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Individual Peer Support: A Qualitative Study of Mechanisms of Its Effectiveness

Article  in  Community Mental Health Journal · December 2014

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Vasudha Gidugu1, E. Sally Rogers1, Steven Harrington1, and Mihoko Maru1, Gene Johnson2, Julie Cohee2, and
Jennifer Hinkel2
1
Boston University

Center for Psychiatric Rehabilitation

940 Commonwealth Ave West

Boston, MA 02215
2
Recovery Innovations

2701 N. 16th Street, Suite #316

Phoenix, AZ 85006

Corresponding Author:

Vasudha Gidugu, Boston University Center for Psychiatric Rehabilitation, 940 Commonwealth Ave W, Boston, MA
02215, USA

E-mail: [email protected]

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication
of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and or publication of
this article: Funding for this study was provided by the National Institute on Disability and Rehabilitation Research
and the Substance Abuse and Mental Health Administration to the Center for Psychiatric Rehabilitation.
 Abstract
Peer-delivered services for individuals with psychiatric conditions have proliferated over the past three decades. The

values and principles underlying peer support have been explored, but we lack an understanding of its mechanisms

of action. To shed light on the processes of peer support, we conducted a study with individuals who had received

substantial individual peer support. We completed individual interviews, audiotaped, transcribed, and examined

them using a thematic analysis approach. Our analyses suggest that individual peer support provided various

practical, emotional, and social supports which were perceived as beneficial. Participants valued having someone to

rely on, a friend, and someone to socialize with. We, however, found that individuals’ expectations of peer support

did not always comport with available services. Participants viewed peer support as especially valuable because of

the opportunity for a non-treatment based, normalizing relationship. We conclude that peer support complements

rather than supplants needed traditional mental health services.

Keywords: boundaries; lived experience; mental health and illness; health care, user’s experiences; social support
Introduction

Peer support began proliferating in the mid 1900’s with the advent of Alcoholics Anonymous and other 12-step

programs that are arguably the “oldest and most pervasive” of peer programs (Solomon, 2004). Such programs were

viewed as a response to the limited effectiveness of traditional services and were also intended to draw on the power

of individuals to offer mutual support, solace, learning, and assistance (Campbell, 2005). Eventually, 12-step

programs evolved beyond substance abuse and addiction to address the needs of mental health consumers through

groups such as Schizophrenics and Emotions Anonymous (cf., Salem, Gant, & Campbell, 1998) and grew

dramatically over the next decades (Clay, Schell, Corrigan, & Ralph, 2005). Today, peer support is offered through

many different service delivery models where individuals with a “lived experience” with psychiatric problems

provide support to others with a psychiatric condition (Chinman et al., 2014; Lloyd-Evans et al., 2014). Peer support

services and programs use an array of program models and have a variety of funding streams, but they tend to have

similar missions, values and goals (Campbell, 2005).

The core values and philosophy that are critical for and inherent in peer and mutual help include:

nonhierarchical relationships, choice, positive role modeling, reciprocity, support, a sense of community

(particularly in programs such as drop in centers), self-help, and self-determination (Holter, Mowbray, Bellamy,

MacFarlane, & Dukarski, 2004; Johnsen, Teague, & McDonel-Herr, 2005; Riessman, 1998). According to early

authors peer support encompasses both emotional support and instrumental or practical support (Gartner &

Riessman, 1984) and is intended to be mutually beneficial through a reciprocal process of giving and receiving

(Mead & MacNeil, 2006). As stated by Copeland and Mead (2004, p.10) “peer support is not like clinical support,

and it is more than being friends. In Peer Support we understand each other because we’ve “been there,” shared

similar experiences and can model for each other a willingness to learn and grow.”

