A review of the literature on peer support in mental health services

Abstract

Although mutual support and self-help groups based on shared experience play a large part in recovery, the employment of peer support workers (PSWs) in mental health services is a recent development. However, peer support has been implemented outside the UK and is showing great promise in facilitating recovery.
This article aims to review the literature on PSWs employed in mental health services to provide a description of the development, impact and challenges presented by the employment of PSWs and to inform implementation in the UK.
An inclusive search of published and grey literature was undertaken to identify all studies of intentional peer support in mental health services. Articles were summarised and findings analysed.
The literature demonstrates that PSWs can lead to a reduction in admissions among those with whom they work. Additionally, associated improvements have been reported on numerous issues that can impact on the lives of people with mental health problems.
PSWs have the potential to drive through recovery-focused changes in services. However, many challenges are involved in the development of peer support. Careful training, supervision and management of all involved are required.

Full text

REVIEW
A review of the literature on peer support in mental health
services
JULIE REPPER
1
& TIM CARTER
2
1
School of Nursing, University of Nottingham, Duncan Macmillan House, Porchester Road,
Nottingham NG3 6AA, UK and
2
Connolly Ward, Peter Hodgkinson Centre, Lincoln County Hospital,
Greetwell Road, Lincoln LN2 5UA, UK
Abstract
Background. Although mutual support and self-help groups based on shared experience play a large
part in recovery, the employment of peer support workers (PSWs) in mental health services is a recent
development. However, peer support has been implemented outside the UK and is showing great
promise in facilitating recovery.
Aims. This article aims to review the literature on PSWs employed in mental health services to
provide a description of the development, impact and challenges presented by the employment of
PSWs and to inform implementation in the UK.
Method. An inclusive search of published and grey literature was undertaken to identify all studies of
intentional peer support in mental health services. Articles were summarised and findings analysed.
Results. The literature demonstrates that PSWs can lead to a reduction in admissions among those
with whom they work. Additionally, associated improvements have been reported on numerous issues
that can impact on the lives of people with mental health problems.
Conclusion. PSWs have the potential to drive through recovery-focused changes in services. However,
many challenges are involved in the development of peer support. Careful training, supervision and
management of all involved are required.
Keywords: Empowerment, mental health, recovery, peer support, service users, social support
Background
There has been exponential growth in the employment of peer support workers (PSWs) in
the US, Australia and New Zealand over the past decade and more recently this expansion
has spread to the UK. A search of the grey literature reveals literally thousands of
descriptions of peer-led and peer-run mental health services around the world. In the US, it
has been reported that services run for and by people and their families with serious mental
health problems now number more than double the traditional, professionally run, mental
health organisations (Goldstrom et al., 2006). In contrast, the paid employment of PSWs
within mental health services has been slower to develop, possibly impeded by negative
assumptions about the abilities of people with mental health problems to support others. It is
Correspondence: Julie Repper, School of Nursing, University of Nottingham, Duncan Macmillan House, Porchester Road,
Nottingham NG3 6AA, UK. Tel: þ0780 195 3188. E-mail: julie.repper@nottingham .ac.uk
Journal of Mental Health,
August 2011; 20(4): 392–411
ISSN 0963-8237 print/ISSN 1360-0567 online Ó2011 Informa UK, Ltd.
DOI: 10.3109/09638237.2011.583947
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only recently, perhaps aided by the promotion of a recovery-focused approach across mental
health services, that the value of peer support in statutory services is becoming recognised.
Davidson et al. (1999), in the first review of the evidence surrounding peer support in
mental health services, describe three broad types of peer support: informal (naturally
occurring) peer support, peers participating in consumer or peer-run programmes and
the employment of consumers/service users as providers of services and supports within
traditional services. A number of reviews of the literature concerned with self-help/mutual
support (Pistrang, Barker, & Humphreys, 2008; Raiff, 1984) and peer-run services (e.g.
Davidson et al., 1999; Humphreys, 1997) have been published. Other reviews have
concerned themselves with all types of service user employment in evaluation, training and
service delivery in mental health (e.g. Simpson & House, 2002). The current review is
primarily concerned with PSWs employed in clinical posts within statutory services.
Aims and objectives
The review aims to draw on published literature to define peer support in statutory services,
to look at the development of specific peer support roles, the characteristics of their
relationships and some of the benefits and challenges reported in the employment of PSWs.
Various terms are used to describe people with lived experience who are employed to
support others who face similar challenges: ‘PSWs’, ‘consumer-survivors’, ‘consumer
providers’, ‘peer educators’, ‘prosumers’ and ‘peer specialists’. For the purpose of clarity,
this article will refer to peer activities as, ‘peer support work (PSW)’, and peers who work
within these initiatives as PSWs.
Method
This review was driven by the pragmatic intention to employ PSWs in local mental health
services. We were therefore interested in clearly defining and distinguishing peer support and in
determining ways in which it could be implemented most effectively. This raised
methodological questions: what type of evidence should be included (i.e. what search and
selection strategy was most appropriate)? How were we defining the intervention (i.e. what
inclusion and exclusion criteria would apply)? Given the breadth of the aims, a pluralistic
approach was adopted to include multiple sources of evidence and types of data. Published
literature in the field consists largely of qualitative studies often with small sample sizes
and descriptive cross-sectional or longitudinal designs. While this may be due to the early stage
of development of the intervention, it may equally be a response to the restrictions imposed by
the process of random assignment in controlled trials. For peer services built on the principle of
inclusion and the development of a supportive, empowering culture, randomised manipulation
may change the peer service being researched (Resnick & Rosenheck, 2008). In addition, since
peer support is relatively innovative and unresearched, the understanding provided by narrative,
personal and qualitative accounts is as valuable as more outcome focused comparative and
quantitative studies. The development of PSW in mental health services raises many questions
and challenges for all concerned, and it is not only whether it makes a difference that is of interest,
but also, in what circumstances, with whom and how that are, as yet uncharted.
