Therapeutic Approaches

Peer Support: Definitions, History and Benefits for Mental Health

Recent times have seen a buzz in mental health circles about peer support. In this and companion articles, we examine what peer support is and how it benefits mental health care systems.

By Mental Health Academy 2023-10-10 04:24:39

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Recent times have seen a buzz in mental health circles about peer support. In this and companion articles, we examine what peer support is and how it benefits mental health care systems.

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Introduction

The COVID-19 pandemic laid bare the overextended state of both private and public mental health care systems in many developed nations of the world, and certainly in Australia. The sharp uptick in mental health issues experienced by most communities (Zhao, Leach, Walsh et al, 2022) came to be pitifully obvious as waiting lists for treatment ballooned, and even private health care professionals, who earlier had struggled to retain sufficient caseloads, announced that they could not take on any more clients (personal communications to author).

But a saving grace of support has appeared from a source that would not have been considered valid just a few decades ago: that of peer support. “Peer support” is an umbrella term which now refers to a multitude of roles in diverse settings, so first we define peer support and list its core principles. We trace its history. Peer support is evidence-based, so we note the main benefits demonstrated by research.

Definitions and core principles

Definitions

The United States Substance Abuse and Mental Health Services Administration (SAMHSA) defines a peer worker as:

“a person who uses his or her lived experience of recovery from mental illness and/or substance use disorder, plus skills learned in formal training . . . to deliver services in behavioral health settings to promote mind-body recovery and resilience” (SAMHSA, 2017, in Gagne, Finch, Myrick, and Davis, 2018)

Australia’s Orygen Institute states simply that:

“Peer support is a mutual relationship that involves someone with lived experience of mental health and other life challenges (peer workers) supporting and advocating for someone who is experiencing these challenges. It is different from a clinical relationship” (Orygen Institute, 2023).

Core principles

The UK-based organisation ImROC (Implementing Recovery Through Organisational Change) generated eight core principles of peer support:

  1. Mutual (shared experience of mental illness)
  2. Reciprocal and non-hierarchical
  3. Non-directive
  4. Recovery-focused
  5. Strengths-based
  6. Inclusive
  7. Progressive
  8. Emotionally safe (ImROC, in Mental Health @ Home, 2021)

If you are a seasoned mental health professional, you will be aware that peer support workers have not always been “front and centre” in the conversations about how to elevate community mental health. Increasingly, however, organisations such as Suicide Prevention Australia cite earlier observations of “substantial international evidence” that the quality of life of those experiencing mental illness “can be substantially enhanced when peer support is an integral part of their treatment and/or interventions” (Felton et al, 1995). Here’s how peer support came to occupy the ever more central role it has in mental health helping.

Brief history

A health system hiring or collaborating with a peer worker is a recent phenomenon, but the notion that such individuals had something to offer peers struggling with mental health and/or substance misuse issues goes back more than a half-century.

1950s to 1970s

U.S. People living with mental health or substance use disorders came to be pioneers leading self-help groups and advocacy organisations. They were passionate about improving mental health treatment services in a then-climate of economic crisis and system restructure, and they were determined to shift negative attitudes about mental health. On both national and international levels, these early peer workers addressed prejudice while trying to promote change in the troubled mental health services systems they were familiar with. Observing that many people living with mental illness had non-clinical needs that could be met through support by others with similar experiences, their basic intention was to eliminate discrimination by providing the non-clinical needs. The community Support Program of SAMHSA Center for Mental Health Services facilitated some of the initial efforts by helping to establish peer support services and research. Even in the 1970s, the role that funders have in shaping the inclusion of peer workers was becoming obvious (Gagne et al, 2018).

Australia. In its earliest forms, lived experience work emerged in the 1950s from grassroots mutual self-help organisations such as Alcoholics Anonymous; these were and continue to be underpinned by the peer support model of mutually offered and reciprocal social, emotional and/or practical support. However, there has been a lot of inconsistency in how the terms “peer support”, “peer work”, “peer support work”, and “lived experience” have been used as the roles have evolved (Victoria State Government Department of Health, 2021); our next article explains that in more detail.

