Part 6: Benefits, Challenges and the Future of Peers

In our most recent blog of our six-part series, we discussed how peers in the United States are gaining increased professional respect. We reviewed the demographics of peers, and the efforts to improve and standardize their credentialing and their economic impact. In our final blog of the series, we will look at the clinical and other benefits of peers, what workforce obstacles peers experience and what their future holds. 

The clinical and financial benefits of peer services are well established. According to the Mental Health Association (2019), the types of improvements that can be had by peers’ involvement include:

• Reduced rehospitalization rates
• A trial program run by Optum served 125 people all of whom had been previously hospitalized. After getting a peer coach, 3.4% were hospitalized.
• Reduced inpatient days
• One Tennessee program showed a 90% decrease in average acute inpatient days per month. A Wisconsin program showed a 71% decrease.
• Lowered overall cost of care
• The State of Georgia saved $5,494 per person per year by using certified peer specialists in their day treatment programs.
• Increased use of outpatient care
• New York decreased the number of people using inpatient care by nearly 50%, the number of inpatient days by 62.5% and a savings of 47.1% in behavioral health costs.
• Improved quality of life indicators
• Peer support has been shown to be superior to usual care in reducing depressive symptoms and in helping people gain employment.

Critics of some peer support studies refer to methodological problems such as poor randomization or other issues. Randomization can be ethically challenging in actual treatment facilities. Quasi-experimental designs and other protocols can be employed to address these criticisms. Still, the sheer volume of positive outcomes across multiple domains suggests there are real effects here. For example, Chinman et al., (2014) reviewed the peer service literature and identified the following outcomes:

• Reduced inpatient service use
• Improved relationship with providers
• Better engagement with care
• Higher levels of empowerment, patient activation and hopefulness for recovery

While there has been increased acceptance of peers in the behavioral health workforce, peers still experience workplace challenges. One is lack of clarity in peer role expectations. Being a relatively new discipline, it isn’t hard to imagine how this could be an issue. The diversity in formal and informal role definitions, titles and expectations clearly contribute to this problem, making standardization a problem. Clear and explicit job descriptions should help remedy this as well as developing national standards for peers.

Another obstacle, better integration into workplace teams, is a bit more complicated. It too has elements of unclear expectations, but it is actually more than that. When asked, peer workers regularly report feelings of stigma and discrimination in the workplace. In one survey of 375 peer workers by Cronise et al., (2016) 64.3% reported experiencing stigma or discrimination by nonpeer coworkers such as licensed professionals while 30% said they had similar experiences from the organization’s leadership and staff. Most surprisingly, 22.1% reported having the same experience from the peers they were there to support. When asked about the sources of discrimination they experienced, 242 peer workers responded with 62% saying unequal compensation was the issue, 58% experienced unfair job advancement opportunities and 44% felt unequal hiring practices were to blame.  

In the same study, seven characteristics were identified that contributed to peer workers’ job satisfaction. They are:

• Responsibility in the job that reflects level of training and lived experience
• Feeling respected by supervisors and colleagues
• Feeling respected by the peers who receive the service
• Perception of having sufficient training to do the job
• Working in community settings and/or peer run programs
• Taking more hours of training to qualify as peer support providers
• Perception that their peer support skills are used

Future

The future of peer services looks bright based on the near-universal acceptance of the roles of peers, the positive clinical outcomes that have been demonstrated and the relatively rapid implementation of reimbursement standards in most states. New opportunities exist in both expansion of the traditional roles of peers and the development of new ways for them to use their talents.

Some peers have already branched out into integrated care but there is still opportunity for growth in this area. The physical health challenges of people with serious mental illnesses are well known and getting peers more engaged in integrated care programs could provide a previously unheard voice that could help improve adherence and follow through for those with complex physical and behavioral health problems.

Standardizing training and credentialing for existing positions and new roles for peers will help solidify their credibility and clarify some of the role confusion issues. This could lead to increased use and standardized, if not improved, reimbursement.

Beck et al., (2018) has pointed out two potential problems facing peer workers.