Inclusion and exclusion criteria
Articles were included only if
.peers were offering support for people with mental health problems
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.peers were working in statutory or professionally led services and
.articles were written/published between 1995 and 2010
They were excluded if
.peers were working in a consumer-led service
.peers were not offering support to others experiencing mental distress and
.peers were employed to provide training, interviewing or research
.articles were published before 1995
Search strategy
The procedure began with a broad inclusive title search of databases CINHAL, MedLine
and PsycINFO using keywords including: ‘mental health’, ‘consumer’, ‘survivor’, ‘recovery’
and ‘peer support’. Subsequently, the abstracts were screened for reference to ‘peer
support’ and ‘mental health’. The screening process involved reviewing abstracts and
filtering out those not applicable to the aims of the review, primarily through assessing the
abstracts using the inclusion and exclusion criteria. Thirty-eight articles met the inclusion
criteria and were retrieved. These are included in a matrix (see Appendix) The search was
strengthened by identifying relevant review articles and retrieving all additional relevant
articles cited in reference lists. In addition, relevant websites were consulted.
Data analysis
The challenge of including all sources of information in one area lies in the sheer volume of
articles generated. A systematic approach was therefore undertaken (a) to identify those that
met the inclusion criteria and (b) to organise selected articles and extract key data. All
selected articles were entered into a matrix describing study design, intervention and
findings (see Appendix), this allowed for systematic critical analysis based on the nature of
the article (qualitative, quantitative and comparative/trial). Findings were then categorised
into a framework of themes reflecting the areas covered, these provide the structure of the
review.
Findings
Definition of peer support
At its core, the peer support ‘approach’ assumes that people who have similar experiences
can better relate and can consequently offer more authentic empathy and validation
(Mead & Macneil, 2004, reflecting on peer support). Peer support is generally described as
promoting a wellness model that focuses on strengths and recovery: the positive aspects of
people and their ability to function effectively and supportively, rather than an illness model,
which places more emphasis on symptoms and problems of individuals (Carter, 2000).
Mead (2003) offers a short and all encompassing definition of peer support as, ‘a system of
giving and receiving help founded on key principles of respect, shared responsibility and mutual
agreement of what is helpful’.
In both mutual support groups and consumer-run programmes, the relationships that
peers have with each other are valued for their reciprocity; they give an opportunity for
sharing experiences, both giving and receiving support and for building up a mutual and
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synergistic understanding that benefits both parties (Mead, Hilton, & Curtis, 2001). In
contrast, where peers are employed to provide support in services, the peer employed in the
support role is generally considered to be further along their road to recovery (Davidson,
Chinman, Sells, & Rowe, 2006). Peers use their own experience of overcoming mental
distress to support others who are currently in crisis or struggling. This shift in emphasis
from reciprocal relationship to a less symmetrical relationship of ‘giver’ and ‘receiver’ of care
appears to underpin the differing role of peer support in naturally occurring and mutual
support groups and PSWs employed in mental health systems (Davidson et al., 1999). It
appears therefore that the degree of reciprocity expected from PSWs varies depending on the
approach being adopted. Nevertheless, it appears that whatever be the setting, reciprocity is
integral to the process of ‘peer–to-peer support’ as distinct from ‘expert worker support’.
This is not to say that peer support is not an ‘expert role’, a point recognised in the training
materials used by META, Arizona: ‘Peer support is about being an expert at not being an
expert and that takes a lot of expertise’. Peer support could therefore be defined as: ‘social
emotional support, frequently coupled with instrumental support, that is mutually offered or
provided by persons having a mental health condition to others sharing a similar mental
health condition to bring about a desired social or personal change’ (Solomon, 2004,
p. 393).
Effectiveness of peer support
Seven randomised control trials (RCTs) met the inclusion criteria for this review (Clarke
et al., 2000; Davidson et al., 2004; Dummont & Jones, 2002; O’Donnell, Parker, &
Proberts, 1999; Rogers et al., 2007; Sells, Davidson, Jewell, Falzer, & Rowe, 2006;
Solomon & Draine, 1995). These describe a range of PSW interventions (peers
employed in traditional case management roles and peers employed in new roles
explicitly to use their experience; peers employed as additional to members of the team
and peers employed instead of traditional members of the team; peers in community
services and peers in inpatient and outpatient services), they present inconsistent findings
and use varied outcome measures. Therefore, for the purpose of this review, a wider
evidence base was used, including follow-up studies and naturalistic comparison studies.
The aggregated results paint a more complete picture of the impact of the employment
of PSWs.
Benefits for consumers
Admission rates and community tenure. RCTs comparing the employment of PSWs with care
as usual or other case management conditions report either improved outcomes or no
change. Solomon and Draine (1995) in a 2-year outcome study reported no differences in
the impact of care provided by peers and care as usual on hospital admission rates or length
of stay. Similarly, O’Donnell et al. (1999) reported no significant difference in admission
rates when comparing three case management conditions; standard case management,
client-focused case management and client-focused case management with the addition of
peer support. It seems prudent to mention that a result of no difference demonstrates that
people in recovery are able to offer support that maintains admission rates (relapse rates) at a
comparable level to professionally trained staff. Interestingly, however, Clarke et al. (2000)
found that when assigned to either all PSW or all non-consumer community teams that
those under the care of PSWs tend to have longer community tenure before their first
psychiatric hospitalisation.