When a young student in a Northern Beaches school (New South Wales) died of a drug overdose in 1971, then-health educator Elizabeth Campbell established the first iteration of the current Peer Support Program for students, called “Fifth Form/First Form”. The program saw 30 students trained as peer leaders, provided the latest information on drug abuse, and shown how to spread the information throughout the school to combat drug abuse problems. Soon, 22 schools were participating in the program and discussion groups were also introduced in primary schools. In 1976, the program was presented in Canada, America, and the U.K. (Peer Support Australia, n.d.).

1980s

U.S. The value of the lived experience perspective began to be seen in the expansion of formal peer support through drop-in centres and other consumer-run organisations for those with mental health issues (Gagne et al, 2018).

Australia. In early 1980, the Rotary organisation became interested in peer support for young people combating drug misuse and was instrumental in establishing a steering committee to administer the Fifth Form/First Form peer program (above) on a statewide basis. The steering committee transitioned the early work into a formal organisation known as the Peer Support Foundation, which in 1983 began setting up offices around Australia to run the program.  By the mid-eighties, thousands of teachers and hundreds of schools were participating in the Peer Support Program.  The Program was being used in more countries such as New Zealand, South Africa, and Singapore (Peer Support Australia, n.d.). 

1990s

U.S. Limited integration began of peer support workers in certain areas of the mental health system, such as outreach and consumer case management. Research on those limited roles showed potential benefits, including decreased hospitalisation rates and improved quality of life (Gagne et al, 2018).

Australia. Adult-to-adult peer support work began to spread (apart from the early forms available through Alcoholics Anonymous and similar organisations), but was generally viewed as a disruptive, consumer-led practice. The first lived-experience positions were created in 1996 when four “Consumer Consultants” were appointed to lead quality improvement projects in each area mental health service. By 1999, the support needs of carers were recognised through establishment of the Carers Offering Peers Early Support (or COPES) project, in which a peer support network for carers was established within the clinical service at Maroondah Hospital and also across one of the local community services in Victoria (Meagher, 2018; Victoria State Government Department of Health, 2021; Peerinside, 2019).

2000s

U.S. The President’s New Freedom Commission report published in 2003 proposed goals to move the system from a disease/treatment orientation to a recovery one; as part of that transformation, it recommended that a strong peer workforce be developed. By 2005, the Department of Veterans Affairs began to fund new positions for veterans with lived experiences of mental health conditions to provide recovery support services to other veterans with behavioural health needs. Peer recovery coaching, as it is known in the field of substance use treatment, formally launched early in the decade (the available roles prior to this were those of counsellor, not peer support worker) (Gagne et al, 2018).

Australia. Following on from introduction of the first Carer Consultant at Victoria’s St. Vincent’s Hospital in 2000, the Department of Health permitted the employment of Carer Consultants in each service. Also in 2002, the first leadership role for “consumer workers” (peer support workers) was set up, growing to .6 of a fulltime job. By 2005, Southern Health had introduced a fulltime executive management position to manage the lived experience workforce. In 2008, the Department of Health Services employed the first Consumer and Carer Participation Policy Officer with declared lived experience (Peerinside, 2019).

2010s

U.S. By 2017, the U.S. Department of Veterans Affairs employed more than 1200 peer workers in a variety of the Department’s programs; expansion of peer support services has generally been occurring since then (Gagne et al, 2018).

Australia. In 2010, Austin Health introduced a senior position of Consumer and Carer Coordinator to manage the Consumer and Carer Consultants. In 2016, the Department of Health funded a new program, the Expanding Post Discharge Support, which has resulted in a rapid growth in the lived experience workforce in clinical mental health services (Peerinside, 2019).

Currently

U.S. The evolution of peer support work has continued with increasingly diverse job titles. Even by 2010, a national survey of certified peer specialists had recorded 105 different job titles of its 291 respondents (Peers for Progress, 2023).

Australia. Australia has been able to count at least 30 different job titles for the “lived experience workforce” (Byrne et al, 2021; Bell, Panther, & Pollock, 2014). Lived experience peer support is now accepted as an important element of good recovery, and in fact, is the most rapidly expanding discipline in mental health services. People with mental health issues, families, and service providers now expect peer work to be a part of the mix of support offerings that are available, and many advocates of lived experience promote the importance of peer support while providing strategies and blueprints for how it may happen (Meagher, 2018; Victoria State Government Department of Health, 2021).

