Developing peer support worker roles: reflecting on ... - Emerald

PEER SUPPORT<strong>Developing</strong> <strong>peer</strong> <strong>support</strong><strong>worker</strong> <strong>roles</strong>: <strong>reflecting</strong>on experiences in ScotlandSimon BradstreetDirector, Scottish Recovery NetworkRebekah PrattDeputy Director, Scottish Primary Care Mental Health Research and Development Programme, University of EdinburghAbstractThis article describes the development of <strong>peer</strong> <strong>support</strong> <strong>roles</strong> and programmes in Scotland, and includesfindings from an evaluation of a <strong>peer</strong> <strong>support</strong> <strong>worker</strong> pilot scheme. The evaluation assessed the impact of thepilot on service users, <strong>peer</strong> <strong>support</strong> <strong>worker</strong>s and the wider service system, along with considering the issuesinvolved in implementing <strong>peer</strong> <strong>support</strong> programmes.Key wordsPeer <strong>support</strong>; Mental health; Service users; ScotlandUnderstanding <strong>peer</strong> <strong>support</strong>‘The most help I got was from the other peoplein the ward who had gone through similarexperiences... The nurses, they’re great butyou find, or I find ... the best people thathelped me were other people that had beenthrough psychosis, had some little pointers,were grounded, that’s the thing.’ (Brown &Kandirikirira, 2007)For many years, people using mental healthservices have described the importance of <strong>support</strong>from others using the same service. This type ofinformal <strong>support</strong> can offer ideas and knowledge notnecessarily gleaned from service providers. The ideaof harnessing this shared experience as one meansof promoting and <strong>support</strong>ing recovery, throughthe development of specific <strong>peer</strong> <strong>support</strong> <strong>worker</strong><strong>roles</strong>, is now gaining prominence in Scotland, theUK and internationally. Since 2005, a programmeof development <strong>support</strong>ed by the Scottish RecoveryNetwork (www.scottishrecovery.net) has seen thecreation of a number of <strong>peer</strong> <strong>support</strong> <strong>worker</strong> <strong>roles</strong> asone part of a wider programme of work to promoteand <strong>support</strong> recovery.Peer <strong>support</strong> <strong>worker</strong>s are people with personalexperience of mental health issues and recovery, whoare trained, and then employed to work in <strong>support</strong>of others in recovery. They can operate in a varietyof settings, but in Scotland and the UK many areattached to community mental health teams or inpatientsettings, where they complement the skill set with thelived experience of mental health issues and recovery.Peer <strong>support</strong> <strong>worker</strong>s can be described as modellingrecovery within teams, offering a lived example of thepossibility of progression and growth – both for peopleusing their services and for other team members. Theywork in a way that embraces key recovery conceptssuch as focusing on strengths and hope. Of centralimportance is the <strong>peer</strong> <strong>support</strong> <strong>worker</strong>’s ability todevelop <strong>support</strong>ive relationships where the appropriate3610.5042/mhsi.2010.0443Mental Health and Social Inclusion • Volume 14 Issue 3 • August 2010© Pier Professional Ltd

<strong>Developing</strong> <strong>peer</strong> <strong>support</strong> <strong>worker</strong> <strong>roles</strong>: <strong>reflecting</strong> on experiences in Scotlandsharing of experiences can engender trust and arecovery-<strong>support</strong>ing environment. In the United Stateswhere <strong>peer</strong>-involved services have existed for sometime, leading commentator and trainer Shery Meadhas defined <strong>peer</strong>-<strong>support</strong> as a ‘system of giving andreceiving help founded on the key principles of respect,shared responsibility, and a mutual agreement of whatis helpful’ (Mead et al, 2001).As <strong>peer</strong> <strong>support</strong> services have developed,an increasing evidence base is describing theimpact and unique contribution of <strong>peer</strong> <strong>support</strong><strong>worker</strong>s within service systems. A literature reviewcommissioned to inform the development of <strong>peer</strong><strong>support</strong> in Scotland identified a range of benefitsfor people using <strong>peer</strong> <strong>support</strong> services, includingreduced time spent in