Impact and Implication

This article describes the implementation of a Peer to peer model in an adult mental health center of the Spanish public health system. The article details the elements of training and integration into the professional´s team. We consider that this study is significant to help other health centers in the execution of this innovative model so necessary for a truly comprehensive therapeutic treatment of patients. In conclusion, this kind of article is essential to help in the recognition as a qualified professional of the Peer to peer figure.

Introduction

Origin of self-help groups in Mental Health

Self-help groups were described as the oldest forms of peer support [1]. This experience begins in Anglo-Saxon countries; the Lunatic Friends’ Society is known as the first peer support group in mental health; It was founded in England in the mid-19^th century [2]. Some peer-led groups also formed in Germany in the late 19^th century, protesting involuntary confinement laws.

Previously, in the 18^th and 19th centuries there are references to several individuals who made their protests known about their treatment in autobiographies and petitions [3] and there are even references to peer support prior to the first asylums [4] Since the middle of the 20^th century, various groups of “survivors” and “consumers” of the mental health system has been organized, such as the pioneers We are not alone [5] to convey their demands for improvement and provide support and accompaniment in times of difficulty. In fact, before the beginning of the implementation process of the recovery model [6], in Anglo-Saxon countries, people with experience of mental disorder were introduced as dynamic agents of the system [7,8].

Different international experiences validate the implementation of these new professional support figures. In the United Kingdom, the government is reinforcing the value of peer support in the country’s mental health strategies. For example, programs carried out in Scotland with the Scottish Recovery Network foundation or Together for Mental Health and Mind’s peer support program in England and Wales. In Canada, successful experiences have been developed and systematized, such as the Toronto Harm Reduction Task force, collected in the Mental Health Peer Support Project Committee. In the United States, Yale University has developed The Yale program for Recovery and Community Health, defending that the active role of people with a mental health problem in supporting others provides a new way of understanding recovery.

Peer support

In our century, peer support begins to be considered in mental health services in a more systematized way and with a purpose aimed at patient recovery. Peer support is about “understanding the other’s situation empathically through the shared experience of emotions and psychological pain” [9]. In the United States, legitimacy for Peer Support began in 2007 by considering the conditions under which Peer Support could be reimbursed by Medicaid [10].

In recent years, there has been rapid growth and expansion of peer support [11]. Due to the policies driven by the orientation towards this mental health recovery model, some states in the US, Canada, Australia, New Zealand, Scotland, Wales and England have designed different stages in their conceptualization and implementation of mental health services peer support.

In German-speaking countries, peer support work has been based on the trialogue ment movement (of users, caregivers and professionals). With similar levels of policy input, in some European countries, former patients/clients, mental health service professionals and researchers have co-produced ‘experts by experience’ programs and therefore support the use of Peer to Peer in mental health services. The development of mental health peer support projects has spread to South America, Africa and Asia [12,13].

The Peer to Peer or Peer Support Technician

The figure of Peer to Peer or Peer Support Technician is a person who experiences or has experienced severe discomfort related to mental health throughout their life and who has received training to work supporting people who are currently in process of recovery from a mental health disorder.

Their role is professional in nature and is based on support between peers, defined as a form of socio-emotional support offered by an individual with a shared life experience in mental health [14], with specific training, to improve and explore the system of giving and receiving help based on the principles of respect, shared responsibility and agreement on what is useful [15].

Various studies indicate the effectiveness of peer support (with a certain variety of results) in mental health on different populations, by people who share similar experiences to achieve the desired emotional or psychological change [14]. The role of this professional figure in supporting people with mental disorders is based on [16]:

• Understand the other person with empathy and from one’s own emotional and psychological experience.
• Provide help based on principles of respect, responsibility and agreement on what is useful.
• Support others without the restrictions of the traditional professional-patient relationship.
• Promote the understanding of psychological suffering and improve adaptation to therapeutic processes.
• Transmit hope.

This approach to mental health support recognizes recovery as a deeply personal journey that is a human experience rather than a medical or illness process [17]. This distinction is deeply important and integral to the models of care that now exist within the non- clinical services sector.

