomenological in nature, and the theoretical basis for such outcomes remains under-developed. This phenomenological study explored the psychological impact of co-production for young people who were paid experts by experience for a young person's mental health charity in a large and diverse urban area in the UK, looking at the what of psychological impact, as well as the theoretical why and how. Semi-structured interviews were conducted with a convenience sample of five males, with a mean age of 25 years. Interpretative phenomenological analysis yielded three master themes: the co-production approach, I'm a professional and identities in transition. Participants valued a collegiate organisational approach that prioritised empowerment, agency and equality between experts by experience and 'experts by qualification', leading to a positive impact on their self-efficacy and self-esteem. Co-production impacted fundamentally on their identity structure, enabling them to explore a new identity as a 'professional'. The results are framed within identity process theory and point to the potential benefits of this model to co-production.

Consumer providers' experiences of recovery and concerns as members of a psychiatric multidisciplinary outreach team: A qualitative descriptive study from the Japan Outreach Model Project 2011-2014

Objective

The objective of this study was to clarify consumer providers (CPs) subjective experiences as members of a psychiatric multidisciplinary outreach team that provided services to individuals with a mental illness living in the community.

Methods

A qualitative descriptive study was conducted through semi-structured interviews. Participants were clients hired as CPs in the Japanese Outreach Model Project from September 2011 until March 2014. Of the seventeen CPs, nine participated in this study. We looked at the CPs' subjective experiences of fulfillment and difficulty.

Results

In the process of providing services, CPs experienced both achievements and concerns. They had a sense of achievement by caring for their clients and they experienced that they themselves were recovering. They were also concerned about having inadequate knowledge and skills to provide psychiatric services to their clients. Further, there were concerns about their dual role on the multidisciplinary team and being support staff while they were still using mental health services themselves.

Conclusion

The results show that the activities of CPs included fulfillment, recovery, and dilemmas. Clarifications will likely contribute to an increase in understanding and cooperation between CPs and other professionals with whom they work. Further studies are needed to investigate policies related to mental health consumers who are also providers of mental health services.

Peer Support Providers' Role Experiences on Interprofessional Mental Health Care Teams: A Qualitative Study

This study explores how peer support providers' roles are defined and integrated in inter-professional mental health care teams, and how these providers relate to other practitioners and clients. Interviews were conducted with peer support providers in two different formal models of peer support employment. Qualitative data analysis was undertaken. The findings indicate that: peer support providers experience ambiguity and that some ambiguity may offer benefits; peer support providers enhance team acceptance of their role through several means and strategies; setting boundaries with clients is a delicate issue that requires several considerations that we discuss.

Participants' employment status and experiences in the year after the Experienced Involvement training

BACKGROUND

Peer support workers (PSWs) are an emerging workforce within the Swiss mental health system. The 'Experienced Involvement' (EX-IN) training programmes prepare and certify individuals who have experienced mental health problems to work as PSWs.

AIMS

This study examined the influence of EX-IN training on participants' employment status and their experiences in the year after training.

METHOD

We employed quantitative and qualitative methods. Quantitative data were collected at baseline, immediately after completion and at 1 year post-training. Additionally, individual narrative interviews were conducted with 10 participants at 1 year post-training.

RESULTS

At 1 year of completion, the majority of participants were in paid employment. Difficulties included unclear PSW roles. The qualitative analyses revealed the following categories: 'Evolving from the patient role despite experiencing effects or consequences of mental illness', 'Feeling welcome and being confronted with conflicting expectations', 'Helping others while being needy at the same time' and 'Doing something worthwhile and the fear of failure'.

CONCLUSION

Clear role descriptions, well-defined expectations, team preparation, acknowledgement of vulnerabilities and institution-level support PSWs are important to safeguard both PSWs and service users by minimising the destabilisation risk. Future EX-IN training graduates can benefit from the establishment of remunerated PSW roles in psychiatric services.

