ABSTRACT

In the context of debates surrounding the training of mental health peer support workers and their incorporation into the Catalan Health System, this article presents a literature review complemented by interviews carried out between 2020 and 2021 with both international and Spanish experts. Based on the information obtained, content analysis of elements of their training and integration within the health system was performed. German-speaking countries offer the most homogeneous training and recruitment programs. In the case of English- and French-speaking countries, non-profit or third sector organizations are usually in charge of training programs and recruitment. Various experiences with training programs exist in the Ibero-American world, although they are not recognized as professional qualifications. Recommendations are offered for the development of this figure in Catalonia, which include advancing towards professional training with recognition as health care providers, as well as contracting options from both socio-health or health care providers or from third sector entities.

KEY WORDS:
Mental Health; Peer Support; Health Systems; Health Human Resource Training

INTRODUCTION

The recovery paradigm

To understand how the phenomenon of incorporating peer support into mental health care systems emerges, we must place ourselves in the paradigm of recovery in the English-speaking world. Recovery as a movement and later as a model - we use the word paradigm to encompass both concepts - is the product of synergies among movements of people with lived experience of mental distress (also called people with experiences in the first person or people affected in Spanish-speaking countries, and, in relation to care systems, called service users, consumers or survivors), as well as relatives and professionals. It was defined in its initial conceptualization as a multidimensional, “deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by illness.”¹1. Anthony WA. Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal. 1993;16(4):11-23. With roots in the introduction of humanist measures after the French Revolution and the American Civil War,²2. Davidson L, Rakfeldt J, Strauss J. The roots of the recovery movement in psychiatry. Chichester: John Wiley & Sons; 2010. this movement proposed shifting the focus of mental health interventions beyond symptomatic remission. The use of the term recovery implied an intentional polysemy: it at the same time referred to a subjective and idiosyncratic process, to a new proposed objective of mental health interventions, and to a large-scale strategy of health services transformation.

The recovery paradigm was born, among other things, inspired by the evidence of symptomatic remission found in the pioneering Vermont study.³3. Harding CM, Brooks GW, Ashikaga T, Strauss JS, Breier A. The Vermont longitudinal study of persons with severe mental illness, I: Methodology, study sample, and overall status 32 years later. American Journal of Psychiatry. 1987;144(6):718-726.^,44. Harding CM, Brooks GW, Ashikaga T, Strauss JS, Breier A. The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry. 1987;144(6):727-735. The results of this longitudinal study, confirmed by evidence produced in the following decades, highlighted that just as total symptomatic remission is possible, even in people with very intense and lasting experiences of mental distress, a significant life can also be led despite being in the process of recovery, that is, while perhaps still experiencing “residual” symptoms.⁵5. Davidson L. The recovery movement: Implications for mental health care and enabling people to participate fully in life. Health Affairs. 2016;35(6):1091-1097.

One proof of the early impact of the recovery movement is the appearance of the concept in the first US Surgeon General’s report on mental health in 1999.⁶6. Satcher D. Executive summary: A report of the Surgeon General on Mental health. Public Health Reports. 2000;115:89-101. The report emphasized the participation of consumers and their relatives in the planning of services and the proposal of a model of care focused on the “restoration of self-esteem and identity and on attaining meaningful roles in society.”⁷7. United States Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health; 1999.

The movements of people with lived experience of mental distress, present since the 19th century England, have demanded, in different ways the humanization of care services. Except for the closure of the large hospitals and the deinstitutionalization of care, the most revolutionary proposals, embodied above all in the antipsychiatry movement, had only been marginally implemented. However, the emergence and institutional recognition of the recovery model made the role of service users in the care relationship a predominant issue of debate. In this context, the different alliances of organizations of professionals and people with lived experience of mental distress and their relatives were involved in the transformation and even appropriation of care systems. The proposal was to move from a vision that situated service users as passive subjects to be cared for by the system, to one in which they are considered subjects of rights and are encouraged to explore their strengths and support other people in this search.⁸8. Chamberlin J. On our own: Patient controlled alternatives to the mental health system. Philadelphia: Hawthorn Books; 1978.

It should be noted that in Spain and Latin America there were some differences with respect to other Western European countries in the implementation of major mental health reforms. Due to the ultra-right dictatorships present in many countries during the 20th century, the deinstitutionalization of the psychiatric system did not begin until the 1980s or 1990s, with the development of resources alternative to large psychiatric hospitals.⁹9. Vázquez-Barquero JL, García J. Deinstitutionalization and psychiatric reform in Spain. European Archives of Psychiatry and Clinical Neuroscience. 1999;249(3):128-135. Subsequently, the arrival of influences from the recovery movement was limited to community rehabilitation services, and it was not until the late 2000s that it spread to other settings through specific projects.

In the case of Spain, the 2008 economic crisis and the related cuts in healthcare budgets led to the withdrawal of funds for many of these projects.¹⁰10. Gili M, Roca M, Basu S, McKee M, Stuckler D. The mental health risks of economic crisis in Spain: evidence from primary care centres, 2006 and 2010. European Journal of Public Health. 2013;23(1):103-108. Furthermore, the 2012 Draft Reform of the Criminal Code promoted by the state government, which proposed the introduction of special security measures for people diagnosed with mental disorders in the Criminal Code, provoked an immediate reaction from the main mental health organizations with representation of people with lived experience of mental distress. This turning point can be considered as a definitive catalyst for what is known as the “first-person” (en primera persona) movement. This movement has included, in addition to a complex constellation of associations, the federation En Primera Persona in Andalusia since 2009, and Veus (Voices), formed in Catalonia in 2014. Both autonomous communities were also pioneers in the implementation of campaigns against stigma at the regional level, becoming especially active territories in the fight for the rights of people diagnosed with psychiatric disorders, notwithstanding the growing activity in the rest of the country. Such activity has crystallized in alliances among the two federations and the rest of the “first person” associations, as well as a “first person” committee within the Mental Health Confederation of Spain, which itself was born of the relatives’ movement.

