Box 14.1 Terms used to describe peer support initiatives

Consumer-delivered services (Salzer & Shear, 2002)
Consumer drop-in centres (Mowbray et al., 2002)
Consumer-operated self-help centres (Swarbrick, 2007)
Consumer-run businesses (Kimura et al., 2002)
Consumer-run services (Goldstrom et al., 2006)
Consumer-run organisations (Clay et al., 2005)
Consumer/survivor initiatives (Nelson et al., 2001)
Mutual-help groups (Corrigan et al., 2005)
Mutual support groups (Chien et al., 2008)
Self-help agencies (Segal & Silverman, 2002)
Self-development programmes (Oades et al., 2009)
Self-help programmes (Chamberlin et al., 1996)

Peer support programmes can sit within traditional community-based psychosocial rehabilitation services as a peer partnership model. This means they give up some control of legal, financial and content of the programme (Solomon, 2004).

Peer support sits on a continuum of helping relationships. On the continuum are unidirectional intentional relationships, with professionals and peers in service settings, reciprocal relationships such as reciprocal groups facilitated by peers as providers of conventional services, to naturally occurring reciprocal relationships with peers in community/and or service settings (Davidson et al., 2006).

Sam’s experiences of peer support

Sam is very committed to getting a job. He is assigned an employment consultant to work with him on individual placement and support. This is an example of a unidirectional relationship with a professional in a service setting. Sam’s confidence in gaining work is low because of his past employment history. The employment consultant suggests that Sam meet regularly with a peer mentor, employed by the service (unidirectional intentional relationship with a peer). Sam continues to meet the employment consultant and the peer mentor. The peer mentor shares her experience in gaining employment and the issues and strategies for working with a mental illness. The employment consultant works on needs assessment, goal setting and goal attainment with Sam and the peer mentor, as a team.

The peer mentor suggests an 8-week peer education course around recovery developed and facilitated by peers employed by the service (reciprocal groups facilitated by peers as providers). In the peer education course, Sam meets other people with similar experiences to himself whilst they work as a peer group on issues such as dealing with stigma, medication, personal treatment strategies, consumer rights and communication. At the completion of the course, Sam has made new friendships, feels confident to update his skills, and has renewed hope in looking for work.

Eventually Sam gains part-time employment. The peer mentor suggests to Sam that he may wish to attend employment dinners with other people who work and have a mental illness. The employment dinners are supported by the psychosocial rehabilitation service and are peer run (self-help mutual support, intentional, voluntary reciprocal relationships). Sam meets other people with similar interests and they decide to go to the pictures on a regular basis (friendship, naturally occurring reciprocal relationships).

Necessary tensions in peer support contexts

We use the phrase ‘necessary tension’ to capture the political essence of many peer support initiatives. One ongoing tension relates to payment for peer support workers. As Crossley (2004) explains, the trend for members of the c/s/x movement to be sought out and paid for their expertise is a double-edged sword: ‘At one level this is a victory for the movement. However, as some consultants and activists recognize, it changes the modus operandi of the movement in significant and not always desirable ways. A political model is replaced by a business model’ (p.176). However, many may argue that the situation is less polarised than this. A peer support employee can have a position description that includes strong advocacy and organisational change. This may be outside the original view of early advocates within the c/s/x movement but may still generate major system transformation.

A further key issue relates to concerns of existing staff members who do not identify as peers. Some mental health professionals may feel concerned about peer support workers for a range of reasons, including reduced productivity, increased risk or simply having their own jobs replaced. An alternative view is that peer support workers are additional resources who will help divert the overload of clients from already overworked mental health professionals (Solomon, 2004; Solomon & Draine, 2001).

In the partnership model, consumers (who have psychiatric diagnoses) partner with mental health professionals (who do not have psychiatric diagnoses) in the co-ordination and delivery of services. Everett (2000) cautions against aspects of partnership models, asserting that those in marginalised positions of power can try to exert their influence on partnership models but their voices will never carry the same weight as mental health professionals ‘because the powerful retain exclusive rights over the definition of what is and is not “normal” ’ (p.164).

As the employment of peer support workers increases within mental health services, the partnership model may take on added complexity or possibly lose its original meaning. Whilst there is a service provider and a service user, the issue of whether the service provider identifies as having used a mental health service or experienced a mental illness may become subsumed as one type of expertise, i.e. lived experience complementing professional training (Blanch et al., 1993).

