In a previous blog “no support for peer support”, I reported on a systematic review of the effectiveness of peer support in mental health. The conclusion of this review was that despite the fact that peer support is a popular idea, valued by service users and carers, as well as organisations, the evidence that it can positively influence service user outcomes (ABOVE AND BEYOND USUAL CARE) is open to interpretation and certainly not clear-cut.
I also drew attention to the issue that peer support is a global term, rather than a specific role or intervention. This lack of a coherent definition, or theoretical understanding of the effectiveness or not of peer support (what the mechanisms and ingredients are that contribute to effectiveness) mean that it is impossible to pool studies together and say definitively that this is a clinically effective intervention that improves outcomes above and beyond what is currently being provided by routine care.
In light of this lack of evidence-base for peer support, Steve Gillard and colleagues undertook a national study of models of peer support in order to understand what is known about peer support delivery in mental health services from a range of perspectives.
They used a qualitative comparative case study design. They developed a conceptual framework, based on what is already known from the literature, as well as the research team’s insight. In turn, they used this framework to inform data collection.
The study took place in 10 contrasting cases, comprising NHS mental health trusts and voluntary or social care sector providers. Service user researchers undertook the majority of the data collection and analysis.
There were a total of 89 participants and all completed an interview that comprised structured and open-ended questions.
Qualitative data was analysed using a framework approach. Data was compared between groups of respondents as follows:
- Employer: NHS, voluntary,
- Organisational context: NHS only, voluntary only; partnership cases,
- Service setting: two inpatient cases, two community cases, two BME (Black and Ethnic Minority) services
- Stakeholder group: peer workers, service users, non-peer staff, line managers, strategic managers, commissioners
Whilst there were a lot of positive findings and experience, there were several concerning factors that emerged:
- It’s not enough to just have “lived experience” to be a peer supporter. It was mentioned several times that interpersonal skills, a passion for the work, and some level of personal resilience is required.
- Breaking down barriers and stigma. Challenging the status quo; there was plenty of evidence that peer supporters, by their existence in a team, could offer another perspective other than a diagnosis-led view of mental distress. However, challenging attitudes is hard and can create tension. There were examples where peer supporters felt able to challenge language and attitudes, but equally some examples where peer supporters heard distressing things said about people with mental illness, but didn’t feel able to say anything.
- Professional boundaries. There are challenges of maintaining the true essence of peer support, whilst being a paid member of an NHS organisation. The rules and constraints this brings at times seemed at odds with the philosophy of peer support.
- Distress and support. Being placed in situations that are harrowing, such as finding someone who was trying to harm themselves in an inpatient setting. Some of the participants mentioned that they were able to access their own peer support for the role; others highlighted not always being able to access support. Managerial support appears very variable.
The strengths lie in the volume of interviews and the diversity of the responses. The participants included a wide range of stakeholders, representing a range of organisations and geographical locations.
Whilst this study really helps us understand the experience of working as a peer supporter in NHS and non-NHS settings, it is not able to provide evidence of effectiveness (essentially, whether peer support improves patient outcomes, over and above usual care).
To answer the question of effectiveness, a different research design would be required (i.e. a randomised trial of peer support versus usual care).
This study reports some really positive findings across the UK, in both the NHS and the third sector. Peer support experience was more positive in posts that had been established over a long time (such as in the third sector). However, some significant and serious problems were identified that need to be resolved specifically for NHS peer supporters.
Really complex issues will always occur with the introduction of a new role (a radical new role) which, by its own existence, significantly challenges the status quo of the mental health service. This challenge is a good thing, and the tension (particularly in the NHS) could lead to a complete culture change. However, this may come at a price. The process will be lengthy and painful, and there may be casualties along the way. It seems that the burden of pushing for this culture change lies with the peer supporters themselves.
I was disappointed (but sadly not surprised) to read that some clinical staff showed a lack of support to their peer supporter colleagues, and expressed stigmatising attitudes towards people who use mental health services. People with lived experience need to be able to engage in a role that is flexible to work with the ebbs and flows of their mental health, and also need to feel in control of this role.
The report mentions some people feeling compelled to discuss their own mental health with co-workers. There is a clear disparity in expectations about disclosure, when it’s not expected of (or it is even frowned upon) for other workers in mental health settings.
I would encourage peer supporters and NHS organisations to read this report and enter into a local (collaborative) dialogue about how some of these issues can be resolved. Peer supporters come into this work wanting to make a difference, and help people in times of distress. Accordingly, they should be supported to undertake this work, and be valued for what they bring to the organisation.
Gillard S, Edwards C, Gibson S, Holley J, Owen K. (2014) New ways of working in mental health services: a qualitative, comparative case study assessing and informing the emergence of new peer worker roles in mental health services in England. Health Serv Deliv Res 2014;2(19).