Peer support — when individuals who have experienced mental illness and recovery help others — has become increasingly popular. Dr Nicola Davies explores the scientific evidence behind peer support, as well as the personal experiences of peer counselors and psychotherapists.
What does the scientific evidence say?
Systematic reviews have confirmed that, while peer support and clinical practice typically perform fairly equally on traditional outcome measures like rehospitalization and relapse, peer support scores better in areas related to the recovery process.1 In particular, peer support tends to offer greater levels of self‐efficacy, empowerment, and engagement.2 This mechanism of benefit could come from the social connectedness experienced from interacting with peers, with one study showing that people with serious mental illness such as schizophrenia, bipolar disorder, and other psychoses value the sense of group belonging that comes from sharing personal stories.3 The mutual exchange of strategies to cope with the everyday challenges of living with a mental illness is also an important aspect of the peer-to-peer community.
“There is a lot of value in sharing with people who have overcome similar mental health challenges,” says psychotherapist Hilary Jacobs Hendel, author of the award-winning book, It’s Not Always Depression (http://www.hilaryjacobshendel.com). “Peer support builds confidence and hope for healing.” Indeed, in a meta-study, Dr Daniela Fuhr and colleagues found that peers have the potential to deliver care to persons with serious mental illness that can result in improved quality of life as a result of such increases in hope.4 Furthermore, there is some evidence that interventions delivered in an individual format work better than group interventions. However, for depression, the team found no effect on improvements in clinical and psychosocial outcomes. Still, the study concludes that peer interventions are an untapped resource in global mental health.
Peer support vs clinical support
A distinction is often made between peer support and the clinical support roles. “What’s nice about peer support is that all group members are equal,” she explains. “Sometimes having a ‘professional’ in the group can be experienced as diminishing, especially if the professional is condescending. In contrast, a peer group leader or guide who knows how to build people up and build on their strengths is a great asset.” In this respect, peers can often form a stronger therapeutic bond with the people they counsel because they have experienced mental health struggles themselves. Not only do they have genuine empathy, a key component of successful therapy, but they are also able to promote treatment engagement through personal empowerment and provide a role model for recovery.
What if the peer group doesn’t share the same mental health experience? They can still be a valuable asset, says Jacobs Hendel. “They can all learn together how to recognize their defenses, calm anxiety, work with child parts and shamed parts, practice sensing emotions in their body, and build a tolerance to positive feelings.” It is important to note that peers who are nonclinical staff never “treat” mental illness, and this is not their role. Peer counselors complement clinical care — often in a big way.
One of the biggest challenges to receiving quality psychotherapy is the cost: it’s expensive. Peer support is a great option for people who can’t afford therapy, or who live in rural communities where it’s not available. However, even for those already in individual therapy, peer input can be a substantial additional support, according to Jacobs Hendel. “People really feel better when they know they are not alone and that other people understand and share their experiences,” she says. “One of the main causes of psychopathology is experiencing overwhelming emotions in the face of too much aloneness. Good therapy and good peer support strive to eliminate aloneness, as well as to provide other benefits.” Peer support can be given in a person’s home or in a public place away from clinical locations, and the process is usually more equal and intimate than clinical treatment.
From patient to peer counselor
The Substance Abuse and Mental Health Services Administration (SAMHSA) have conducted research to identify the critical knowledge, skills, and abilities needed by anyone providing peer support services to people with, or in recovery from, a mental health or substance use condition.5 The core competencies, such as establishing collaborative and caring relationships, providing support by conveying hope and celebrating accomplishments, and personalizing support should be acquired by a person aspiring to help others as a peer counselor.
Alan Schmidt struggled with addiction from a young age. “I was an alcoholic by 11 and addicted to opioids by 13,” he shares. Now he is a substance abuse counselor intern at the Riverside University Health System Medical Center in Moreno Valley, California. “You must be honest, sincere, and authentic with your clients,” says Schmidt. “Never go beyond your scope of practice… ever. Our words can have a lasting effect and if we are out of our area of practice, the harm we could do could have fatal effects. I am conscious of everything I say to a client.”
It is a win-win situation if those in recovery are trained and hired to provide peer support to those currently struggling mentally. The client receives support from peers who can model self-care and help them navigate the health care system, while the peer counselors are gainfully employed in a job that supports their own recovery by providing meaningful work.
The future of peer support
Peer support has matured significantly over the years and agreement about a common set of practitioner competencies5 and a set of national guidelines6 for peer support services in behavioral health have been implemented by SAMHSA. The American Psychiatric Association issued a position statement in 2018 noting, “The [Association] supports the value of peer support services and is committed to their participation in the development and implementation of recovery-oriented services within systems of care.” The statement also stipulated, “Peer support personnel should have training appropriate to the level of service they will be providing.”7 To this end, there are state and national certification programs available for individuals wanting to become peers in the United States.
According to Mental Health America, “Although they go by many names, like peer support specialist or recovery coach, all model recovery, share their knowledge, and relate in a way that have made this evidence-based practice a rapidly growing field.” Indeed, today, peer support is available in all 50 states. It is reimbursable by Medicaid in 35 states and is considered a best practice by SAMHSA.8
1. Bellamy C, Schmutte T, Davidson L. An update on the growing evidence base for peer support. Mental Health and Social Inclusion. 2017;21(3):161-167.
2. Farkas M, Boevink W. Peer delivered services in mental health care in 2018: infancy or adolescence? World Psychiatry. 2018;17(2):222-224.
3. Naslund JA, Aschbrenner KA, Marsch LA, Bartels SJ. The future of mental health care: peer-to-peer support and social media. Epidemiol Psychiatr Sci. 2016;25(2):113-122.
4. Fuhr DC, Salisbury TT, De Silva M, et al. Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2014;49:1691-1702.
5. Substance Abuse and Mental Health Services Administration. Core Competencies for Peer Workers. https://www.samhsa.gov/brss-tacs/recovery-support-tools/peers/core-competencies-peer-workers. Updated December 19, 2018. Accessed May 1, 2019.
6. US Department of Health and Human Services. What Are Peer Recovery Support Services? https://store.samhsa.gov/system/files/sma09-4454.pdf. 2009. Accessed May 1, 2019.
7. APA. Position Statement on Peer Support Services. https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2018-Peer-Support-Services.pdf. May 2018. Accessed May 1, 2019.
8. Mental Health America. Peer Services. https://www.mentalhealthamerica.net/peer-services. 2019. Accessed May 1, 2019.