Peer Support in Integrated Health Settings Leads to Better Community Mental Health
Inside this story:
- Certified Peer Support Specialists share their lived experiences of mental illness and recovery to give others hope, support and tools for their own mental health journeys.
- Although more than 1,500 Peer Support Specialists have been certified in Texas, a general lack of understanding around the qualifications and functions of peer support services in primary care settings can make it difficult for health centers to implement the model.
- Hope Family Health Center (HOPE) was one of three community health centers to receive funding in 2015 through the Hogg Foundation’s Advancing Peer Support in Integrated Health Care grant program.
- Grantees use an integrated health care approach to incorporate Certified Peer Support Specialists into their broader ecosystem of health care and mental health supports, and thus into their communities and the Texas mental health workforce at large.
Texans Without Health Insurance
In 2015, Elsa Roman was suffering from severe depression and urgently seeking help. Like more than 4.5 million fellow Texans, she didn’t have health insurance—a barrier that prevents many people from accessing health care and clinical services that address both their physical and mental health conditions.
When a friend told Elsa she might find solace in laughter yoga, her subsequent search for a session led her to Hope Family Health Center (HOPE). The McAllen-based primary care clinic and counseling center provides free services—laughter yoga among them—to medically uninsured residents of the Lower Rio Grande Valley in Texas.
Recalling the first time she walked through their doors, Elsa says, “I told myself, I know that place is going to help me.” After a couple months as a client, she regained her ability to hold a job and began volunteering at the clinic. Today, she serves as their Peer Support Specialist Coordinator.
The term “peer support,” according to Hogg Foundation grantee Via Hope, is “the act of people who have had similar experiences with mental health challenges giving each other encouragement, hope, assistance, guidance, and understanding that aids in recovery.” As a peer, Elsa’s style of caregiving is more flexible and less specialized than that of a traditional mental health provider. Rather than relying on schooling or expertise for credibility, Peer Support Specialists use lived experience and “day-to-day empathy,” in Elsa’s words, to reach the hearts and minds of clients.
The same year Elsa began her recovery journey, HOPE became one of three community health centers to receive funding through the Hogg Foundation’s Advancing Peer Support in Integrate Health Care grant program. The grantees, which include Project Vida Health Center (El Paso, Texas) and Gulf Coast Health Center (Port Arthur, Texas), used an integrated health care approach to incorporate certified Peer Support Specialists like Elsa into their broader ecosystem of mental health supports. Clients already receiving counseling and medical services at HOPE can now be referred to the Peer Support Department, where they gain access to peer support groups (known as “empowerment groups”) and one-on-one visits with peers.
“If you have a broken leg, you need a cane. Peer support is your cane. You might need surgery for your leg—that’s counseling.”Elsa Roman
Peer Support Specialist Coordinator, Hope Family Health Center
Peer support is an evidence-based practiced with a growing body of research behind it, and as of May 2018 all but five states have either established peer training and certification programs or are in the process of doing so. Although the model has come a long way since 2001, when it earned state recognition for the first time, a need for greater clarity around the boundaries of the peer support role can make it difficult to implement and evaluate.
If an agency’s organizational culture isn’t already rooted in person- or recovery-centered principles, onboarding even one of Texas’ 1,500-plus Certified Peer Specialists will inevitably challenge—if not upend—the preexisting status quo.
Not surprising, then, that Elsa’s arrival was initially greeted with some resistance from her clinic’s counseling team, who questioned the ethical implications of the arrangement. As Rebecca Stocker, Licensed Clinical Social Worker (LCSW) and HOPE executive director, points out, “There’s a lack of conversation about the role that a counselor can play and a peer can play together in one organization.”
Until that conversation becomes commonplace, extensive education and advocacy efforts—both in the workplace and in the community—are needed for patients, health care providers and local mental health authorities to understand and eventually embrace peer support services. To help accomplish this, HOPE devotes a significant amount of time and resources to organizing community events and investing in media advertising. Elsa translates all educational materials into Spanish, the primary language spoken by about 85 percent of HOPE clients.