Job satisfaction of Department of Veterans Affairs peer mental health providers

OBJECTIVES

Department of Veterans Affairs (VA) peer specialists and vocational rehabilitation specialists are Veterans employed in mental health services to help other Veterans with similar histories and experiences. Study objectives were to (a) examine job satisfaction among these employees, (b) compare them to other VA mental health workers, and (c) identify factors associated with job satisfaction across the 3 cohorts.

METHODS

The study sample included 152 VA-employed peer specialists and 222 vocational rehabilitation specialists. A comparison group included 460 VA employees from the same job categories. All participants completed the Job Satisfaction Index (11 aspects and overall satisfaction ratings). Linear regression was used to compare job satisfaction and identify its predictors among the 3 cohorts.

RESULTS

Job satisfaction was fairly high, averaging "somewhat satisfied" to "very satisfied" in 6 (peer specialists) and 9 (vocational rehabilitation specialists) of the 11 aspects and overall job ratings. Adjusting for length of employment, age and gender resulted in no significant group differences with 2 exceptions: White peer specialists were less satisfied with pay and promotion opportunities than vocational rehabilitation specialists and comparison-group employees. Across all cohorts, shorter length of time employed in the job was associated with higher job satisfaction.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The high job satisfaction levels among the 2 peer cohorts suggest support for the policy of hiring peer specialists in the VA. Furthermore, the results are consistent with those of the nonveteran samples, indicating that integrating peer providers into mental health care is possible in VA and non-VA settings.

A Comparative Study of Nurses as Case Manager and Telephone Follow-up on Clinical Outcomes of Patients with Severe Mental Illness

BACKGROUND

Providing community-based mental health services is crucial and is an agreed plan between the Iranian Mental Health Office and the Regional Committee for the Eastern Mediterranean (affiliated with WHO). The aim of this study was to determine the effectiveness of home-visit clinical case-management services on the hospitalization rate and other clinical outcomes in patients with severe mental illness.

METHODS

A total of 182 patients were randomly allocated into three groups, namely, home-visit (n=60), telephone follow-up (n=61) and as-usual care (n=61) groups. Trained nurses as clinical case-managers provided home-visit services and the telephone follow-up tasks. Hospitalization rate as a measure of recurrence, as well as burden, knowledge, general health condition of caregivers with positive/negative symptoms, satisfaction, quality of life, and social skills of the consumers were assessed as the main and secondary outcomes, respectively.

RESULTS

Most clinical variables were improved in both intervention groups compared with the control group. During the one year follow-up, the rate of rehospitalization for the telephone follow-up and as-usual groups were respectively 1.5 and 2.5 times higher than the home-visit group.

CONCLUSION

Trained clinical case-managers are capable of providing continuous care services to patients with severe mental illness. The telephone follow-up services could also have beneficiary outcome for the consumers, their caregivers, and the health system network.

Understanding Universal Elements in Mental Health Recovery: A Cross-Examination of Peer Providers and a Non-Clinical Sample

In our study, we examined underlying human elements embedded in mental health recovery, by exploring shared positive change among peer providers with serious mental illnesses in recovery and a normative sample in spiritual growth following adversity. We conducted secondary analysis based on two independent qualitative study samples consisting of 31 American peer providers and 27 Israeli adults. We identified three shared and two distinct enablers of positive change: peer groups, significant mentor, self-transcendent experiences. Distinct enablers were having meaningful task/role (clinical sample) and deliberate choice to commit to change in face of uncertainty (non-clinical sample). Enablers facilitated positive processes of meaning making and enhancement of agency. Enablers provided opportunities to which the person responded and made use of--thus, enacting a positive reinforcement of change processes. The findings highlight the value of examining mental health recovery in a broad holistic perspective and have implications for practice.