• In some states, the list of approved services peers can provide includes terms like provide “emotional and social support”. This phrase and others like it could be interpreted as “counseling”. Since peers in mental health facilities work under supervision, they are not certified to practice independently so “counseling” is not in their span of authority. It is unlikely that this is what was intended by the phrase “emotional and social support”, but it is open to interpretation. Credentialing bodies and trade associations like the National Association of Peer Support (NAPS) could be helpful in clarifying this issue.
• Many states and organizations require peer workers to disclose their recovery history to be credentialed and/or hired. While such disclosure is unlikely a HIPAA violation, many recovery programs (e.g., AA) promote anonymity as a core principle. Disclosure requirements may inhibit hiring opportunities if peers are unwilling to break their anonymity commitments.  

One currently underserved area that could be a good fit for peers is in Employee Assistance Program (EAP) services. EAP managers frequently use mental health professionals to provide services for employees dealing with personal issues. It wouldn’t be a huge stretch to see peers increasing these services especially, but not exclusively, for employees with behavioral health histories. Since the current model for EAP mental health services requires employees be referred after a certain number of EAP-funded sessions, the same model could easily be applied to a peer providing support. 

To supplement traditional crisis “hot lines”, in 2020 legislation calling for the development of “peer run warm lines” was introduced in Congress. Although not mandated, as of April 2021, 41 states and the District of Columbia have peer run warm lines in place and some states have several (NAMI National Warmline Directory). The goal of these warmlines is to divert calls that aren’t true crisis calls to peers who can provide support. Peers manning these calls are trained to escalate the call if it is clear the services offered by a warm line are insufficient to meet the caller’s needs. These warm lines offer an excellent opportunity for increased recognition for peer workers. 

As mentioned previously, there exist some philosophical concerns about peer workers being employed by mental health facilities (Penney, 2018). While parties can agree or disagree about whether peers working for mental health facilities are somehow compromised based on their employment status, all can probably agree that what makes peer workers special should be protected. If peers in mental health facilities are, as said earlier, “provider extenders”, what they bring to the lives of people in their care is different than and supplemental to traditional mental health treatment. The outcomes data support that so not only the peers working in mental health facilities must protect the unique value of “lived experience” but so must facility administrators and other leaders.     

If COVID has taught us nothing else, it has shown us that digital health is here to stay. All aspects of healthcare are targets for digital disruption including peer services. Oss (2021) provided a summary of some of the peer support activities that are moving to digital platforms:

• MAP Health Management (MAP) is an all-virtual peer services organization that was recently purchased by Cigna to provide behavioral health peer support services in 22 states. The service provides recovery support sessions from a certified peer support specialist and connections with other consumers in recovery.
• Collaborative Addiction Recovery Management and Assistance health (CARMA) (recently acquired by MAP) offers a virtual peer-led behavioral health home model.
• Thrive Peer Support (Thrive) recently contracted to use the Connections App developed by Comprehensive Health Enhancement Support System Health (CHESS) which offers 24/7 access to a peer-moderated recovery community and virtual Cognitive-behavioral therapy (CBT) interventions.
• PeerRx is a program to help connect provider organizations and other entities in need with peer supports. When a facility such as a hospital emergency room needs a peer, the request goes out via the app and peers on the network are alerted and can respond in person or via video.
• Behavioral HealthLink in Georgia has developed an app, myGCal, for adolescents and teens that provides a warm support line that supports text, chat and phone. (St George, L. 2021)

Dr. John Torous and his team at Beth Israel Deaconess Hospital have reconceptualized the concept of a Health Navigator and extended it into the digital realm. They are training people to be “digital navigators” to assist consumers and staff of behavioral health facilities in their use of smartphones and other digital tools and “support the digital therapeutic alliance by helping patients customize and troubleshoot technology” (Wisniewski et al., 2020). As they correctly point out, “The role of a digital navigator is suitable as an entry level healthcare role, additional training for an experienced clinician, and well suited to peer specialists.” They have also developed programs targeting digital literacy for persons with serious mental illnesses. The Digital Opportunities for Outcomes in Recovery Services (DOORS) (Rodriguez-Villa, E. 2021, Hoffman, L 2020), is an 8-session digital health training program that showed good results in helping people with serious mental illness gain competency and mastery of their cell phones especially in regard to their care.