In Latin America there is a growing interest in the recovery model¹¹11. Oliveira WF, Renato Pinto AP, Cidade A, Bessa SL, Bess E. Recovery e saúde mental: uma revisão da literatura latinoamericana. Revista Iberoamericana de Psicología. 2021;14(2):69-81. especially as a tool for institutional transformation¹²12. Costa MN. Recovery como estratégia para avançar a Reforma Psiquiátrica no Brasil. Cadernos Brasileiros de Saúde Mental. 2017;9(21):1-16.^,1313. Brandão ADL, Figueiredo AP, Delgado PGG. Incorporações e usos do conceito de recovery no contexto da Reforma Psiquiátrica Brasileira: uma revisão da literatura. Trabalho Educação e Saúde. 2022;20:1-21. and citizenship advocacy¹⁴14. Agrest M, Garber Epstein P, Geffner N. Recuperación, un concepto de frontera (Parte II) Perspectivas latinoamericanas. Vertex. 2017;XXVIII(136):430-433. inspired by the process in the US. The promoters of the ideas of recovery in Latin America consider themselves part of the legacy of movements and ideas with local roots, such as the anti-asylum struggle of Nise da Silveira, the liberation pedagogy of the Brazilian Paulo Freire¹⁵15. Freire P. La educación como práctica de la libertad. México DF: Siglo XXI Editores; 1965. or the social psychology of Pichon-Rivière,¹⁶16. Pichon-Rivière E. El proceso grupal: Del psicoanálisis a la psicología social. Buenos Aires: Ediciones Nueva Visión; 1971. pioneer along with Harry Stack Sullivan²2. Davidson L, Rakfeldt J, Strauss J. The roots of the recovery movement in psychiatry. Chichester: John Wiley & Sons; 2010. in the training of mental health service users as facilitators of the recovery of others.¹⁷17. Carpintero E, Vainer A. Las huellas de la memoria: 1957-1969. Buenos Aires: Topía; 2004.

The implementation of these ideas in health management systems has not been exempt from controversy and the need for readjustments in the expectations of activists - if not downright disappointment. The British collective Recovery in the Bin is likely the organization to have best made explicit their criticisms. Its members accuse the recovery model of having been colonized and implemented with neoliberal bases (for example, hiding staff cuts behind “self-managed recovery plans”) in a decontextualized and homogenizing way that ignores the fact that many people will not be able to recover if social justice is not achieved.¹⁸18. Recovery in the Bin. RITB - Key Principles [Internet]. 2016 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/4ujmzf9r .
https://tinyurl.com/4ujmzf9r...

Peer support

One of the distinctive elements of the recovery model - sometimes even confusingly used as a metonymy, as if the recovery model involved just the incorporation of peer support into the system⁵5. Davidson L. The recovery movement: Implications for mental health care and enabling people to participate fully in life. Health Affairs. 2016;35(6):1091-1097. - are interventions carried out by people with lived experience of mental distress.¹⁹19. Ahmed AO, Doane NJ, Mabe PA, Buckley PF, Birgenheir D, Goodrum NM. Peers and peer-led interventions for people with schizophrenia. Psychiatric Clinics of North America. 2012;35(3):699-715. Examples are mutual aid (defined as the creation and moderation of self-help groups) and peer support (defined as the training and incorporation into the health system of people with lived experience of mental distress). Both mutual aid and peer support consist primarily of the support provided to people with lived experience of mental distress by people who have had similar experiences. It promotes recovery regardless of diagnoses or biomedical classifications and is based on theories that consider that social proximity fosters motivation,²⁰20. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist. 2000;55(1):68-78. provides a reference for comparison²¹21. Festinger L. A theory of social comparison processes. Human Relations. 1954;7(2):117-140. and increases the understanding of one’s own situation.²²22. Sanchez-Moscona C, Eiroa-Orosa FJ. Training mental health peer support training facilitators: a qualitative, participatory evaluation. International Journal of Mental Health Nursing. 2021;30(1):261-273. This type of accompaniment expands social networks and offers acceptance, support, understanding, empathy and a sense of community, which increases hope, autonomy, self-efficacy and the assumption of responsibilities.²³23. Bradstreet S, Pratt R. Developing peer support worker roles: Reflecting on experiences in Scotland. Mental Health and Social Inclusion. 2010;14(3):36-41. Specifically, because of its role within the system, peer support allows the adoption of valuable social roles, no longer restricted to the passive role of service user, but also that of role model.²⁴24. Davidson L, Chinman M, Kloos B, Weingarten R, Stayner D, Tebes JK. Peer support among individuals with severe mental illness: A review of the evidence. Clinical Psychology: Science and Practice. 1999;6(2):165-187. In addition, it can be implemented at low cost and maintains its usefulness combined with traditional professional practices.¹⁹19. Ahmed AO, Doane NJ, Mabe PA, Buckley PF, Birgenheir D, Goodrum NM. Peers and peer-led interventions for people with schizophrenia. Psychiatric Clinics of North America. 2012;35(3):699-715. Although the implementation of mutual support has so far focused on adult populations, there are also starting to be programs focused on child and adolescent populations.²⁵25. Ballesteros-Urpí A. El suport mutu (peer support) en salut mental i la seva aplicabilitat en infants i adolescents. Educació Social. 2020;(75):47-63.

A Delphi study identified the key elements of the training of this professional figure internationally called “peer”: lived experience as a resource, ethical practice, self-well-being, focus on recovery and communication skills.²⁶26. Charles A, Nixdorf R, Ibrahim N, Meir LG, Mpango RS, Ngakongwa F, et al. Initial training for mental health peer support workers: Systematized review and international delphi consultation. JMIR Mental Health. 2021;8(5):e25528. Once incorporated, the tasks performed by these people can be categorized as direct or indirect support.²⁷27. Jacobson N, Trojanowski L, Dewa CS. What do peer support workers do? A job description. BMC Health Services Research. 2012;12:205.⁾ The activities considered direct tasks are the defense of rights (providing information and support), connecting service users to resources (such as desired services), sharing common experiences, building community (connecting the person with programs that link them to the community), building relationships (based on trust), facilitating group activities, developing skills and objectives, socialization, and the development of self-esteem. Indirect tasks include administration, communication, supervision, training, receiving support, and obtaining and verifying information. In addition, the work of peer support workers also includes actions aimed at building relationships with professionals and legitimizing the role of the figure.²⁸28. Gagne CA, Finch WL, Myrick KJ, Davis LM. Peer workers in the behavioral and integrated health workforce: Opportunities and future directions. American Journal of Preventive Medicine. 2018;54(6):S258-S266. In this way, the tools that peers require to perform their functions go beyond the experience of mental distress, including life experience of recovery and resilience, a respectful approach, genuine presence, modeling, collaboration, and engagement.²⁷27. Jacobson N, Trojanowski L, Dewa CS. What do peer support workers do? A job description. BMC Health Services Research. 2012;12:205.

