Developing a Strategy to Embed Peer Support into Mental Health Systems

Implementing peer support work in mental health care in Germany: The methodological framework of the collaborative, participatory, mixed-methods study (ImpPeer-Psy5)

BACKGROUND

Starting in the 1990s in the United States, individuals with lived experience of mental health crises and recovery have been employed as peer support workers (PSWs) internationally. However, the implementation of PSW in clinical contexts remains challenging.

METHODS

This manuscript presents and discusses the methodological framework of the ImpPeer-Psy5 study on the PSW implementation in the German mental healthcare sector. This study used a mixed-methods and collaborative research approach, as well as participatory research strategies. After describing the study design, populations, teamwork and assessments, the epistemic challenges of its methodological framework will be critically discussed and how it has iteratively shaped the object of study.

DISCUSSION AND PRACTICAL IMPLICATIONS

The healthcare, policy and funding context of PSW implementation as well as the study's methodological framework have differently influenced the ways in which the implementation of PSW has been conceived in this study. The choice of a collaborative or participatory methodological framework is advised to better align research questions and procedures to the specific needs and challenges of PSWs and other stakeholders concerned with PSW implementation.

PATIENT AND PUBLIC CONTRIBUTION

The research team of the ImpPeer-Psy5 study was collaboratively staffed by a portion of researchers who also identify as users or survivors of psychiatric services. A nonprofit organization for the training of PSWs served as a practice partner throughout the research process. Different participatory formats involve a significant number of diverse stakeholders relevant to PSW implementation.

A systematic scoping review of peer support interventions in integrated primary youth mental health care

Peer support, defined as the social and emotional support offered and received by individuals with a shared experience of mental health difficulties, is gaining popularity in youth mental health settings. This systematic scoping review aimed to collate and synthesise the evidence on key aspects of peer support interventions within integrated youth services and educational settings. Specifically, it synthesised evidence on the (1) assessed mental health outcomes in peer support interventions, (2) key characteristics and associated roles of peer support workers (PSWs) and (3) barriers and facilitators to implementation. A search of peer reviewed articles from January 2005 to June 2022 across five electronic databases (PsychINFO, Pubmed, Scopus, ERIC and CINAHL) was conducted. A total of 15 studies retrieved in the search met the inclusion criteria and were included in the review. This review supports previous research indicating that peer support has potential for improving recovery related outcomes. While a variety of interventions and PSW roles were reported, studies could be strengthened by providing more in-depth information on intervention content. Examples of barriers to implementation included staff concerns around confidentiality of peer support relationships as well as PSWs' confidence in their roles. Facilitators included positive support from staff members and role clarity.

Peer Support for Patients With Heart Failure: A Systematic Review and Meta-Analysis

Peer support, which is given by people with similar life experiences and experiential knowledge, has been shown to be effective for patients with diabetes and mental illness. However, the impact of such peer support on patients coping with heart failure remains indeterminate. The objective of this systematic review and meta-analysis is to scrutinize the potential benefits of peer support for patients with heart failure. We included randomized controlled trials (RCTs) evaluating the effectiveness of peer support for patients with heart failure in contrast to those without peer support. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, WHO International Clinical Trials Registry Platform, and ClinicalTrials.gov until October 2022. We pooled the data on mortality, readmission rate, and quality of life (QoL) as primary outcomes. The certainty of evidence was evaluated by the grading of recommendations assessment, development, and evaluation (GRADE) approach. We included three studies with 390 patients with heart failure. Peer support may have resulted in a slight increase in mortality (risk ratio (RR)=1.16, 95% confidence interval (CI)=0.61-2.21; low certainty of the evidence) and in a reduction in the readmission rate (RR=0.93, 95% CI=0.74-1.17; low certainty of the evidence). The evidence was very uncertain about the effect of peer support on QoL (standardized mean difference 2.03 higher in the intervention group, 95% CI=1.79 lower to 5.84 higher; very low certainty of the evidence). Despite that the certainty is low or very low, the extant data available evidence suggests that peer support may not yield substantial improvements in critical outcomes for patients with heart failure. Consequently, endorsing peer support for patients with heart failure currently seems unjustifiable.

Managers as peer workers' allies: A qualitative study of managers' perceptions and actions to involve peer workers in Norwegian mental health and substance use services

BACKGROUND

Citizens with experience and knowledge about what it is like to use mental health and substance use services are increasingly employed within similar services as peer workers. Peer workers are portrayed as achieving societal obligations and help ensure that the outputs from service provision are more effective. Even though peer workers have worked in mental health and substance use services for a while, few studies have focused on exploring managers' experiences and perspectives about involving peer workers. This knowledge is needed because these managers can enable and hinder equitable involvement and collaboration with peer workers.