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The majority of the wider evidence on admission rates report positive results, suggesting
that people engaging in peer support tend to show reduced admission rates and longer
community tenure. Chinman, Weingarten, Stayner, and Davidson (2001) compared a peer
support outpatient programme with traditional care and found a 50% reduction in
rehospitalisations compared to the general outpatient population and only 15% of the
outpatients with peer support were rehospitalised in its first year of operation. Similarly,
Forchuk, Martin, Chan, and Jensen (2005) in an evaluation of a model of discharge
involving peer support reported that peer support used as part of the discharge process
significantly reduces readmission rates and increases discharge rates. In a longitudinal
comparison group study, Min, Whitecraft, Rothband, and Salzer (2007) found that
consumers involved in a peer support programme demonstrated longer community tenure
and had significantly less rehospitalisations over a 3-year period. Finally, in an evaluation of
an Australian mental health peer support service providing hospital avoidance and early
discharge support to consumers of adult mental health services, Lawn, Smith, and Hunter
(2008) found in the first 3 months of operation, more than 300 bed days were saved when
peers were employed as supporters for people at this stage of their recovery.
Empowerment. A raised empowerment score has been reported in several studies of peer
support (Corrigan, 2006; Dummont & Jones, 2002; Resnick & Rosenheck, 2008).
Davidson et al. (1999) attributed improvements in empowerment to the new ways of the
thinking and behaving that occur when engaging in reciprocal peer support relationships
(PSR).
In a qualitative study of consumer views, Ochocka, Nelson, Janzen, and Trainor (2006)
reported that participation in peer support as both a provider and recipient resulted in an
increased sense of independence and empowerment. Specifically, consistent engagement in
peer support increased stability in work, education and training, which will allow for a sense of
empowerment. Furthermore, participants reported gaining control of their symptoms/
problems by researching their illness independently, and, consequently becoming more
involved in their treatment, thereby moving away from the traditional role of ‘mental patient’.
Related to this, several studies state that peer support can improves self-esteem and
confidence (Davidson et al., 1999; Salzer & Mental Health Association of Southeastern
Pennsylvania Best Practices Team, 2002). This has been attributed to the mutual
development of solutions, the shared exploration of ‘big’ feelings (Mead, 2004) and the
normalisation of emotional responses that are often discouraged and seen as crises in
traditional health care.
Social support and social functioning. Social isolation is often one of the most significant
challenges faced by individuals with mental health problems. Other than superficial social
contacts with sales assistants or cashiers, many people have little social contact that does not
involve mental health staff (Davidson et al., 2004).
Mead et al. (2001) assert that engagement in a PSR allows participants to create
relationships and practice a new identity (rather than that of mental patient) in a safe and
supportive environment. This is supported by Yanos, Primavera, and Knight (2001) in a
cross-sectional study where individuals involved in consumer-run services had improved
social functioning compared to individuals involved in traditional mental health services.
One explanation for such a change is that when engaging in peer support, consumers are
exposed to differing perspectives and successful role models who may share problem-solving
and coping skills and thereby improve social functioning (Kurtz, 1990).
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In a longitudinal study, Nelson, Ochocka, Janzen, and Trainor (2006) reported that at
3-year follow-up, consumers continuously involved in peer support programmes scored
significantly higher than comparison groups on a measure of ‘community integration’, which
was assessed using the meaningful activity scale (Maton, 1990). This finding is consistent
with a previous qualitative study in which members of peer support initiatives in Ontario
reported enhanced community integration (Trainor, Shepherd, Boydell, Leff, & Crawford,
1997).
Ochocka et al. (2006) reported that at 9 and 18 months follow-up that consumers
receiving peer support reported more friends and more social support not only within the
initiatives they were involved with, but also from other settings and relationships compared
with participants not receiving peer support. Similarly, Forchuk et al. (2005) found that
participants who received peer support demonstrated improved social support, enhanced
social skills and better social functioning.
Empathy and acceptance. An important aspect of peer support is the sense of acceptance and
real empathy that the peer gains through a sharing relationship (Davidson et al., 1999). In a
qualitative study exploring the PSR within mental health, Coatsworth-Puspokey, Forchuk,
and Ward Griffin (2006) found that consumers believed that the experiential knowledge
provided by PSWs created a ‘comradery’ and a ‘bond’, which made them feel that their
challenges were better understood.
Similarly, Paulson et al. (1999) demonstrated through qualitative data that there were
significant differences in the focus of consumer and non-consumer providers of assertive
community treatment (ACT). Specifically, the consumer providers emphasised ‘being’
with the client, whereas the non-consumer providers emphasised the importance of
‘doing’ tasks. Moreover, both sets of providers asserted that it was the consumer providers
better understanding of what the patient was going through, which was their greatest
strength.
Finally, in an RCT comparing the outcomes of people receiving peer support with
traditional care, Sells et al. (2006) demonstrated that individuals receiving services from
PSWs reported having greater feelings of being accepted, understood and liked
compared with individuals receiving traditional care by mental health providers after 6
months.
Reducing stigma. Ochocka et al. (2006) found that participants involved in peer support were
less likely to identify stigma as an obstacle for getting work and were more likely to have
employment. This makes sense as peers embody the possibility of acceptance and success,
so that they can challenge the barriers created by self-stigmatisation: anticipation of
discrimination. Indeed, Mowbray, Moxley, and Collins (1998) reported that PSWs
recognised that through engaging in peer support they were altering attitudes to mental
illness and as such breaking down the stigma and fostering hope in the peers they were
working with.
