Peer Support for Youth and Young Adults who Experience Serious Mental Health Conditions: State of the Science
Peer support for youth and young adults who experience serious mental health conditions (SMHCs) is rapidly growing in popularity as an addition to the mental health service array in communities around the United States. Research focusing on various aspects of the youth/young adult peer support role has been accruing in recent years; however, many questions remain regarding how the role is defined and supported, and what sort of outcomes can and should be expected once peer support is implemented as a service. This brief reviews the research literature that bears on these topics, describes how current work at Pathways RTC is helping to build new knowledge about peer support, and outlines implications for a research agenda going forward.
"Peer Support for Youth and Young Adults who Experience Serious Mental Health Conditions: State of the Science" (2018)
By Janet Walker, Caitlin Baird, & Mary Beth Welch
Peer Support Roles and Functions
Peer support is a quickly emerging workforce in mental health services generally (Cronise, Teixeira, Rogers, & Harrington, 2016; Lloyd-Evans et al., 2014; Myrick & del Vecchio, 2016), and increasing its availability has been advocated by service users, researchers, and government commissions (Faulkner & Bassett, 2012; Halvorson & Whitter, 2009; Myrick & del Vecchio, 2016; U.S. Department of Health and Human Services, 2004). Peer support is based on the idea that people who have experienced and overcome a particular type of adversity can serve as source of support, encouragement and hope to others experiencing similar situations, and may also be uniquely positioned to promote service engagement (Davidson, Chinman, Sells & Rowe, 2006; Myrick & del Vecchio, 2016; Lloyd-Evans, et al., 2014).
There has been speculation in the research literature that peer support may be uniquely useful in the context of providing services to youth and young adults with SMHCs, because existing services and systems do not adequately attract, engage or serve young people (Biddle, Donovan, Sharp, & Gunnell, 2007; Davis, 2007; Jivanjee, Kruzich, & Gordon, 2007; Vogel, Wade, & Hakke, 2006). What is more, systems- experienced young people themselves see peer support as one of the most important remedies for these service deficiencies (Strachan, Gowen, & Walker, 2009; Walker, et al., 2013). Peer support may also be uniquely helpful in a bridging/brokering role with youth and young adults because of peers' potential to help build better understanding between adult providers and young people receiving services, and to assist young people in navigating through disconnected child and adult service systems (Gopalan, et al., 2017).
To date, most of what has been hypothesized regarding unique aspects of the youth/young adult peer support role remains speculative, and there has been little theoretical clarification of specific ways in which peer support for young people might differ from peer support for adults in general. However, this has not deterred researchers and providers from starting to explore—and to some extent, to evaluate— a variety of roles and functions for youth/young adult peer support providers. In a recent scoping review, Gopalan and colleagues (Gopalan et al., 2017). identified from published and unpublished literature a total of 30 programs that included a youth/young adult peer support component. Of these, 20 included peer support as a part of interventions or programs that were provided by non-peer providers, and that were intended to improve emotional/behavioral functioning and/or to support transition to adulthood. The remaining 10 programs were fully peer delivered, and all focused exclusively on advocacy for systems change. Gopalan and colleagues identified the functions performed by peers in the programs, with the most common function being instruction/ skills development/mentoring (present in 24 of the 30 programs), followed by information, advocacy and action planning/priority setting (present in 18, 17 and 11 of the programs, respectively). As the article points out, these functions had previously been identified in the adult peer support literature, so while the scoping review does clarify the functions that are most typically included within the peer support roles, it does not provide information about whether or how these roles may be qualitatively different from adult peer support roles.
Research on Impacts of Peer Support
Despite the growing popularity of peer support in mental health services, there is only limited evidence of its effectiveness, and research assessing effectiveness comes almost exclusively from studies examining peer support for adults. The most rigorous research available, as summarized by Lloyd-Evans et al. (2014), provides "little evidence" of effectiveness. However, less rigorous studies have have found that peer support services can have positive impacts in a variety of areas, including hope and belief in the possibility of recovery; empowerment and increased self-esteem; self-efficacy and self-management of difficulties; social inclusion; engagement; and increased social networks (Repper & Carter, 2011; Davidson, Bellamy, Guy, & Miller, 2012). Additionally, there have been a number of studies comparing peer and non-peer staff who are functioning in the same conventional service provider role, e.g., case manager, rehabilitation staff, or outreach worker. In these studies, peer staff were generally found to perform at least as well as non-peer staff; what is more, a subset of studies found that peer staff were actually superior in terms of promoting outcomes in areas such as engagement, and reductions in hospitalizations and inpatient days (Davidson et al., 2012).