Accompaniment and Mutual Support consists of a separate and different intervention from the clinical intervention, which it complements and reinforces within the care process.

The Peer to Peer in a mental health team

In Catalonia, the strategic lines of the 2017 20 Mental Health and Addictions Master Plan already include the possibility of introducing these new professional roles within mental health care.

First-person movement initiatives such as the EMILIA Association carry out training, not currently regulated, to train people with lived experiences to develop their professional activity as Peer Support Technician in the mental health environment.

The Nou Barris Mental Hygiene Center Foundation (FCHMNB) is an assistance service specialized in Mental Health and integrated into the public health network of the Catalan Health Service (SCS) that since 1981 has served the population of the 8^th district of Barcelona in a sectorized manner (Nou Barris), currently with a population of about 170,000 inhabitants.

It is made up of two adult mental health centers (CSMA Nord and CSMA Sud) and two intensive home care teams (PADI), which serve adults with mental health problems in the district under a community model.

The FCHMNB has a history of innovative initiatives to improve user engagement and quality of care with the goal of recovery. With the objective of innovation and improvement of recovery, in May 2022, the FCHMNB makes the decision to establish collaboration with the Veus Federation and through this, the figure of the Peer Support Technician is incorporated into its mental health care teams.

Development of the Peer to Peer model at the Fundació Center Higiene Mental Nou Barris

The model consists of the incorporation of the figure of the Peer to Peer Support Technician for users with Severe Mental Disorder within the care process of the Mental Health teams. The objective is to complement the care work, improve the patient’s connection with the various care and rehabilitation resources and all this by improving awareness of the disorder and therapeutic commitment.

In the design of the Peer to Peer incorporation into the multidisciplinary teams of our centers, the following phases were considered:

Design

• Review by the Management of the Nou Barris Mental Hygiene Center Foundation of the published international bibliography and successful model cases.
• Meetings during the second half of 2021 FCHMNB – Federació Veus to incorporate the proposal into the healthcare model and establish the contractual relationship.
• Information to the teams in the first quarter of 2022 of the future incorporation of the Peer to Peer to promote its reception.

Immersion First month

• Incorporation of the Peer Support Technique to healthcare teams in May 2022.
• Presentation to the Foundation teams and the different mental health and community facilities of the AIS   Barcelona North.
• Provision of technical resources: mobile phone and computer.
• Team support with a nurse on the first visits.

• Full autonomy

• One month after joining: accompaniments with her own agenda. Referrals of people linked to the Severe Mental Disorder Program (TMS) and Intensive Home Care Program (PADI).

• Follow-up

• Quarterly.
• Joint supervision, monitoring and detection of needs by the Management of the Veus Foundation and FCHMNB.
• Continuous monitoring and support carried out by a nurse from the FCHMNB.

Participants

The intervention study incorporates the figure of the Peer to Peer

Support Technician for 13 months, during which we worked with 30 users (Table 1), people linked to the Severe Mental Disorder Program (TMS). A total of 257 accompaniments have been carried out, that is, an average of 8.5 accompaniments per user.

Table 1: Sociodemographic and clinical characteristics of the patients admitted to the study.

The experience has been developed in the two Adult Mental Health Centers (CSMA Nord and CSMA Sud), through the Peer to Peer program developed thanks to the collaboration of the Nou Barris Mental Hygiene Center Foundation and the Veus Federation. The 30 cases handled are referred by different CSMA professionals: 13 come from psychiatry, 5 from nursing, 10 from the (PADI) Intensive Home Care Program, and 2 from PSI (Individualized Support Program).

Of the 30 cases carried out: 2 have done 20 or more accompaniments; 6 users have carried out 12 or more accompaniments; 6 users, 10 or more accompaniments; 5 users, 6 or more accompaniments; 4 users, 5 accompaniments; and 7 users, less than 5 accompaniments. The Peer to Peer intervention begins in May 2022 and this article collects the experience until July 2023. The intervention continues today with new users of the aforementioned mental health teams.

The integration of the Peer Support Technician in the community Mental Health team

The figure of the Peer Support Technician works jointly and in coordination with the healthcare team. Thus, a process of adaptation to the team’s values and way of working is progressively established.