Summary

From its humble beginnings in a French mental hospital to legislatively mandated services, recovery and peer support have truly come of age. Adoption of the models is wide but varied. There are organizations that have not yet adopted these principles, others that are fully on board that strongly embrace peers and recovery and a large number in between. In this middle group are organizations that believe they have embraced these models but in fact have put a polish on recovery and peer support over largely traditional services. Change is hard but change will come. Like any disruptive technology, these models of peer support, in their current iteration, have challenged the behavioral health status quo for only 40 years and full adoption will take time. There can be little question about the clinical and financial advantage of either of these models so those who are resistant to change, whether from lack of understanding, buy-in or preconceived notion, will ultimately be won over. What is clear is most organizations are barely scratching the surface in terms of how peers can be fully leveraged, and recovery can be embraced.

Part 1: Origins of Peer Support in Mental Health

Part 2: Development of Peer Support in the United States and Other Regions of the World

Part 3: Public Policy and the Professionalization of Peers

Part 4: Role of Peers and Mutual Support in Alcoholics Anonymous

Part 5:  Current State of Peers in the United States: Demographics and Economic Impact

References Part 6

• Beck, AJ., Page, C., Buche, J., Rittman, D. and Gaiser, M. (2018) Scopes of Practice and Reimbursement Patterns of Addiction Counselors, Community Health Workers, and Peer Recovery Specialists in the Behavioral Health Workforce. University of Michigan. https://www.behavioralhealthworkforce.org/publications/
• Chinman, M., George, P., Dougherty, RH, Daniels, AS, Ghose, SS, Swift, A., and Delphin-Rittmon, ME. (2014) Peer support services for individuals with serious mental illnesses: assessing the evidence. Psychiatric Services. https://pubmed.ncbi.nlm.nih.gov/24549400/
• Clark, C. (September, 2021) Personal Communication

• Covington, D. (September, 2021) Personal Communication

• Cronise, R., Teixeira, C., Rogers, S. and Harrington, S. (2016) The Peer Support Workforce: Results of a National Survey. Psychiatric Rehabilitation Journal. https://pubmed.ncbi.nlm.nih.gov/27618458/
• Evidence for Peer Support. (2019) Mental Health America. https://mhanational.org/peer-support-research-and-reports
• Hoffman, L., Wisniewski, H., Hays, R., Henson, P., Vaidyam, A., Hendel, V., Keshavan, M., and  Torous, J. (2020) Digital Opportunities for Outcomes in Recovery Services (DOORS): A Pragmatic Hands-On Group Approach Toward Increasing Digital Health and Smartphone Competencies, Autonomy, Relatedness, and Alliance for Those With Serious Mental Illness, Journal of Psychiatric Practice: https://journals.lww.com/practicalpsychiatry/Abstract/2020/03000/Digital_Opportunities_for_Outcomes_in_Recovery.2.aspx
• National Warmline Directory. (2019) NAMI. https://www.nami.org/NAMI/media/NAMI-Media/BlogImageArchive/2020/NAMI-National-HelpLine-WarmLine-Directory-3-11-20.pdf
• Oss, M. (2021) Peer Supports? There’s An App For That. Open Minds Executive Briefing. https://openminds.com/market-intelligence/executive-briefings/peer-supports-theres-an-app-for-that/
• Penney, D. (2018) Defining “Peer Support”: Implications for Policy, Practice, and Research. https://www.mamh.org/assets/files/DPenney_Defining_peer_support_2018_Final.pdf 
• Rodriguez-Villa, E., Camacho, E. and Torous, J. (2021) Psychiatric rehabilitation through teaching smartphone skills to improve functional outcomes in serious mental illness. Internet Interventions. https://www.researchgate.net/publication/348570526_Psychiatric_Rehabilitation_Through_Teaching_Smartphone_Skills_to_Improve_Functional_Outcomes_in_Serious_Mental_Illness
• St George, L. (Feb 2021) Personal Communication.
• Wisniewski, H., Gorrindo, T., Rauseo-Ricupero, N., Hilty, D. and Torous, J. (2020). The Role of Digital Navigators in Promoting Clinical Care and Technology Integration into Practice. Digital Biomarkers. https://www.researchgate.net/publication/347591897_The_Role_of_Digital_Navigators_in_Promoting_Clinical_Care_and_Technology_Integration_into_Practice