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The Coalition of Behavioral Health Agencies, Inc. Coalition Briefs
An electronic newsletter of the Coalition's Center for Rehabilitation and Recovery

Elizabeth Saenger, PhD, Editor and Writer
No. 109-1, November 15, 2014

The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects.

The Evidence For — and Against — Peer Services

What evidence supports the use of peer support services for people with a diagnosis of serious mental illness? Perhaps more to the point, at what kinds of positions do peers excel? And how strong is the evidence? The answers to these questions can enable programs to place peers where they will do the most good clinically.

Fortunately the 2014 review Psychiatric Services commissioned from peer services superstar Matthew Chinman, PhD, and his colleagues, provides state-of-the-art answers to most of these questions. The Chinman team looked at the effectiveness of three categories of service:

  • Peers added on to traditional services, such as peers that work with ACT (Assertive Community Treatment) teams staffed by professionals
  • Peers substituting for non-peers, for example, peers replacing non-peers as outreach workers
  • Peers facilitating curricula in groups, such as WRAP

Adding Peers to Traditional Services

Eight of 13 studies found that adding peers to traditional services improved outcomes. For example, a randomized controlled study of people who were frequently hospitalized (at least three times in the 18 months before the study) found that those who were given a peer mentor in addition to usual care (vs. peers with usual care) had fewer subsequent admissions and hospital days. Another study, which added peers onto an ACT team, found that this addition decreased hospitalizations and emergency room visits.

These studies and others suggest that adding peers to the behavioral health workforce reduces inpatient admissions and improves other outcomes. Since hospitalization in particular is a major cost, the ability of peers to decrease inpatient admissions could save a great deal of money.

Peers Replacing Non-Peers in Existing Job Roles

The few studies on peers replacing non-peers in existing job roles have limited samples, and the evidence is mixed. For example, one small two-year study relying on the self-report of peers found no difference between case management services delivered by peers vs non-peers.

Peers Delivering Curricula

Several studies found that peer-led WRAP groups reduced reported psychiatric symptoms, decreased the self-reported use of formal services, and increased participants’ hopefulness, self-advocacy, and self-perceived recovery. (See abstracts here, here, and here.) Peer-led psychoeducation improved participants’ sense of recovery and hopefulness (Cook et al 2012, Pickett, 2012).

A Dissonant Note

One dissonant observation in the literature should be noted. A 2014 study of Medicaid in Georgia found peer support associated with higher total costs ($5,991), including higher prescription drug costs and higher professional expenses, but lower facility costs. This could be the result of more consistent use of medication, and earlier attention to symptom flare-ups, or other reasons, but this has not been studied.

This research did not look at how peer support might help clients lead more stable lives, and thus reduce other possible costs in the system, such as police involvement with patients who decompensated, or the number of people collecting entitlements. Similarly, the study did not examine how peer support might result in people taking on new roles, or strengthening specific skills, such as parenting.

Perhaps a more holistic picture of peer support — albeit a more complex one — would find that this help paid off financially.

Measuring Attitudes Toward Recovery: Nuts and Bolts

G compass and rulerWould you like to measure attitudes to find out how clients, their family members and friends, the providers in your agency, and administrators or managers, feel about recovery? Such activity, and its documentation, can spark discussion; help identify potential problems in your agency; or serve as a benchmark against which to measure progress. In other words, getting quantitative feedback about your work can be instructive and potentially profitable.

A chart at the beginning of the 2013 Measuring Recovery: A Toolkit for Mental Health Providers in New York City identifies forty outcome measures you can use. Also included are the domains they cover (for example, hope for the future, self-esteem, relationships); who should complete the measure; how many items the measure has; whether you need permission to use it; and online sources for additional information.

Additional, more technical, information about how the measures were derived, their validity, and so on, is available in the 257-page Measuring the Promise of Recovery: A Compendium of Recovery Measures.

Three established measures reproduced in both the Compendium and an Appendix in the Toolkit are described below. None of these three instruments is copyrighted, and no permission is needed to use them.

Sample items include, “Staff work hard to help me fulfill my personal goals,” and “Agency staff are diverse in terms of culture, ethnicity, lifestyle, and interests.” The set of four versions, and scoring instructions, are available together.

  • Illness Management and Recovery (IMR) Scale. This instrument was created to evaluate IMR (a blend of three evidence-based skill building programs discussed in an earlier issue of RECOVERe-works under its New York State name, Wellness Self-Management). This fifteen-item measure is now used to evaluate other types of recovery-oriented programs too. Details and the scale are available from SAMHSA here, as well as in the Compendium and the Toolkit.

A sample item for clients is, “How much do you feel like you know about symptoms, treatment, coping strategies (coping methods), and medication?” Providers answer a matched question.

  • Recovery Assessment Scale. This inventory, only for consumers, measures five factors: confidence/hope; willingness to ask for help; goal and success orientation; reliance on others; and no domination by symptoms.

Many other measures are available, but a little research may be necessary before deciding to use one. For example, the “Recovery Culture Progress Report” in the Toolkit is not designed to be an outcome measure, but rather a tool to inspire discussion on different topics, such as consumer inclusion, and quality of life focus.

Recommended Resources

Helpful resources on peer services include:

The Yale Program for Recovery and Community Health, led by Larry Davidson, PhD, covers four areas: peer services and research, research and evaluation, health care disparities and cultural competence, and system transformation. In addition to conducting research, the program provides training and policy development.

The Boston University Center for Psychiatric Rehabilitation has a Recovery Education Center, and a Rehabilitation Research and Training Center which focus on research, services, training, and technical assistance, and online resources.

The Coalition of Behavioral Health Agencies’ Parachute wiki is a collection of articles and resources on integrating peers service providers into the workforce. The wiki includes the latest draft of a slide deck on peer specialist certification, including a draft of the peer specialist Code of Ethics, from the New York State Office of Mental Health.

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The opinions expressed in RECOVERe-works do not necessarily reflect the views of the Coalition of Behavioral Health Agencies.

To subscribe or unsubscribe to RECOVERe-works, a free publication of the Center for Rehabilitation and Recovery at the Coalition, please email esaenger@coalitionny.org.

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