Hope. One of the essential benefits gained from peer support is the sense of hope – a belief
in a better future – created through meeting people who are recovering, people who have
found ways through their difficulties and challenges (Davidson et al., 2006). The inspiration
provided by successful role models is hard to overstate. So many people who have been
supported by peers describe their surprise when meeting others who describe similar
experiences (cf. Ratzliff et al., 2006).
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Benefits for PSWs
Aiding continuing recovery. Giving peer support, like receiving it, results in increased sense of
self-esteem. Salzer and Shear (2002) in a qualitative study of 14 interviews with PSWs
showed that over half of respondents indicated that they benefited from the feeling of
being appreciated and felt their confidence and self-esteem increased and further facilitated
their recovery. Similarly, Ratzlaff, McDiarmid, Marty, and Rapp (2006) found that the self-
esteem of PSWs improved.
Interestingly, Bracke, Christiaens, and Verhaeghe’s (2008) results showed that providing
peer support is more beneficial than receiving it in terms of self-esteem, empowerment, etc.
This could be due to the importance of employment and the identity shift from consumer to
provider, and therefore becoming a ‘valued and contributing citizen’ (Hutchinson et al.,
2006).
Mowbray et al. (1998) interviewed 11 PSWs, 12 months after their employment ended.
The PSWs identified money as the primary benefit of the role, followed by the structure of
the job, the supervision provided and the safety of a job in which they could disclose their
prior difficulties. Respondents felt that the role had allowed them to gain skills, personal
growth and self-esteem through doing something worthwhile. Salzer and Shear (2002) also
reported that PSWs continued their own recovery by the way of skill development and
personal discovery.
Challenging issues in peer support
Boundaries. PSWs may be viewed more like friends than non-peer case managers or clinical
staff, especially since they are not only allowed, but also are in fact expected, to disclose
personal information and to share intimate stories from their own lives. Mowbray et al.
(1998) found that there were some difficulties when PSR took on more friendship roles.
Particular to the US context, this brought into question what was considered reimbursable
or billable use of time. In the Nottingham project (Coleman & Campbell, 2009), questions
arose about how close a PSW should get to the peers with whom they worked – particularly
when they had often become friends while using services; socialising might involve drinking,
dancing, travelling home together – and then it could be difficult to resume a more
therapeutic relationship within a work context. However, Mead et al. (2001) suggested that
egalitarian relationships provide an opportunity for both peers and PSWs to grow and create
meaningful and reciprocal relationships; boundaries should be flexible and individually
governed as to avoid perpetuating the power structure of traditional, formal professional
relationships. Furthermore, in a series of interviews with PSWs, Macneil and Mead (2003)
found that boundaries, varied from individual to individual and that the PSWs evolved
professionally as they learned to reflect upon and articulate their limits.
Power. Mead et al. (2001) pointed out that formalising peer support by offering payment,
training and titles will inevitably lead to power differences – even if these are minimised.
Furthermore, if these power differences go unrecognised or are not worked through then it
could lead to peers being less than honest and saying or not saying things through fear of
retribution.
Additionally, many PSWs may have to work with professionals who have treated them in
the past (Fisk, Rowe, Brooks, & Gildersleeve, 2000). This could challenge the possibility of
respectful equal relationship within the team as staff may fail to treat them as professional
equals (Mowbray et al., 1998) or continue to view them as ‘patients’ (Davidson et al., 1999).
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An example of which was reported by Mowbray et al. (1998) who stated that PSWs
experienced feelings on the one hand part on the team, however, always of lower status than
the other professionals. These attitudes/beliefs are, in actuality, examples of discrimination
and, as such, agencies hiring PSWs that do not proactively address this issue will in all
likelihood fail. However, it is important to point that although discriminatory beliefs about
PSWs ability exist, some research suggests that mental health professionals do view
consumer-delivered services helpful [e.g. Hardiman (2007) found that 84% of professionals
surveyed believed that service users could provide effective services], but less helpful than
professionally delivered services. Interestingly, Dixon, Hackman, and Lehman (1997)
examined attitudes towards PSWs comparing staff members who worked with ‘consumer
advocates’ with attitudes of staff members who did not. They found significant differences in
5 of the 30 items examining attitudes and on each of these staff working with PSWs scored
more positively. This suggests that PSWs are their own best advocates – changing attitudes
through experience of working together. With this in mind, a suggestion presented by the
author to address the discrimination issues would be to invite professionals to PSW training
courses, they could therefore meet the PSWs and discuss with them the nature of their role
and how they fit into the service and so on.
Stress for PSWs. Chinman, Young, Hassell, and Davidson (2006) found that providers were
concerned that PSWs might be exposed to stress that could result in a reoccurrence of
symptoms that may result in rehospitalisation. This would be detrimental to the PSW and
the people with whom the PSW was working – due to the effect it may have on the sense of
hope instilled by the perceived recovery of the PSW. Paulson et al. (1999), comparing
differences in practices of consumer and non-consumer providers, found that the biggest
weakness of the non-consumer teams was the lack of workforce stability due to relapse.
