Why Does Peer Support Work? Change Mechanisms Underlying Mental Health Peer Support
Huyen Vu, MSPH
Involving peer support workers in mental health services is an effective means to improve the recovery outcomes for people living with mental illness. Evidence from the U.K., Australia, New Zealand and the U.S. suggests that by sharing their own experience of mental illness and supporting other patients in their own recovery journeys, peer workers can significantly improve treatment and recovery outcomes of people with psychiatric disability, and contributes to a substantial reduction in re-admission rates and bed days of mentally ill patients.
In the U.S., peer worker programs should grow in importance as the Affordable Care Act comes into effect. With an additional 8 million people eligible for Medicaid, and with the requirement to include mental health service coverage in all health plans, peer worker programs may be an effective strategy to alleviate the shortage of mental health professionals.
However, inclusion of the peer worker interventions as part of a national strategy for mental health care has been hampered by a lack of systematic evidence and robust evaluation on the value of peer workers as measured by gold-standard trials. A group of Australian researchers conducted a systematic review of 11 randomized control trials and found inconclusive evidence of the benefit of peer workers as providers of mental health services, and concluded that the lack of a clear change model was the potential limitation for those trials. (A change model is “an understanding of how what peer workers do is associated with outcomes.”)
To this end, Steve Gillard and colleagues recently developed a model articulating the change mechanisms that highlight the impact of peer workers on mentally-ill patients (Figure 1). Theoretical and practical components included in the model were derived from a comparative, qualitative case study. Seventy-one peer workers from 10 mental health services in England were interviewed about their role as peer workers and the implementation issues they experienced, such as human resource issues, working on teams, and training and support.
Analysis of the qualitative data helped the researchers to construct a change model for peer worker interventions. It indicates that building trust relationships based on shared experience is the primary mechanism behind the success of peer worker interventions, and establishing a personal connection is the necessary first stage of relationship building. Specifically, peer workers might share their lived experience of mental illness, or of utilizing services, which patients may recognize as a similar or shared experience. The next stage in building a trust relationship is through talking and listening. In this stage, it is important that peer worker shows understanding of the patient’s experiences based on their own lived experience, and give the patient a sense of validation. Once the relationship is formed, the peer worker should allow the patient to initiate discussion and disclosure instead of requiring it from them. Patients may thus be more willing to share their experience with peer workers and listen to their advice.
As the relationship is established, two parallel mechanisms arise from the trust relationship:
- Role model for recovery and learning to live with mental health problems: Peer workers act as role models to the patients they support by showing their own recovery progress and ability to function well socially. Patients then observe that the peer worker has moved on from where they currently see themselves, and they start to develop a sense of hope for the future. Seeing peer workers in the care role also has a significant impact on the patient, as it demonstrates their usefulness and value, and acts as a powerful symbol of recovery. As role models, peer workers challenge the self-stigmatizing effects of mental illness by the fact of their working role, increased resilience, empowerment and self-efficacy, and this prompts patients to engage in better self-care and to improve their social functioning.
- Bridging the engagement with mental health services and the community: As the relationship between the patient and peer worker grows stronger, it helps ease the patient’s engagement and connection with mental health professionals, care services, and the wider community. Through this bridging function, the patient’s trust in peer workers can also be extended to other non-peer members of the team which may enable the patient to overcome their fear of being stigmatized and their reticence to disclose difficult personal issues with the mental health team. In this role, peer workers may facilitate patients’ engagement with the community by encouraging them to attend outside activities, helping them break their isolation and increase the range and quality of their social networks.
Gillard’s change model aligns closely with the four key functions of peer support, as articulated by Peers for Progress. Our experience with peer support programs have taught us that building rapport between the peer supporter and the patient is the first step in engaging that patient. We share the belief that fostering positive interpersonal relationships is the driving force in peer support interventions.
In summary, the change model can provide a theoretically grounded framework to develop, evaluate, and plan peer support interventions. The model can identify associations between process outcomes and clinical outcomes, thus providing a strategy for formal evaluation of peer support interventions. This approach would facilitate the inclusion of the peer worker role and intervention as a recognized element of a national strategy for mental health care.