Summary of evidence from peer support programmes

The traditional empirical approach with the randomised experimental design seen as the highest standard of evidence may be of little value to many involved in peer support initiatives. This again is part of the necessary tension that occurs, and is yet another example of the differences between the medical paradigm, which places great importance on ‘objectivity’, and a c/s/x perspective which highly values subjective personal experiences and context.

The empirical literature on peer support consists largely of quasi-experimental studies, qualitative reports and anecdotal accounts of innovative programmes, as opposed to randomised trials. There has been a systematic review of empirical studies that assessed whether participating in mutual help groups for mental health problems leads to improved psychological and social functioning (Pistrang et al., 2010). The 12 studies that met the criteria provided limited but promising evidence that mutual help groups benefit people with three types of problems: chronic mental illness, depression/anxiety and bereavement. These authors report that five of the 12 studies demonstrated no differences in mental health outcomes between mutual help group members and non-members. None of the studies showed evidence of negative effects. The studies varied greatly in terms of design quality and more high-quality outcome research is needed.

Repper and Carter (2011) reviewed research on peers offering support for people with mental health problems working from professionally led mental health services (e.g. statutory or public services). They located seven randomised controlled trials that described a wide range of peer support work interventions – for example, peers employed as case managers, additional to team members, in outpatient and inpatient services. They reported ‘inconsistent findings’ across studies due to highly variable outcome measures. However, the most consistent finding appeared to be that those services using peer support workers demonstrated a reduction in hosptial admissions and longer community tenure amongst those consumers or mental health services with whom they worked. A range of other benefits were reported from either single studies or qualitative studies. These included a greater sense of independence and empowerment, improved social functioning, feeling more accepted, understood and liked, experiencing stigma as less of a barrier to employment. There were also multiple benefits reported for the peer support workers themselves (e.g. personal growth, esteem).

The evidence base for peer support in mental health services is growing but there is a need for organisational studies. That is, it is not sufficient to conceptualise peer support initiatives only at the individual level and assess the benefits and psychological functioning of the individual. Peer support initiatives should also be investigated as to how they lead to organisational transformation of culture, and how they interface with the policy related to recovery-oriented service provision (Slade et al., 2008).

The following is a brief example of a peer support service provided by a psychosocial rehabilitation service in Australia that attempts to addresses some of the organisational issues that arise.

Example of a peer support service

The example is set in a psychosocial rehabilitation service that incorporates peer support services. The service established a consumer participation unit (CPU) which broadly aimed to facilitate communication and understanding of the lived experience of mental illness in the context of traditional service provision. Staff who have experienced mental illness were employed. Their role was to facilitate community participation, participation within the organisation and participation by individuals with their own healthcare planning. The role of the unit in the organisation was to inform and support the organisation on consumer issues. A specific example of activity facilitated by the CPU was the establishment of and support for a speaker’s bureau of peers to educate the community and staff on issues to do with having a mental illness. The CPU trains and supports peers to facilitate an 8-week peer education course. The unit co-trains staff on rehabilitation practices. It works with day programmes to incorporate peer programmes within traditional service offerings. It also aims to bring the latest evidence and practice on peer support and consumer issues to the organisation within a recovery framework.

Recommendations regarding implementation of peer support initiatives

In their review, Repper and Carter (2011) identified a number of challenges in peer support work. These challenges include multiple boundary issues such as being perceived as more of a friend to service users as a result of sharing personal information and experiences. Power issues emerge as a result of peer workers being formally employed with all of the associated benefits, thus potentially elevating their status in relation to the consumers they work with. Similarly, they may be viewed as ‘patients’ by other professional staff with whom they work, undermining their status. Stress has been identified as a potential challenge since it could result in recurrence of mental health problems. Worry about this concern may mean that fewer demands are placed on peer support workers by line management, which may limit the roles they are able to play in the service. The final challenge identified involves maintaining a distinct role for peer support workers. This issue intersects with the ‘necessary tensions’ noted above in that consumers need to maintain the principles associated with recovery-oriented practices and take care not to be socialised into the traditional way of working in mental health services.

In this final section, the aim is to provide recommendations to those who aim to commence peer support groups or improve those already under way. These recommendations address a number of the challenges noted. Below a set of prescriptions (things to do) and proscriptions (things to avoid) are provided, written predominantly in the context of peer groups within or attached to a mental health system.

Prescriptions

1. Clarify early and gain input from a range of people about the primary focus of groups. That is, are they remedial, focusing on the personal processes of recovery, interactional, emphasising the interpersonal relationships and personal experience, or social, integrating the personal, interpersonal and political, which the authors refer to as social change and empowerment of oppressed populations?

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