Early intervention in psychosis (EIP) services provide treatment to those experiencing a first episode of psychosis. Although functional recovery in first episode of psychosis is considered crucial, service users do not always reach functional recovery despite clinical remission (Lieberman et al., 1993). Service users also experience self-stigma due to their symptoms (Payne et al., 2006; Sartorius & Aichenberger, 2005), which is associated with decreased self-esteem and hope (Yanos et al., 2008), social support and quality of life (Livingston & Boyd, 2010). By understanding how to best address self-stigma, contributions to develop solutions improving functional recovery in first episode of psychosis may be possible.
The National Institute for Health and Care Excellence (NICE, 2014) recommends peer support in EIP services. Peer support can be defined as those with lived experience of a similar mental health difficulty providing support for service users, empathising on hope and empowerment (Schutt & Rogers, 2009). This includes application of experiential knowledge, connection to community, relationship building, choice and control, and mutuality and reciprocity (Gillard et al., 2017).
Frequent peer support may kill two birds with one stone: benefiting service users regarding improved social support, increased quality of life and self-efficacy (Castelein et al., 2008; Mahlke et al., 2017), and benefitting peer support workers by improving their self-esteem and wellbeing (Bracke et al., 2008). Peer support can also challenge organisational structures and stereotypes, and reduce discrimination (Faulkner & Basset, 2012; Pyle et al., 2018; White et al., 2017).
There is limited understanding of the mechanisms by which peer support may cause change (Pitt et al., 2013; Llyod-Evans et al., 2014), and how peer support workers can be best supported in EIP. Thus, Nguyen et al. (2021) explored peer support workers’ experiences of working within early intervention in psychosis (EIP) services and how they may be best supported.
This study was qualitative, following the consolidated criteria for reporting qualitative research (COREQ; Tong et al., 2007).
Purposive sampling was used to recruit peer support workers within EIP services, who provided informed consent and were verbally fluent in English.
Semi-structured interviews were held either face-to-face or via telephone, recorded using a digital recorder, and transcribed verbatim after interviews.
Transcripts were analysed using thematic analysis (Braun & Clarke, 2006), utilising a hybrid inductive and deductive approach. Prior to publication, participants cross-checked the analysis to see whether this reflected their views, and for any comments or suggested improvements, with participants who responded giving their full approval of the analysis.
Seven participants were recruited. They were four females and three males with lived experience of psychosis from 1.5-33 years since their diagnosis and 2.5-33 years since their first episode. They were aged 36-51, all White British, and spoke English as their first language. All participants had been peer support workers between 1 month and 6 years, with five currently employed as peer support workers, and three having experience of receiving peer support, with one receiving this within EIP. One participant was gay, five participants were heterosexual, and one preferred to not disclose their sexual orientation.
Four thematic domains were found. Destigmatising psychosis was a central concept apparent throughout all themes, with one participant viewing psychosis as psychologically surviving trauma and abuse, referring to psychosis as a “survival gift”. As such, experiencing psychosis and recovering may help to change participants’ knowledge about psychosis, and facilitate beliefs regarding self-efficacy.
The benefits of peer support in EIP
- Peer support workers felt empowered through their role and evoked hope in service users.
- Through emotional validation, service users’ trauma was acknowledged, they felt valued, and had a safe space to work on their recovery. Service users also felt less isolated and were able to focus on functional recovery.
- Peer support reduced the barrier between service users and professionals, with service users sharing their experiences in a non-judgemental and accepting context.
The ideal requirements of peer support workers
- Ideally, peer support workers should have similar symptoms and demographics to service users and should have experience of being in psychiatric services as this helps them be aware of power dynamics between service users and professionals.
Delivering peer support
- Peer support groups should be widely available, e.g., to those discharged and those outside the geographical area.
- Peer support should cover all important aspects of service users’ lives.
- Training should focus on effective working, challenging stigma, maintaining professional boundaries, improving communication skills, teamwork, and maintaining well-being. Signposting resources such as the “Hearing Voices Network” would provide helpful information.