Solomon (2004) hypothesized that peer support was effective through processes such as social and

emotional support, experiential or reciprocal learning, social learning (e.g., role modeling), and mechanisms related

to social comparison theory (e.g., the sense of normalcy provided by sharing with individuals who have had similar

experiences, “upward comparison” and the offer of hope and optimism, “downward comparison” and the

recognition that things could be worse). However, in order for peer support to become an evidence-based practice,

we need to know more about its mechanisms of action and how peer specialists use their lived experience to

promote recovery in others (Davidson, Chinman, Sells, &Rowe, 2006). Other studies have suggested that the role of
the peer provider can be ambiguous (Moran, Russinova, Gidugu, Yim, & Sprague, 2012; Miyamoto & Sono, 2012)

in terms of the nature of the relationship and in their activities.

More recently, attention has turned to assessing the effectiveness of peer-delivered services. Study findings

have been largely very mixed, depending on the authors (Author, 2009; Chinman, et al., 2014; Lloyd-Evans, et al.,

2014; Pitt, et al., 2013). Studies of structured interventions run by peers such as the Wellness Recovery Action Plan

(WRAP; Cook et al., 2012a), Building Recovery of Individual Dreams and Goals through Education and Support

(BRIDGES; Cook et al., 2012b; and a 12-week group course on recovery (van Gestel-Timmermans, Brouwers, Van

Assen, & van Nieuwenhuizen, 2012) are providing robust evidence of effectiveness. The growing evidence of the

effectiveness for interventions such as WRAP and BRIDGES might be ascribed to their structure and consistent

delivery of, clear and commonly understood, active ingredients related to recovery. Most studies of individual, one-

on-one delivery of peer support lack any information about possible mechanisms of action, or about the duration,

frequency, quality or intensity of the peer support services (Author, 2009).

We undertook this study with the intent of clarifying ambiguities in the role of the peer support specialist,

to further elucidate the nature and processes of individual peer support, and to clarify what makes peer support

effective from the point of view of the recipient.

Method

This qualitative study was conducted as part of a larger experimental study1 of the effectiveness of individual peer

support (Author, 2012). The interviews took place between September 2008 and April 2010. The research

methodology was that of thematic analysis drawing on a constructivist grounded theory approach of themes

emerging from the data while also being informed by existing theory in the field (Charmaz, 2006). All procedures

and materials, including recruitment flyers and our interview guide were approved by the University IRB.

Study Participants

To be eligible for the study individuals had to: (a) be an adult with a psychiatric condition, (b) be served by the local

behavioral healthcare organization, (c) have received a minimum of 10 sessions of individual peer support, and (d)

be able to give full and knowing consent for the qualitative interview.

Setting

We conducted this study in a large not-for-profit organization in the southwest United States whose mission is to

provide a variety of peer-delivered services, including individual peer support, peer-led groups, peer-led social
events, and so forth. Peer support specialists undergo a rigorous 80 hour training program during which they are

taught the principles and values underpinning recovery and peer support. They work alongside other professionals

providing crisis, case management, recovery education, peer support, supported housing and employment services.

Research Procedures

We developed an interview guide by examining the existing literature on the nature of peer support and the possible

mechanisms of its effectiveness, and by soliciting input from a variety of peer support specialists. The interview

guide was developed to prompt study participants as well as to allow explorations of potentially new areas of inquiry

that we might have otherwise overlooked. The research interviewer employed the interview guide to solicit

information in several areas: (a) the nature of the peer relationship, (b) expectations held by the recipient for peer

support, (c) the nature of the support provided as perceived by the recipients, and (d) perceptions of effectiveness of

that support. Each interview was audiotaped and all audiotapes were transcribed verbatim.

Data analysis

Data were analyzed after all interviews were completed. We found in initial review that not all interviewees had

received adequate peer support to be eligible and that one interviewee provided only monosyllabic responses. As a

result we excluded seven of the original 26 interviews from analysis.

Two researchers were responsible for reading and coding the transcribed interviews: a postdoctoral fellow

with experience as a peer-advocate, trainer, and peer support specialist, and a Senior Research Coordinator with

experience in qualitative data analysis. A senior researcher consulted with the team and assisted them to reach

consensus when needed. The researchers assigned descriptive codes to text pertaining to the nature of peer support

services and participants’ perceptions of the effectiveness of those services. After initial coding was completed, the

researchers met to compare these descriptive codes and arrive at a consensus about them. The codes were then

organized into themes and thematic categories were developed based on conceptual similarity. The researchers then

recoded the transcripts using the final list of thematic category codes, which were then refined and organized to

address the study question of how various mechanisms of action of peer support might be perceived by recipients.

