Peer Support: Is it really not so effective after all?
5-minute read
Peer Support: Is it really not so effective after all?
A new study published appears to smash the case for peer support as an effective means to help people with mental health issues.
No fewer than 18 authors contributed to the journal article ‘Peer support for discharge from inpatient mental health care versus care as usual in England (ENRICH): a parallel, two-group, individually randomised controlled trial’, published in The Lancet with the headline grabbing conclusion:
“peer support at discharge does not have a significant effect on subsequent hospitalisation, days in hospital, or severity of symptoms”
It is important for peer support practitioners and allies of the movement to accept challenges, investigate and seek truth, and to make the delivery and design of peer support services as strong, and as evidenced based as possible. It is also a responsibility of peer supporters, service designers and system leaders to question, provide context and integrate findings into how we work.
What does the report say?
The study particularly focuses on the transition from clinical mental health supports, back into the community. Critically, it found the impact of providing peer support to those transitioning had a negligible impact on symptom severity, days in hospital or readmission. The report definitively stated that “peer support should not be implemented to reduce readmission post-discharge for patients at risk of readmission”.
What did they measure?
The study was focused on 590 adult (18+) psychiatric inpatients, who had at least one previous admission in the past 2 years, recruited from 7 mental health services across England. It excluded people with a primary diagnosis of learning disability, an eating disorder, or drug or alcohol dependency. Their primary outcome measure was psychiatric readmission 12 months after discharge (number of people readmitted at least once).
Two groups were created: one control group who had no access to peer support, and the other group who was given access to 1:1 peer support from admission until 4 months post-discharge. The peer support offered focused on building individual strengths and engaging in activities in the community.
What did they fail to measure?
Our experience in evaluating highly complex systems inside and outside of formal healthcare settings leads us to query the specific details of the environments in which research like this often happens. What problems, and most importantly, whose problems are trying to be solved by the research? Is it for the benefit of individuals with a mental health experience, or is it to tackle system issues like a lack of hospital bed or clinical programme capacity?
This research study uses one specific success metric: whether there was a readmission to hospital.
While this is a metric important to many, it is just one of many metrics that contribute to a person’s overall wellbeing and recovery. It can also be argued that it is also a metric that focuses more on fixing system pressures than on the individual outcomes of a person.
The authors indicated the limitations and caveats of the study. As peer community and practice builders, we think we can go further. For example, we don’t know:
What level and quality of training all the peer supporters and teams involved in this project received?
how the quality of the services they delivered was assured?
How much and what type (if any) of mentorship did the peer supporters receive to ensure they did not succumb to peer drift?
If, and how well, the pathways to peer support offered were integrated and/or endorsed by the health system or clinical team delivering overall services.
What assessment was carried out to determine that 1:1 peer support was the most effective modality of peer support, given the environment?
With small variations in how peer support is delivered, the effectiveness of a peer support intervention can be vast. Recruitment, training, mentorship and supervision, pathway integration, teams being ready for, and understanding the role of peer support etc. can all effect the practice quality and overall outcomes and impact that peer support can have.
Why we shouldn’t just rely on the headline
We have met so many people with lived experience during our careers who talk endlessly about how well peer support made them feel, how critical it was in their recovery journey, and how, given the overwhelming positive impact it has had, they wouldn’t want it any other way.
Balancing and integrating personalised experiences and high-quality research will mean better services in the end. We need to understand and respond to the detail, not take conclusions from opinion, experience or research that hasn’t been written, nor widely shared for critical appraisal.
Our response cannot ignore highlighting the difference in the treatment of Peer Supporters in an ethics panel for a study like this one. Could we imagine ethics approval in this study that resulted in someone experiencing a mental health issue would be given a treatment plan without access to a psychiatric nurse, therapist, or psychiatrist? And yet, that was the equivalent for the control group in this study.
This is a hard topic to have a conversation about. More than anything, it demonstrates that the Peer Supporter role is still the newest role in the sector. Most can easily imagine the system without the Peer Supporter role. Perhaps if the academic peer review process could include ‘Peers’ there would be new and different perspectives.
There are also other exciting findings in this study that we can use to build better community-based and transition-based supports for people experiencing mental health or substance-use challenges, such as:
“We found that patients of any Black ethnicity receiving peer support were significantly less likely to be re-admitted in the year post-discharge than those of any other ethnicity, compared with corresponding patients in the control group.”
The authors are clear that there are not enough participants in the study who are Black to infer too much from the sentence above. Then again, this finding adds to the many programme/services evaluations from across the UK and internationally: when mental health services have an element of peer support, the user profile better reflects the demographics in the areas in which they are deployed. People from ethnically diverse communities actually feel more comfortable to access and participate in services.
What the report is missing
Training, practice quality, collaboration, mentorship, and supervision are all the areas that are within our control of us as peer support facilitators, leaders, and innovators. There are many levers, questions, and opportunities we will take as partners at Habitus Collective and as witnesses of the impact of peer support. This article does add to our movement, it is a challenge to continue to widen and explore the conversation on peer support.
We need to widen our net of collaboration to make sure the movement doesn’t stall, but is strengthened by the findings of this paper. Bad psychiatric nursing means bad outcomes. Does that mean no nursing is the answer? No, of course not. Accordingly, let’s not infer the same for peer support.
Conclusion
Taking a strength-based perspective (like anyone who has taken peer supporter training should), we need to celebrate that peer support research has appeared in The Lancet. On its own, this is a major shift and, hopefully, another milestone in reducing stigma. The sheer number of authors included and academic might of the study, lends itself to high-quality methodology and conclusion.
We need to resist the temptation to reject the findings. The paper is academically and specifically written like it should be. The conclusion is specified to readmission, days in hospital and severity of symptoms.
Even so, the framing of this story is critical for the future of peer support. While one article does not indicate or completely steer the future, anyone can misread this document, unintentionally or otherwise. It does not say that peer support does not work. It does not say that peer support services, innovations, and projects should not be commissioned by government. Yet, mainstream journalists or people with vested interests do not quote (or sometimes even read) an entire article. Instead, they repeat a headline, partially repeat a comment, and give an incomplete reference from a conclusion. They listen to easy-to-remember sound bites.
How we talk about this in social media, at consultancy, and policy meetings with our managers and in our services, will all have an impact. Commissioners whose scope includes mental health services should be the target audience whenever we discuss and share evidence like this of peer support in transition settings.
Therefore, let's not allow this article to be boiled down to a sound bite. The quote in its entirety reads:
“one-to-one peer support for patients at risk of readmission should not be commissioned with the expectation that it will reduce readmission following discharge.”
Let’s broaden the scope of what success looks like, the different factors that help achieve these outcomes and identify the right type of peer support, in the right places and spaces that can achieve these aims.
Our job as peer support leaders is to realise the impact of peer support in its entirety. As practitioners and leaders, we know for peer support to work well it is not completely down to the peer support worker on their own. So often the success of peer support comes down to the workplace, the team, the organisation, and the systems readiness to accept it. Peer Supporters are an integral part of a holistic healthcare offer to people experiencing challenges with their mental health and substance use, let’s keep promoting its importance in helping people.
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