Peer Support Workers in Health: A Qualitative Metasynthesis of Their Experiences

OBJECTIVE

Peer support models, where an individual has a specific illness or lifestyle experience and supports others experiencing similar challenges, have frequently been used in different fields of healthcare to successfully engage hard-to-reach groups. Despite recognition of their value, the impact of these roles on the peer has not been systematically assessed. By synthesising the qualitative literature we sought to review such an impact, providing a foundation for designing future clinical peer models.

METHODS

Systematic review and qualitative metasynthesis of studies found in Medline, CINAHL or Scopus documenting peer worker experiences.

RESULTS

1,528 papers were found, with 34 meeting the criteria of this study. Findings were synthesised to reveal core constructs of reframing identity through reciprocal relations and the therapeutic use of self, enhancing responsibility.

CONCLUSIONS

The ability of the Peer Support Worker to actively engage with other marginalised or excluded individuals based on their unique insight into their own experience supports a therapeutic model of care based on appropriately sharing their story. Our findings have key implications for maximising the effectiveness of Peer Support Workers and in contributing their perspective to the development of a therapeutic model of care.

Developing a change model for peer worker interventions in mental health services: a qualitative research study

AIMS

A range of peer worker roles are being introduced into mental health services internationally. There is some evidence that attests to the benefits of peer workers for the people they support but formal trial evidence in inconclusive, in part because the change model underpinning peer support-based interventions is underdeveloped. Complex intervention evaluation guidance suggests that understandings of how an intervention is associated with change in outcomes should be modelled, theoretically and empirically, before the intervention can be robustly evaluated. This paper aims to model the change mechanisms underlying peer worker interventions.

METHODS

In a qualitative, comparative case study of ten peer worker initiatives in statutory and voluntary sector mental health services in England in-depth interviews were carried out with 71 peer workers, service users, staff and managers, exploring their experiences of peer working. Using a Grounded Theory approach we identified core processes within the peer worker role that were productive of change for service users supported by peer workers.

RESULTS

Key change mechanisms were: (i) building trusting relationships based on shared lived experience; (ii) role-modelling individual recovery and living well with mental health problems; (iii) engaging service users with mental health services and the community. Mechanisms could be further explained by theoretical literature on role-modelling and relationship in mental health services. We were able to model process and downstream outcomes potentially associated with peer worker interventions.

CONCLUSIONS

An empirically and theoretically grounded change model can be articulated that usefully informs the development, evaluation and planning of peer worker interventions.

Peers experience of delivering a problem-solving programme to enhance antipsychotic medication adherence for individuals with schizophrenia

ACCESSIBLE SUMMARY

No research has been conducted into the experience of peer support in improving adherence with oral antipsychotic medication for consumers with schizophrenia. Altruism influences peers to participate in peer support. Engagement in peer support can be challenging and rewarding for peers, and helps improve their own confidence and well-being.

ABSTRACT

Many consumers with schizophrenia are reluctant to take their prescribed antipsychotic medications; however, non-adherence can lead to relapse. The aim of this study was to evaluate peers' perspectives of their participation in a problem-solving peer support programme to enhance adherence in consumers who are reluctant to take antipsychotic medication. Peers contacted consumers by a weekly telephone call for 8 weeks, and used a problem-solving approach to inform their discussion about medication adherence. Semi-structured qualitative interviews were used to evaluate peers' perspectives of their involvement in the programme. Three main themes were abstracted from the data: motivation to participate in the study, experience of peer support programme, and rewards and challenges of the peer experience. Helping others was an important motivator for peers in agreeing to participate in the study. Telephone delivery was a convenient way to deliver the peer support programme. However, at times, it was difficult to contact consumers by telephone and this caused some frustration. Despite these difficulties, peers recognized that being involved in the programme increased their confidence and made them feel worthwhile. The findings have implications for the use of peer support as an adjunct intervention to promote medication adherence in consumers with schizophrenia.