Difficulties and controversies regarding the implementation of peer support

Care systems have identified problematic issues associated with peer support. Examples are the difficulties of integration in health teams, the presence of negative attitudes towards the recovery model in other professionals, conflict and confusion of roles, the lack of policies and practices regarding confidentiality, organizational structures and cultures without sufficient definition, and the lack of support and networking.²⁹29. Gates LB, Akabas SH. Developing strategies to integrate peer providers into the staff of mental health agencies. Administration and Policy in Mental Health. 2007;34(3):293-306.^,3030. Kilpatrick E, Keeney S, McCauley CO. Tokenistic or genuinely effective? Exploring the views of voluntary sector staff regarding the emerging peer support worker role in mental health. Journal of Psychiatric and Mental Health Nursing. 2017;24(7):503-512. doi: 10.1111/jpm.12391.
https://doi.org/10.1111/jpm.12391.... As strategies to improve these aspects, it is recommended that structures, policies and practices be established that guide the incorporation of peers and that help to define more clearly their role,²⁹29. Gates LB, Akabas SH. Developing strategies to integrate peer providers into the staff of mental health agencies. Administration and Policy in Mental Health. 2007;34(3):293-306.^,3131. Ibrahim N, Thompson D, Nixdorf R, Kalha J, Mpango R, Moran G, et al. A systematic review of influences on implementation of peer support work for adults with mental health problems. Social Psychiatry and Psychiatric Epidemiology. 2020;55(3):285-293.^,3232. Sticher L, Bonsack C. Les pairs praticiens en santé mentale: une nouvelle profession en psychiatrie. Revue Médicale Suisse. 2017;13(575):1614-1616. doi: 10.53738/REVMED.2017.13.575.1614.
https://doi.org/10.53738/REVMED.2017.13.... as well as the supervision and accompaniment of other professionals, both those of peer support and typical clinicians.³³33. Agrest M, Geffner N, Neistadt A, Iconicoff A, Pérez F, Minvielle M, et al. La incorporación de pares en los equipos de salud mental. En: Investigaciones y Experiencias en Salud Mental y Adicciones en Argentina. Ciudad Autónoma de Buenos Aires: Ministerio de Salud y Desarrollo Social de la Nación; 2019. p. 177-182.^,3434. Burke EM, Pyle M, Machin K, Morrison AP. Providing mental health peer support 1: A Delphi study to develop consensus on the essential components, costs, benefits, barriers and facilitators. International Journal of Social Psychiatry. 2018;64(8):799-812. doi: 10.1177/0020764018810299.
https://doi.org/10.1177/0020764018810299...

Within the movements of people with lived experience of mental distress, doubts about the implementation of peer support as a professionalized figure problematize the adoption of a role of “expert” or person who “possesses expert knowledge” in contraposition to one’s own lived experience or “profane knowledge.”³⁵35. Correa-Urquiza M. La condición del diálogo: Saberes profanos y nuevos contextos del decir. Revista de la Asociación Española de Neuropsiquiatría. 2018;38(134):567-585. doi: 10.4321/s0211-57352018000200012.
https://doi.org/10.4321/s0211-5735201800... In other words, if the inclusion of peers in the system was proposed as a spearhead to promote reforms through work that recognizes the value of experience and horizontality in treatment, but many of these peers end up adopting a professional identity similar in its verticality to that of traditional professionals, the only change that will have been made is in the person, who will have adapted to the system as it is.³²32. Sticher L, Bonsack C. Les pairs praticiens en santé mentale: une nouvelle profession en psychiatrie. Revue Médicale Suisse. 2017;13(575):1614-1616. doi: 10.53738/REVMED.2017.13.575.1614.
https://doi.org/10.53738/REVMED.2017.13.... In this case, the inclusion of peers could even help uphold the existing care system, justifying that “changes” have been made when in reality everything remains the same. Additionally, it is also argued that maintaining an identity closely linked to the past as service users can distance peer support workers from a professional identity necessary for integration within professional teams.³⁶36. Jones N, Niu G, Thomas M, Riano NS, Hinshaw SP, Mangurian C. Peer specialists in community mental health: Ongoing challenges of inclusion. Psychiatric Services. 2019;70(12):1172-1175. doi: 10.1176/appi.ps.201800552.
https://doi.org/10.1176/appi.ps.20180055... As the synthesis of a reflection regarding a pioneering experience in Argentina,³⁷37. Ardila Gómez SE, Agrest M, Abadi D, Cáceres C. El aporte de los pares al trabajo en salud mental: consideraciones acerca de las relaciones entre los sistemas formales e informales de ayuda: Relato de una experiencia. Vertex. 2013;XXIV:465-471. the possible contribution of the incorporation of peers to mental health teams is posited as an aid to professionals in reflecting on the relational dimension of their work, and on their ways of treating and thinking about service users.