hospital, reduced isolation, aswell as benefits for <strong>peer</strong> <strong>support</strong> <strong>worker</strong>s, includingenhanced well-being (Woodhouse & Vincent,2006). More recently, as new evidence becomesavailable on the key role of empowerment and selfstigmain personal recovery, <strong>peer</strong> <strong>support</strong> involvedservices are seen as one way of promoting controland confidence for <strong>peer</strong> <strong>worker</strong>s, while ensuringenhanced outcomes for people using <strong>peer</strong> <strong>support</strong>services (Warner, 2010).Increasingly, policy-makers and plannersdescribe the potential for the employment of<strong>peer</strong> <strong>support</strong> <strong>worker</strong>s to offer multiple gains. Thedevelopment of <strong>peer</strong> <strong>support</strong> <strong>roles</strong> has been citedas one example of good practice in relation to theemployment of people with experience of mentalhealth problems (Perkins et al, 2009). Elsewhere<strong>peer</strong> <strong>support</strong> services have been cited as a powerfulmeans of promoting recovery-focused services thatbetter value the lived experience of mental healthissues (Shepherd et al, 2008).<strong>Developing</strong> <strong>peer</strong> <strong>support</strong> inScotlandIn 2005, the Scottish Recovery Network held aconference to broaden awareness of the workof <strong>peer</strong> <strong>support</strong> services in the United States andto introduce the concept as one potential meansof promoting recovery in Scotland. This event,which included input from leading exponents of<strong>peer</strong> <strong>support</strong> in the United States, had a powerfulimpact and generated considerable enthusiasm forthe development of <strong>peer</strong> <strong>roles</strong>. Early developmentsfollowing the conference included the opening ofScotland’s first <strong>peer</strong> <strong>support</strong> service, Plan2Change(a partnership between Penumbra and NHS Lothian)and work to assess and build on learning from <strong>peer</strong>involvedservices elsewhere. In 2006, a commitmentto recovery-focused practice and the development of<strong>peer</strong> <strong>roles</strong> was included in the Scottish Government’smental health service policy (Scottish Executive,2006), and as a result pilot projects were developedin five health board areas, across which 15 <strong>peer</strong><strong>support</strong> <strong>worker</strong>s were employed in a range ofcommunity and inpatient settings.National Peer SupportWorker Pilot Scheme: keyresearch findingsThe National Peer Support Worker Pilot Schemewas evaluated by researchers from the University ofEdinburgh and the Scottish Development Centre forMental Health (McLean et al, 2009). The evaluationaimed to assess the impact of the pilot on serviceusers, <strong>peer</strong> <strong>support</strong> <strong>worker</strong>s and the wider servicesystem, along with considering the issues involvedin implementing this innovative pilot in both NHSand community-based settings. Here we presentsome key points from the evaluation about theoverall implementation, and the impact on serviceusers, <strong>peer</strong>s and the service system.Overall implementationThe overall message from the evaluation was that<strong>peer</strong> <strong>support</strong> can be successfully implemented ina wide range of settings, including acute inpatientcare and community-based teams. Despite beingchallenging to implement, it offered positivebenefits for service users, <strong>peer</strong>s and the servicesystem. One key finding, however, was that <strong>peer</strong><strong>support</strong> works best when <strong>peer</strong>s are based insettings that have a pre-existing commitment tothe values and principles of recovery. Peer <strong>support</strong><strong>worker</strong>s greatly enhance that commitment torecovery, however the role should not be used tointroduce recovery to settings that do not alreadyhave a commitment to the values of recovery.Peer <strong>support</strong> <strong>worker</strong>s had a unique and distinctrole, offering mutuality, empowerment, modellinghope and the sharing of lived experience withservice users. The way in which this was achievedvaried depending on the setting the <strong>peer</strong>s werebased in. Activities undertaken by <strong>peer</strong>s includedrunning groups, drop-in sessions, having formalcaseloads, developing and working towardsMental Health and Social Inclusion • Volume 14 Issue 3 • August 2010 © Pier Professional Ltd 37