For young people, The Peer Support Foundation (now trading as Peer Support Australia), sees thousands of schools participate each year and more than 500,000 students participate annually in a Peer Support Program. These have broadened to include leadership opportunities and provision of skills and strategies to enhance mental, emotional, and social wellbeing (Peer Support Australia, n.d.).

In the U.S., Australia, and other countries where peer support is happening, peer support has demonstrated multiple benefits in studies.

Demonstrated benefits of peer support

In an older Australian study, Lawn, Smith & Hunter (2008) undertook an evaluation of the first three months’ operation of a peer support service that aimed to provide hospital avoidance and early discharge for adult consumers. It was found that 300 bed days were saved over the 49 service packages provided, equivalent to a saving of over $90,000 for the health system. In addition, feedback from all key stakeholders – consumers, family/carers, mental health staff and the peer support workers – was identified as being “overwhelmingly positive” (Lawn, Smith & Hunter, 2008).

Mental Health America released a paper summarising evidence for peer support. Citing numerous studies in each category of evidence, they noted that peer support is an evidence-based practice for individuals with mental health conditions or challenges, and that both quantitative and qualitative studies indicate the following benefits. We include a sample study for each benefit demonstrated, but see Mental Health America, 2019, for the full discussion.

Reduced re-hospitalisation rates

Pierce County Washington reduced involuntary hospitalisation by 32% by using certified peer specialists offering respite services, leading to a savings of 1.99 million dollars in one year.

Reduced days inpatient

In the TN PeerLink Program, there was a significant decrease of 90% in average number of acute inpatient days per month.

Lowered overall cost of service

A study of Medicaid claims and enrolment data in New York City found that in the month of peer-staffed crisis respite use and the following 11 months, Medicaid expenditures per person averaged $2,138 less per Medicaid-enrolled month.

Increased use of outpatient service

90% of the participants in PEOPLe Inc’s Rose House crisis respite program in Orange County, New York did not return to hospital in the following two years (2010 program evaluation data).

Increased quality of life outcomes

A meta-analysis in General Hospital Psychiatry, Volume 33(1), showed peer support is superior to usual care in reducing depressive symptoms.

Increased engagement rates

A Mental Health America and Kaiser Permanente Peer Support Pilot Study showed participants who received peer support had increased trust in services and increased team collaboration.

Increased whole health

The preliminary study findings of the Peer Support Whole Health and Resiliency (PSWHR) randomised controlled trial included these results:

  • 100% self-reported reaching a whole health goal, such as eating five healthy meals per week, jogging 20 minutes twice a week, or eating seven servings of fruits and vegetables a week  
  • 78% of PSWHR participants were very satisfied
  • 100% strongly liked listening to other people’s challenges & successes
  • 89% self-reported improvement in whole health since starting PSWHR (Mental Health America, 2019)

Focusing on benefits to the individuals involved in peer support programs, the review by Canada’s Center for Addiction and Mental Health found that peer support workers are in a better position than health professionals to support improvements in these areas:

  • Empowerment
  • Self-esteem
  • Self-efficacy
  • Social inclusion
  • Reduction in self-stigma
  • Functional ability
  • Quality of life
  • Belief that recovery is possible (Mental Health @ Home, 2021)

Summary

Peer support, the mutual relationship of someone with lived experience of mental health or substance misuse supporting and advocating for someone experiencing those challenges, has been a growing phenomenon for over half a century, with research demonstrating multiple benefits to the individuals and to the health systems where peer support is undertaken.

Follow-up article: Peer Support: Roles, Clients and Settings.

Key takeaways

  • Peer support is the non-clinical support of someone experiencing mental health or substance misuse challenges from someone who has the lived experience of those issues
  • In both the United States and Australia, peer support has been growing into its present forms for over half a century
  • Multiple studies, especially over the last several decades, have demonstrated benefits such as self-esteem and empowerment to the individual and reduced re-hospitalisation rates and lowered overall cost of services to the health systems utilising peer support.

References

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