At the scientific level, the supposed scarcity of empirical evidence supporting the effectiveness and efficacy of peer support is one of the main arguments of people who do not support its implementation. However, there are a total of nine review and quantitative synthesis works,³⁸38. Pitt V, Lowe D, Hill S, Prictor M, Hetrick SE, Ryan R, et al. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database of Systematic Reviews. 2013;28(3):CD004807. doi: 10.1002/14651858.CD004807.pub2.
https://doi.org/10.1002/14651858.CD00480... ^,3939. Fuhr DC, Salisbury TT, De Silva MJ, Atif N, van Ginneken N, Rahman A, et al. Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Social Psychiatry and Psychiatric Epidemiology. 2014;49(11):1691-1702. doi: 10.1007/s00127-014-0857-5.
https://doi.org/10.1007/s00127-014-0857-... ^,4040. Lloyd-Evans B, Mayo-Wilson E, Harrison B, Istead H, Brown E, Pilling S, et al. A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness. BMC Psychiatry. 2014;14:39. doi: 10.1186/1471-244X-14-39.
https://doi.org/10.1186/1471-244X-14-39.... ^,4141. Burke EM, Pyle M, Machin K, Varese F, Morrison AP. The effects of peer support on empowerment, self-efficacy, and internalized stigma: A narrative synthesis and meta-analysis. Stigma Heal. 2019;4(3):337-356. doi: 10.1037/sah0000148.
https://doi.org/10.1037/sah0000148.... ^,4242. Chien WT, Clifton AV, Zhao S, Lui S. Peer support for people with schizophrenia or other serious mental illness. Cochrane Database of Systematic Reviews. 2019;4(4):CD010880. doi:10.1002/14651858.cd010880.pub2.
https://doi.org/10.1002/14651858.cd01088... ^,4343. Huang R, Yan C, Tian Y, Lei B, Yang D, Liu D, et al. Effectiveness of peer support intervention on perinatal depression: A systematic review and meta-analysis. Journal of Affective Disorders. 2020;276(6):788-796. doi: 10.1016/j.jad.2020.06.048.
https://doi.org/10.1016/j.jad.2020.06.04... ^,4444. White S, Foster R, Marks J, Morshead R, Goldsmith L, Barlow S, et al. The effectiveness of one-to-one peer support in mental health services: a systematic review and meta-analysis. BMC Psychiatry. 2020;20(1):1-20. doi: 10.1186/s12888-020-02923-3.
https://doi.org/10.1186/s12888-020-02923... ^,4545. Lyons N, Cooper C, Lloyd Evans B. A systematic review of the effectiveness of group peer support interventions for mental health conditions. BMC Psychiatry. 2021;21(315):1-17. doi: 10.1186/s12888-021-03321-z.
https://doi.org/10.1186/s12888-021-03321... ^,4646. Smit D, Miguel C, Vrijsen JN, Groeneweg B, Spijker J, Cuijpers P. The effectiveness of peer support for individuals with mental illness: systematic review and meta-analysis. Psychological Medicine. 2022;1-10. doi: 10.1017/S0033291722002422.
https://doi.org/10.1017/S003329172200242... although it is true that six of them have been published since 2019. The approaches of these studies (for example, comparisons with other professionals, such as case managers, or between situations in which the figure is or is not added) and the variables they address, often classified around symptomatology, use of services or subjectivity (recovery, hope and empowerment) are very different. In all cases, without exception, reference is made to the low quality of the studies and high risk of bias. Recommendations range from fierce criticism of the implementation of professionalized peer support without clear evidence⁴⁰40. Lloyd-Evans B, Mayo-Wilson E, Harrison B, Istead H, Brown E, Pilling S, et al. A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness. BMC Psychiatry. 2014;14:39. doi: 10.1186/1471-244X-14-39.
https://doi.org/10.1186/1471-244X-14-39.... ^,4545. Lyons N, Cooper C, Lloyd Evans B. A systematic review of the effectiveness of group peer support interventions for mental health conditions. BMC Psychiatry. 2021;21(315):1-17. doi: 10.1186/s12888-021-03321-z.
https://doi.org/10.1186/s12888-021-03321... , to neutrality³⁸38. Pitt V, Lowe D, Hill S, Prictor M, Hetrick SE, Ryan R, et al. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database of Systematic Reviews. 2013;28(3):CD004807. doi: 10.1002/14651858.CD004807.pub2.
https://doi.org/10.1002/14651858.CD00480... ^,4242. Chien WT, Clifton AV, Zhao S, Lui S. Peer support for people with schizophrenia or other serious mental illness. Cochrane Database of Systematic Reviews. 2019;4(4):CD010880. doi:10.1002/14651858.cd010880.pub2.
https://doi.org/10.1002/14651858.cd01088... or cautious support,³⁹39. Fuhr DC, Salisbury TT, De Silva MJ, Atif N, van Ginneken N, Rahman A, et al. Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Social Psychiatry and Psychiatric Epidemiology. 2014;49(11):1691-1702. doi: 10.1007/s00127-014-0857-5.
https://doi.org/10.1007/s00127-014-0857-... ^,4141. Burke EM, Pyle M, Machin K, Varese F, Morrison AP. The effects of peer support on empowerment, self-efficacy, and internalized stigma: A narrative synthesis and meta-analysis. Stigma Heal. 2019;4(3):337-356. doi: 10.1037/sah0000148.
https://doi.org/10.1037/sah0000148.... ^,4343. Huang R, Yan C, Tian Y, Lei B, Yang D, Liu D, et al. Effectiveness of peer support intervention on perinatal depression: A systematic review and meta-analysis. Journal of Affective Disorders. 2020;276(6):788-796. doi: 10.1016/j.jad.2020.06.048.
https://doi.org/10.1016/j.jad.2020.06.04... ^,4444. White S, Foster R, Marks J, Morshead R, Goldsmith L, Barlow S, et al. The effectiveness of one-to-one peer support in mental health services: a systematic review and meta-analysis. BMC Psychiatry. 2020;20(1):1-20. doi: 10.1186/s12888-020-02923-3.
https://doi.org/10.1186/s12888-020-02923... with the notable exception of the most recent meta-analysis, of higher quality and including more studies, whose conclusions support the implementation of the figure with no more reservations than the commitment to higher quality studies (an ever-present tagline in practically any meta-analysis of psychosocial interventions).⁴⁶46. Smit D, Miguel C, Vrijsen JN, Groeneweg B, Spijker J, Cuijpers P. The effectiveness of peer support for individuals with mental illness: systematic review and meta-analysis. Psychological Medicine. 2022;1-10. doi: 10.1017/S0033291722002422.
https://doi.org/10.1017/S003329172200242... The most widespread conclusion in all these studies is that peer support would only have an effect on recovery, hope, and empowerment variables; but not symptomatology, use of services, or physical health³⁹39. Fuhr DC, Salisbury TT, De Silva MJ, Atif N, van Ginneken N, Rahman A, et al. Effectiveness of peer-delivered interventions for severe mental illness and depression on clinical and psychosocial outcomes: a systematic review and meta-analysis. Social Psychiatry and Psychiatric Epidemiology. 2014;49(11):1691-1702. doi: 10.1007/s00127-014-0857-5.
https://doi.org/10.1007/s00127-014-0857-... ^,4040. Lloyd-Evans B, Mayo-Wilson E, Harrison B, Istead H, Brown E, Pilling S, et al. A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness. BMC Psychiatry. 2014;14:39. doi: 10.1186/1471-244X-14-39.
https://doi.org/10.1186/1471-244X-14-39.... ^,4141. Burke EM, Pyle M, Machin K, Varese F, Morrison AP. The effects of peer support on empowerment, self-efficacy, and internalized stigma: A narrative synthesis and meta-analysis. Stigma Heal. 2019;4(3):337-356. doi: 10.1037/sah0000148.
https://doi.org/10.1037/sah0000148.... ^,4242. Chien WT, Clifton AV, Zhao S, Lui S. Peer support for people with schizophrenia or other serious mental illness. Cochrane Database of Systematic Reviews. 2019;4(4):CD010880. doi:10.1002/14651858.cd010880.pub2.
https://doi.org/10.1002/14651858.cd01088... ^,4444. White S, Foster R, Marks J, Morshead R, Goldsmith L, Barlow S, et al. The effectiveness of one-to-one peer support in mental health services: a systematic review and meta-analysis. BMC Psychiatry. 2020;20(1):1-20. doi: 10.1186/s12888-020-02923-3.
https://doi.org/10.1186/s12888-020-02923... ^,4545. Lyons N, Cooper C, Lloyd Evans B. A systematic review of the effectiveness of group peer support interventions for mental health conditions. BMC Psychiatry. 2021;21(315):1-17. doi: 10.1186/s12888-021-03321-z.
https://doi.org/10.1186/s12888-021-03321... with the exception of use of emergency services³⁸38. Pitt V, Lowe D, Hill S, Prictor M, Hetrick SE, Ryan R, et al. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database of Systematic Reviews. 2013;28(3):CD004807. doi: 10.1002/14651858.CD004807.pub2.
https://doi.org/10.1002/14651858.CD00480... and depressive symptomatology.⁴³43. Huang R, Yan C, Tian Y, Lei B, Yang D, Liu D, et al. Effectiveness of peer support intervention on perinatal depression: A systematic review and meta-analysis. Journal of Affective Disorders. 2020;276(6):788-796. doi: 10.1016/j.jad.2020.06.048.
https://doi.org/10.1016/j.jad.2020.06.04... These conclusions are refuted by the most recent work, published in September 2022, which confirms efficacy in terms of symptomatology as well as recovery, hope and empowerment, although not functionality.⁴⁶46. Smit D, Miguel C, Vrijsen JN, Groeneweg B, Spijker J, Cuijpers P. The effectiveness of peer support for individuals with mental illness: systematic review and meta-analysis. Psychological Medicine. 2022;1-10. doi: 10.1017/S0033291722002422.
https://doi.org/10.1017/S003329172200242...

