Systematic Review of Peer Delivered Services Literature 1989 – 2009
Suggested Citation: Rogers, E. S., Kash-MacDonald, M., Brucker, D. (2009). Systematic Review of Peer Delivered Services Literature 1989 – 2009. Boston: Boston University, Sargent College, Center for Psychiatric Rehabilitation, http://www.bu.edu/drrk/research-syntheses/psychiatric-disabilities/peer-delivered-services/
Conducted by The Center for Psychiatric Rehabilitation with support from the National Institute on Disability and Rehabilitation Research.
Table of Contents
Plain language summary
Methods and procedures
Results and conclusions
Review conducted using a system for rating the rigor and meaning of disability research (Farkas, Rogers and Anthony, 2008). The first instrument in this system is: “Standards for Rating Program Evaluation, Policy or Survey Research, Pre-Post and Correlational Human Subjects” (Rogers, Farkas, Anthony and Kash, 2008) and “Standards for Rating the Meaning of Disability Research (Farkas and Anthony, 2008).
Peer delivered services for individuals with severe psychiatric disabilities are based upon the premise that an individual with a “lived experience” is uniquely able to contribute to the rehabilitation and recovery of a person needing services. Peer delivered services have proliferated greatly in the past decade to the point where they are now an accepted component of mental health services and programs in many states. Peer services are an outgrowth of the consumer movement which emphasizes that mental health policies and services should embrace a philosophy of “nothing about us without us” and that there should be dignity, equity and mutuality in all helping relationships. Despite the proliferation of peer run services, there is no accepted or widely used typology of peer delivered services which both hampers the field and complicated this systematic-review. For this review, we divided the studies of peer services into the following categories and report the plain language summary in the same way: peer delivered services added to traditional services; peer delivered services offered in mutual support groups; peer delivered services in the context of drop in centers; peer delivered services offered primarily in a one-to-one service, peer delivered residential services and other.
Results of this review suggested that adding peer delivered services to traditional mental health or to case management services does not result in significant differences in outcomes that favor the peer delivered services over traditional services. A small number of studies indicate advantages of peer delivered services in engagement and retention of individuals in services, but not in outcomes. These results suggest that peer providers may offer unique and distinctive skills and experiences that can be helpful in the engagement and retention of individuals in services however, that evidence is modest. There is also evidence that peers provide services differently in terms of the focus on face-to-face interactions outside of the traditional office milieu. Taken together, these studies do not provide clear evidence that peer delivered services provide advantages in terms of client outcomes such as employment, perceived social support, criminal justice involvement, housing stability, working alliance, service use, re-hospitalizations, quality of life, or substance abuse. Several authors have suggested that these results should be interpreted as supportive of the notion that peer providers can deliver equivalent services to those of professionals, rather than expecting peer delivered services to out-perform traditional services.
There is some evidence that peer delivered services, provided in a group context, can be effective in engaging individuals and in improving outcomes. The peer delivered group interventions vary substantially one from another, making conclusions difficult to draw in this category. The data do suggest that individuals who adhere to group interventions (i.e., attend a substantial number of sessions) appear to benefit whether the intervention is more tradition in nature, is similar to AA, or a different model altogether. However, conclusions from randomized designs using intent-to-treat analyses (i.e., involving all subjects randomized) do not reveal significant positive outcomes. Observational and correlational studies, such as those done in drop in centers or in Double Trouble for Recovery groups, suffer from problems with attrition and loss to followup. Despite this, it is safe to conclude that of those people who engage in peer delivered interventions in groups regularly, benefits do accrue in the areas of abstinence from substance abuse, stability of psychiatric symptoms, self esteem, self efficacy, empowerment, quality of life, perceived social support, satisfaction with services, medication adherence, reduced criminal justice involvement. The extent to which attrition and selection factors affect these outcomes cannot be estimated, but do pose a threat to these conclusions.
For the one large study of peer delivered interventions using multiple models (drop in centers, mutual support groups, and education and advocacy) and multiple sites, there is evidence that participation in a peer delivered intervention was associated with global positive changes in well-being. In terms of peer delivered residential interventions there is equivocal evidence of outcomes when examining level of functioning, quality of life or other outcomes. In two studies of a primarily one–to-one peer delivered service focusing on social supports there is no consistent evidence of effectiveness. Service satisfaction, however, does appear to favor individuals receiving peer delivered services.
Peer Delivered Services Study Group:
E. Sally Rogers,
Center for Psychiatric Rehabilitation
E. Sally Rogers, Sc.D. Director of Research
Sargent College of Health and Rehabilitation Sciences
940 Commonwealth Avenue West
Boston, MA 02215
Megan Kash, M.S. Research Associate
Deb Brucker, Ph.D. Consultant
Rationale for the Review.
Development and funding of peer delivered services have increased dramatically over the past decade (Clay, 2005). Peer delivered services occur in various agency settings and are alternately called self-help agencies, consumer survivor initiatives, consumer run organizations, peer support, consumer operated programs, or, programs run by and for consumers. These programs have developed along multiple paths resulting in a variety of program typologies, service structures, and funding streams and many have similar missions and goals (Campbell, 2005). Such programs began to proliferate in the mid-1900’s with the advent of groups like Alcoholic’s Anonymous and other so-called “12-step” programs. Programs involving peers and peer support were seen as a response both to the limited effectiveness of traditional approaches and to treat problems of addiction. Simultaneously, they benefit from the power of groups to come together to offer support, solace and assistance in a way that traditional mental health services can not. These 12-step programs, arguably the “oldest and most pervasive” of peer programs (Solomon, 1994) evolved beyond substance abuse to address the needs of mental health consumers including groups such as Schizophrenics Anonymous (cf., Salem, Gant and Campbell, 1998). This growth in peer support has been so robust that recent U.S. national survey identified a total of 7,467 such mental health mutual support groups and consumer-operated services – a figure exceeding the number of traditional mental health organizations (Goldstrom, Campbell, Rogers, et al., 2006).
Because the empirical base of studies of peer delivered services has grown, a systematic review of these studies and outcomes is warranted.
Objectives of the Review
The objectives of this review were to identify and review all literature related to peer delivered services for individuals with severe mental illness and to not limit the systematic review to only randomized clinical trials. The assumption for this systematic review was that there is important and significant literature that has been published in the field of peer support that needs to be synthesized for the mental health field. In addition to the knowledge gained from RCT’s, the study group presumed that there was valuable information that could be gleaned from studies not employing a randomized design and that synthesizing the literature could be useful to stakeholders, end users, and other constituents in the mental health field.
Any study (see definitions below) describing the effects of peer delivered services on outcomes for individuals with psychiatric disabilities was considered for inclusion. Peer delivered services were defined as those provided by a consumer of mental health services or an individual with a “lived experience” of a psychiatric disability. In order to be considered for inclusion, the studies considered for review had to examine the characteristics of the peer delivered services or its effects on consumers.. A significant number of studies examined the effects of peer delivered services that were embedded within a traditional service, largely, case management. Further, in order to be considered for inclusion, a major component of the study or interventions had to be peer delivered services as opposed to a traditional service such as a clubhouse with minimal peer services embedded in it. Consumers had to be significantly involved in the design/delivery of services. We included studies that involved peer delivered services but may have been administratively controlled by professionals. Our rationale for including programs that may have been administratively controlled by professional staff, but when services were delivered by consumers was two-fold: first, many studies do not sufficiently define how the services are administrated to make such a decision and secondly, such a criterion would have significantly limited the literature we examined, particularly older literature since the administrative control of services by consumers is a more recent phenomena.