The Peer Support Technician is another professional on the team. In addition, she attends care team meetings in which she actively participates, providing her first-person view of the difficulties and challenges that the patient may encounter.

The selection of candidate patients is established jointly by the care team (psychiatrist, nurse, psychologist...) and people who are in the Severe Mental Disorder (SMD) program are chosen.

A referral document has been created for professionals to express the objectives and purpose of support within the therapeutic strategy of each patient.

The referring professional introduces the patient and in the first follow-up visit the role of the Peer Support Technique is defined, differentiated from the roles of other professionals. Presenting the figure and making the modus operandi clear is the most basic thing when receiving the user. As this is a new role, it is important to highlight what our purposes, limits and objectives are. The operation, especially with the clarified setting, is something that the user must leave with on the first day planned and agreed upon between both. This first accompaniment lays the foundations for the future relationship.

It is proposed to carry out a maximum of 12 accompaniments for each user, so that the link between the Peer Support Technique and the user is not excessively close and to avoid confusion with other types of roles, such as that of therapist or PSI.

The accompaniments are carried out regularly on a weekly or biweekly basis and are adapted to the individual characteristics of each patient.

In some cases, mixed accompaniment has been carried out, in which in addition to the Peer to Peer, a nurse or the PADI team (Intensive Home Care Program) has participated, which has made it possible to provide a global and interdisciplinary vision of the moment of user recovery.

During the accompaniment with the Peer Support Technique, the patient is also asked about upcoming visits with the rest of the professionals, highlighting the importance of attending and taking advantage of the consultation time, trying to clarify the important issues to be discussed in each case.

Furthermore, throughout the experience, new processes were incorporated such as the derivation document based on the CEISE system (Connection, Empowerment, Identity, Meaning and Hope) (18) in which the objectives to be worked on are established, and the document end of process, which includes an evaluation of the work performed.

At the end of the process, a satisfaction survey is given to the user. The Peer to Peer must also complete a document evaluating the work carried out called Closing sheet, which is in line with the objectives of the Referral sheet.

Assessment of the peer-to-peer model implemented

For more than a year, the Peer to Peer or Peer Support Technician program has been implemented in the Mental Health Centers of Nou Barris.

In our case, it has been a Peer Support Technician who has assisted 30 patients with diagnoses of Severe Mental Disorder (SMD) to whom this mode of intervention has been proposed within their therapeutic plan.

This intervention represents an innovative experience in the field of mental health in our environment, since there are still few similar experiences in Spain. The situation in Spain of the figure of Mutual Support in Mental Health has experienced significant changes in the last decade, such as, for example, the programs implemented in Andalusia, Castilla-La Mancha, the Valencian Community and Madrid.

In Catalonia, there are two accredited training programs. Regarding incorporation, some health provider entities have started hiring in Catalonia, establishing agreements with entities “In the first person.” Furthermore, Catalonia leads the implementation of mutual support in pediatric mental health [19].

Our assessment of the experience is based on the reflections made by the Peer Support Technician in assessment meetings with the healthcare teams and with the Management of the Nou Barrris Mental Hygiene Center Foundation.

The incorporation of the figure of a Peer Support Technician has had a positive impact not only on the users themselves, but has also influenced the care teams themselves.

Users have felt listened to by someone who could understand their concerns with empathy and from the point of view of someone who has had their own psychological suffering, which facilitates their responsibility for the treatment and increases their perception of recovery, very important factors in the case of people with serious mental disorders.

Through this experience, what users highlight most is being able to share their concerns regarding their disorders and share their emotional experiences from mutuality and horizontality, without feeling judged and without the need to talk about diagnoses or labels.

In the satisfaction surveys to assess the Peer to Peer experience, statements such as: “confidence”, “calmness”, “positivity”, “feeling better”, “understanding my situation”, “understanding to accept the situation” are collected.

The regularity of the accompaniment provides users with important emotional security and has allowed some of them to escape situations of high family dependency or loneliness, thus changing social isolation. On several occasions the accompaniments have encouraged the user to leave the house and create a weekly routine.