The controversy surrounding the empirical evidence of peer support generates discussions even in regions such as North America, where implementation is advanced. In a 2018 opinion piece, the popular mental health law expert DJ Jaffe,⁴⁷47. Jaffe DJ. Jury is out on paid peer support for people with mental illness. Psychiatric Times [Internet]. 2018 [citado 10 oct 2022]. Disponible en: https://tinyurl.com/45j3tbe5.
https://tinyurl.com/45j3tbe5... now deceased, argued that many of the studies on the effectiveness of professionalized peer support have been conducted by the programs themselves, that they lack experimental rigor, and that they do not indicate the diagnosis or severity of the disorders of the people being treated. In this way, Jaffe argues that conclusions cannot be drawn regarding the value of this type of support in people with “severe mental disorders,” making a clear distinction with people with other severity levels. Likewise, referring to the comparison between peer support workers with professionals in similar roles that was carried out by the Cochrane collaboration,³⁸38. Pitt V, Lowe D, Hill S, Prictor M, Hetrick SE, Ryan R, et al. Consumer-providers of care for adult clients of statutory mental health services. Cochrane Database of Systematic Reviews. 2013;28(3):CD004807. doi: 10.1002/14651858.CD004807.pub2.
https://doi.org/10.1002/14651858.CD00480... Jaffe raises the question whether the favorable results of some studies can be justified by the mere presence of a person regardless of his or her background or orientation. In addition, he criticizes that in most studies backing professionalized peer support, improvements are only reported in “soft measures” such as hope, self-esteem or empowerment, without mentioning the “hard, meaningful metrics” that according to the author would be the rates of homelessness, arrest, needless hospitalization, incarceration, suicide, and victimization.

In response to this article, a group of advocates for professionalized peer support led by Yale University professor Larry Davidson⁴⁸48. Davidson L, Bellamy C, Chinman M, Farkas M, Ostrow L, Cook JA, et al. Revisiting the rationale and evidence for peer support. Psychiatric Times. 2018;35(6):11-12. consider it inaccurate to talk about lack of evidence, since in 2018 more than 30 studies found positive results in a number of areas. By way of clarification, they state that there is a big difference between treating a disorder and helping someone who is in a recovery process, and that people living with significant mental distress require more assistance and support than can be provided at a strictly biomedical level. They consider that the fact that the deployment of peer support increases the use of crisis services and decreases hospitalizations, thereby increasing some costs,⁴⁹49. Landers G, Zhou M. The impact of Medicaid peer support utilization on cost. Medicare & Medicaid Research Review. 2014;4(1). doi: 10.5600/mmrr.004.01.a04.
https://doi.org/10.5600/mmrr.004.01.a04.... must be interpreted favorably. They believe that otherwise many of these people would have been disconnected from outpatient care and even if health costs decreased, social costs would increase significantly. Training and hiring people in recovery to support others benefits all parties in fragmented systems with scarce resources: service users receive support from professionals who foster hope and help them navigate the health system, these professionals have paid employment in a role that supports their own recovery, and the systems obtain qualified staff that drives the achievement of results associated with the recovery of a meaningful life and not with the reduction of symptoms. The role of the peer support worker does not include treating one’s own symptoms or replacing the functions of other professionals, but seeks to complement clinical care, without minimizing the importance of addressing aspects such as incarceration, hospitalization, or homelessness. Evidence in this regard emphasizes that peers help involve people in affective relationships; improve relations between service users and outpatient service providers, decreasing their use of emergency services and the cost of care; decrease substance use and increase hope, empowerment, self-efficacy, self-care, and quality of life.