Researchers did not limit themselves to the topics in the interview guide for coding, which allowed for emergence of

themes that were not explicitly in the interview guide; the boundary issues described in the results are an example of

such a theme that was not queried on, but emerged.

Of the participants included in the analysis, 63% were women and the average age was 47 years (±12). The racial

composition of participants was 47% White, 21% African-American, 25% Hispanic, and 5% Native American. A

majority of participants were either single or divorced. Most participants lived in independent community settings.

All participants were eligible for a variety of mental health services, including peer support services.

Initial Expectations and Introduction to Peer Support

Each interview began by asking participants how they learned about peer support and what motivated them to

receive these services. With a few exceptions, participants responded that when they first heard about the

opportunity to receive peer support, they were not really familiar with it. The following is a reflection of this in the

words of Heather1 who said “I didn’t really know what kind of program I was going into when I got there. Yeah, I

had no idea what that was.” This unfamiliarity included for some not knowing that it was a service delivered by a

person with “lived experience” of a mental illness. Quite a few participants were skeptical about peer support and

needed additional encouragement by their case manager to try pursue it. Others decided to receive peer support

because they were exposed to a peer specialist in their residential program (the residential peer specialists of this

organization are not assigned to work one-on-one in the more intensive relationship we were seeking to study).

Participants’ expectations of peer support were quite varied. Some participants didn’t know what to expect,

like Will who said he tried peer support- “because I needed something to do… instead of staying home all day.”

Others had expectations that they could receive help with day-to-day practical needs like grocery shopping and

transportation; someone who would be there to talk to them and provide emotional support; and help expand their

social activities. Undoubtedly, the different descriptions and/or ways in which participants understood peer support

had a role to play in their varying expectations. The descriptions that interviewees recalled they were given about

peer support included: someone being available to provide support with any challenges/anything they need help

with/day-to-day problem solving; someone who could help with promoting recovery and support relapse prevention;

and someone to be available as a friend. Perceptions of the scope of peer support varied widely and could be

confusing for some, such as for Cynthia who described that there were budgetary changes related to what the peer

1
All names have been changed to preserve participant anonymity. “Heather” is a fictitious name given to this study participant.
specialist could and could not do, leading her to ask of the peer specialist’s supervisor, “Could you please,

somebody, give me a job description of what my peer support person can and cannot do.”

Activities of Peer Support

Participants’ experiences of peer support services were quite varied as well. The interviewees were asked about

several categories of activities that are often part of peer support including, practical, social support, and emotional

supports, guidance and advocacy for their mental health treatment and goal planning and skills teaching. The full

range of activities is reflected in the interviewees’ descriptions and is detailed below

Tangible or practical supports. In most cases, tangible supports involved the peer support specialist

accompanying or assisting the participant with errands and appointments including driving them to places in the

community; accompanying them to appointments; helping with needed paperwork; and providing help to shop, do

laundry, and other assorted activities of daily living. These practical supports for some individuals were the main

feature of their peer support experiences. As Tyrone put it, “…what I really use him for is to try to get, uh, business

taken care of with my…uh, with my situation. Like, right now, we’re going through housing.” Maria mentioned

receiving support with medication management, “Yeah. And then writing, you know, seeing what kind of

prescriptions I needed and stuff. .. And she always made sure, like, I was taking, you know, medications.”

Other practical supports included linking people to resources and activities by providing information or

making arrangements so participants could access these opportunities on their own. Some peer specialists provided

assistance outside of their normal duties such as driving participants to places outside of their scheduled work time,

picking up a check for a participant when he was unable to, dropping off groceries, helping a participant obtain a

store discount by using their store card, spending time looking for housing, and giving a participant needed clothes.

