Peer delivered services in mental health care in 2018: infancy or adolescence?

Peer support is now considered to be a central component of the behavioral health care system in countries such as the US, Canada, Australia and the UK. Professionals looking to improve their ability to promote recovery have strategies and training programs that include collaborating with peers in their services (e.g., Boston University's Recovery Promoting Competencies Toolkit). In 2012, Davidson et al1 characterized in this journal peer delivered services as being still in their infancy. They pointed out that, while there was a proliferation of peer support workers in the mental health field, their roles and tasks were unclear and the existing research base mostly focused on feasibility studies, often with significant methodological problems. It is our contention that, six years on, the field of peer delivered services has matured significantly. Recent work has aimed to achieve a common understanding of roles and possible quality indicators for peer services. For example, Chinman et al2 are developing a peer specialist fidelity measure for two content areas: services provided by peer specialists and factors that support or hamper the performance of those services. Cronise et al3 conducted a US national survey to identify the roles, tasks, settings, job training and compensation currently offered to those with the title of “peer specialist”. They found that peers are no longer just part-time workers in community based settings. Data from 597 respondents revealed that more than 64% worked in full-time positions in a wide range of settings, including treatment and forensic organizations. The incorporation of peers into the standard mental health workforce has seen the majority hired into roles regarded as unique to a person with personal mental health experience. However, others hold positions in which peers' personal experiences are not required, but considered additive. This includes, for example, rehabilitation workers such as case managers, employment specialists and job coaches. Agreement about a common set of practitioner competencies (https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers/core-competencies-peer-workers), complementing a set of agreed-upon national guidelines for peer support services in behavioral health in the US (https://inaops.org/national-standards), has begun to emerge since Davidson et al's article. Peer support has also evolved in Europe, as evidenced by new training programs for peers, including, for example, those identified by the European Union's Compass Consortium4 as a best practice (e.g., Peer2Peer in Spain), as well as university based programs, such as a two-year Associate Degree program in “Experts by Experience” at Hanze University in the Netherlands. Functions or processes overlapping across the totality of these efforts suggest that there is growing agreement about some basic qualities unique to peer support (i.e., relationships based on shared lived experience/validation of experiential knowledge and a deliberate focus on enhancing strengths, hope and empowerment, among other qualities). Recent systematic reviews5 have confirmed that, while peers and clinicians typically performed fairly equally on traditional outcome measures (e.g., rehospitalization, relapse), peer outcomes were better in areas such as self-efficacy, hope, empowerment, engagement, and others more related to recovery processes. Responding to earlier criticisms, research on peer support has advanced, with growing examples of well controlled studies. For example, Mahlke et al6, in their randomized controlled trial (RCT) of 261 peers, clearly indicated tasks to be delivered, specified a standardized training for the peers, and selected peer support workers with similar experiences. The study found that one-to-one peer support plus treatment as usual was associated with significantly higher scores of self-efficacy at six-month follow-up compared to treatment as usual alone. Manualized interventions created by peers themselves or led by peers have multiplied over the past six years. They have made better controlled studies possible, and thus provided better evidence for outcomes, than the less well defined service of one-to-one peer support. For example, in an RCT, Wellness Recovery Action Planning7 has been found more effective in reducing psychiatric symptoms, enhancing participant hopefulness and improving quality of life in people with severe and persistent mental illness, as compared to usual care. A peer-led manualized intervention to combat self-stigma was investigated in an initial RCT with positive results8. Other programs such as the peer-developed Spanish program Education: Tool to Fight Stigma and Discrimination are now included in European Union's Compass Consortium Best Practices guide4. Peer-led health interventions such as self-management, as well as the use of peer navigators to link individuals with mental illnesses to health services, have shown evidence for their effectiveness9. A recent RCT of a program named Toward Recovery, Empowerment and Experiential Expertise – TREE, developed by peers in the Netherlands, found the intervention, added to care as usual, to be more effective than care as usual only, in terms of outcomes such as empowerment, mental health confidence and loneliness10. Taken together, the number of manualized peer developed/peer led interventions, and the expanding number being studied in RCTs, reflect the emerging sophistication of peer delivered services. While implementation and methodological issues still exist, the greater clarity around what peer support actually is, the greater variety of available training programs, the current development of a fidelity scale, the suggestion of standardized competencies, better designed RCTs, and the emergence of manualized peer developed/led interventions, are exciting advances in the growth of peer delivered services over the past six years. These advances justify characterizing peer support services as well beyond their infancy. Rather, they are an established, maturing area of development and study, with great promise for the future of services to promote recovery. Marianne Farkas1, Wilma Boevink2 1Center for Psychiatric Rehabilitation, Boston University, Boston, MA, USA; 2Trimbos Institute, Utrecht, The Netherlands M. Farkas acknowledges the support of the US National Institute on Disability, Independent Living and Rehabilitation Research; the Administration for Community Living; the Substance Abuse and Mental Health Services Administration; and the Department of Health and Human Services. The contents of this paper do not necessarily represent the policy of the above entities.

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