Apart from these discussions taking place in North America, from the point of view of our incipient experience in Catalonia it seems important to us to emphasize that the requirement of demonstrating the effectiveness of a profession and not of its interventions is unprecedented in the field of health. Today no one would question the usefulness of a health profession; its concrete interventions are evaluated, not its existence in general. That is why we believe that with peer support the level of rigor should be similar: evaluate the interventions, not the existence itself. On the contrary, very different things are likely being conflated. Some approaches to peer work are likely to work better than others, but doubting the advantages of empowering people with lived experience of mental distress - regardless of the effect on variables considered “hard” - has important ideological implications in terms of justifying a coercive and vertical system.

Objective

The aim of this work is to identify and describe the existing experiences of implementation of peer support in mental health at the international level, but with a special focus on Spain, since, apart from its academic value, we develop this work in the context of the preparation of possible implementation programs in Catalonia. A content analysis of documents and interviews on the implementation of this figure in the health systems of various countries is proposed. Finally, the article presents a series of short and long-term recommendations regarding the implementation of certified training programs and the process of incorporating peer support workers, as well as their integration into the mental health care system.

METHODS

As a starting point, a literature review was carried out between 2020 and 2021 on the implementation of peer support in various countries using Google searches with the aim of finding gray literature, and the following databases with the aim of finding peer-reviewed articles: Google Scholar, Scopus, APA PsycINFO, and Medline. The search terms used included: mutual support, peer support, implementation, incorporation, integration, recruitment, and training. Searches were conducted in English, Catalan, French, German, Italian and Spanish. To be included in the review, the documents had to address the training and/or incorporation of the professionalized figure of peer support worker into one or more health systems. For reasons of completeness and space, we do not include information on mutual aid groups or other self-managed initiatives independent of health systems.

In parallel, with the aim of complementing the review in cases where information was missing, emails were sent to key actors in the implementation of peer support at the international level. Based on the answers obtained and using a snowball method, we proceeded to interview various experts (see acknowledgements) by phone or email about the type of incorporation and other factors related to the implementation of peer support in the health systems of their countries. Based on all the information extracted from these sources, a content analysis was carried out. The criterion for content extraction was that it provided information on training systems and incorporation into the health system of peer support.

All documents analyzed are referenced in the corresponding section. The list of people interviewed can be found in the acknowledgments section.

RESULTS

The summary of the results can be found in Table 1. Several countries have peer support training programs with different levels of recognition and accreditation. However, the biggest challenge remains the incorporation of this figure within health systems

There have been six international projects that deserve separate mention. Firstly, the project Empowerment of Mental Illness Service Users: Lifelong Learning, Integration and Action (EMILIA),⁵⁰50. CORDIS. Empowerment of Mental Illness Service Users: Lifelong Learning, Integration and Action [Internet]. 2022 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/yar8fbz4 .
https://tinyurl.com/yar8fbz4... part of the European Commission’s sixth research framework program, was implemented between 2005 and 2010. Teams from Bosnia-Herzegovina, Greece, Denmark, Finland, France, Lithuania, Norway, Slovenia, Spain, Sweden, Poland, and the United Kingdom participated. One of the activities of the project included the training of “expert” service users. Although this concept does not fully coincide with the definition we use in this work, it is one of the most recent precedents. The implementation of the project involved opening of two lines of workplace involvement: the “expert” person as a trainer of service users and as a mediator between health institutions and service users.⁵¹51. Palomer E, Izquierdo R, Leahy E, Masferrer C, Flores P. El usuario como experto: concepto, modalidades y experiencia desde el Proyecto Emilia. Revista de la Asociación Española de Neuropsiquiatría. 2010;30(105):109-123.^,5252. Nieminen I, Ramon S, Dawson I, Flores P, Leahy E, Pedersen M, et al. Experiences of social inclusion and employment of mental health service users in a european union project. International Journal of Mental Health. 2012;41(4):3-23. doi: 10.2753/IMH0020-7411410401.
https://doi.org/10.2753/IMH0020-74114104...

Secondly, the projects Experienced Involvement (EX-IN)⁵³53. Experten durch Erfahrung in der Psychiatrie. (EX)perienced (IN)volvement [Internet]. 2005 [citado 10 oct 2022]. Disponible en: Disponible en: https://ex-in.info/#idee .
https://ex-in.info/#idee... and Peer to Peer: A route to recovery of People with Mental Illness through Peer Support Training and Employment, shortened to Peer2Peer,⁵⁴54. peer2peer [Internet]. 2013 [citado 10 oct 2022]. Disponible en: Disponible en: http://p2p.intras.es .
http://p2p.intras.es... of the Leonardo da Vinci program (currently integrated into the Erasmus+ macro-program) should be highlighted. The first, more focused on German-speaking countries, will be discussed later in the corresponding section for that geographic area. The Peer2Peer project, made up of teams from Austria, Spain, Scotland (United Kingdom) and Romania, was the first implementation at a European level of the North American peer support framework. As a continuing education project, its activities were very focused on the creation of a common training framework⁵⁵55. Christie L, Smith L, Bradstreet S, Orihuela T, Conde H, Marcos S, et al. Peer2peer. Curso de formación profesional. Edimburgo: SRN, Fundación INTRAS, EASP, En Primera Persona, Pro mente Oberösterreich, LRPSM; 2015. adapted from the Professional Development Award (PDA) in Mental Health Peer Support program developed by the Scottish Recovery Network, one of the organizations that led the consortium.

More recently, the Using Peer Support in Developing Empowering Mental Health Services (UPSIDES) initiative has established an international peer support research and practice community, through funding from the European Commission’s research framework program.⁵⁶56. Puschner B, Repper J, Mahlke C, Nixdorf R, Basangwa D, Nakku J, et al. Using Peer Support in Developing Empowering Mental Health Services (UPSIDES): Background, Rationale and Methodology. Annals of Global Health. 2019;85(1):1-10. doi: 10.5334/aogh.2435.
https://doi.org/10.5334/aogh.2435.... The project is a five-year, six-country study which replicates and scales-up peer support interventions, generating evidence of sustainable best practice in high-, middle- and low-income countries (two sites each in Germany and UK; one site each in India, Israel, Tanzania, and Uganda).