Several participants described these practical supports as helping to address needs that were not met by their regular

mental health providers.

Quite a few participants described how these supports besides “getting things done” played a more

significant role in terms of giving them a sense of relief and feeling emotionally supported. This is how Deja

explained it, “I needed the tangible, and I needed the personal and emotional support, also. And, with her helping me

with both of those situations, it took the stress off of me, where I could focus on other things that were important.”

Social support. The opportunity to participate in recreational activities and socialize was part of the peer

support offered to all participants. Activities ranged from going out for coffee or meals, bingo or other game nights
at local recreational centers, movies, hikes or other group activities. Social activities provided a way for some

participants to overcome their isolation like Lela said, “I was at home all the time when I wasn’t working, so it was

giving me a little outing every Monday.” For others it was about gaining confidence in social settings like Pablo

who said, “And I have fun. . . . Cause I am not sociable . . . and before, I wouldn’t talk. I, I get tongue twisted, and I

get nervous. But she’s helped to where I don’t have to worry or be afraid, anymore.”

Others like Will described these activities as opening up new possibilities for: “. . . she introduced me to

new possibilities. New opportunities, new things to do, new places to go, and new friends to meet.”

Not all participants, however, wanted to focus on their social life, like Tara who said, “No, at that particular

time I didn’t want to go anywhere.” Others wanted to focus on the practical supports they felt were more important

for their future, like Tyrone saying, “So, you know, as opposed to goin’ to the movies, as opposed to goin’ to the

bowlin’, I’d rather he, you know, try to get some of the things that’ll help me out in the future, you know”; or

wanted their independence like Cody who said, “No, ... they approached me, just say I like my independence…”

Emotional support. Nearly all of the participants described receiving emotional support including helping

them stay motivated and hopeful when they felt like giving up, saying things that built their self-esteem, conveying

respect and providing encouragement to work through their challenges. The form of emotional support that

participants described most often was “just someone being there”. This was reflected by Diego who said- “it was

very much a sense of, uh. . . bein’ there emotionally for me, than anything else.” Participants shared the unique

sense of support they felt because that person had an understanding of what it is like to have a psychiatric condition,

like Will who said- “It’s like I had a partner and a friendship! Like a partner I can lean on.” Alongside feeling

understood, Tyrone contrasted his experience with that of his case manager, saying, “She doesn’t work as hard or

maybe it’s because she has so many cases to deal with, I don’t know. But, for some reason, like, when I’m with my

[peer support specialist], it seems like I’m the only person in the world that matters.” Feeling respected had a part to

play in the sense of being emotionally supported like Lela described - “and a lot of people have treated me as. . . let

me down to being confident, and um, they disparage me. And, uh, he gives me a sense of confidence . . . .Um, it

makes me feel supported.” Many individuals described not having anyone else supporting them. . For Deja it was

this support that kept her from a breakdown- “And, if she had not been there . . . I might have had a complete

nervous breakdown. I mean, completely, and not recover.”

advocates for the participants, helping them navigate the mental health system and get the services they needed. This

included working with case managers as Pablo described- “She talked to my case manager and got on his case. . . .

And I got some backup, because this guy wasn’t doin’ nothin’. My bus passes . . . or the taxi wouldn’t show up on

time . . . . She helped me do that, fixed it.” Others talked about receiving coaching on how to self-advocate with

doctors, peer specialists advocating for them at doctor’s appointments and treatment planning meetings.

Goal planning and skills teaching. Some participants described moving beyond day-to-day supports to

defining and making plans to work on future goals. Others reported that their peer support specialists taught them

self-help skills, like encouraging them to self-advocate with service providers. Some participants found the

opportunity for mentoring from someone with similar experiences to be the most helpful about peer support. Kate

stated the following as the most important benefit of peer support among the many ways in which it was helpful: “I

think the role model . . . or the mentor, because that’s the ultimate example, and that entails a lot of things.”