Paulson et al. (1999) go on to suggest that an adjustment of staffing patterns is required to
account for PSWs greater vulnerability. Yuen and Fossey (2003) found that PSWs
emphasise that they need to monitor their own workloads and demands that placed on them,
they also need to feel able to take time out when required. McLean, Biggs, Whitehead, Pratt,
and Maxwell (2009) also reported that several of the 11 PSWs in the Scottish pilot study had
experienced readmissions to hospitals since starting in the role. These admissions were not
in the same service that the PSW was working in and that was believed to be a key factor
in preserving relationships with colleagues and peers. Furthermore, the PSWs used the
experience to enhance the ways in which they could apply their experience to their role.
PSWs reflecting on the benefits and limitations of their employment (Mowbray et al.,
1998) stated that some of the people who they were assigned to work with, created stress
because they directly affected the PSWs ability to do their job. For example, peers who were
‘uncooperative’, ‘unmotivated’, did not turn up for appointments, peers who were very
troubled or in major debt, created feelings of frustration, disappointment, failure, fear and
guilt. PSWs who had little training were shocked at the levels of disturbance in some clients,
some wanted to separate themselves from the people they worked with; some did not feel
able to admit their feelings to the staff team; some found it hard to work out what they were
supposed to do. This clearly demonstrates the need for support and training.
Accountability. The PSWs in Chinman et al’s (2006) study also voiced worries about
accountability, especially relating to risk. Mead and Macneil’s (2004) talk of a shared
responsibility between PSW and peer that moves away from risk assessments towards
mutually responsible relationships. This is increasingly referred to as relational risk
management or negotiated safety planning wherein control, as far as possible, remains with
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the person who appears to be at risk. They are asked what can be done to help them to feel
safe; what they would like, where they want to be. The PSW might suggest alternatives that
they themselves have found useful or that others have utilised, but ultimately the decision
lies with the individual about what will make them feel most comfortable.
Maintaining PSWs’ distinct role. It appears to be the case that peer support offers distinctive
features that are not currently provided by professional workers: support based on
experience rather than professional expertise, more reciprocal relationships and more
egalitarian conversations. Questions remain about whether it is possible for professionals
who have personal experience of mental health problems to offer this kind of support.
Solomon (2004) states that, ‘consumer provided services need to remain true to themselves
and not to take on characteristics of traditional mental health services’ (p. 8). However, there
is the risk of PSWs becoming socialised into the ‘usual ways of working’ or following
professional role models in a bid for respect. This is particularly likely when professionals do
not value the PSWs’ role (see challenges above). Mead and Macneil (2004) assert that the
language of mental health plays a crucial role in separating the peer support roles from
traditional mental health care. If PSWs feel the need to talk about peers in medical terms to
‘fit in’ with the team, they neglect the unique personal experience of the peer that they are in
a position to capture. Ultimately, this undermines the potential of peer support. One way of
maintaining distinctiveness and continually maintaining awareness of the peer relationship is
through peer-led training and peer supervision, provided by a service user led organisation
and group supervision to share insights, coping strategies and experiences.
Discussion and conclusion
This review has examined the literature and research that describes PSW in professionally
led services. In doing so, it has reported on some of the benefits and challenges presented in
the employment of PSWs in statutory services as well as attempting to define peer support in
statutory services.
Although scarce in the literature, the few experimental trials show that at the very least,
PSWs do not make any difference to mental health outcomes of people using services. When
a broader range of studies are taken into account, the benefits of PSW become more
apparent. What PSWs appear to be able to do more successfully than professionally qualified
staff is promote hope and belief in the possibility of recovery; empowerment and increased
self-esteem, self-efficacy and self-management of difficulties and social inclusion, engage-
ment and increased social networks. It is just these outcomes that people with lived
experience have associated with their own recovery; indeed these have been proposed as the
central tenets of recovery: hope, control/agency and opportunity (Repper & Perkins, 2003;
Shepherd, Boardman, & Slade, 2008). In addition, employment as a PSW brings benefits
for the PSWs themselves in every reported evaluation. The experience of valued work in a
supported context, permission to disclose mental health problems – which are positively
valued – all add to self-esteem, confidence and personal recovery. Employment as a peer
support working also increases chances of further employment and continued recovery.
The literature also presents a number of common challenges in the employment of PSWs,
notably, where PSWs accountability begins and ends, where the boundaries in PSW
relationships belong, power issues, both within the peer relationships and with other
professionals and the stress of the role on the PSW. Peer support is, however, in its infancy
and as such challenges in its introduction are inevitable, the amalgamation of the challenges
offered in the current review provide invaluable scope for future research opportunities.
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The current study’s limitations include the lack of a framework to critically analyse the
included articles. Furthermore, due to the wide scoping aims of the review, the findings had
to be on a more general level, although this allowed for a wide variety of themes to be
covered, each theme in itsself (effectiveness and challenges) could be reviewed exclusively in
detail.
The authors propose that future research concentrates on establishing a robust evidence
base for the effectiveness of peer support in mental health services in the UK, with a focus on
random controlled trials, where appropriate. Furthermore, attention is required into
whether PSWs are employed in addition to the team they are working with or included in the
team as a part of the numbers/staff rotation. This would provide invaluable insight into how
the peer support movement is progressing.
Declaration of interest: The authors report no conflicts of interest. The author(s) alone
(is)are responsible for the content and writing of the paper.
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Appendix
Study Nature of intervention Study design (inc sample) Outcomes/results
RCT
Clarke et al. (2000) Conditions were compared on psychiatric
hospitalisation, emergency room visit,
arrest and homelessness within the 2-year
study period between both teams and with
community care as usual
Randomised comparison of two ACT
experimental conditions (staffed by
consumers or non-consumers) and usual
community care. Sample: 163 subjects
(60.7% male, 39.3% female; mean age,
36.5) all met the Oregon definition of
chronically mentally ill
First psychiatric hospitalisation occurred earlier
on an average among people receiving
non-consumer ACT than with consumer
ACT subjects
Davidson et al.