We found that much of the early literature focused on model descriptions of the programs and key elements of consumer delivered services without information as to the effects of these programs on consumer outcomes. These “model descriptions”, or descriptions of the essential ingredients of consumer run programs, were not included in the systematic review since they did not speak client outcomes or the general effectiveness of programs.
Another important caveat is on order: we attempted in this review to differentiate between types of peer delivered services and to analyze the data from that perspective. However, we had no criterion based approach to analyzing whether a peer delivered service was exclusively focused on one-to-one peer support; peer support delivered in groups; peers added to traditional service models such as case management; or drop in centers This is obviously a very complicated undertaking since there is often considerable overlap (e.g., drop in centers provide one-on-one peer and group support). There are also insufficient measures of peer delivered interventions (fidelity or adherence to different models) in these studies to make clear differentiations. Therefore, we divided the studies based on what appeared to be the predominant service offered and as described in the article. The results of systematic review therefore are divided as follows: 1) peer delivered services added to a traditional mental health service; 2) peer services delivered in mutual support groups; 3) peer delivered service in drop in centers; 4) peer support delivered in a one-to- -one services; 5) peer delivered services in residential settings; 6) services in a one to one service types of services and studies that did not fit into the above categories, such as peer delivered socialization.
We excluded studies of 12-step programs that were focused primarily on substance use or problems that would not be considered to involve serious mental illness or psychiatric disability. We did include studies of the 12 step program called “Double Trouble for Recovery” since it is targeted to individuals with psychiatric disabilities and co-occurring substance abuse problems and the studies included focused on mental health outcomes.
In terms of exclusion by research design, acceptable study designs for review included:
- pre-post study
- survey research
Determining the type of design was not without problems when designs were poorly described or poorly planned and executed. This lead to some difficulties in categorizing the designs used. For example, when correlational methods were used to address questions of effectiveness of an intervention, we coded that design as a pre-post or quasi-experimental design because of the intention of the researchers.
The study group excluded the following types of studies/publications/documents:
- Policy statements
- Needs assessments
- Instrument development articles
- Housing satisfaction
- Program models
- Conceptual models of peer support
- Process evaluations
- Studies of the beliefs and attitudes about peer support services unless those studies contrasted the views of various groups.
- Conference proceedings
The rationale for these exclusions was that such studies and articles, while important for the field, could not be subjected to ratings for their rigor and their meaning.
Search terms used:
- Self help groups
- Drop in Centers
- Advocacy programs
- Internet online support groups
- Peer delivered services
- Peer run or operated services
- Peer employees
All of the above terms were paired with: serious mental illness, psychiatric disability, and mental illness. We searched pubmed, Medline, and psycInfo, and Google Scholar. We also examined the Cochrane Central Register of Controlled Trials (CENTRAL) and the CIRRIE International Database of Rehabilitation Research. We examined the citations contained in each article for additional potential articles and reports to review (i.e. ancestor citations). All citations contained in the background and included articles were carefully screened for relevance and inclusion.
Two research assistants were responsible for querying the databases and locating articles. Titles of articles were initially scanned for relevance to the peer support topic by the lead reviewer. If the title appeared relevant, the abstract was reviewed and if it was deemed likely to meet inclusion criteria, the article was obtained. A checklist of inclusion/exclusion criteria was completed for each article and to facilitate tracking of screened articles. In some cases, once the article was reviewed, it was clear that the inclusion criteria were not met. Occasionally, one or more members of the study group had to be consulted to make a determination about including or excluding an article. Ancestor citations were located by examining the list of citations of all full articles that were screened in for review.
Once a complete list of articles for review was compiled, that list was sent to 12 experts in the field of peer support, primarily individuals who had written articles on peer support (Segal, Dumont, Salzer, Yanos, Goering, Davidson, Solomon, Kaufmann, Knight, Lucksted, Brown, Campbell). We asked those experts to review the list of articles considered to insure that no relevant study was omitted. This step yielded several new citations that were appropriate for review.
In the end, we considered 127 articles for inclusion. Articles that were excluded from the review were those that did not examine a peer or peer run intervention or have outcomes related to peer support, were review articles, policy statements and the like. The excluded articles were categorized by reasons excluded:
The reasons for exclusion were:
- The articles contained descriptions of peer models of service delivery (n=20)
- The articles did not contain sufficient outcome data to be included (n=13)
- The articles contained process or conceptual information (n=9)
- The studies were not about peer delivered services in mental health (n=4)
- The studies were qualitative in nature (n=4)
- Other (n=2; one was a measurement development article, the other contained duplicate data to a study that was reviewed)
After the inclusion and exclusion criteria were applied and non-relevant articles were excluded, 63 articles were screened in and rated for quality and for meaning. Because of poor ratings of quality, 10 of these 63 articles were then excluded from the narrative review presented below.
Each reviewed article was also classified by design type. The bulk of the articles reviewed were classified as correlational in their designs (n=24), with experimental (n=15), quasi-experimental (n=10), and pre-post, observational, survey or their designs following (n=4). After the ratings were done by reviews, a total of 6 studies were excluded from the narrative synthesis because their methodology scores were low enough that the conclusions could not be considered robust or valid. Issues such as very poor research designs with major threats to internal validity, retrospective measurement, or very large attrition of study subjects were the major reasons for exclusion.
Ratings of the Quality of the Research
Quality of the research for this systematic review was determined by examining both the rigor (traditional indicators of the quality and appropriateness of the methodology) and the perceived meaning of the research (that is, the perceived utility and meaning the research has for the field, for policy makers and providers, for consumers and family members). As can be seen from the Rigor Scale conducted in the appendix, there are 20 items designed to assess how well the authors developed the rationale for the study, implemented the study, described the results and explained the findings and their relevance for the field. Items were measured on a 1-4 scale with 1 being inadequate and 4 being very adequate.
We used as a cutoff any study that scored a 2.0 or below for the following methodology item (“The study/research uses rigorous or sound research methods that allow the questions of interest to be addressed”). Any study which scored a 2.0 or below on this item was excluded from the narrative synthesis.
As noted above, of the 53 articles rated for rigor 6 were excluded from the narrative synthesis based upon their poor methodology scores. Studies that employed weak designs for the questions they were addressing or had severe threats to internal validity, were excluded we then tallied the rating scores.
Results suggested that the highest average scores were given in the introduction and rationale for the studies. That is, most authors were able to effectively establish the need for their study and review extant literature in their field resulting in a coherent argument for the need for the research. The methodology and the discussion sections resulted in the lowest ratings with some average methods ratings being just barely rated adequate (3.00). Specifically descriptions of independent variables, details on data collection and the handling of the data including the handling of missing data were problematic. Author’s descriptions of the control or comparison conditions were often less than adequate. Authors often failed in their discussion section to address the implications of the findings for the field, or to address how their findings fit into the broader empirical literature. Many authors did not adequately describe the limitations of their research and the parameters of their ability to generalize their findings, resulting in ratings for the discussion section that were on average, lower than other sections.
The second part of the rating process of the screened in articles examined “meaning” or perceived utility for stakeholders. The Meaning Scale (see Appendix for Meaning Scale) contains 19 items, measured dichotomously as Yes/No. The first section of the Meaning Scale rates how much consumers are involved in the research study.