- Team-working created opportunities for peer support workers to give and receive valuable advice from colleagues, particularly when work was challenging and they felt emotionally drained.
- It is important for peer support workers to have their role clarified, i.e., understanding their key responsibilities and duties, as staff did not always have extensive knowledge on this role.
- Management is important to provide reasonable adjustments and to help to establish their role within the team. Supervision helped manage caseloads and reduce burnout.
Working alongside service users
- Building relationships with service users is crucial, such as by validating feelings, doing activities together, having conversations about daily life, and providing hopeful but realistic perspectives of recovery.
- Peer support workers did not always have sufficient resources to work on personal goals and handle practical advice when service users were acutely unwell.
- Peer support workers should understand what service users’ perceptions of recovery are and encourage this to be realistic.
- Peer support workers should encourage risk-taking, e.g., living independently, and encourage self-efficacy which can help combat self-stigmatisation as a barrier to independence.
- Confidence helped service users learn skills with long-term benefits.
- This study highlights that peer support may:
- contribute to functional recovery,
- increase social connections and self-efficacy,
- reduce self-stigmatisation,
- and provide hope for service users.
- There seems to be benefits for both service users and peer support workers, though training and support suggestions from the findings can help to ensure adequate provision of the role.
Strengths and limitations
Steps were taken to increase study creditability and validity such as following the COREQ guideline (Tong et al., 2007), collecting demographics, and cross-checking the data with participants.
However, the sample size was small, which begs the question whether data saturation was reached, potentiality impacting validity (Fusch & Ness, 2015), and all participants were White British, thus limiting transferability of findings to the wider population. Future research should recruit a larger participant pool and include perspectives from black and ethnic minorities for a more holistic view, especially as there is an over-representation of black ethnic groups within psychosis services (Morgan et al., 2004; Singh et al., 2007).
Moreover, whilst demographics were collected regarding peer support workers, without service users’ demographics, it is difficult to state whether this participant pool was similar to service users. This may be important considering the study’s finding concerning the importance of similar peer support workers regarding demographics and symptomology.
Lastly, future research should capture perspectives of service users receiving peer support, to better understand the holistic experiences relating to peer support within EIP services.
Implications for practice
As peer support seems to be a beneficial role within EIP services, EIP services should consider this study’s findings regarding training and support for peer support workers to increase the role’s effectiveness.
Peer support seems particularly helpful in the context of functional recovery, isolation, and self-stigmatisation; thus, peer support could be considered in cases where this is most relevant to service users. This could be developed through signposting within the service, if not already done, to ensure increased organisation and effective use of peer support within EIP services.
While it seems that the participants’ understanding of peer support and its benefits are congruent with peer support principles (Gillard et al., 2017) suggesting similar implementation of peer support across mental health services, future research should consider how peer support can be adapted to EIP services specifically.
Statement of interests
Nguyen, J., Goldsmith, L., Rains, L. S., & Gillard, S. (2021). Peer support in early intervention in psychosis: a qualitative research study. Journal of Mental Health, 1-7. https://doi.org/10.1080/09638237.2021.1922647
Bracke, P., Christiaens, W., & Verhaeghe, M. (2008). Self-esteem, selfefficacy, and the balance of peer support among persons with chronic mental health problems. Journal of Applied Social Psychology, 38(2), 436–459. https://doi.org/10.1111/j.1559-1816.2008. 00312.x
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. [Database] https:// doi.org/10.1191/1478088706qp063oa
Castelein, S., Bruggeman, R., Van Busschbach, J. T., Van Der Gaag, M., Stant, A. D., Knegtering, H., & Wiersma, D. (2008). The effectiveness of peer support groups in psychosis: A randomized controlled trial. Acta Psychiatrica Scandinavica, 118(1), 64–72. https:// doi.org/10.1111/j.1600-0447.2008.01216.x
Faulkner, A., & Basset, T. (2012). A helping hand: Taking peer support into the 21st century. Mental Health and Social Inclusion, 16(1), 41–47. https://doi.org/10.1108/20428301211205892
Fusch, P. I., & Ness, L. R. (2015). Are we there yet? Data saturation in qualitative research. The qualitative report, 20(9), 1408.