(2004)
Comparison of outcomes of symptoms,
well-being, self-esteem, social functioning,
employment and social support
Comparison of outcomes on three social
support conditions: (1) matched with peer
volunteer and given an allowance per
month for recreational activities,
(2) matched with non-peer and given same
allowance per month for recreational
activities or (3) allowance only with no
matched volunteer. Sample: 260 adults
receiving outpatient care at community
mental health centres with a diagnosis of
a serious mental illness
No significant differences were found between
the conditions only when frequency of
meetings with volunteer were taken into
account. In condition (1) improvements were
seen only when participants did not meet up
with their peer. Whereas in condition
(2) participants improved when meeting with
their partners. Implications are discussed
Dummont and
Jones (2002)
Determining if people with access to a peer-
run crisis hostel would experience greater
recovery and increased empowerment,
lower use of crisis services and reduced
total mental health treatment costs when
compared to persons without access
265 Participants with a severe and enduring
mental illness. Randomised, experimental
design with assessment at baseline, 6
months and 12 months
At 12 months, the experimental group had better
healing outcomes, greater levels of
empowerment, shorter hospital stays and less
hospital admissions
O’Donnell et al.
(1999)
Compared outcomes between the three
conditions of functioning, disability,
quality of life, burden of care, service
satisfaction, number of hospitalisations,
crisis visits and compliance with treatment
Comparison of three case management
conditions: (1) standard case
management, (2) client-focused case
management and (3) client-focused case
management with the addition of peer
support. Sample: 119 service randomly
allocated to one of three conditions
No significant differences found between the
three conditions
(continued)
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Appendix (Continued).
Study Nature of intervention Study design (inc sample) Outcomes/results
Rogers et al.
(2007)
Examined the effects of consumer-operated
service programmes (COSPs) on various
aspects of empowerment within the
context of a multisite, federally funded,
randomised clinical trial of COSPs
Sample: 1827 Individuals from traditional
mental health providers. Participants were
randomised to either (1) the experimental
(attendance at the COSP under study in
addition to usual traditional mental health
services) or (2) control group (usual
traditional mental health services only)
Individuals who received the consumer-operated
services perceived higher levels of personal
empowerment than those in the control
intervention. However, results were modest
Solomon and
Draine (1995)
Looked at: symptoms, social support,
hospitalisations, quality of life, satisfaction
and working alliance
RCT; comparison of two case management
teams comprised of (1) non-peers and
(2) peers. Sample: 96 service users
No significant differences found between
conditions
Sells et al. (2006) Compared the quality of treatment
relationships and engagement in
peer-based and regular case management
Sample: 137 People with severe mental
illness. Longitudinal randomised clinical
trial with two levels of case management
intervention (peer and regular) and two
interviews (6 and 12 months)
Participants perceived higher positive regard,
understanding and acceptance from peer
providers rather than from regular providers
at 6 months only. No differences observed at
12 months
Quantitative research
Corrigan (2006) Cross-sectional design comparing measures
of recovery and empowerment on people
having received peer support and those
that have not. Sample: data obtained from
1824 service users with a DSM-IV
diagnosis during a baseline assessment of a
consumer-operated services project
To examine the relationship between
receiving peer support and measures of
recovery and empowerment
Participation in peer support was associated with
increased levels of empowerment as measured
by an empowerment scale
Forchuk et al.
(2005)
Description and evaluation of a model of
discharge; transitional discharge, which
involves peer support
Peer support used as part of discharge process
reduces readmission rates and increases
discharge rates
Hardiman (2007) Mailed survey, self-administered
questionnaire and random sample; 335
mental health providers
Knowledge of consumer-run programmes,
attitude towards consumer-run
programmes and referral rates to
consumer-run programmes
53% of respondents knew about local
consumer-run services, 45% of respondents
had referred to consumer-run services and
94% respondents stated that trained
professionals provide ‘the best’ mental health
services
(continued)
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Appendix (Continued).
Study Nature of intervention Study design (inc sample) Outcomes/results
Hodges et al.
(2003)
Sample: 311 service users who used
professional mental health services.
151 (49%) of which also used self-help
services. Multiple regression analysis of
scores on a client satisfaction scale
(CSQ 8)
To test the hypothesis that users of mental
health self-help services would be more
satisfied with professional mental health
services than clients who did not use self-
help services
Multiple regression analysis of scores shows that
being involved in self-help services encourages
satisfaction with professional mental health
services
Hutchinson et al.
(2006)
66 Individuals participated in an evaluation of
a 60-hour, 5-week long peer training
programme. Participants were assessed
prior to and after the training on scales to
measure recovery, empowerment and self-
concept
Examination of the feasibility of a structured
peer provider training programme and its
effect on peer providers with respect to
their own personal and vocational recovery
Participants experienced gains in perceived
empowerment, attitudes towards recovery
and self-concept. Trainees went on to obtain
peer provider positions within the mental
health agency in which they received the
training and 89% of those trained retained
employment at 12 months
Lawn et al. (2008) Evaluation of the first 3 months of operation
of an Australian peer support service
providing hospital avoidance and early
discharge support
Key indicators: Bed days saved, readmission
rates
Three hundred bed days saved. Peer support
suggested to be highly effective as an adjunct
to mainstream services
Min et al. (2007) Longitudinal, comparison study. Sample:
106 individuals participating in the peer
support programme
A comparison on 3-year rehospitalisation
patterns of people participating in a peer
support programme and matched
individuals who had not been involved
with the service
Peer support programme participants show
longer community tenure. Over the 3 years,
73% in comparison group rehospitalised
compared to 62% of those involved in the
peer support programme
Nelson et al.