Finally, the projects funded within the Erasmus+ program currently running are Peer Support+ which includes partners from Estonia, Iceland and the Netherlands, and TuTo3-PAT-Peer and Team Support, including partners from Germany, Belgium, Spain, France, Norway, Quebec (Canada), and Romania. The first is focused on the development of training materials in “experiential support” methodologies and was developed between 2020 and 2022. The second, inaugurated in 2022, aims to go beyond the results of the Peer2Peer project by defining a competency and training framework (for both peers and the teams into which they are integrated), facilitating professional recognition at the European and international level.

Next, we will present the current panorama of various countries in which the figure of peer support is in the process of implementation. We try to combine chronological and geographical order, discussing first, inasmuch as possible, regions where the appearance of the figure was earlier. In territories where implementation is recent, such as Iberoamerica, we follow an alphabetical order.

English-speaking countries

Canada

In Canada, a pioneer in the implementation of peer support in the support system for people with disabilities, there is a project called Peer Support Canada.⁵⁷57. Peer Support Canada. Peer Support Certification [Internet]. 2021 [citado 10 oct 2022]. Disponible en: Disponible en: https://peersupportcanada.ca .
https://peersupportcanada.ca... It is linked to the Canadian Mental Health Association which is responsible for professional peer certification, and the Canadian Mental Health Commission,⁵⁸58. Mental Health Commission of Canada [Internet]. 2021 [citado 10 oct 2022]. Disponible en: Disponible en: https://www.mentalhealthcommission.ca .
https://www.mentalhealthcommission.ca... which has published practice guides for peer support⁵⁹59. Sunderland K, Mishkin W. Guidelines for the Practice and Training of Peer Support [Internet]. 2013 [citado 10 oct 2022]. Disponible en: https://tinyurl.com/3u95nkej.
https://tinyurl.com/3u95nkej... and monitors its implementation and impact on the health system.⁶⁰60. Cyr C, Mckee H, O’Hagan M, Priest R. Making the case for peer support: Report to the Peer Support Project Committee of the Mental Health Commission of Canada [Internet]. 2016 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/2p84xvsw .
https://tinyurl.com/2p84xvsw...

At the training level, Canada has an official program recognized by the main mental health providers at the federal level. This country has approved and established national standards of practice that include knowledge, competency, experience and code of conduct requirements to effectively provide peer support services.⁵⁷57. Peer Support Canada. Peer Support Certification [Internet]. 2021 [citado 10 oct 2022]. Disponible en: Disponible en: https://peersupportcanada.ca .
https://peersupportcanada.ca... As for incorporation, there are several requirements that include having completed the training, undergoing background checks, and having carried out additional practice placements.

Furthermore, Canada has local initiatives such as the Ontario Peer Development Initiative (OPDI), previously known as the Consumer Survivor Development Initiative (CSDI), founded in 1991.⁶¹61. Ontario Peer Development Initiative. Ontario Peer Development Initiative [Internet]. 2021 [citado 10 oct 2022]. Disponible en: Disponible en: https://www.opdi.org/ .
https://www.opdi.org/... This project provides solid training for peer support workers, as their experiences have shown the importance of establishing a minimum standard of such training, especially in rural areas.⁶²62. Rebeiro Gruhl KL, LaCarte S, Calixte S. Authentic peer support work: challenges and opportunities for an evolving occupation. Journal of Mental Health. 2016;25(1):78-86.

United States

The United States is another veteran in implementing peer support programs in its complex health care system. Most states have already established programs to train and certify peer support workers or are in the process of implementing a program, a University of Texas monitoring system shows.⁶³63. Kaufman L, Brooks W, Steinley Bymgarner M, Stevens Manser S. Peer Specialist Training and Certification Programs: A National Overview. Austin: The Center for Social Work Research, University of Texas at Austin; 2012.^,6464. Kaufman L, Kuhn WB, Manser SS. Peer specialist training & certification programs: National Overview 2016. Austin: The Center for Social Work Research, University of Texas at Austin; 2016. Training programs differ between states, but most are run by organizations managed by people with lived experience of mental distress and have their own certification exams. Thus, training programs are mandatory to obtain certification, and to be able to request reimbursements through Medicaid, the government insurance intended for people whose income and resources are insufficient to pay for medical care.⁶³63. Kaufman L, Brooks W, Steinley Bymgarner M, Stevens Manser S. Peer Specialist Training and Certification Programs: A National Overview. Austin: The Center for Social Work Research, University of Texas at Austin; 2012. The incorporation is carried out by specific agencies that recruit using generic paraprofessional labor categories that do not require licenses granted by the states, as is the case of the rest of health professions.

United Kingdom and Ireland

Peer support is a recognized profession in both Ireland and the United Kingdom, although differently in each. There are well-established charitable bodies that encourage training and incorporation such as the Mental Health Foundation or the Scottish Recovery Network. In Scotland, while at first peer support training was conducted by the US provider Recovery Innovations, an adaptation to its national context has taken place. To promote its durability and its adaptation to the Scottish reality, the Scottish Recovery Network worked with the Scottish Qualifications Authority in the development of a national accreditation.²³23. Bradstreet S, Pratt R. Developing peer support worker roles: Reflecting on experiences in Scotland. Mental Health and Social Inclusion. 2010;14(3):36-41. Thus, currently, training programs are carried out by independent organizations such as the Scottish Recovery Network, which is valid within the Scottish Credit and Qualifications Framework.²³23. Bradstreet S, Pratt R. Developing peer support worker roles: Reflecting on experiences in Scotland. Mental Health and Social Inclusion. 2010;14(3):36-41.^,6565. Campbell J, Gallagher R. A literature review and documentary analysis on recovery training in mental health practice [Internet]. 2007 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/4w9b8drj .
https://tinyurl.com/4w9b8drj... This training consists of two units: one theoretical (recovery context), based on the concepts of recovery, empowerment, mutuality and the role of peer support workers; and another practical (developing practice), which aims to bring participants closer in a more applied way to all the knowledge, skills and values required for their practice.⁶⁶66. Scottish Qualifications Authority. Mental Health Peer Support: Developing Practice [Internet]. 2012 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/bdhex4yt .
https://tinyurl.com/bdhex4yt... Incorporation is mostly carried out in the third sector, through non-governmental organizations (NGOs) and social care providers. In addition, the Scottish Recovery Network was involved in the aforementioned Peer2Peer project,⁵⁴54. peer2peer [Internet]. 2013 [citado 10 oct 2022]. Disponible en: Disponible en: http://p2p.intras.es .
http://p2p.intras.es... which led to training programs elsewhere.