METHODS

A qualitative explorative study was chosen to explore the following research question: How do managers in Norwegian mental health and substance use services experience, relate to, and embrace peer workers as assets in these services? A researcher (Ph.D. student) and a coresearcher (peer worker) conducted four online focus groups with a strategic selection of 17 Norwegian mental health and substance use services managers who had some experience with the involvement of peer workers in their organizations.

RESULTS

The results identified using systematic text condensation are as follows: [1] Peer workers boost the ongoing shift toward increased service user involvement. [2] Peer workers are highly valued in the service transformation process. [3] Managers involve peer workers as partners in co-creation. The results show that managers connect with peer workers and facilitate their involvement in collaborative activities across the service cycle. Peer workers' proximity to service users and bridging capacity is highlighted as the reasons for their involvement. Thus, peer workers are involved in co-defining challenges, co-designing potential solutions, co-delivering those service solutions, and, sometimes, co-assessing service solutions to rethink and improve services. As such, peer workers are considered partners in co-creation.

CONCLUSION

As managers involve peer workers, they increasingly discover peer workers' value, and because peer workers are involved, they increase their skills and capacity for collaboration. This research strengthens the knowledge base of the perceived value of peer workers' roles, bringing in new perspectives from management about utilizing and evaluating peer worker roles.

Peer Workers in Co-production and Co-creation in Mental Health and Substance Use Services: A Scoping Review

People with lived experience of mental health challenges are extensively employed as peer workers within mental health and substance use services worldwide. Research shows that peer workers benefit individuals using such services and can have essential roles in developing recovery-oriented services. However, understanding how peer workers' contributions, by their role, functions, and input can be better used remains a critical challenge. Research on public sector innovation has focused on relevant actors collaborating to tackle complex demands. Co-production and co-creation are concepts used to describe this collaboration. Co-production refers to the collaboration between providers and users at the point of service delivery, whereas co-creation refers to collaboration starting in the early service cycle phases (e.g., in commissioning or design), including solution implementation. We overviewed research literature describing peer workers' involvement in mental health and substance use services. The research question is as follows: How are peer workers involved in co-production and co-creation in mental health and substance use services, and what are the described outcomes? A literature search was performed in 10 different databases, and 13,178 articles were screened, of which 172 research articles describing peer workers' roles or activities were included. The findings show that peer workers are involved in co-production and function as providers of pre-determined services or, most often, as providers of peer support. However, they are rarely engaged as partners in co-creation. We conclude that the identified peer worker roles have different potential to generate input and affect service delivery and development.

The impact of peer support work on the mental health of peer support specialists

Background

Peers support specialists have positive impacts on the mental health of their service users. However, less is known about how their mental health changes as a result of their activities.

Methods

We followed 10 peer support specialists over their first year of employment and interviewed them thrice. We used grounded theory to analyse the way in which the health of participants changed.

Results

Self-reported mental health of our participants did not change over the course of the study. However, the role did help participants grow and learn about their condition and their strengths. While sharing their past experiences could be taxing, they learned how to harness their recovery journey without risking relapse.

Conclusion

Entering the role of a peer support specialist does not appear to negatively impact mental health, but might enhance insight and resilience. However, this appears to occur in individuals who already possess an inclination toward introspection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-022-00561-8.

Use of Psychics for Stress and Emotional Problems: A Descriptive Survey Comparison with Conventional Providers and Informal Helpers

Conventional mental health treatments do not meet the needs of all who seek help: some consult informal and alternative providers. Researching the use and perceived benefits of these non-conventional sources of help may contribute to understanding help-seeking behavior and inform mental health policy. We explored the experiences of people consulting psychics (a type of alternative provider) for mental health needs, through comparisons with experiences of people consulting conventional and informal providers. An online survey sought feedback on help seeking for stress or emotional problems from 734 adults who had consulted a psychologist or counsellor; doctor or psychiatrist who prescribed medication; friend or family member; or psychic or similar alternative provider. Analyses included descriptive and inferential statistics and content analysis of textual responses. Problems were commonly described in symptom or disorder terminology with considerable overlap across groups. Content analysis of reasons for choice of helper identified four main categories-functional, reasoned, emotional, and passive-which differed significantly across groups (Cramer's V = 0.26), with consulting psychics predominantly a reasoned choice. Ratings of overall effectiveness of help by those consulting psychics were greater than for the three other groups (d = 0.31 to 0.42), with very few adverse outcomes in any group. Help seeking for stress or emotional problems includes consultations with psychics or similar alternative providers, with self-reported outcomes better than for conventional providers. Further research is warranted to establish whether psychic consultations may serve a useful public health function.