(2006)
Longitudinal comparison study of (1) active
participants in consumer/survivor
initiatives (CSIs), (2) non-active
participants. Sample: CSI participants
(n¼61), non-active participants (n¼57)
Social support, community integration,
personal empowerment, quality of life,
symptom distress, days of hospitalisation
and use of emergency services
At 9 months, significant reduction in use of
emergency room services for active
participants compared to non-active. At 18
months, significant improvement in social
support, quality of life and reduction in days
in hospital for active participants. No
significant changes on these outcomes for
non-active participants
(continued)
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Appendix (Continued).
Study Nature of intervention Study design (inc sample) Outcomes/results
Nelson et al.
(2007)
Longitudinal comparison study of: (1) active
participants in CSIs at 36 month follow-up
(n¼25), (2) active participants at 9 and 18
month follow-up but not at 36 months
(n¼35) and (3) non-active participants
(comparison group) (n¼42)
Social support, community integration,
personal empowerment, quality of life,
symptom distress, days of hospitalisation,
use of emergency services and
instrumental role involvement
The active participants at 36 month follow-up
scored significantly higher on community
integration, quality of life and instrumental
role involvement and significantly lower levels
of symptom distress
Paulson et al.
(1999)
Comparison of practice of consumer-run
ACT and non-consumer run ACT. Teams
were in separate offices but shared a
psychiatrist, clinical director and nurse
practitioner. Each team comprised five
staff and had caseloads averaging five per
staff member
Practice assessed through daily activity log,
case manager interviews at 6, 12 and
18 months and observations after 8 and
16 months
Practice patterns reflect normal expectations of
assertive outreach model. Neither significant
differences in type, amount or location of
activity, nor in levels of consumer
participation in care. But consumers saw
more clients at office (boundaries less
distinctive) and consumer service was closely
aligned to recovery with relationships and
clients’ choice paramount. Conclude that
cultures differed: being vs doing
Resnick and
Rosenheck
(2008)
Peer education and support vs standard care
on measures of recovery orientation,
confidence and empowerment, symptoms,
functioning, quality of life and
engagement. PSW was support by and for
veterans with professional assistance only
as requested by participants
Participants were recruited in two
consecutive cohorts between 2002 and
2006, one before the implementation of
the Vet-to-Vet (peer support) programme
in June 2002 (cohort 1; n¼78) and one
after (cohort 2; n¼218). Follow-up
interviews were conducted at 1, 3 and 9
months, respectively
Significant differences in improvement for
Vet-to-Vet group on empowerment,
confidence and functioning
Schmidt, Gill,
Pratt, and
Solomon (2008)
Consumer provider on a conventional case
management team serving people with a
serious mental illness improves service
delivery and client outcomes when
compared to teams staffed only by
non-consumers
Retrospective co-hort study with random
assignment of consumers of mental health
services to community mental health
teams. The study compared client
outcome measures and service delivery
with teams staffed by non-consumers
Overall results show that consumer providers
with significant life experience, but limited
post-secondary education, can be effective
members of conventional case management
teams that produce comparable outcomes to
teams comprised exclusively of
non-consumer, professionally trained staff
(continued)
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Appendix (Continued).
Study Nature of intervention Study design (inc sample) Outcomes/results
Solomon and
Draine (1996)
Determined whether a team of mental health
service consumers delivered intensive case
management services differently than a
team of non-consumer case managers
Sample: 96 people with mental health
problems randomly assigned to consumer
or non-consumer case managements
Consumer case managers delivered more
services face-to-face with the client and fewer
services in the office and in interactions with
family members or other mental health service
providers
Verhaeghe,
Bracke, and
Bruynooghe
(2008)
Structured questionnaire. Sample: 595
clients at rehabilitation centres
Self-esteem and stigmatisation Peer support associated with less stigmatisation.
However, only with clients with fewer
stigmatisation experiences
Yanos et al. (2001) 60 Participants with past or present
psychiatric diagnosis
Recruitment from a mental health centre and
two consumer-run programmes to
determine if involvement in consumer-run
services is positively associated with
recovery
Participants in consumer-run programmes had
better social functioning than those in
traditional mental health services
Qualitative research
Bracke et al.
(2008)
The effects of the reciprocity of peer support
on self-esteem and self-efficacy are
explored in the peer groups of clients of
day-activity programmes of rehabilitation
centres
A survey using structured interviews to
collect data from clients at rehabilitation
centres providing day-activity programmes
for people with chronic mental health
problems in Flanders (Belgium) Sample:
628 (396 male, 232 female, mean
age ¼44) users of vocational and
psychiatric rehabilitation centres (n¼51)
Providing peer support is more beneficial than
receiving it. One conclusion is that the net
beneficial effects of receiving support from
peers are overestimated. Support providers
are also more willing to seek support from
others and vice versa
Chinman et al.
(2006)
Focus groups and interviews used to assess the
similarity and differences in beliefs towards
peer support services from patients,
providers and administrators. Also
strategies discussed to overcome potential
challenges of peer support services
Surveys, interviews and focus groups.
Sample: 110 Administrators, patients and
providers at three veteran administration
clinics in Southern California
Numerous concerns from providers about PSWs
competence and vulnerability. Number of
strategies discussed to overcome potential
barriers to peer support implementation
Coatsworth-
Puspoky et al.