Because we are using an innovative approach to rating meaning or perceived utility for this project, ratings of meaning were not used to exclude articles from the narrative synthesis but rather to get a preliminary sense of whether and how the meaning of the studies reviewed could be rated using this newly developed scale.
Overall, results suggested that consumers are frequently involved in the design, implementation or review of research studies (up to 78% of authors reported that consumers were involved in the study design or conduct which is a fairly high percentage relative to other reviews we have conducted. Perhaps this is expected given that these are studies of peer delivered services). It is also possible that more involvement in the design and conduct of the study occurred but was not reported by authors. We also rated whether information was collected and presented in the article using the World Health Organization framework for reporting functioning, disability and health rather than a simple focus on impairment symptoms or diagnosis. Ratings in that section suggested that data are presented on indicators of health and role functioning quite often (90% of the time and 78% of the time respectively). Data were presented much less frequently on environmental factors related to activity or participation, another item on the scale. We also rated whether the authors of the article articulated implications of the research for various levels of stakeholders, including policy makers, service providers, practitioners, consumers, and families. Implications of the research for policy are fairly frequently present in the articles (59% of the time) and for practitioners (43% of the time) and much more frequently for programs and services (77% of the time). Implications are rarely presented for the daily life of the individual with the disability, for their family members, or for underserved consumers (i.e., consumers receiving services in rural areas for example).
The final section of the Meaning Scale asks about the availability of information, tools or other supports to put the intervention or information studied to use in the field. We found that about 92% of the articles enumerated one or more values underlying the intervention or service being studied, but other supports were virtually never present in the article (that is, supports such as materials or tools for implementation, costs of implementation or maintenance, help with translating the findings into practice or support for underserved populations). Given that values and philosophy of peer delivered services are a cornerstone of those programs, it is not surprising perhaps that values underpinning the services were addressed.
Time Period of the Studies and Research Covered.
We considered any study published in the 20 years prior to the date of the systematic review (1989-2009). Data could have been collected prior to 1989 but any article reviewed would have had to of been published by 2009. However, there were very few empirical studies published before 1989.
Training of Reviewers.
A total of 3 raters were used for this systematic review. All were individuals affiliated with the Center for Psychiatric Rehabilitation including research staff, and consultants.
Each rater was knowledgeable prior to the beginning of the systematic review about research methods so that the training focused on what kind of evidence for research quality might be encountered in a published article and what would be an acceptable indicator that quality had been achieved at each of the 4 points on the rating scale as described above. All individuals were trained in the use of the rating scales by reviewing each item in the scale and discussing the meaning of the item and the evidence that could be considered for each indicator. Research articles were used as training devices by having each rater independently review articles and then discuss their ratings until agreement was achieved. Formal tests of inter-rater reliability were conducted and 75% agreement was reached between raters. Early in the process of training, reviewers’ consensus ratings were used between two members of the study group as a way of insuring that the most accurate and reliable ratings were being employed for the final ratings. Consensus ratings were needed occasionally when a reviewer felt unable to come to a decision about a rating without additional input.
In the process of searching for articles to include in the systematic review, several articles were located that were not suitable for ratings of rigor and meaning because they were review articles themselves. Because these articles provided invaluable background information for the context of this review, we elected to summarize them and their findings here.
The importance of a systematic review in peer delivered services is evident when one examines the growth of such programs nationally; mutual support, self-help, peer support and consumer run programs have burgeoned in the last three decades. In an early study of self help programs Emerick (1989) conducted a survey of self help groups for individuals with psychiatric disabilities. He examined 104 programs nationally and concluded that the average self help program operated in an urban area, was typically fairly new (2-3 years old), operated on a budget of $30,000 and served about 33 people. This data was collected early in the self help movement and is not reflective of later practices and the huge growth of peer delivered services. Just two decades later, Goldstrum, Campbell, Rogers, Lambert, et al., (2006) reported on a national survey and identified 7,476 of such programs nationwide (including groups run for family members). Included in this figure were 3,315 mutual support groups serving over 41,000 individuals, 3,019 self help organizations serving over one million individuals and 113 consumer-operated programs serving over one-half million individuals. This is contrasted with 4,546 traditional mental health organizations. This suggests that peer, self help and mutual support services have eclipsed traditional mental health services.
Descriptions of the Peer Support/Mutual Support Models and the Peer Role
In 2000, the Substance Abuse and Mental Health Services Administration published an analysis of 13 self-help programs who had received their funding in the 1980’s (Van Tosh and del Vecchio, 2001). This effort to fund self-help or peer-run programs was the first of its kind at a national scale and took place in the following states: CA, CO, IN, ME, MO, NH, NY, OR, TN, VT, WA, WV, and WI. At the time, the peer programs embodied the following characteristics and factors: a non-reliance on professionals, voluntary attendance, equality, a non-judgmental environment, and informality. Results of the process evaluation conducted in these 13 peer programs suggested that the following objectives and activities were their hallmark: providing mutual or peer support; attending to basic human needs (such as food and housing); increasing empowerment, providing public education and information dissemination, and providing rights protection. The services studied included drop in centers, support groups, information and referral services, information dissemination, outreach, advocacy, technical assistance and training and direct services to assist with independent living and employment.
In addition to early evaluations of self-help, mutual and peer support programs, several attempts have been made to elucidate categories of peer support, or the essential ingredients of peer support (cf., Campbell, 2004; Solomon, 2004; Holter, et. al., 2004; Johnsen, Teague and McDonel Herr, 2005). Solomon (2004) for example used several definitions of peer support to guide a synthesis of peer delivered services. She then examined literature which suggested that peer delivered services are those provided by individuals who identify themselves has having a mental illness and who are recipients of services. Solomon includes peer run or operated services, “peer partnership” services, and peer employees. Peer run or operated services are those that are planned, operated and evaluated by people with psychiatric disabilities. Peer employees are individuals who fill designated unique peer positions as well as peers who are hired into traditional mental health positions. Schmidt describes a “consumer provider” as a person who is providing traditional mental health services but happens to be a peer.
In terms of definitions of peer support provided in the context of group services, Pistang, Barker and Humphreys (2008) defined a mutual help groups as one of people sharing a similar problem who meet regularly to exchange information and to give and receive psychological support (a definition agreed upon by in Chinman et al, 2002). Goldstrum et al (2006) defined mutual support groups as follows: people who get together regularly on the basis of a common experience or goal to help or support each other. Professionally led groups are excluded. Self-help agencies are those organizations run by and for consumers which undertake activities to educate them or their community, engage in political or legal advocacy, or provide services to members. Consumer operated services are programs, businesses or services controlled and operated by people who have received mental health services. Davidson and his colleagues suggest that peer support differs from the mutual support offered in groups such as Recovery Inc. or Schizophrenics Anonymous and from consumer-run drop-in centers or consumer-run businesses. In order to be considered “peer support” the relationship must be reciprocal and involve 1 or more persons “who have a history of mental illness and who have experienced significant improvements in their psychiatric condition offering services and/or supports to other people with serious mental illness who are considered to be not as far along in their own recovery process” (Davidson, et al., 2006).