Peer worker roles and risk in mental health services: a qualitative comparative case study

New peer worker roles are being introduced into mental health services internationally. This paper addresses a lack of research exploring issues of risk in relation to the role. In-depth interviews were carried out with 91 peer workers, service users, staff and managers. A grounded analysis revealed protective practice in minimising risk to peer worker well-being that restricted the sharing of lived experience, and a lack of insight into how peer workers might be involved in formal risk management. Alternatively, analysis revealed potential new understandings of risk management based on the distinctive, experiential knowledge that peer workers brought to the role.

The professional experiences of peer specialists in the Georgia Mental Health Consumer Network

There has been an increase in the number of peer-led services within the mental health care system. There however remains little information about the experiences of peers serving in such helping roles. This study explored the professional experiences of peer specialists including the basic roles, benefits, and potential challenges of the peer specialist role. Peer specialists (N = 84) completed a battery of surveys and questionnaires. Qualitative analysis of participants' responses indicated that peer specialists face difficulties such as poor compensation, limited employment opportunities, work stress, emotional stress in helping others, and maintaining personal wellness. Quantitative analyses revealed that recovery attitudes may confer clinical and psychosocial benefits for peer specialists and employment may contribute to hope, empowerment, social engagement, and competence. Peer specialists would benefit from resources and supports aimed at their continued training and supervision. Fostering the vocational advancement of peer specialists could potentially enhance their experiential recovery and community functioning.

New ways of working in mental health services: a qualitative, comparative case study assessing and informing the emergence of new peer worker roles in mental health services in England

Background

A variety of peer worker roles are being introduced into the mental health workforce in England, in a range of organisational contexts and service delivery settings. The evidence base demonstrating the effectiveness of peer worker-based interventions is inconclusive and largely from outside England. An emerging qualitative literature points to a range of benefits, as well as challenges to introducing the peer worker role.

Aims

In this study we aimed to test the international evidence base, and what is known generally about role adoption in public services, in a range of mental health services in England. We also aimed to develop organisational learning supporting the introduction of peer worker roles, identifying learning that was generic across mental health services and that which was specific to organisational contexts or service delivery settings.

Team

The research was undertaken by a team that comprised researchers from a range of academic and clinical disciplines, service user researchers, a peer worker, and managers and service providers in the NHS and voluntary sector. Service user researchers undertook the majority of the data collection and analysis. We adopted a coproduction approach to research, integrating the range of perspectives in the team to shape the research process and interpret our findings.

Study design

The study employed a qualitative, comparative case study design. We developed a framework, based on existing evidence and the experiential insight of the team, which conceptualised the challenges and facilitators of introducing peer worker roles into mental health services. The framework was used to inform data collection and to enable comparisons between different organisational contexts, service delivery settings and the perspectives of different stakeholders.

Settings

The study took place in 10 contrasting cases comprising mental health NHS trusts, voluntary sector service providers and partnerships between the NHS and voluntary sector or social care providers. Peer workers were employed in a variety of roles, paid and unpaid, in psychiatric inpatient settings, community mental health services and black and minority ethnic (BME)-specific services.

Participants

Participants were 89 people involved in services employing peer workers, recruited purposively in approximately equal proportion from the following stakeholder groups: service users; peer workers; (non-peer) coworkers; line managers; strategic managers; and commissioners.

Data collection

All participants completed an interview that comprised structured and open-ended questions. Structured questions addressed a number of domains identified in the existing evidence as barriers to, or facilitators of, peer worker role adoption. Open-ended questions elicited detailed data about participants’ views and experiences of peer worker roles.

Data analysis

Structured data were analysed using basic statistics to explore patterns in implementation across cases. Detailed data were analysed using a framework approach to produce a set of analytical categories. Patterns emerging in the structured analysis informed an in-depth interrogation of the detailed data set, using NVivo 9 qualitative software (QSR International Pty Ltd, Victoria, Australia) to compare data between organisational contexts, service delivery settings and stakeholder groups. Preliminary findings were refined through discussion with a range of stakeholders at feedback workshops.