The Peer to Peer intervention has also made it possible to make accompanied referrals to the Matissos association, with the aim of informing these users about the different artistic workshops. Some of the users served have shown their interest in joining the world of associations (Associació SocioCultural Matissos or Associació Emilia BCN).

On the other hand, in the team meetings the Technician has tried to contribute her first- person point of view when necessary, which has had a positive influence on the care team since it has expanded the way of understanding the needs of the patient more beyond the conventional therapeutic approach.

This year of experience has meant mutual learning of the professional teams and the Peer Support Technician and we consider that this Peer to Peer intervention model enriches the professional quality of the Mental Health teams.

Discussion

The decision to incorporate the professional figure of Peer to Peer in care teams represents an innovative experience that can offer people with serious mental health disorders better coping skills, greater resilience, confidence, motivation and self-awareness.

Peer to Peer has proven valuable in developing internal resilience to stigma and discrimination by creating hope [20]. Peer Support Workers are increasingly being deployed in low-resource settings as a cost-effective approach and as a way of “task sharing” to help support the service delivery of already overstretched mental health systems.

The benefits of the peer to peer model show positive results in the areas of improved quality of life, hope and empowerment, especially for patients with serious mental illness. Several qualitative and observation-based studies confirm that peer support has clear benefits [21]. Formal task such as Peer to Peer has been associated with improved qualityof life, reduced symptoms, and greater self-reported recovery in people receiving support [22].

This type of resource contributes to improving self-confidence, hope and social connection. This can better help people with mental health problems regain a sense of self beyond their diagnosis and provide a sense of hope, choice, and self-efficacy [23].

The professional figure of the Peer Support Technician provides [23]:

• A deeper understanding of strategies to support personal recovery and peer support in mental health recovery.
• An identified need for the sustainability of peer recovery programs with unmet psychosocial support needs.
• The value of integrating the experiences of those with lived experiences of mental health challenges into peer support models aimed at assisting recovery pathways.

“The qualitative approach captured the voices of the study participants more authentically and provided a better understanding of their first-hand experiences with the Peer to Peer approach” [23]. Participants reported improved coping skills, increased resilience, confidence, motivation, and self-awareness. Additionally, they reported that the program also helped them overcome social isolation and better understand their mental health challenges. Overall, the program empowered participants to better cope with their mental health problems, and was seen as an alternative to medicalized, diagnosis-based treatment options [23].

The relationship is the engine that allows change, in the case of technicians it is a horizontal and mutual relationship per se, which puts us in a different situation in relation to the relationship of the rest of professionals.

However, the concrete experience of Peer to Peer professionals on a daily basis with various types of patients can raise new difficulties and new questions that must be addressed conceptually and in practice.

For example, an important aspect to clarify is the division of responsibilities between collaborating parties [24]. Other aspects are the forms of coordination and the coordination work with the care teams, to establish useful models for sharing clinical and care information.

In our experience, we have observed that the incorporation of the Peer to Peer figure in meetings with healthcare teams produces a change in the attitude of professionals, given that they are someone with first-person experience of mental health. This leads to a different awareness of the patient when talking about his mental health problems. In this sense, the Peer to Peer also offers a different view of mental health problems and the challenges and difficulties that the patient may have, so that the therapeutic approach is enriched.

In relation to the incorporation of the Peer Support Technician, it is also essential to consider the needs of emotional support for the Peer to Peer himself, given that, in his work of patient care, the peer to peer may encounter highly burdensome psychological and emotional difficulties. Finally, there are ethical considerations such as those related to data protection that must be considered. For example, in our case the Peer Support Technician does not have access to the patient’s Medical History data.

In conclusion, use of Peer to Peer support for mental health disorders is a tool that is progressively spreading in the field of mental health. To achieve it more concretely, it is necessary to disseminate new studies that expose peer support programs and their implementation in mental health organizations.

Authors Contributions

PL, AG, GR, AM and RC: conceptualization, methodology, and supervision. AG and GR: data curation. AG, GR and RC: writing, review and editing. All authors contributed to the article and they all read and approved the final manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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