Active Ingredients of Peer Delivered Services
Over and above definitions of the roles of the individual providing the peer delivered service is the information available in the literature which helps to elucidate the active ingredients of peer support or peer delivered services. According to Solomon, the underlying processes making peer support potentially effective include: social support (or “the availability of people on whom we can rely”), experiential knowledge (“specialized information and perspectives that people can obtain from living through the experience” of having a psychiatric disability; Solomon and Draine, 1994). Using social learning theory as the framework, individuals with a “lived experience” have more credibility and are better role models for change and inspiring hope that change is possible. Individuals interacting with peers who have had positive outcomes may gain confidence and optimism. Peer support services also may benefit the giver of help through the “helper therapy principle” (Reissman, 1965) that is, the notion that one receives a benefit from helping others. Empirical evidence suggests that the use of experiential learning, the principle of mutual benefit, the development of natural social supports, the voluntary nature of the service, and the control of services by individuals with psychiatric disabilities are all critical ingredients in peer support services (Solomon, 2004). Solomon (2004) also states that in order for these services to be most effective, peer providers should have experience with the mental health service system should be stable in recovery and should not be experiencing substance abuse problems.
Some authors have systematically examined the critical ingredients of peer delivered services within drop in centers and other consumer run programs. Holter, Mowbray, Bellamy, MacFarlane, and Dukarski (2004) conducted a survey to examine the critical ingredients of consumer run drop in programs. Their findings concur with those of Solomon (2004). They concluded that peer support programs must be: consumer run, consumer controlled, voluntary, focused on member self determination, acceptable (environment is acceptable and appropriate to the needs of the consumers), accessible, have freedom from coercion, offer respect, be flexible, facilitate referrals, focused on retention (i.e., tries to retain its members), do outreach, activities and services based on consumers’ needs, available (center’s availability is predictable and consistent), and focused on consumer satisfaction (consumers have ability to register satisfaction-dissatisfaction with the program).
Further, Holter and colleagues (2004) found that beliefs in empowerment (both group and individual), recovery, and advocacy underlie self help programs. Additional beliefs had to do with: the non-hierarchical relationships, active participation by members, choice, positive role modeling, and the ability to practice and improve skills (through participation in decision making for example). In terms of social support, they found the following critical ingredients: reciprocity, support, sense of community, self-help, awareness (improving understanding by sharing life experiences). Wituk and colleagues (2000) found in a survey of 253 self help groups that many groups rely on shared leadership but also receive assistance from professionals.
In an effort to operationalize the common ingredients of consumer run programs Johnsen, Teague and McDonel Herr (2005) conducted an empirical analysis of both consumer run programs and traditional mental health programs that were participants in the multi site study funded by the Substance Abuse and Mental Health Services Administration (see Campbell, 2004). Programs participating in this study included those administratively controlled by consumers, and thus would not cover all peer delivered services such as those where a peer specialist is added onto a traditional case management team. Through an extensive process of conceptualizing the common ingredients of consumer run programs and then determining how those ingredients could be measured, the authors developed a tool called the FACIT (Fidelity Assessment Common Ingredients Tool). In the end, after many iterative processes and visits to traditional mental health programs and consumer operated programs in the study, they defined the following elements of this tool: 1) the Program structure (including whether the program is consumer run, responsive to participants, linked to other supports); 2) the Environment of the program (including accessibility, safely, informality, and presence of reasonable accommodation); 3) the Belief Systems under which the program operates (including the peer principle, the helper principle, empowerment, choice, recovery, acceptance of diversity and a focus on spiritual growth); 4) Peer Support (including both formal and informal peer support, the ability of members to “tell their story”, consciousness raising, crisis prevention and peer mentoring and teaching); 5) Education (including self management and problem solving strategies, as well as other educational opportunities); 6) Advocacy (including self- and peer- advocacy).
Reissman (2006) described the 10 principles that guide the “self help paradigm”. Arguing that self help has revolutionized the concept of help, he discusses the importance of examining the effects of giving help on the helper as well as the helpee. The 10 principles are as follows: 1) social homogeneity –members possess social homogeneity, and they share a similar condition; 2) self determination—meaning that self help is determined internally by the individual or the self help community; 3) helper therapy and the re-structuring of help, i.e., giving help is the best way of being helped; 4) consumer as producer and consumer capital: consumers can give help at one point in time and receive help at another; 5) a focus on strength versus pathology; 6) non-commodification –self help is not a commodity to be sold and bought; 7) social support, i.e., a concept that is broader than self help and provides a buffer against stress; 8) Ethos, the values that emanate from self help groups are important; 9) the self help solution, that is, self help is not given by experts but by people with the same problem or condition and the act of seeking help is not stigmatized; and finally, 10) internality, that self help programs share an internal focus rather than relying on external interventions by experts. The emphasis is on what is internal to the individuals or community. It should be noted few if any of these principles advanced by Reissman or others have been the object of rigorous study.
Early evidence for the benefits of peer support
Humphreys (1997) found the following benefits from mutual help organizations: friendship and belonging, spiritual renewal, increased political activism, enhanced civil society (by encouraging diversity and offering ways of solving problems), reduced health care resource use. VanTosh and DelVecchio (2001) in their evaluation of 13 self help programs nationally, found anecdotal evidence that participation in self help increased self-efficacy, boosted social supports, enhanced employment and expanded members education and knowledge.
In 2001, Solomon and Draine examined the effectiveness data that existed at that time for consumer run programs. They examined three models of consumer services: consumer run or operated mental health services; “consumer partnership” services and “consumers as employees”. They concluded that there was insufficient data available to make a conclusion about the effectiveness of consumer delivered services. At the time, they concluded that only one study provided strong empirical evidence of the effectiveness of peer support services, that conducted by Paulson and his colleagues (1999). Solomon and Draine’s other studies provided some evidence of effectiveness (1995; 1996) and all of these studies are included in the current systematic review. Solomon and Draine commented on both the dearth of studies in this area and the lack of rigorous studies. They conclude that “at best, it the evidence to date seems to indicate that consumer delivered services have promise, but no conclusions can be reached about the effectiveness of consumer provided services.” (p. 26).
Simpson and House (2002) performed a systematic review of studies which involved users in the delivery and evaluation of mental health services. They performed an extensive electronic search for articles from 1966-2001 for articles that focused on consumer participation, and consumer organizations within mental health populations and agencies. They located 10 studies related to involving current or former users of mental health services as providers; all but one of these articles is included in the current systematic review. (They also found several articles related to users of mental health services as trainers or interviewers; those studies were not considered relevant for this review.) The authors concluded that users of mental health services, including individuals with serious mental illness, can be involved as employees of such services without adverse effects on the consumer/employees themselves. The authors suggested that individuals may need support to function as employees. They also concluded that most of the studies involving consumers as providers originated in the United States (the systematic review was conducted in the UK), had many methodological weaknesses, and had small numbers. They suggest that as of the date of their systematic review 2002, there was little evidence about the effectiveness of such consumer provided services and that more formal evaluations were needed.
In a more recent review, Davidson (2006) examined evidence for peer support services added to traditional services. He located 4 reviewable studies and concluded in three studies that there were no differences between the peer delivered service and the traditional services. In one study (Clarke, et al., 2000), peer services added to case management resulted in fewer hospitalizations and longer community tenure than traditional case management alone. He concluded that there is insufficient evidence to comment on the effective ingredients of peer support, but that there is data to suggest that adding peer services to traditional services “will not in any way compromise the quality or effectiveness of current services, while there may still be much to be gained…” (p. 449).