Rebecca also cites the valuable contributions of consultant and advocate Anna H. Gray, whose Prosumers International peer support groups meet across the state. To stay abreast of developments in the peer world and maximize impact on the ground, Elsa and Rebecca travel to conferences and forums where best practices and new ideas are exchanged. Elsa speaks, she says, “wherever they give me the mic.”
“Educating the community on behavioral health sometimes makes people more aware of their need for support, and that need for support turns into using our services.”Rebecca Stocker
Executive Director, Hope Family Health Center
Community Impact of Peer Support
In her empowerment groups, Elsa sometimes facilitates discussions about famous cultural and historical figures whose legacies are as daunting as they are inspiring. Turning the dialogue back on participants, she asks, “What’s the difference between those people and us?”
The question makes it clear that Elsa not only recognizes the validity of their position, but has also been there—and from time to time still finds herself returning to that place. Though Elsa can’t offer professional therapy, the empathetic voice of confidence she provides as a peer reinforces the possibility of recovery and does wonders for her clients’ self-esteem.
“Within peer support groups, people create their own emotional support groups. They start talking with each other, exchanging numbers, sharing rides, bringing food.”Elsa Roman
Eventually, the sense of agency and belonging individuals discover through regularly attending meetings begins to surface elsewhere. In other words, Elsa says, “People stop coming to the groups because they go back to their lives.” Whether it’s reentering the workforce, securing stable housing or making vital social connections, helping participants find something to live and hope for is the ultimate goal.
Since implementing peer support services, HOPE has assisted community partner El Milagro Clinic in adopting their own version of the model and becoming part of the peer support network. A Methodist Healthcare Ministries Sí Texas grant, leveraged by the Hogg Foundation grant, made it possible for HOPE to officially become a fully integrated behavioral health clinic in 2018.
Today, Elsa’s role at HOPE continues to evolve in exciting ways. She runs the newly launched HOPE Peer Support Warmline, a toll-free, non-crisis line that helps her connect with and give emotional support to people all over the Rio Grande Valley community. The Warmline was funded through an Texas House Bill 13 grant using matching funds from their Hogg Foundation grant.
“I would like everyone to know that recovery is possible. During your life, you hear so many negative things—you’re worthless, you’re a failure. We need to retrain our brains to receive the good message.”Elsa Roman
Peer Support Specialist, Hope Family Health Center
“HOPE has done a terrific job incorporating peer support. It’s shifting the health care organizational culture to a truly recovery-oriented, whole health approach,” says Hogg Foundation Program Officer Rick Ybarra. “The Si Texas grant and Texas House Bill 13 awards are a testament to their tremendous efforts. Peers provide an
Open Dialogue and Intentional Peer Support: Experiences of Parachute NYC Enrollees
Study finds positive experiences with the Parachute program in New York City, which combined Open Dialogue and Intentional Peer Support.
A new study investigates how a combination of Open Dialogue and Intentional Peer Support was experienced by clients and network members receiving services through the Parachute program in New York City. The Parachute program was designed as an alternative to standard psychiatric care that could respond to psychiatric crises with home visits and network meetings. The results of the new study, published the Community Mental Health Journal, show that participants valued the lack of hierarchy in teams, the accessibility of receiving care in their home environment, and had positive experiences with peer specialists.
“For most,” the authors write, “the network meetings appear to have provided a route by which those experiencing distress and their networks could take time to reflect, be heard, and gain a better understanding of what each other were going through.”
The Open Dialogue approach was developed in Finland in the 1980s as a form of psychotherapy and a way to organize mental health systems. The approach, originally designed for persons experiencing psychosis for the first time, relies on network meetings where family members and other natural supports are invited to a joint forum where language can be created to deal with distressing and difficult situations.
Network meetings usually happen in the home environment, and teams are composed of at least two therapists. Observational studies of the approach show that, in Wester Lapland, Finland, around 80% of persons experiencing a first episode psychosis recovered after receiving Open Dialogue.
The research conducted by the developing team in Finland has attracted international attention for their remarkable outcomes. Since then, several countries have adapted and implemented the Open Dialogue approach in different ways.
Parachute NYC was launched in 2012 to provide a “soft landing” for persons experiencing a psychiatric crisis. The program was funded through a federal grant from the Centers of Medicaid and Medicare Services and provided services through mobile teams and respite centers. Mental health professionals worked alongside peer specialists to offer network meetings to individuals and their natural supports who were 16 years of age or older, had received a diagnosis of a severe mental illness, and had at least one network member who agreed to participate in meetings.