Virtually no research addresses the impact of peer support implemented specifically for youth or young adults with SMHCs (Gopalan et al., 2017). However, Ansell and Insley (2013) list a number of programs, not specifically mental health programs, that incorporated peer support services for youth, and that reported positive evaluation findings; and Radigan et al. (2014) found that young people with mental health conditions who had access to peer advocates—as compared to those who lacked such access—had more favorable views regarding access to services, appropriateness of services and participation in services, as well as higher overall/global satisfaction. Regarding the 30 programs included in their scoping review, Gopalan, et al. concluded that "this review manifested that few programs employed rigorous research designs, with only three (10%) programs using randomized controlled designs. At the same time, none of these studies were designed to evaluate the unique contribution of [youth peer support services] in the context of other program components, nor were there specific hypotheses testing particular models of peer services. (p. 105)"
Challenges in Research and Implementation
Discussions of the implications of existing research are remarkably consistent in their descriptions of the challenges that need to be overcome in order to ensure high quality research and implementation for peer support roles in mental health. As might be expected, given that the bulk of the literature on peer support in mental health focuses on adults, most of the recommendations are neither specific to—nor specifically inclusive of—youth/young adult peer support. However, where recommendations specifically for youth/young adult peer support do exist they tend to echo those for adult peer support. Some exceptions to this general pattern are noted within the relevant topics, below.
Understanding the Role
Not surprisingly, given documentation of the wide range of roles and functions that are described as peer support, a frequently-cited challenge is the lack of specification regarding peer support role/s. For example, both Repper and Carter (2011) and Lloyd-Evans, et al. (2014) cite the lack of clarity regarding the peer support role/s as a main barrier to better research and to wider and more effective implementation of peer support within the array of mental health services. Kemp and Henderson (2014) and Daniels, et al. (2010) make a similar point, highlighting the need to provide clarity around peer support role expectations. Indeed, qualitative research confirms that peer support providers are themselves unclear about their roles and tasks (Cronise et al., 2016; Kemp & Henderson, 2014). Regarding peer support for youth and young adults specifically, role clarity is also consistently mentioned as a challenge (Delman & Klodnick, 2017, 2016; Gopalan et al., 2017), and one that contributes to several other challenges as described below.
Challenges stemming from a lack of role clarity are compounded by a lack of clear specification regarding the mechanisms of change and the unique contribution of "peerness" (i.e., the unique aspects of peer roles) to outcomes, both for adult peer support providers and for youth/young adult peer support providers specifically (Delman & Klodnick, 2017; Gopalan et al., 2017; Silver, Nemec, & Hampshire, 2016). This leads to recommendations that the next phase of designing and evaluating peer support interventions (or intervention enhancements/ add-ons) should include a focus on understanding and capitalizing on what is unique to the role; as well as a focus on measuring the outcomes that should be most particularly influenced by the receipt of peer support, such as hope, empowerment, self-esteem, self-efficacy, treatment engagement/ therapeutic alliance, and social networks (Gopalan et al., 2017; Delman & Klodnick, 2017). However, efforts to clearly define peer support roles are complicated by fundamental philosophical arguments regarding extent to which clarifying and standardizing the role may undermine its effectiveness as a form of support that is qualitatively different from non-peer services; yet without standardization and the ability to assess fidelity, it is unclear how to ensure that peer support roles will be carried out with high quality (Rogers & Swarbrick, 2016; Silver et al., 2016).
Training and Supervision
A lack of clarity regarding peer support role/s contributes in obvious ways to difficulty in training and supervising peers to undertake the work. Similarly, the lack of clarity regarding specific mechanisms of change gives rise to challenges around training and supervision for issues related to peerness, and specifically how to operationalize in practice what are generally seen as core functions of the role, such as inspiring hope, role modelling, building social networks and strategic self-disclosure (Gopalan et al., 2017; Delman & Klodnick, 2016; Myrick & del Vecchio, 2016).
For peer specialists, it is ideal that they be supervised by someone who has previously held the role and who has worked as a peer specialist, though this is rarely the case (Silver, Nemec, & Hampshire, 2016). Thus, supervisors are often seen by peer support providers as not clearly understanding the peer support role, which makes it difficult for supervisors to provide support and skill development, particularly relative to the unique aspects of peer roles, and contributes to conflicting role expectations (Kemp & Henderson, 2014).
Regarding youth and young adults specifically, there is recognition that training and supervision should be tailored to young adults' unique needs and stage of development (Gopalan, et al., 2017; Delman & Klodnick, 2016, 2017). What is more, young adult peer support providers often have limited or no prior work experience, and thus need support in developing professional skills such as time management and communication skills (Research and Training Center on Pathways to Positive Futures, 2013a). Thus, existing training and supervision strategies utilized in adult and family peer-to-peer models likely need significant adaptation in order to be optimal for young adults.