Pistang, Barker and Humphreys (2008) performed a review of “mutual help groups” for individuals with psychiatric problems. They identified three studies for individuals with mental illness and that investigated the effects of Recovery Inc, GROW and Double Trouble in Recovery. Though these were not controlled studies, they concluded that the results suggested that consistent attendance or longstanding membership in such mutual support groups was associated with improvement. They note that these findings could be a result of differential attrition and that randomized trials are difficult to use to study the effects of self help groups.
The Addition of Peer-Delivered Services
In terms of the broad adoption of peer delivered and self-help services, several authors have investigated this growing paradigm shift in mental health services. Salzer, McFadden and Rappaport (1994) conducted a survey suggesting that professionals hold attitudes which may interfere with their willingness to work with self help or mutual aid organizations. A much later survey reported by Chinman and colleagues (2006) within the Veterans Administration may reflect how the field has changed in terms of attitudes toward self help. Respondents, including providers and administrators of VA programs did acknowledge significant benefits of peer delivered services, though they also expressed several serious reservations. They found that the majority of patients, administrators, and providers were in agreement that peers could be helpful in the recovery of individuals with psychiatric disabilities, over and above professional services.
Peer delivered services for individuals with psychiatric disabilities have proliferated in the last three decades. As might be expected, early writings about peer programs explored the underlying values and philosophy of such services as well as various typologies and program models. There appears to be a consensus about the needed ingredients of peer delivered services and the critical values that must drive these services and programs. The role of the peer in the delivery of services has also been explored. To date, there are several early reviews of the effectiveness of peer delivered services that have been largely inconclusive or negative. Given the state of understanding of the field, and the studies available, a systematic review of peer delivered services appears warranted.
Measurement of Outcomes
Categorizing the outcomes examined in studies of peer delivered services is difficult because of the broad array of factors that such services are hypothesized to affect. The majority of outcomes in the studies in this review included:
- quality of life measures
- recovery attitudes
- perceptions of empowerment
- self confidence
- self esteem
- psychiatric symptoms
- criminal justice involvement
I. Experimental and Quasi-Experimental Studies of peer delivered services added to traditional services
Several studies suggested that adding peer delivered services to traditional mental health or to case management services does not result in significant differences in outcomes that favor the peer delivered services over traditional services. A small number of studies indicate advantages of peer delivered services in engagement and retention of individuals in services, but not in outcomes. These results suggest that peer providers may offer unique and distinctive skills and experiences that can be helpful in the engagement and retention of individuals in services, however, that evidence is modest. There is also evidence that peers may provide services differently in terms of the focus on face-to-face interactions outside of the traditional office milieu. Taken together, these studies do not provide clear evidence that peer delivered services when added to traditional services provide advantages in terms of client outcomes such as employment, perceived social support, criminal justice involvement, housing stability, working alliance, service use, re-hospitalizations, quality of life, or substance abuse. Several authors of these studies have suggested that these results should be interpreted as supportive of the notion that peer providers can deliver equivalent services to those of professionals, rather than expecting peer delivered services to out-perform traditional services.
a. Experimental Studies
- Kaufmann (1995) examined the outcomes of a project designed to test the effects of peer mutual support and self-help in conjunction with professional vocational rehabilitation services on employment using a sample of 161 individuals who were randomly assigned to either an experimental or a control group. Outcomes measured in intervals of six months included time to first job and earnings. Individuals assigned to the experimental group received a 5-stage model of intervention: a) engagement; 2) job skills training; 3) individual job seeking and support; 4) support; 5) graduate groups. Stages 1 and 2 were delivered by professionals and Stages 3, 4 and 5 were delivered by peers. Consumers randomized to the control group were given an information packet about vocational services and asked to continue with their customary services. All individuals in the study (experimental and control) were referred to the state office of vocational rehabilitation. Results suggested no differences between groups at the 6 month follow-up (19% of experimental and 16% of control groups were working at a paid job for 16 hours per week or more) but were significant at the 12-month follow-up (19% of experimental and 7% of control were working at a paid job for 16 hours per week or more). However, because the intervention was delivered by both professionals and peers, it is difficult to conclude that the differences observed were due to the peer delivered service.
- Solomon and Draine (1995) examined the two year outcomes and efficacy of a consumer case management team compared to regular case management. The study was conducted in an urban community mental health center providing a full range of outpatient, day program, and residential services. They examined differences in clinical outcomes, social outcomes and quality of life and concluded that there were no statistically significant differences in outcomes and that a service coordination model of case management services provided by consumers was as effective as that provided by non-consumers.
- In an early randomized study of the addition of peer support to traditional case management services, Solomon and her colleagues (Solomon, Draine and Delaney, 1995) found no differences between the case management delivered with the addition of peer support and without peer support in terms of the working alliance that was established between the client and the workers.
- No differences were found in the number of contact hours reported by family members of clients in the consumer delivered case management versus non-consumer case management. Family members felt that consumer case managers were less inclined to meet the medication assessment and monitoring needs of their ill relative (Solomon and Draine, 1994).
- No differences were found between clients served by consumer or non-consumer case managers in terms of the number of service contacts or total service units. This is despite the fact that differences were noted in the location, manner, and with whom services were provided (e.g., consumer case managers provide twice as many face-to-face service contacts when compared to traditional providers, provided fewer services in an office setting, and had more interaction with client family members (Solomon and Draine, 1996).
- O’Donnell et al (1999) found no differences between individuals receiving client-focused case management (with or without consumer advocacy) when compared to clients receiving standard case management on outcomes such as staff-rated measures of functioning, disability, medication compliance, treatment response, service compliance or the case manager’s perception of the client’s link to services. In addition, no differences were found for quality of life, satisfaction with services (as rated by the client), or number of days hospitalized.
- There were no differences between ACT teams with and without peer delivered services with respect to longitudinal risk for psychiatric hospitalizations, number of emergency room visits, or homelessness. While time to first arrest was shorter among usual care clients, the 34 day difference was interpreted as relatively minor. The small differences favoring the consumer ACT team in terms of hospitalization was explained by possible higher motivation among consumer providers to prevent their clients from being hospitalized (Clarke et al., 2000).
- Case management services provided by consumers compared to non-consumers were associated with equivalent client outcomes on measures of housing status, substance use, length of time homeless, physical health, level of social support, employment, income, criminal involvement, quality of life, victimization experiences, and therapeutic relationship (Chinman, Rosenheck, Lam, and Davidson, 2000).
- Rivera, Sullivan and Valenti (2007) found that strengths-based case management with peer enhancement, when compared to control conditions not involving peer delivered services, yielded similar outcomes for symptoms, use of health care, satisfaction, and quality of life.
- Clients receiving peer assisted case management reported feeling more liked, understood, and accepted by their providers than those receiving standard case management six months after entering treatment, but these effects were not apparent at 12 months. Participants receiving peer delivered services also showed an increasing number of contacts with providers during the early phase of treatment when compared to those receiving standard case management who showed a decreasing number of contacts (Sells et al., 2006; 2008).
b. Quasi Experimental Studies
- Felton et al, (1995) conducted one of the few studies in which clients served by teams with peer specialists demonstrated greater gains in several areas of quality of life and an overall reduction in the number of major life problems when compared with clients in the control groups. Clients served by teams with peer specialists also reported more frequent contact with their case managers and larger gains in the areas of self-image, outlook and social support.