Role of Shared Experience

Normalizing. We asked participants about the role that the shared experience of a psychiatric disability

played in their relationship with the peer support specialist. Many participants said it made them feel “normal,” that

they belonged or were not alone, like Kate who said, “them just talking about their experiences was more of a help

than I think a lot of . . . than they could imagine, ‘cause it made me realize there’s other people.” and Tyrone saying,

“before I met him, um . . . there was only one person that I’ve ever known that had some type of a mental illness, . . .

he’s let me know that there are other people like, uh . . . either like me or goin’ through the same things.”

Comfort and personal connection. Several participants described how the knowledge of shared experience

enhanced comfort with the peer specialist to share more openly, and develop a personal connection. Cynthia’s

statement exemplifies this, “and shared a little of her story with me. And, um . . . that was very comfortable. Um . . .

it made it a lot more comfortable to share back. It makes it more . . . more personal. Not . . . so clinical.” The value

of a nonclinical relationship is evident from these quotations and also speaks to the unique role of peer support.

Inspiring hope. In addition working with someone who had similar experiences of having lived with a

psychiatric condition provided participants with a sense of hope. As Pablo said, “And, seeing that she has done it . . .

is motivational. She did it . . . if she can do it, I can do it, you know?” Heather shared something similar, “I’ve been
in the mental health system since I was twelve-years old. I’m forty!. . . to hear somebody else with their story and

their time in it, and to see where they’re at now, is . . . I mean, it gives me hope.”

Role Boundaries and Nature of Relationship

We also discovered themes related to the role peer specialists played in the lives of participants and the nature of

those relationships that we categorized as follows: (a) mutuality of relationship, and (b) negotiating role boundaries.

Mutuality of relationship. The relationship that a many participants shared with peer specialists appeared to

be one of “mutual” support. This was important to participants because they felt they were “giving something back”

or “bringing something to add too.” Cody’s statement reflects some of these ideas, “We just talk and, and just share

our support. Share our support. I like to think I’m giving some, too, back.” Mutuality, or the notion that the

relationship is not a solely a “one way” exchange, is a core value that underpins peer support initiatives.

Negotiating role boundaries. Many participants did not have friends or family and the personal connection

they developed with their peer specialists filled this void. Some participants, like Deja, saw the peer specialist as

playing several of these roles in their lives- “It made me feel like I had family. I told her that, I told her, ‘You’re like

my doctor, the sister. And I don’t feel alone.’ ” The relationship, for some, became so close that they spent holidays

together. In some cases the closeness of the peer support relationship brought into focus questions and dilemmas

about the boundaries of the peer relationship. For example, a participant described asking his peer specialist to

mediate in a marital conflict and had to be reminded that the peer specialist could only help him. Peer specialists

varied in their comfort in sharing their own experiences with mental illness and the mental health system, and based

on participants’ expectations for sharing this affected their relationships. One participant, Diego, described not

wanting to pry but feeling “distant” because the peer specialist had not initially shared a lot about his own lived

experience. Others described challenges in wanting to respect the peer specialist’s time boundaries but becoming so

reliant on them for support that they would call even after hours. One participant and her peer specialist started

communicating via text messages instead of talking after hours as a way for her to maintain time boundaries.

Discussion

As described above, the expectations of peer support varied greatly. These initial expectations and

introductions to peer support might have colored the nature of the relationship between respondents and their peer

specialists. We found that the practical or tangible supports were viewed as critical because it reduced participants’

stress and worry about tasks of daily living, consistent with the findings of Cohen and his theory about the nature of
social support (Cohen, Mermelstein, Kamarck, & Hoberman, 1985). We suggest that practical supports should not

be underestimated for their ability to assist individuals in day-to-day coping and eventual recovery. As noted by one

peer support specialist, tangible supports can also provide a vehicle for more therapeutic aspects of peer support,

such as relationship building, teaching, and mentoring (Harrington, personal communication, 2012).

Social activities served multiple functions including reducing social isolation, increasing social skills,

widening social networks, and decreasing social anxiety. Research suggests that having social contact and social

activities improves quality of life among individuals with psychiatric conditions (Lehman, 1983), and counters

social isolation which has a host of deleterious effects (Nicholson, 2012). Peer support may reduce the negative

effects of social isolation by providing support that might not otherwise be available in the mental health system.