Effective Peer Employment Within Multidisciplinary Organizations: Model for Best Practice

This study sought a clearer understanding of organizational mechanisms reinforcing effective peer employment and organizational change from the perspectives of peer workers, non-peer staff and management in multidisciplinary mental health and substance use recovery services. Findings were used to develop a model for organizational best practice for peer employment and associated organizational change to promote recovery-oriented and person-directed services. Qualitative research was undertaken, involving 132 people participating in 14 focus groups and eight individual interviews. These people were employed across five U.S. multidisciplinary organizations providing mental health and substance use recovery services and deemed by a panel of experts to provide effective employment of peer workers. Study findings include the articulation of an interactive working model of best practice, comprising organizational commitment, organizational culture and effective organizational strategies necessary for a "whole-of-organization" approach to support authentic peer work and enable organizational transformation, to actualize recovery-oriented values and person-driven services. Strategies include Human Resources engagement, peers in positions of senior organizational authority, recurring whole of workforce training, along with peer training and peer-led supervision. Findings suggest whole-of-organization commitment, culture and practice are essential for the organizational transformation needed to support effective employment of peers in multidisciplinary environments.

Evolvement of Peer Support Workers' Roles in Psychiatric Hospitals: A Longitudinal Qualitative Observation Study

Peer support workers (PSWs) use their experiential knowledge and specific skills to support patients in their recovery process. The aim of our study was to examine the integration and role-finding process of PSWs in adult psychiatric hospitals in Germany. We conducted open nonparticipant observations of 25 multiprofessional team meetings and 5 transregional peer support worker meetings over a period of six months. The data were analyzed using qualitative content analysis. Regarding the integration of PSWs into multiprofessional teams, we identified three subcategories: "Features of success," "challenges" and "positioning between team and patients." Concerning the PSWs' roles, we developed two subcategories: "Offers" and "self-perception." The PSWs' specific roles within a multiprofessional mental healthcare team evolve in a process over a longer period of time. This role-finding process should be supported by a framework role description which leaves sufficient freedom for individual development. Regular opportunities for mutual exchange among PSWs can help to address specific support needs at different points in time.

Diary of a Mental Health Peer Worker: Findings From a Diary Study Into the Role of Peer Work in a Clinical Mental Health Setting

Introduction: The importance of peer support workers in mental health care delivery has been extensively advocated for in mental health policy frameworks. However, there has been limited research examining the implementation of paid peer workers in clinical settings. This study explores the experience of paid peer support workers integrated within a clinically-operated community-based residential rehabilitation service for people diagnosed with a mental health disorder experiencing challenges living independently in the community. Methods: A general inductive approach was taken in the analysis of diaries completed by a newly employed peer workforce. These diaries focussed on what they viewed as significant interactions in fulfilling their role. Composite vignettes were generated to illustrate key themes. Findings: Thirty-six diaries were provided; these reported unplanned and spontaneously occurring interactions. Peer workers emphasized the importance of connecting with people while they were engaging in everyday activities as an opportunity for personal growth of the residents. The diaries also focussed on the peer workers' ability to connect and establish trust by sharing similar experiences with residents or family members. Peer workers also believed that they brought a different perspective than clinical staff and were able to refocus attention from clinical diagnoses and symptoms to other aspects of the resident's lives. Discussion: Peer support workers described their work as flexible, responsive, and adaptable to the resident's needs. They believed that their roles brought a different lens to interactions on the unit and fostered a more inclusive and personal way of working for the team. Conclusion: To ensure that peer workers can engage authentically with residents and family members, it is critical that the role and principles of peer work are valued and understood by all.

Mutual Capacity Building to Reduce the Behavioral Health Treatment Gap Globally

Use of lay health workers for the treatment of common mental disorders is an expanding, yet still underutilized, opportunity for closing the behavioral health treatment gap globally. In this commentary, we describe how "mutual capacity building," an equal exchange of ideas between low and middle-income countries (LMICs) and high-income countries (HICs) to promote shared learning, could promote the development and scale-up of therapies using lay health workers. We propose ways that task sharing models for behavioral health can inform and be supported by bidirectional learning across HICs and LMICs.