- Schmidt, Gill, Pratt, and Solomon (2008) found no significant difference between the experimental (Intensive Case Management (ICM) with the addition of a consumer provider) and control groups (ICM with a traditional provider ) on retention in ICM services, number of face-to-face or failed contacts with case managers, hospitalizations, crisis center visits, housing stability, substance abuse, medication adherence, or mental health service use. There was some evidence that the consumer-provider intervention was better able to retain individuals in service with a diagnosis of schizophrenia or depression.
II. Studies of peer delivered services in groups
- There is some evidence that peer delivered services, provided in a group context, can be effective in engaging individuals and in improving outcomes. The peer delivered group interventions vary substantially one from another, making conclusions difficult to draw in this category. The data do suggest that individuals who “adhere” to group interventions (i.e., attend a substantial number of sessions) appear to benefit whether the intervention is more tradition in nature, is similar to AA, or is a different model altogether. Conclusions from one randomized study using intent-to-treat analyses (i.e., involving all subjects randomized) did not result in positive outcomes while two quasi experimental studies suggest some benefits of peer support delivered in a group. Observational and correlational studies, such as those done in drop in centers or in Double Trouble for Recovery groups, suffer from problems with attrition and loss to followup. Despite this, it is safe to conclude that of those people who regularly engage in peer delivered interventions in a group context, benefits do accrue in the areas of abstinence from substance abuse, stability of psychiatric symptoms, self esteem, self efficacy, empowerment, quality of life, perceived social support, satisfaction with services, medication adherence, and reduced criminal justice involvement. The extent to which attrition and selection factors affect these conclusions cannot be estimated, but do pose a threat to these conclusions.
Experimental and Quasi-Experimental Studies of peer delivered services in groups
- Examining a “citizen focused” intervention using a randomized design delivered by peers, Rowe, et al., (2007) found that those who received the intervention had significantly lower levels of alcohol use at 6 and 12 month follow-up points when compared to those who did not receive the intervention. There were no significant differences between groups for criminal justice involvement or drug use at follow-up. There was also no significant relationship between outcomes and attendance in the intervention classes with one exception (criminal involvement was negatively correlated with certain class attendance).
- Using a “minimally guided” group peer delivered intervention and a randomized design, Castelein, Bruggeman, van Busschbach, et al, (2008) found no differences in self efficacy, self esteem or quality of life between those receiving the intervention and the control condition when they examined all individuals randomized to both conditions. (The experimental intervention was a group intervention in which the group was lead by a peer but also in attendance was a nurse who provided informal and occasional guidance). There was minimal evidence to suggest that those receiving the experimental intervention experienced better social support. However, when they examined the data by high attenders versus low attenders in the intervention, they found significant differences on almost all outcomes, including some aspects of self esteem, social support, mental health confidence, and quality of life.
- Using both “intent to treat” and “as–treated” analytic approaches, Powell et al (2000) found that having a peer introduce the concept of group peer support and accompany an individual to their first self help group meeting was a significant predictor of later attendance. In the as treated analyses, the proportion of persons attending one or more times on their own was more than triple the comparison group where the individuals did not have the experimental intervention (i.e., the introduction or the accompaniment of a peer).
- Magura, Rosenblum, Villano, Vogal, Fong et al., (2008) examined Double Trouble for Recovery (DTR) groups using a quasi-experimental study design. They concluded that attendance at DTR groups for individuals with dual diagnoses of psychiatric and substance use disorders can improve substance abuse outcomes and medication adherence; they found no differences in psychiatric symptoms between groups attending and not attending DTR.
- Resnick and Rosenheck (2008) conducted a quasi experimental study of a “Vet–to-Vet” program using peer delivered group services. Using a fairly complicated study design with three cohorts, results suggested that the vets exposed to the Vet to Vet program had superior outcomes on measures of empowerment, self efficacy, and functioning.
Correlational studies of peer delivered services in groups
Double Trouble Groups
Laudet, Magura and their colleagues did a large longitudinal study of Double Trouble for Recovery—a group focused on dual recovery from substance use and mental illness. The following studies and publications were derived from that original study.
- In their initial publication Laudet and his colleagues (2000) found that higher levels of perceived social support and more participation in DTR meetings were associated with more successful recovery as measured by fewer mental health symptoms,
- Magura, Laudet, et al (2002) found that attending Double Trouble for Recovery (DTR) groups improved medication adherence. Better adherence to medications was significantly associated with an absence of an inpatient episode during the follow-up period.
- Magura and colleagues (2003), using the same study of attendees at DTR mentioned above found that the helper-therapy principal and reciprocal-learning activities of DTR were associated with better abstinence outcomes, independent of other attitudes and behaviors of the members. However, the authors found that the emotional support provided by group attendance was not related to outcomes.
- Similarly, Laudet, Cleland, Magura, Vogel et al., (2004) found that longer DTR participation during the first year of the study was associated with lower substance use at follow up and greater likelihood of abstinence after controlling for other important variables such as psychiatric symptoms.
- At a two year followup, Laudet, Magura, Cleland, Vogel et al, (2004) found that ongoing DTR attendance and greatly perceived social support were significantly associated with a greater likelihood of abstinence after controlling for other important variables such as psychiatric symptomatology.
- In 2007, Magura and colleagues found that degree of DTR affiliation (both in terms of attendance and involvement) was significantly associated with self efficacy for recovery and three quality of life measures (leisure time activities, perceived well being and social relationships).
Pre-Post Studies of peer delivered services in groups
- Lucksted, A., McNulty, K., Brayboy, et al., (2009) found that participants receiving a peer-to-peer mentoring classes (a structured, experiential group aimed at empowerment, wellness, and relapse prevention) showed significant positive gains in terms of self reported ability to manage their mental illness; their sense of confidence about their lives, and their and their sense of connection with others (this study however, had numerous threats as it was a simple pre post design).
III. Studies of Peer Delivered Drop-In Programs
- There is some evidence that peer delivered services provided in a drop-in center can be effective. Peer delivered drop-in centers vary substantially one from another, making conclusions difficult to draw in this category as with the group intervention category above. In addition, drop in centers frequently provide a myriad of services/functions/activities which are not completely described and quantified in these studies. Therefore, it is difficult to know which of such services are effective and what their essential ingredients may be. There are no published randomized studies of drop in interventions. Data from two quasi-experimental studies are equivocal. The observational and correlational studies do suggest that individuals who attend drop in centers regularly appear to benefit. Observational and correlational studies of drop in centers suffer from problems with attrition and loss to followup. Despite this, it is safe to conclude that of those people who regularly engage in peer delivered drop in services, benefits do accrue in the areas of hospitalizations, perceived social support, role involvement, goal achievement, empowerment, self-esteem, improved coping, and increased optimism. The extent to which attrition and selection factors affect these conclusions cannot be estimated, but do pose a threat to these conclusions.
Quasi Experimental Studies of Peer Delivered Drop-In Self Help Programs
- Nelson, Ochocka, Janzen and Trainor (2006) found marginally significant differences between groups in that active recipients of drop in services when compared to non-active participants had fewer emergency room visits and better quality of life. Significant differences were found in greater social support, greater instrumental role involvement and decreases in psychiatric hospitalization when examining changes from baseline to 18 months among active participants when compared to non-active participants.
- Burti, Amaddeo, Ambrosi, Bonetto, Cristofalo et al. (2005) concluded that there were no significant differences between those receiving the peer delivered drop in services and those not receiving the service in terms of global functioning, satisfaction with work or education, psychiatric symptoms, or functioning. The authors report that there was stability in the average number and severity of needs among the self help attenders but a worsening among the non attenders.