For many individuals, the peer specialist embodied their own aspirations, such as achieving stable housing

and obtaining paid employment making them more credible as role models and mentors, consistent with findings

suggesting that shared experiences facilitate effective role modeling (MacCallum & Beltman, 2002). Peer support

specialists imparted their knowledge and skills about coping with problems and specific stress reduction techniques,

and served as advocates helping individuals obtain the mental health services they needed, and guided them in

becoming “self-advocates”.

Some of the more intangible yet vitally important aspects of the peer support relationship are the “core

conditions” (Rogers, 1956) of respect, warmth, empathy, and genuineness that underlie all helping relationships

(Russionova, Rogers, Cook, Ellison, and Lyass, 2013). Respondents in this study confirmed reported feeling

respected, listened to, and valued as a human being which is often diametrically different from the way they are

treated in psychiatric institutions or by traditional mental health providers (Deegan, 1996). Being respected in turn

promoted a sense of self-worth and confidence in participants. The ability to identify with the peer specialist

because of the shared lived experience might be a critical and unique dimension that cannot be duplicated by other

mental health providers (Corrigan, Mueser, Bond, Drake, & Solomon, 2008; Sells, Black, Davidson, &, Rowe,

2008). Having a helper with a “lived experience” also promoted a sense of normality that enabled individuals to feel

that they were not different and alone, thus improving their self-esteem. Some studies have hypothesized that shared

experiences can lead to a more potent helping relationship which in turn can lead to greater independence and

recovery (Sells, Davidson, Jewell, Falzer, & Rowe, 2006; Sells et al., 2008). Taken together, the benefits of peer

support identified by its recipients-- respect, sharing and identification, and mutuality- are similar to the “non-
specific factors” which have been the topic of voluminous scientific investigations (Horvath, Del Re, Flückiger, and

Symonds, 2011). To our knowledge, these relational variables have not been studied systematically in peer support

and given the qualitative nature of our study we can merely hypothesize that these variables serve as critical

pathways for effectiveness.

Our research and that of others suggests that role and time boundaries are a concern for peer specialists and

those that receive support from them (Moran et al., 2012; Miyamoto & Sono, 2012). In contrast to volunteer peer

support through the organizations such as Alcoholics Anonymous, many peer support specialists are now in paid

employment and therefore in roles that require them to fulfill job expectations and have constraints around their

professional functions, such as time commitment and the extent of support they can offer The notion that a peer

support specialist is more than just another provider in the mental health system, and someone with whom one could

develop a close friendship, appears to lead to ambiguity in the relationship.

This study has several limitations that should be noted. First, we used a convenience sample, drawn from

one agency and individuals receiving one-on-one peer support. Our findings, therefore, might not generalize to

different types of peer relationships, such as those that are unpaid, arise from group interventions, are less structured

or more casual, or formed in particular settings (i.e., residential settings). All participants received at least 10 weeks

of peer support, but we did not examine differences in experiences based on duration or frequency of peer support.

This qualitative study was informed by extant research on the peer support relationship at the time of this study.

More literature now exists (e.g., Moran et al., 2012; Miyamoto & Sono, 2012) that might help future investigators

and direct empirical inquiries on this topic. In addition, we did not contrast or compare the peer support relationship

to relationships with other mental health providers. Future research might wish to focus on gaining a better

understanding of the unique contribution of peer support to recovery from the perspective of the service recipient.

Conclusions

Peer support services and programs have burgeoned in the past two decades, but we have a limited empirical

understanding of the nature of the peer support relationship, the usual activities engaged in, or a sense of what is

perceived as helpful by recipients. This qualitative study suggests that peer support relationships have hallmarks of

traditional helping relationships. Practical supports, role modeling and mentoring, and social opportunities alongside

getting emotional support through a normalizing relationship with someone with similar experiences stand out as

possibly the most critical and effective aspects of the peer support specialist’s roles and duties.
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