Gillard, S., Foster, R., Gibson, S., Goldsmith, L., Marks, J., & White, S. (2017). Describing a principles-based approach to developing and evaluating peer worker roles as peer support moves into mainstream mental health services. Mental Health and Social Inclusion, 21(3), 133–143. https://doi.org/10.1108/MHSI-03-2017-0016
Lieberman, J., Jody, D., Geisler, S., Alvir, J., Loebel, A., Szymanski, S., Woerner, M., & Borenstein, M. (1993). Time course and biologic correlates of treatment response in first-episode schizophrenia. Archives of General Psychiatry, 50(5), 369–376. https://doi.org/10. 1001/archpsyc.1993.01820170047006
Livingston, J. D., & Boyd, J. E. (2010). Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Social Science & Medicine (1982), 71(12), 2150–2161. https://doi.org/10.1016/j.socscimed.2010.09.030
Mahlke, C. I., Priebe, S., Heumann, K., Daubmann, A., Wegscheider, K., & Bock, T. (2017). Effectiveness of one-to-one peer support for patients with severe mental illness – A randomised controlled trial. European Psychiatry, 42, 103–110. https://doi.org/10.1016/j.eurpsy. 2016.12.007
Morgan, C., Mallett, R., Hutchinson, G., & Leff, J. (2004). Negative pathways to psychiatric care and ethnicity: The bridge between social science and psychiatry. Social Science & Medicine, 58(4), 739–752. https://doi.org/10.1016/S0277-9536(03)00233-8
National Institute for Health and Care Excellence. (2014). Psychosis and schizophrenia in adults: Treatment and management (clinical guideline 178). NICE.
Payne, J., Malla, A., Norman, R., Windell, D., & Brown, N. (2006). Status of first-episode psychosis patients presenting for routine care in a defined catchment area. The Canadian Journal of Psychiatry, 51(1), 42–47. https://doi.org/10.1177/070674370605100108
Pitt, V., Lowe, D., Hill, S., Prictor, M., Hetrick, S. E., Ryan, R., & Berends, L. (2013). Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database of Systematic Reviews, (3), CD004807. https://doi.org/10.1002/14651858. CD004807.pub2.
Pyle, M., Pilling, S., Machin, K., Allende-Cullen, G., & Morrison, A. P. (2018). Peer support for internalised stigma experienced by people with psychosis: Rationale and recommendations. Psychosis, 10(2), 146–152. https://doi.org/10.1080/17522439.2018.1437212
Sartorius, N., & Aichenberger, M. (2005). The WPA global programme to reduce the stigma and discrimination because of schizophrenia. In Bibliography, 2005. World Psychiatric Association.
Schutt, R. K., & Rogers, E. S. (2009). Empowerment and peer support: Structure and process of self-help in a consumer-run center for individuals with mental illness. Journal of Community Psychology, 37(6), 697–710. https://doi.org/10.1002/jcop.20325
Singh, S. P., Greenwood, N., White, S., & Churchill, R. (2007). Ethnicity and detention in the UK: A systematic review and metaanalysis. European Psychiatry, 22(S1), S168–S168.
Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042
White, H., Price, L., & Barker, T. (2017). Exploring the impact of peer support in early intervention in psychosis. Mental Health and Social Inclusion, 21(2), 102–109. https://doi.org/10.1108/MHSI-12-2016- 0036
Yanos, P. T., Roe, D., Markus, K., & Lysaker, P. H. (2008). Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatric Services, 59(12), 1437–1442. https://doi.org/10.1176/appi.ps.59.12.1437
- Photo by Sam Manns on Unsplash
- Photo by Womanizer Toys on Unsplash
- Photo by felipepelaquim on Unsplash
- Photo by Tim Marshall on Unsplash
- Photo by Terry Vlisidis on Unsplash
- Photo by Javier Allegue Barros on Unsplash