Correlational Studies of Peer Delivered Drop in/Self-Help Programs
- Mowbray and Tan (1993) in a very early study of the milieu of drop in centers found that respondents attending self help perceived people at the centers as being generally friendly, supportive, and helpful. They expressed pride about the group, felt close and intimate with each other, shared their thoughts and feelings, and believed that people were encouraged to make decisions on their own and have personal freedom. The people benefiting from the centers were mainly the intended target group: mental health consumers, many who had hospitalization histories.
- Chamberlin, Rogers and Ellison (1996) found that among individuals attending drop in centers, respondents reported feeling more positive about themselves as a result of self-help involvement having more respect for themselves, more productive and capable, better about themselves, and better able to recognize their strengths.
- Yanos, Primavera and Knight (2001) Found that psychological variables and involvement in consumer-run services were significantly associated with social functioning even when they statistically controlled for the effect of pre-morbid and demographic variables. Only partial support was found for the notion that the relationship between involvement in consumer-run services and community adjustment would be affected by the psychological variables.
- Segal and his colleagues published two related articles from a study of 4 drop in programs in San Francisco (Hodges and Segal, 2002; Segal, and Silverman, 2002).
Examining approximately 300 drop in attenders, they (Hodges and Segal, 2002) found that the majority of individuals reported having a goal to work on and at a 6 month followup, only 26% reported that they had not accomplished their goal and were no longer interested in achieving it. Only 19% reported having achieved their goal but this may be due to the magnitude of the goals set (residential, educational; Hodges and Segal, 2002). They found that having faith in professional help predicted goal achievement which the authors found to be counter to the self help philosophy. They also found that higher anger and impulsiveness scores were predictive of not achieving goals. The authors found that personal empowerment among the clients of the self-help agencies increased, independent social functioning remained the same, and assisted social functioning decreased during the 6 month follow-up period. Individuals who reported that they had a higher sense of control and empowerment in relation to their drop in center experienced better outcomes (Segal and Silverman, 2002).
- Brown, Shepherd, Merkle, Wituk, and Meissen (2008) found that among individuals attending 20 drop in self help centers in Kansas, the socially supportive and empowering experiences that participants participated in were related to progress towards recovery but that socially supportive experiences had a stronger relationship with recovery than empowering experiences.
- Nelson and Lomotey (2006) found among members of self help agencies that the quality, but not the amount, of participation was significantly related to perceived social support at 9 and 18 months and to community integration, quality of life (daily activities), and employment/education at 9 months.
- Brown (2009) found the following categories of self reported positive change among individuals attending drop ins: improved self-esteem and social skills, increased activity, improved coping and problem solving, increased optimism and increased conscientiousness (these are the top 5 only categories of personal change). Individuals reported that by increasing their social network and social support, by providing help through interpersonal interactions, work involvement, being in a positive atmosphere, and having access to recreational activities, that positive changes accrued to them. The author suggests that within drop in centers, the development of positive roles and relationships were fostered by: 1) resource exchange (opportunities for paid employment, social support, information); 2) self appraisal (self-esteem and optimism), 3) building role skills (e.g., social skills, job skills); and providing opportunities for identity transformation (e.g., independence).
IV. Experimental study of different models of Peer Support
For the one large study of peer delivered interventions using multiple models (i.e., drop in centers, mutual support groups, education and advocacy) and multiple sites, there is evidence that attendance in a peer delivered intervention was associated with global positive changes in well being.
- Campbell and colleagues (2004) conducted a study funded by the Substance Abuse and Mental Health Services administration. Participants in this large (n=1,827) (COS) multisite study were randomly assigned to consumer-operated service programs using three models of services: drop-in, advocacy and education, and mutual support programs/groups. They also received their traditional mental health services. Those receiving COS services were compared to individuals who received only traditional mental health services. Experimental participants showed greater improvement in well-being over the course of the study than participants randomly assigned to receive only traditional mental health services.
V. Experimental Studies of Residential Options
Only two studies were located involving peer delivered residential interventions and together they present equivocal evidence of outcomes. Service satisfaction does appear to favor the individuals receiving peer delivered services. For the two studies involving residential options delivered by peers there is modest evidence of effectiveness.
- Greenfield, Stoneking, Humphreys, Sundby and Bond (2008) conducted a unique study of a consumer run hostel inpatient program (CRP) when compared to a traditional locked inpatient unit for individuals presenting themselves for care in a psychiatric crisis. They found no differences between these two modes of care in terms of level of functioning and quality of life outcomes except for social activity which was higher. While the group receiving the consumer run services made greater gains in terms of symptom reduction, at the 1 year follow-up there were no differences between groups. Treatment satisfaction however was significantly different between the two groups with higher scores among the consumer-run condition.
- Dumont and Jones (2002) conducted a study of a hostel intervention that has not been published in the peer reviewed literature. The authors found that the participants receiving the peer delivered hostel residential service had better “healing outcomes” and greater empowerment at a 6 and 12 month follow-up. There were no differences in number of hours spent in paid employment or volunteering over the entire study period. The experimental group had greater levels of service satisfaction and significantly lower psychiatric hospital costs.
VI. Peer Delivered Services in a One-to-One Format
In the two studies that focused primarily (but not entirely) on one-to-one peer delivered services and particularly on social support, no differences were found between those receiving the intervention and those not receiving the intervention in terms of rehospitalization and social functioning.
a. Experimental Studies
- Davidson and his colleagues (2004) studied the effects of a peer delivered social support intervention. The results were complicated by the fact that intent-to-treat analyses produced no significant differences between experimental and the control groups. This may have been due to the fact that one-third of participants assigned to meet with a peer-partner did not do so regularly. Thus, results were reported for separately those who did and did not meet regularly with their assigned partner. Results are equivocal with outcomes suggesting improvement in social functioning and well being when participants did not meet with their peer. Satisfaction was similarly equivocal.
- Chinman, Weingarten, Stayner, et al., (2001) examined a “Welcome Basket” intervention that was peer delivered for individuals coming out of psychiatric hospitals. More information about intervention Analyses suggested no significant difference between participants receiving the Welcome Basket and those not in terms of number of readmissions to the hospital.
VI. Descriptive studies
Included in this section are studies that provided descriptive information about peer delivered services but that were not primarily designed to provide effectiveness information. They are included as a way of providing additional helpful information about peer support. Individuals were introduced to peer support while still hospitalized and upon discharge were offered a “welcome basket” (of food, plants, coupons, etc.) and offered social activities and transportation.
- Young and Williams (1988), performed a correlational study of GROW members, a group oriented 12-step program modeled after AA and developed in Australia. They examined demographics, presenting problems, and perceptions of the usefulness of the program using a 30-item questionnaire administered to all GROW members in Australia. They identified five groups who make up GROW membership in Australia. Cluster 1 members were middle-aged, married or widowed, in the low ranks of the occupational spectrum, and were seeking assistance with symptom management and recovery. Cluster 2 members were older and single or separated and were seeking social networking. Cluster 3 members were young and had experienced a wide range of life traumas that GROW had not been able to address. Cluster 4 members were older and likely to be widowed and reported that membership in GROW had done little to change their condition. Cluster 5 members were more likely to be middle-aged men who had no children, had higher occupational status, were better educated, and were newer GROW members. The study was mostly descriptive and has limited generalizability due to being conducted in Australia.