<strong>Developing</strong> <strong>peer</strong> <strong>support</strong> <strong>worker</strong> <strong>roles</strong>: <strong>reflecting</strong> on experiences in Scotlandrecovery goals, <strong>support</strong>ing people to use wellnessrecovery action plans (WRAP), <strong>support</strong>ing peoplethrough transitions, participating in team meetingsand raising staff awareness. The types of activitiesoffered also depended on how the <strong>peer</strong> felt bestable to share his or her lived experience. Widerservice system staff were mostly very positive andappreciative of the role, seeing it as complementingthe overall goal of <strong>support</strong>ing wellness andrecovery for service users.Impact on service usersService users welcomed the <strong>peer</strong> <strong>support</strong><strong>worker</strong> role, and a high level of satisfaction wasreported. One key impact was the potential toimprove relationships between people usingand working in services – <strong>peer</strong>s were widelyperceived to be helping bridge the gap between‘us’ and ‘them’. This included <strong>support</strong>ing staff toconsider alternative perspectives about serviceuser experiences, and <strong>support</strong>ing service users tounderstand staff expectations. Benefits reportedby people using <strong>peer</strong> services included beingencouraged to take more control of their ownrecovery, learning new self-management skills,reducing fear, challenging stigma and giving animportant sense of hope for recovery.‘Reassurance there is hope for recovery.’(Service user)‘A good source of encouragement and a goodrole model.’ (Service user)Impact on <strong>peer</strong> <strong>support</strong> <strong>worker</strong>sBecoming a <strong>peer</strong> <strong>support</strong> <strong>worker</strong> was bothchallenging and rewarding. For many it markeda significant point in their own recovery journey.Peer <strong>support</strong> <strong>worker</strong>s did require <strong>support</strong> andsupervision from the team they worked with,particularly during the period of setting up therole and integrating into the team. For some,the role was a return to work following a longperiod out of paid employment, so <strong>support</strong>including negotiating complex benefits systemsand navigating the sometimes hostile occupationalhealth requirements was important. As this wasa pilot scheme, there were additional pressuresrelated to being part of a high profile initiative andthe need to develop a new and unfamiliar role.Addressing and working through the challengesinvolved in this new and innovative role reinforcedand promoted the <strong>peer</strong>s’ own sense of recovery.Some did have periods of becoming unwell, andfor some this was in part due to the stress involvedin undertaking the <strong>peer</strong> <strong>support</strong> <strong>worker</strong> role. Mostwho became unwell returned to work feelingthat they could positively and constructively usethat experience in continuing to offer <strong>support</strong>and mutuality to service users. Some <strong>peer</strong>s alsodescribed how, despite the challenges of returningto paid employment, the positive rewards fromtheir role and structure of work life, was part oftheir continued wellness.‘I would recommend it to a <strong>peer</strong> <strong>support</strong><strong>worker</strong>. That is the thing that will make youthe strongest, having an episode and comingthrough it, that is when your strengths reallystart’. (Peer <strong>support</strong> <strong>worker</strong>)Peer <strong>support</strong> <strong>worker</strong>s did face some challengesfrom encountering staff or practices that were nonrecovery-focused. Some described their <strong>roles</strong> asalso being about using their <strong>peer</strong> <strong>worker</strong> skills withstaff, helping staff to also have hope for recoveryfor service users.‘It is allowing me to make something thatI was trying to forget about, into makingit valuable, to make it purposeful andbeneficial. And I think that’s a sort of positivereinforcement for my own recovery.’ (Peer<strong>support</strong> <strong>worker</strong>)Impact on the wider servicesystemIt was clear that having <strong>peer</strong> <strong>support</strong> <strong>worker</strong>s in teamsenhanced commitment to recovery and the impact onthe wider service system was also clear. Staff reportedbeing more aware of their use of language and beingmore reflective on recovery-oriented practices in theirservices. There were some staff who were resistantor sceptical about the role, and that could lead tochallenges but, overall, staff were enthusiastic aboutthe benefits of having a <strong>peer</strong> <strong>support</strong> <strong>worker</strong> as partof the team. As described previously, a conclusion ofthe research was that, despite these impacts, <strong>peer</strong>sshould not be placed in services where there is littlepre-existing commitment to recovery.38Mental Health and Social Inclusion • Volume 14 Issue 3 • August 2010© Pier Professional Ltd