(2006)
To explore and describe the PSR Ethonursing, interviews. Sample: 14 service
users who had previously received support
in PSR
PSRs develop or deteriorate in three overlapping
phases
(continued)
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Appendix (Continued).
Study Nature of intervention Study design (inc sample) Outcomes/results
Dixon et al. (1997) Semi-structured interviews and
questionnaires. Sample: Staff in assertive
community teams who (1) worked with
consumer advocates and (2) didn’t work
with consumer advocates
Attitudes of staff towards service users Staff who had experience of working with
consumer advocates had a more positive
attitude towards service users
Gates and Akabas
(2007)
This study informs new strategies that
promote integration of peer providers into
the staff of social service agencies
Executive directors, human resource
managers, supervisors and co-workers at
27 agencies in New York city were
interviewed in-depth. Focus groups with
peers were conducted
Respondents identified attitudes towards
recovery, role conflict and confusion,
lack of policies and practices
around confidentiality, poorly defined
job structure and lack of support as
problems that undermined integration.
Strategies to overcome these issues are
discussed
Janzen, Nelson,
Trainor, and
Ochocka (2006)
System-level findings reported on: public
education, political impacts, community
planning and collaboration impacts
Quantitative and qualitative report on system-
level findings of a longitudinal study of
CSIs
Qualitative data suggests a number of
perceived system-level outcomes. Also
that the staff and members of CSIs
participated actively in system-level
activities
Leung and De
Sousa (2002)
Interviews with stakeholders currently
delivering or having had experience
with peer support services to give
direction to the Canadian mental health
association
30-minute interviews. Sample: 15
stakeholders (consumers, consumer
groups and agencies)
Conclusions made included that peer support
offered adjunct to mainstream services will
contribute to fulfilment and self-actualization
Macneil and Mead
(2003)
Share findings that begin to identify fidelity
standards of peer support
Report on ethnographic evaluation study of a
peer-run crisis service
Peer support promotes critical learning, provides
a sense of community, provides flexibility of
support and there is a sense of mutual
responsibility in the PSR
Mowbray et al.
(1998)
PSWs were trained and provided with paid
employment and supervision. They
recognised advantages of non-stigmatising
environment and the skills learnt on the
job
Interviews with PSWs employed on the
WINS (work incentive and needs study)
for people with substance misuse problems
12 months after employment ended.
Sample size (n¼11, 6 males and 5
females)
Benefits: source of income, rewards of work,
transferable skills like coping with the routine
of work, skills in getting work, assertiveness
skills and confidence, personal growth –
patience, anger management, normalising
preparation for other employment and
Friendship network. Negatives: Could be
dtd
(continued)
Peer support in mental health services 409
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Appendix (Continued).
Study Nature of intervention Study design (inc sample) Outcomes/results
difficult working with people who would not
help themselves; some of the clients did not
want to engage, which was frustrating. Tough
job, some were disappointed with their own
performance, some always felt slightly
unprepared or unsupported
Mowbray et al.
(1996)
Examination of the issues created by
employing consumers as peer support
specialists for the project. Roles and
benefits of these positions are analysed
Data evaluated from a CSP-funded research
demonstration project designed to expand
vocational services offered by case
management teams serving people with
serious mental illness
Implications for consumer role definition,
supports for role effectiveness and the
structuring of these types of positions are
discussed
Salem, Reischl,
Gallacher, and
Randall (2000)
Identifying the role of referent power and
expert power with schizophrenia
anonymous (SA) members, SA leaders
and with mental health professionals
Sample: 156 Users of SA survey Participants reported higher levels of expert
power for mental health professionals and
higher levels of referent power with SA
members
Salzer and Shear
(2002)
Systematically examination of consumer–
provider benefits
Sample: 14 Peer providers from friends
connections, a peer-support programme
for persons with recurring mental health
and substance use disorder interviews
Responses indicate that peer providers benefit
from their roles as helpers, a finding consistent
with the helper-therapy principle. Implications
for research and policy are discussed
Trainor et al.
(1997)
The impact of consumer/survivor
development initiative (CSDI)
membership on the use of mental health
services was examined
Over 600 consumers from the CSDI of
Ontario, Canada
CSDI members used a fewer mental health services,
noted an increase in community involvement
and contacts, found consumer/survivor
organisations to be more helpful than traditional
mental health services and found other
consumer/survivors as individuals to be more
helpful professionals with mental health issues
Yuen and Fossey
(2003)
Identifying the rewards and challenges of
working as a PSW
Purposeful sampling; three PSWs interviews Analysis of participants’ views identified eight
themes: (1) wanting purposeful activity,
(2) the importance of work, (3) rewards of
helping others, (4) re-establishing social
networks, (5) gaining a sense of belonging,
(6) experiencing teamwork, (7) challenges of
working and (8) maintaining well-being
(continued)
410 J. Repper & T. Carter
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Appendix (Continued).
Study Nature of intervention Study design (inc sample) Outcomes/results
Literature/systematic reviews
Davidson et al.
(2006)
Review of four RCTs on peer support All RCTs demonstrated very few differences
between conventional care and care provided
by PSWs. It is suggested that peer support
requires further exploration and evaluation if
it is to be considered as a form of mental
health service provision
Davidson et al.
(1999)
Literature review on peer support
Kurtz (1990) Review of self-help research
Nelson et al.
(2006)
Literature review on CSIs
Simpson and
House (2002)
Systematic review
Woodhouse and
Vincent (2006)
Literature review
Peer support in mental health services 411
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