- Emerick (1990) found that development of partnerships with professionals among a national sample of self help groups varied significantly depending on factors of group structure, group affiliation, and service model. Emerick concluded in this study of 104 self help groups that “radical separatist” self-help groups, those structured to reject professional assistance, showed the lowest levels of interaction and the most negative attitudes towards professionals. The conservative groups had the highest levels of pro-professional attitudes and interactions with professionals. Group structure was a better predictor of levels of interactions than attitudes towards professionals and group affiliation better predicted attitudes than levels of interaction. Service model was associated with differences among groups as well. For example, therapy groups were more proprofessional and involved in interactive partnerships with professionals. Groups that adopt the social movement model of service are more anti professional and engage in low levels of interaction with professionals.
- Luke, Roberts, and Rappaport (1994) found that the median survival time (time attending the GROW groups) was 2.8 months. Persons who were most like the typical GROW member (educated, older, not married, and lower functioning) were most likely to return after the first meeting. Gender mix of the meeting was related to subsequent attendance patterns. Marital status and hospitalization history influenced participation patterns over time.
- In an early study, Segal, Silverman, and Temkin (1995) compared characteristics of clients at two self-help agencies (SHAs) to clients at two mental health clinics using administrative data found that a much higher percentage of persons served by the self-help agencies were homeless compared to the two mental health clinics, suggesting that SHA/drop in centers may appeal to individuals who are homeless. The populations served by the self-help agencies and by the clinics did overlap, however in some characteristics.
- Kessler, Mickelson, and Zhao (1997) found that self-help group participants are more likely than nonparticipants with the same problems to be young, female, white and unmarried. Participants generally have lower incomes than nonparticipants. Those reporting less support and more conflict in their social networks were more likely to participate in self-help groups than those with more supportive networks. Generally, those with a lower sense of personal control and higher levels of neuroticism were more likely to participate in self-help groups than their counterparts. The largest segment of lifetime self-help participants were people with substance use problems.
- Roberts, Salem, and Rappaport, et al., (1999) found, consistent with the “helper therapy” principle, that providing help to others predicted improvements in one’s own psychosocial adjustment; giving advice was a unique predictor. Total amount of help received was not associated with adjustment, but receiving help that provided cognitive reframing was associated with better social adjustment. A predicted interaction suggested that receiving help was related to better functioning when members experienced high levels of group integration.
- Powell and his colleagues (2001) found that among attendees of Manic Depression and Depression Association (MDDA) self help groups, predictors of psychosocial outcomes for people with mood disorders differ from those that predict symptom and recurrence outcomes. Daily functioning was positively related to employment and education. Management of illness was predicted by education.
- In a study comparing users of drop in self help agencies (SHAs) in San Francisco and comparing them to community mental clients, Segal, Hardiman, and Hodges (2002) found that clients of community mental health agencies (CMHA) had more acute symptoms, were more likely to have major depression, lower levels of social functioning, and more life stressors than clients of self-help agencies. The self-help agency cohort evidenced greater self-esteem, locus of control, and hope about the future. Clients of self-help agencies had received more services from facilities other than self-help or community mental health agencies in the previous six months, and clients of self-help agencies who were not African American had more long-term mental health service histories. Similarly, Segal, Hodges, and Hardiman (2002) found that the clients attending drop in/self help agencies clients were more likely to have been informally referred for services (via a friend or word of mouth), while CMHA clients were more likely to have been referred by a social worker or case manager; the SHA clients scored higher on perceived helpfulness of mental health treatment, lower on the fear of coercive care and lower on fear of inadequate care relative to the CMHA clients. CMHA clients were more likely to seek counseling and medication, while SHA clients were more likely to seek socialization, housing assistance and self-help ideology.
- Mowbray, Robinson, and Holter, (2002) found that consumer-run centers when compared to “consumer involved” drop in centers, reported more direct consumer control over decision-making and operations, were more likely to have received start-up assistance from other consumers or consumer groups and were more likely to have a mission statement and bylaws. More consumer-run drop-in centers had received monetary donations and consumer-run drop-in centers provided significantly fewer types of services. Consumer-involved centers also reported more problems with inconsistent attendance, women being uncomfortable at the center, and use of drugs or alcohol by center users.
- Hardiman and Segal (2003) examined factors predicting whether persons attending self help drop in centers would likely have a peer in their social network. They found that being African American was associated with not having a peer in one’s social network. Self esteem was a predictor of having a peer in one’s network and those with a higher sense of organizational empowerment were more likely to include individuals with psychiatric backgrounds in their social networks. No psychological variable (i.e., symptoms, empowerment, hope, self esteem, presence of dual diagnosis, attitudes toward psychiatric disabilities) predicted who would be in the individual’s social network.
- Mowbray, Holter, and Mowbray (2005) compared clubhouses to consumer directed initiatives (CDI) and found that clubhouses had a higher number of staff per consumer and a higher hourly budget per consumer served. Members of CDIs had more control over agency decisions. Clubhouses reported more services offered, roughly 75% of the services listed, while CDIs only offered roughly 50%. CDIs were found to better meet consumers need for “food and fun” compared to clubhouses. CDIs reported a higher level of weekend availability than clubhouses. While clubhouses reported that more members attended their program for social reasons than did directors of CDIs. They found significantly more within group variation in the CDI group (compared to the relatively more homogenous clubhouse group).
- Goering, Durbin, Sheldon, Ochocka, Nelson, et al. (2006) concluded in their study of consumer/survivor initiatives (CSI’s) that when compared to ACT programs that consumer programs serve a broader population of individuals who include a significant subgroup of persons with severe mental illness along with others with a mixed picture of higher functioning and greater instability. There is little overlap in the use of these modes of service delivery (CSI vs. ACT), which suggests that maintaining operations within systems of care is critical to ensuring coverage and access for the broader population.
This systematic review was performed to add to the body of knowledge about the effectiveness of peer delivered services. Results overall remain equivocal for the question of effectiveness of peer delivered services. Peer delivered services may fill a unique niche in the array of mental health services, may complement such services and may add to the service array in a way that cannot be accomplished by the delivery of traditional mental health services. Evidence does suggest that peer delivered services when added to traditional services can be as effective as those services delivered by professionals. If individuals engage sufficiently in group delivered peer services they also accrue benefits. Overall however, there is not sufficient evidence about the effectiveness of many peer delivered services.
This systematic review was hampered by a lack of description of the peer delivered activities, services and supports being provided, a lack of information about the intensity of those services and supports, and little information about the models and contexts of the service delivery. In essence, authors often provided insufficient information on the fidelity of the services and the service environment. These factors made it difficult to perform this systematic review. If the field is to move forward and be adequately reviewed as an evidence-based practice, future research activities should focus on improving the state of our understanding of peer delivered services. The following items, if addressed, could assist in this way:
- More complete descriptions of the peer delivered services including: the who, what, when, where, and how of the service/support elements being delivered (e.g., “one-to-one contacts for the purposes of transporting peers to critical appointments”, “group sessions focused on stigma”; etc.).
- More complete descriptions of the persons delivering services including the demographic characteristics of the peer support specialists, their educational background, and information about their training in peer delivered services.
- The intensity of services received during the evaluation or research period along with the types of services (e.g., information about the number of units of services delivered, groups run, meals provided, etc).
- A full description of the context of service delivery (e.g., to say simply that the services were provided in a drop in center is insufficient in terms of detail; information should be provided about the inputs and processes of the agency or organization).
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