All staff were trained in both Open Dialogue and Intentional Peer Support. Intentional Peer Support is an approach developed by and for peers and focuses on relationships and mutuality to foster hope and partnerships during times of crisis. The combination of Open Dialogue and peer support had never been attempted before Parachute. However, it is now being tested in a large randomized clinical trial in the UK.
Network meetings included mental health professionals and a peer specialist. The needs of the persons served determined the frequency, format, and content of the meetings. The sessions invited multiple perspectives in a non-hierarchical way to ensure that all voices were heard and dissonance respected.
Professionals engaged in the technique of reflection, where they discussed concerns among each other while the network listened and was invited to comment, increasing transparency in decision-making processes. Use of medication and inpatient treatment were openly discussed, hospitalization was seen as a last resort, and the respite centers were utilized when needed.
While there is an increasing number of Open Dialogue-informed programs being developed in the United States and other countries, research into how these programs can benefit individuals is still lacking. Considered by many to be an approach aligned to the human rights paradigm in mental health, the Open Dialogue approach was largely successful in Finland in reducing hospitalization, avoiding over-medicalization, and fostering recovery.
This study offers insight into how participants of Parachute experienced the program and is an essential contribution to the literature to support further development of Open Dialogue-informed programs.
The study described the experience of Parachute enrollees and their networks through qualitative interviews. Interviews were audio-recorded and transcribed, and researchers explored the themes that emerged from the data. Researchers sought to explore the following questions with participants:
- How the features of Parachute were received by participants, such as home visits and having a peer specialist present;
- How care received through Parachute was experienced compared to previous treatment experiences;
- How Parachute facilitated or did not facilitate changes in perceptions of self and relationships. Eighteen individuals were interviewed.
Their results show that participants had positive experiences with the network meetings and the availability of the Parachute team. Comparing the experience of Parachute with hospitalization, participants stated that home-based care was less intimidating, in the words of one participant:
“It was important to do it [hold network meetings] in a setting that was like a safe place for us, intimate, you know–home.”
The study reports participants experiencing the presence of peer specialists in network meetings as generally positive. Participants noted that the presence of a person with lived-experience offered a unique perspective to the treatment. Additionally, having more than one therapist in the room was welcomed by participants as this quote illustrates:
“stronger support…two brains thinking at the same time.”
Finally, participants acknowledged how network meetings changed the way they saw themselves, contributing to new ways of understanding experiences and developing coping mechanisms. Including the natural supports of persons at the center of concern was described as having a ripple that benefited the entire network. Some participants felt that there was a lack of structure in the meetings, and there was some concern related to how the medication was handled by the teams.
The authors concluded that overall, the Parachute program was well received and positively viewed by participants with instances of discomfort related to the novelty of the approach compared to more traditional treatment modalities – such as meetings where no one plays the expert role and discussions about medication not necessarily taking center stage.
This study provides evidence that the combination of Open Dialogue and Intentional Peer Support was well received by Parachute participants. More importantly, it shows that a psychiatric crisis can be dealt with in a community setting by mobilizing natural supports and creating a safe environment for all.
In contrast with current approaches to crises that involve the police, involuntary treatment, hospitalizations, and rely mostly on medications, the Parachute program offered an alternative that may be more aligned with the needs and wishes of persons experiencing extreme states and their families. The current research in the mental health field is still primarily focused on randomized clinical trials as the gold standard for high-quality evidence. However, qualitative studies like this show that in-depth explorations of individual experiences offer great insight about treatment that goes well beyond the usual outcomes defined by professionals and researchers.
There has been an ongoing debate in the field as to the quality of the evidence to support the implementation and expansion of Open Dialogue-informed programs. While one randomized clinical trial is underway in the UK, qualitative studies such as this are well suited to investigate in depth how participants experience different types of treatments in ways that RCTs can’t possibly capture. This points to a need to re-examine the dominance of the medical model in research in mental health and contributes to a rich body of evidence that values people’s experiences and helps close the gap between research and real life.
invaluable support to persons with mental health conditions and their recovery journey.”