Findings

Many of the facilitators of peer worker role adoption identified in the existing evidence base were also evident in mental health services in England, although there were issues around pay, leadership, shared understanding of the role, training and management where good practice was uneven. A number of examples of good practice were evident in the voluntary sector, where peer worker roles had been established for longer and organisations were more flexible. In the NHS there were a range of challenges around introducing peer worker roles into existing structures and cultures of practice. Peer workers were able to engage people with services by building relationships based on shared lived experience – the language they used was particularly important in BME-specific services – but barriers to engagement could be created where roles were overformalised.

Conclusions

Key barriers to, and facilitators of, peer worker role adoption were identified, including valuing the differential knowledge and practice that peer workers brought to the role (especially around maintaining personally, rather than professionally defined boundaries); maintaining peer identity in a role of work; changing organisational structures to support peer workers to remain well in their work; and challenging organisational cultures to empower peer workers to use their lived experience. Recommendations for future research include developing a theoretical framework articulating the change mechanisms underpinning ‘what peer workers do’, piloting and formally evaluating the effectiveness and cost-effectiveness of peer worker interventions, and mixed-method research to better understand the impact of working as a peer worker.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

From end user to provider: making sense of becoming a peer support worker using interpretative phenomenological analysis

Purpose

– There has been extensive growth in the employment of mental health peer support workers (PSWs) over the last decade. However, limited research exists when exploring how PSWs make sense of the transition of entering and enacting the role. The purpose of this paper is to explore the lived experience of NHS employed PSWs’ transition from their own experiences of mental health problems to provide a service to support individuals with their mental health problems.

Design/methodology/approach

– The study used purposive sampling to recruit seven participants who were individually interviewed using a semi-structured interview schedule. Interviews were transcribed verbatim and analysed using interpretative phenomenological analysis (IPA).

Findings

– Three superordinate themes were identified: fluctuating identities, PSW role and organisational culture. These were interpreted as interdependent with interrelating subordinate themes.

Research limitations/implications

– Participants considered the complex, idiosyncratic and changeable nature of the transitions and the impact on their individual, interpersonal and collective identities. Emotional and practical support appeared to assist the transition whilst competing roles and blurred boundaries constrained the enactment of the new role. Implications for practice and research are provided.

Originality/value

– Reports on original research and adds to the sparse UK literature in this area.

Motivations of persons with psychiatric disabilities to work in mental health peer services: a qualitative study using self-determination theory

INTRODUCTION

Individuals with psychiatric disabilities have low rates of employment and occupational rehabilitation success. Mental health peer services are a new occupational modality that opened a promising occupational path: persons with serious mental illnesses employed to provide support to others with psychiatric conditions. However challenges to successful peer work exist. Work motivation is central to understanding and supporting peer workers, yet little is known about sources of motivation to work as mental health peer providers. The aim of this study was to identify what drives individuals to mental health peer work using self determination theory (SDT).

METHODS

Motivations of 31 mental health peer workers were explored as part of a larger study. A theory driven approach was employed to emerging qualitative data using SDT concepts: external motivation and internally regulated motivations derived from basic needs (autonomy, competence, relatedness).

RESULTS

External motivations included generic occupational goals and getting away from negative work experiences. Internal motivations corresponded with SDT basic needs: autonomy met-needs was reflected in having freedom to disclose and finding that work accords with personal values; competence met-needs was reflected in using personal experience as a resource to help others; and relatedness met-needs were reflected in having opportunity to connect intimately and reciprocate with consumers.

CONCLUSION

This study identified external and internal motivations of persons with psychiatric disabilities to work as peer providers-a novel occupation in mental health. Employing personal experience and enabling peer contact emerge as major motivational tenets of mental health peer work. According to SDT instrumental occupational goals are considered more external than satisfaction of basic psychological needs. The study demonstrates the applicability of SDT in the design of autonomy supported environments to promote work engagement and sustenance of mental health peer providers.