Relationships with Colleagues
Numerous commentaries in the literature point to significant friction between peer and non-peer staff as one of the central challenges to implementing the role successfully. A lack of role clarity is cited as a significant contributor to this problem. Often, organizations do not clearly understand and/or articulate the role and value of the peer support providers to other staff. This can result in a variety of misunderstandings that can lead to non-peer staff members stigmatizing, ostracizing or disrespecting peer staff (Cronise et al., 2016; Daniels et al., 2010; Dixon, Krauss, & Lehman, 1994; Kemp & Henderson, 2014; Myrick & del Vecchio, 2016). Indeed, one study focused on the perceptions of peer staff found that their top work-related challenge was non-peer staff members' lack of understanding of the peer support role, which led peer staff to experience a sense of exclusion. These tensions are likely even more pronounced for young adult peer support providers, who report feeling ignored and belittled by colleagues, which in turn can lead to increased job stress (Delman & Klodnick, 2017).
Response to Challenges, Research at Pathways RTC, and Next Steps
Anecdotal evidence and information from the internet indicates that there are a number of stakeholder groups engaged in responding to these challenges. In particular, work is underway to adapt existing adult peer support curricula to be more developmentally appropriate and to better meet the training needs of young adult peer support staff; however, evaluations of these efforts have yet to be published.
Providing high-quality, developmentally appropriate training is not likely to be sufficient for producing skilled peer support, however. It is generally known that training alone, while it may increase knowledge, is extremely unlikely to produce skilled practice (Davis & Davis, 2009; Sholomskas, et al., 2005; Lyon, et al., 2011; Carroll & Rounsaville, 2007; Beidas & Kendall, 2010). In contrast, effective training approaches often involve multifaceted strategies including a treatment manual, multiple days of intensive workshop training, ongoing coaching, live or taped review of client sessions, supervisor trainings, booster sessions, and the completion of one or more training cases (Herschell et al., 2010). The follow-up coaching—provided either by designated coaches or by supervisors—is particularly essential for learning new practice, and should include observation of practice (either live or via audio- or video recording) and provision of feedback in a manner that is connected to the intervention theory and based on objective criteria (Beidas & Kendall, 2010; Garland, 2013; Herschell et al., 2010; Milne et al., 2011; Rakovshik & McManus, 2010).
This kind of comprehensive support is likely even more important for young adults training to be peer support providers, since they do not have prior experience delivering interpersonal interventions. However, providing comprehensive support for skill acquisition is likely to be particularly difficult for young adult peer support providers, since, as noted previously, organizations find it difficult to access coaches, trainers and supervisors who have provided peer support in the past, and who understand the role and how to build skills that are particular to the unique aspects of the role. More generally, the cost of providing comprehensive support has proven to be a major barrier to implementation of training and coaching best practices (Herschell et al., 2010; Lyon et al., 2011).
Pathways RTC is exploring a response to these challenges by developing and testing an enhancement for the youth/young adult peer support role called AMP+. AMP+ is an adaptation and extension of the empirically-supported Achieve My Plan enhancement (i.e., "original" AMP; Walker, Seibel, & Jackson, 2017) that is designed to be implemented by providers who work with youth and young adults to build self-determination and create person-centered plans (e.g., transition, treatment, Wraparound or other types of service/support plans). AMP+ responds to challenges noted here by providing a clear model for practice and reliable fidelity assessment; comprehensive training and coaching via the internet and a proprietary web-based platform so as to comply with best practices while keeping costs down; training and coaching provided by peers experienced in these roles; and clear definition of skills related to "peerness." In a recently completed study, peer support providers participating in AMP+ enhancement demonstrated significant increase in relevant skills, decreased job stress, and increased confidence in their capacity to promote self-determination and to support young people to create and carry out plans and activities in service of personally meaningful goals. More information on the AMP+ study can be found in the project description.
In sum, while there are many challenges associated with implementing peer support for youth and young adults, there are also well-informed and creative responses to these challenges being developed. This work contributes to optimism that peer support programs can and will be successful when peers are provided with appropriate practice models, training and supervision; when mental health professionals are educated about the roles and benefits of peer support; and when measures are taken to reduce peer support providers' isolation by ensuring that they are seen as a critical part of efforts to promote mental health and wellness, as well as successful transitions to adult roles and responsibilities.
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Walker, J.S., Baird, C., & Welch, M.-B. (2018). Peer Support for Youth and Young Adults who Experience Serious Mental Health Conditions: State of the Science. Portland, OR: Research and Training Center for Pathways to Positive Futures, Portland State University.