<strong>Developing</strong> <strong>peer</strong> <strong>support</strong> <strong>worker</strong> <strong>roles</strong>: <strong>reflecting</strong> on experiences in ScotlandThere were different models of providing<strong>peer</strong> <strong>support</strong> – some services were NHS-based,others involved the voluntary sector, and somewere partnerships between the two. Each type ofsystem faced particular barriers, particularly theNHS where much work was done to create a newrole and to ensure appropriate occupational healthpractices and staff inductions were in place. Otherissues required clarification, such as developingreferral processes and common understandingsabout the sharing of information (if appropriate).It may also have been appropriate to considerplacing more experienced <strong>peer</strong>s in the morechallenging environments, such as acute wards.Overall, there was a clear message that <strong>peer</strong><strong>support</strong> <strong>worker</strong>s should not be given the roleof being ‘change agents’, but that <strong>peer</strong>s clearlyenhanced service effectiveness through uniquecontributions that strengthened team approachesand positively influenced service culture.‘I think it’s quite powerful for the staff to see“Oh gosh! They are just like us”. Becausein a big institution you often get thatseparation of them the service users and uskind of thing. They don’t eat together; theyhave separate toilets and all these sort ofthings. There are people in the office talkingabout service users and I think it does allowthem to be a bit more challenged about theirthoughts, beliefs and stigmatising behaviourand I think that’s going to be quitepowerful in maybe potentially breakingdown barriers.’ (Wider service systemrepresentative)Continuing thedevelopment of <strong>peer</strong><strong>support</strong> in ScotlandAs part of its commitment to <strong>peer</strong> <strong>support</strong> andrecovery-focused practice, the Scottish RecoveryNetwork (SRN) continues to <strong>support</strong> thedevelopment of <strong>peer</strong> <strong>support</strong> <strong>roles</strong>. It hosts regularlearning events where people with an interest inthe delivery or development of <strong>peer</strong> <strong>support</strong> cometogether to share experiences and ideas. SRN iscurrently developing implementation guidelinesbased on the experiences of developing <strong>peer</strong>services in Scotland. They will offer pointers andsuggestions to anyone interested in the creation of<strong>peer</strong> <strong>support</strong> <strong>roles</strong>.Up until this point, training for <strong>peer</strong> <strong>support</strong><strong>worker</strong>s in Scotland has been delivered byUS-based provider, Recovery Innovations. Topromote longer-term sustainability, and to tailorlearning outcomes to a Scottish context, SRN isnow working with SQA (the national accreditationand awarding body in Scotland) to develop anew nationally recognised award for the nextgeneration of <strong>peer</strong> <strong>support</strong> <strong>worker</strong>s. The validatedaward is split into two units, one theoretical andone practical, and will be delivered by peoplewith lived experience of mental health issues.Learning materials to supplement the awards arecurrently in development (see Table 1).Table 1: Mental health <strong>peer</strong> <strong>support</strong> higher national unit – knowledge and skillsUnit 1: Recovery contextOutcome 1: Explore the development of the recovery approach in mental health• Mental health recovery and the recovery approach• Key concepts of recovery• Factors that can impact personal recovery• Societal influences• Effects of force and traumaOutcome 2: Define and understand <strong>peer</strong> <strong>support</strong> and its role in recovery• Peer <strong>support</strong> through relationships• Types of <strong>peer</strong> <strong>support</strong>• Peer <strong>support</strong> and recovery• How and why communicating experiences matters• Self-help and self-management tools(continued)Mental Health and Social Inclusion • Volume 14 Issue 3 • August 2010 © Pier Professional Ltd 39

