Position Statement 37: Peer Support Services

Policy

Mental Health America (MHA) believes that peer support is an essential element of successful communities that is integral to recovery from mental health and substance abuse conditions. MHA calls on states and communities to incorporate peer support into community-based mental health and substance use treatment services. Peer mental health and substance abuse support services make use of empathy and empowerment to help support and inspire recovery.

Background

A decades-long study by the World Health Organization found that individuals diagnosed with schizophrenia usually do better in countries in the developing world – such as India, Nigeria and Colombia – than they do in such Western nations as Denmark, England and the United States.[1]According to an analysis of results, “Patients in developing countries experienced significantly longer periods of unimpaired functioning in the community, although only 16% of them were on continuous antipsychotic medication (compared with 61% in the developed countries). . . . The sobering experience of high rates of chronic disability and dependency associated with schizophrenia in high-income countries, despite access to costly biomedical treatment, suggest that something essential to resilience and recovery is missing in the social fabric.”[2]

One such essential factor is peer support, which the Substance Abuse and Mental Health Services Administration (SAMHSA) has identified as a vital component in recovery.[3] Since the mid-20th century, individuals who have psychiatric diagnoses have been creating effective and cost-efficient services that provide that missing factor.[4] Peer-run services are based on the principle that individuals who have shared similar experiences can help themselves and each other. MHA believes that a peer-led vision of recovery needs to be the aim of all, even those most profoundly troubled, for whom friendship and belonging to a community in recovery can work wonders.

Peer support programs provide an opportunity for communities of individuals who have significantly recovered from their illnesses to help others direct their own recoveries by teaching one another the skills necessary to lead meaningful lives in the community.[5] Peer support services have demonstrated effective outcomes such as reduced isolation and increased empathic responses.[6] Research has also shown that outcomes improve when individuals serve as peer specialists on care teams.[7] Serving others also helps to sustain recovery. The only downside is the “glass ceiling” that can relegate people with lived experience of mental health conditions to peer-serving jobs, precluding advancement.

Peer support services present six advantages over traditional mental health and substance abuse services:

• First, there is a sense of gratitude that is manifested in compassion and commitment.

The peer specialist’s compassion and commitment comes out of a deep sense of gratitude. There is something different about caring for another person because you see yourself in that person. You see where you were at one time in your life. Their pain, loneliness, and despair was once your pain, loneliness and despair. Because of this awareness, peer specialists find it more difficult to give up on someone because people did not give up on them.

• Second, there is insight into the experience of internalized stigma.

Most peer specialists know that what they believe about themselves because they have a mental health condition can often be more disabling than the condition itself. They are aware that when they have the symptoms of the condition under control, their fears, low self-esteem and negative self-talk can still make it difficult for them to function in the way society expects people to function.

• Third, peer specialists have been there through lived experience.

There is no more freeing experience than meeting a peer and truly feeling one is not alone. This experience of “I am not alone” brings a sense of understanding, trust and hope.

• Fourth, they have had the experience of moving from hopelessness to hope.

When one believes that there is nothing that she can do to improve the quality of her life, the person does nothing – not out of laziness or apathy, but out of hopelessness, despair and resignation. Most peer specialists have experienced this at one time in their lives. Yet they have been able to move through and beyond that hopelessness to believe they can act on their own behalf to create the life that they want. There is nothing more empowering to a person who has given up.

• Fifth, they are in a unique position to develop a relationship of trust with their peers.

People are often more willing to share their real issues, concerns, hopes and dreams with a peer specialist than with non-peer, clinical staff.

• Sixth, they have developed the gift of monitoring their illness and managing their lives holistically, including both mind and body.

Peer specialists are in a unique position to teach and motivate their peers toward whole health self-management. They have learned to recognize triggers and early warning signs, counteract the negative impact of stress, and create plans for taking care of themselves. They understand what it takes to integrate medical care with peer support and wellness in order to help others to recover from disabilities and respond to challenges.

The Centers for Medicare & Medicaid Services (CMS) issued the following statement as part of a letter to state Medicaid offices encouraging the use of peer specialists:[8]

"States are increasingly interested in covering peer support providers as a distinct provider type for the delivery of support services to Medicaid eligible adults with mental illnesses and/or substance abuse disorders. Peer support services are an evidence-based mental health model of care which consists of a qualified peer support provider who assists individuals with their recovery from mental illness and substance abuse disorders. CMS recognizes that the experiences of peer support providers, as consumers of mental health and substance abuse services, can be an important component in a State's delivery of effective treatment. CMS is reaffirming its commitment to State flexibility, increased innovation, consumer choice, self-direction, recovery, and consumer protection through approval of these services.”

Peer support services are part of the array of services necessary for a culturally competent, recovery-based mental health and substance abuse system. Peer support services are equal partners with more traditional clinical services and may extend services to underserved populations. However, MHA recognizes that peer support should not be used as a cost-saving substitute for clinical services, especially during the current era of budgetary constraints. As a means of securing reimbursement and ensuring quality care, peer services may include a certification process and should be available on a parity basis to all in need, regardless of the financing mechanism.

MHA recognizes that while peer support programs today are often funded through state revenue, Medicaid, largely through managed care, has become a major funding stream.  Medicaid is increasingly being viewed as a means to fund mental health services and an increasing number of states are successfully implementing independent peer support services programs that bill Medicaid directly or through managed care organizations.

Call to Action

• MHA affiliates, service provider organizations, and other advocates should advocate for making peer support an integral part of mental health and substance abuse service delivery.
• To successfully recruit and retain excellent peer supporters, people with extensive experience in peer support should be involved at multiple levels of planning and implementation of peer support services, including senior management positions in service programs.
• Affiliates should review state statutes governing the practice of mental health professions to remove barriers that artificially restrict the scope of activities of peer support specialists.
• Federal funding for the increased use of peer support services and peer support training should be a priority area for the Substance Abuse and Mental Health Services Administration (SAMHSA).
• States should set aside an appropriate percentage of state funds for peer support programs.
• Family and adolescent peer support services should be developed to complement adult peer services.
• Federal providers of mental health services, such as the military, should support training and employment of peer support specialists.
• Federal, state, and local governments should assure that trained peer advocates are included among the groups of people permitted to provide crisis support in emergency preparedness and response plans.
• Academic institutions and federal entities, such as the National Institute of Mental Health, should support research on the efficacy of peer support programs and different structural and training considerations that promote greater efficacy.
• Since peer support services are often located in small and frequently consumer-run agencies, MHA encourages Medicaid and other authorities to minimize the reporting burden while maintaining accountability in order to facilitate service provision and entry of peers into the services environment.
• Certification and advanced certification play a critical role in promoting professionalism and in obtaining reimbursement for services, but opportunities for peers without certification to provide support should be available. Prior experience is a prerequisite for certification.
• Medicare and private health insurers should reimburse for peer support services when provided by peer specialists who have achieved advanced level national certification. National certification provides uniformity of standards and professionalism across state lines. .
• States without a certification process should provide peer specialist training and develop state certification requirements.
• MHA supports the expansion of the availability of peer support services throughout health care, and opportunities for career advancement and pay increases for qualified peer support workers.
• MHA also supports the evolving role of peers trained for whole health recovery to help reduce the 10- 25-year average premature death of those served by public mental health services.

Effective Period

The Mental Health America (MHA) Board of Directors approved this policy on September 8, 2018. It is reviewed as required by the Mental Health America (MHA) Public Policy Committee.

Expiration: December 31, 2023