Study Examines Barriers to Peer Support

A recent study, published in Social Psychiatry and Psychiatric Epidemiology, examines the barriers and facilitating elements of peer support implementation for mental health recovery. The team of researchers performed a systematic review of different factors involved in both the success and failure of implementing peer support models, as an alternative to traditional psychiatric care. The results of the study suggest multiple factors which can be considered in order to facilitate the effective implementation of formal peer support networks.

“Peer support is increasingly being adopted around the world, as an approach to transforming mental health towards a recovery orientation. A focus on recovery involves institutional transformation, with more emphasis on shared decision making especially in relation to medication, and different approaches to compulsory care,” write the international team of researchers led by Dr. Nashwa Ibrahim and Dr. Dean Thompson.

Peer support and consumer service-oriented approaches to mental health recovery are on the rise. A growing number of psychiatric survivors, mental health professionals, and concerned individuals are criticizing traditional psychiatry for its imbalance of power between doctor and patient, its coercive interventions, and its failure to take seriously the perspectives of those who are most impacted by its services. One proposed alternative is the peer support model or the consumer service model, which emphasizes non-hierarchical relationships and a sharing of lived experience around emotional distress.

“Peer support promotes person-centred recovery by enabling contact between people with lived experience to foster a sense of connectedness by communicating shared experiences.”

Evidence suggests that peer support models are effective at reducing psychiatric readmission. Additionally, many have argued that peer support models are more relationally sensitive and reciprocal, as well as more closely aligned with human rights than traditional psychiatry.

On the other hand, some have expressed worry that peer support is shifting away from its original progressive orientation into the hands of the medical model and run-of-the-mill psychiatric services. Peer support specialists often engage in paraprofessional work within traditional settings and may provide the same sort of hierarchical services as conventional psychiatry. Moreover, they are not always provided with adequate resources or support, and are sometimes mistreated. In order to improve the situation, it is suggested that organizations should focus on providing resources, training, and assistance to peer support specialists, as well as being clear about their role.

The current study took a closer look at multiple factors involved in successful peer support implementation, as well as barriers and challenges. The researchers collected data from several online databases, eventually identifying 53 relevant studies based on their inclusion criteria. These criteria excluded online-only programs, purely peer-run organizations, informal forms of peer support, and substance abuse populations. Through coding procedures and thematic analysis, the researchers determined different influences on the success and failure of formal peer support implementation. They believe that considering these influences can improve implementation of future peer support efforts.

The identified influences consist of organizational culture, peer support worker (PSW) training, PSW role definition, staff willingness and ability to work with PSWs, resource availability, financial arrangements, support for PSW well-being, PSWs own access to a peer network, PSW’s ability to manage their own well-being, expectations held by PSWs, organizational processes, and research design needs.

Additionally, the researchers identified two further influences: match between PSW and patient, and emotional intensity of the work. The impact of these two influences on implementation was unclear.

Organizational culture was the most frequently identified influence throughout the studies. The researchers discovered that successful peer support implementation often involved organizations with clear goals and a flexible, open-minded orientation prioritizing recovery. In these settings, PSWs were often central figures and were seen to “fit in” to the organization, although PSWs did not necessarily work as employees of the organization. This is contrasted with less successful organizations which were less flexible, focused more on traditional hierarchical relationships and notions of clinical risk, and demonstrated less commitment to the PSWs. The PSWs were frequently co-opted into more traditional psychiatric roles and practices in these settings.

PSW training was the second most frequent identified influence. Successful programs offered ongoing training and support to their PSWs, while less successful programs did not offer supervision and were not able to encourage a sense of competence in their PSWs.

PSW role definition was also important. In successful programs, the role of the PSW was clearly defined, and PSWs were trained in maintaining appropriate boundaries. PSWs in successful programs understood patient confidentiality and were required to share patient information with the organization. In unsuccessful programs, the PSW role was unclear, and there was often ambiguity between staff and PSWs as to the exact role of the PSW. Moreover, PSWs were often unclear about appropriate self-disclosure with patients.

Closely related was the influence of staff willingness and ability to work with PSWs. Successful programs were accepting of PSWs and leadership was supportive of their work. For unsuccessful programs, there was often resistance to hiring PSWs, conflicting expectations between PSWs and staff, and other forms of interpersonal conflict, such as hostility or disrespect shown toward the PSWs.

The other influences were less frequently identified, but of note was PSW access to resources and time, support provided for PSWs to manage their own self-care, and making sure that PSWs had their own support networks outside of the organization.

This study provides an evidence base for the successful implementation of peer support organizational models, with the first systematic review of its kind. Future peer support efforts can apply this information in their own organizational structures to ensure that programs are both effective and committed to human rights and non-coercive, respectful, person-centered forms of recovery.

The researchers conclude:

“Evidence-based approaches are emerging to change organisational culture, including a greater emphasis on supporting strengths, self-management, hope, well-being and more use of new interventions such as positive psychology, recovery colleges and a greater focus on human rights.”

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Ibrahim, N., Thompson, D., Nixdorf, R., Kalha, J., Mpango, R., Moran, G., . . . Slade, M. (2019). A systematic review of influences on implementation of peer support work for adults with mental health problems. Social Psychiatry and Psychiatric Epidemiology. https://doi.org/10.1007/s00127-019-01739-1 (Link)