<strong>Developing</strong> <strong>peer</strong> <strong>support</strong> <strong>worker</strong> <strong>roles</strong>: <strong>reflecting</strong> on experiences in ScotlandTable 1: Mental health <strong>peer</strong> <strong>support</strong> higher national unit – knowledge and skills(continued)Outcome 3: Describe and explain the key concepts of formalised <strong>peer</strong> <strong>support</strong>• Hope and belief and their contribution to recovery• Empowerment, control and self-advocacy• Choice and opportunity• Mutuality and empathy• Strengths-based approach to validating experience• Positive risk-taking and moving forwardUnit 2: <strong>Developing</strong> practiceOutcome 1: Apply a range of theories and concepts in the <strong>peer</strong> <strong>support</strong> role• Purpose and principles of <strong>peer</strong> <strong>support</strong>• Role modelling, hope and belief• Resilience• Power, choice and control• Labelling, identity and self-esteem• Trauma-informed <strong>peer</strong> <strong>support</strong> practice• Strengths-based approachesOutcome 2: Develop relationships based on <strong>peer</strong> <strong>support</strong> principles• Establishment of <strong>peer</strong> relationships that are mutual and empathic• Concept of the individual as an expert by experience• Key ethical and diversity issues• Communication and recording, with a focus on active listening and recovery language• Working with riskOutcome 3: Understand perspectives of the work role• Peer <strong>support</strong> environment• Role tension and boundaries• Safe practice, self-care and confidentiality• Role of supervision• Setting personal goals and managing setbacks• Promoting recovery culture and the understanding of changeConclusion<strong>Developing</strong> <strong>peer</strong> <strong>roles</strong> requires that planners,service providers and service users question andassess their role and identity. It prompts complexquestions in relation to attitudes and values andaround the extent to which recovery-focusedpractice can flourish in statutory services. Despitethis, the experience in Scotland strongly suggeststhat it is an approach that can bring rich rewardsfor <strong>peer</strong> <strong>worker</strong>s, those using <strong>peer</strong> services andthe wider service system. To some extent thegenie is now out of the bottle with <strong>peer</strong> involvedservices. The challenge now is to embed therole in a way that remains true to <strong>peer</strong> recoveryvalues, while ensuring quality service deliveryfrom a well-prepared and <strong>support</strong>ed <strong>peer</strong>workforce.ReferencesBrown W & Kandirikirira N (2007) Recovering MentalHealth in Scotland: Report on narrative investigationof mental health recovery. Glasgow: Scottish RecoveryNetwork.McLean J, Biggs H, Whitehead I, Pratt R & Maxwell M(2009) Evaluation of the Delivering for Mental HealthPeer Support Worker Pilot Scheme. Edinburgh: ScottishGovernment.Mead S, Hilton D & Curtis L (2001) Peer <strong>support</strong>: atheoretical perspective. Psychiatric Rehabilitation Journal25 (2) 134–141.Perkins R, Farmer P & Litchfield P (2009) RealisingAmbitions: Better employment <strong>support</strong> for people with amental health condition. London: Department for Workand Pensions.Scottish Executive (2006) Delivering for Mental Health.Edinburgh: Scottish Government.40Mental Health and Social Inclusion • Volume 14 Issue 3 • August 2010© Pier Professional Ltd

<strong>Developing</strong> <strong>peer</strong> <strong>support</strong> <strong>worker</strong> <strong>roles</strong>: <strong>reflecting</strong> on experiences in ScotlandShepherd G, Boardman J & Slade M (2008) MakingRecovery a Reality. London: Sainsbury Centre for MentalHealth.Warner R (2010) Does the scientific evidence <strong>support</strong> therecovery model? The Psychiatrist 34 (1) 3–5.Woodhouse A & Vincent A (2006) Development of PeerSpecialist Roles: A literature scoping exercise. Glasgowand Edinburgh: Scottish Recovery Network and ScottishDevelopment Centre for Mental Health.Simon Bradstreet is Director of the Scottish Recovery Network. For moreinformation about the Scottish Recovery Network phone 0141 240 7790,email info@scottishrecovery.net or visit www.scottishrecovery.netRebekah Pratt is Deputy Director of the Scottish Primary Care Mental HealthResearch and Development Programme at the University of Edinburgh.Mental Health and Social Inclusion • Volume 14 Issue 3 • August 2010 © Pier Professional Ltd 41