It should be noted that in the United Kingdom, peer support programs have also been developed for the child and adolescent population. An example is the Nottingham Healthcare NHS Foundation Trust, which has begun to develop a project of peer support among service users of its child and adolescent mental health services (CAMHS), obtaining satisfactory results.²⁵25. Ballesteros-Urpí A. El suport mutu (peer support) en salut mental i la seva aplicabilitat en infants i adolescents. Educació Social. 2020;(75):47-63.

In Ireland, although the incorporation of peer support workers has been more recent, it is currently fully standardized, with certifications from the City of Dublin and the Atlantic Technology universities and recruitment possibilities in the health system.⁶⁷67. Health Service Executive. Peer Support Work [Internet]. 2022 [citado 10 oct 2022]. Disponible en: https://tinyurl.com/5c68e8uk.
https://tinyurl.com/5c68e8uk... The mental health office of the National Health Service Executive has recently published an extensive report on its impact on mental health care services.⁶⁸68. Hunt E, Byrne M. Peer support in mental health services: A Report on the Impact of Peer Support Workers in Mental Health Services [Internet]. 2019 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/5fp3wntc .
https://tinyurl.com/5fp3wntc...

Australia and New Zealand

In both countries the implementation of the profession is well advanced. Training programs are usually run by NGOs. Regarding recruitment, in both countries there are specific professional categories and there are job opportunities both through the third sector and mental health systems.

In New Zealand, peer support training is currently a level 4 certificate in the national qualifications framework. A new academic program at the Auckland University of Technology will commence in 2023, leading to a bachelor’s degree in Lived Experience Leadership. Additionally, a New Zealand national workforce development unit has published a document with a clear strategy for implementing peer support between 2020 and 2025.⁶⁹69. Te Pou. Consumer, peer support and lived experience July 2020 Mental health and addiction workforce development strategy: 2020-2025 [Internet]. 2020 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/3hm5nf9b .
https://tinyurl.com/3hm5nf9b...

South Africa

In South Africa the implementation of the figure is still incipient. There are recent studies on the strengths and limitations of the process of introducing peers into the care system.⁷⁰70. de Wet A, Sunkel C, Pretorius C. Opportunities and challenges: a case for formal peer support work in mental health in a South African context. Advances in Mental Health. 2022;20(1):15-25. doi: 10.1080/18387357.2022.2032776.
https://doi.org/10.1080/18387357.2022.20...

Israel

Although not a formally English-speaking country, Israel is a country where peer support is deeply rooted, including an implementation coordinator in the Ministry of Health, following a training and incorporation model similar to that of English-speaking countries.⁷¹71. Moran GS. The mental health consumer movement and peer providers in Israel. Epidemiology and Psychiatric Sciences. 2018;27(5):420-426. doi: 10.1017/S2045796018000173.
https://doi.org/10.1017/S204579601800017...

Italy

Italy has its own model of community mental health with roots in the anti-psychiatry movements of the mid-20th century. Although it has similarities with the recovery model, Italy was a pioneer in the processes of deinstitutionalization and its model can be considered a precedent. In recent years in regions such as Lombardy, experiences of user training and peer support have been developed based on forms of collaborative management between cooperatives and the health system.⁷²72. Airoldi M, Canzian V, Goglio M, Kauffmann O, Lucchi F, Mastroeni A, et al. Esperto in supporto tra pari per la salute mentale. 2014.⁾ Currently, about one hundred workers provide their service in a dozen Lombardy mental health centers, paid directly with funds from the region or through agreements with cooperatives providing services.⁷³73. Gli esperti supporto tra pari: dall’esperienza personale ad una futura professione. [Internet]. 2015 [citado 10 oct 2022]. Disponible en: https://tinyurl.com/mpvrszm5.
https://tinyurl.com/mpvrszm5... Other places of classic importance in the Italian community mental health model, such as Trieste, have also incorporated peer support workers.⁷⁴74. Mezzina R. Community mental health care in trieste and beyond: An “open door-no restraint” system of care for recovery and citizenship. The Journal of Nervous and Mental Disease. 2014;202(6):440-5. doi: 10.1097/NMD.0000000000000142.
https://doi.org/10.1097/NMD.000000000000... In 2021, the first National Congress of User and Family Experts in Peer Support [Conferenza Nazionale degli Utenti e Familiari Esperti nel supporto tra Pari] was held, which has led to the publication of a national document on peer support in mental health sponsored by the Ministry of Health that defines competencies and functions of the figure.⁷⁵75. 1a Conferenza Nazionale degli Utenti e Familiari Esperti nel supporto tra Pari. 1a Carta Nazionale. Esperti in supporto tra pari in Salute Mentale [Internet]. 2021 [citado 10 oct 2022]. Disponible en: https://tinyurl.com/2yy6yu6e.
https://tinyurl.com/2yy6yu6e...

German-speaking countries: Germany, Austria, and Switzerland

These three German-speaking countries have organizations derived from the aforementioned EX-IN project,⁷⁶76. Hegedüs A, Burr C, Pfluger V, Sieg D, Nienaber A, Schulz M. Peer support worker training: Results of the evaluation of the Experienced Involvement training programme in Switzerland and Germany. International Journal of Mental Health Nursing. 2021;30(2):451-460. doi: 10.1111/inm.12805.
https://doi.org/10.1111/inm.12805.... ^,7777. Hegedüs A, Seidel E, Steinauer R. Participants’ employment status and experiences in the year after the Experienced Involvement training. The International Journal of Social Psychiatry. 2016;62(3):214-220. doi: 10.1177/0020764015623969.
https://doi.org/10.1177/0020764015623969... ^,7878. Daszkowski J. EX-IN-Ausbildungen: Experienced Involvement - Pro & Kontra. Psychiatrische Praxis. 2012;39(5):202. implemented between 2005 and 2007. These countries have developed a program integrated into their vocational training systems. The curriculum of the program was developed cooperatively between mental health service users and professionals and researchers and trainers, and is led by certified trainers. Additionally, the figure has been officially integrated into the health service delivery systems of the three German-speaking countries. Adding to this solid line of training and incorporation is the more recent German arm of the UPSIDES consortium with presence in three German cities.⁷⁹79. Haun M, Bilmayer S, Heuer I, Mahlke C, Puschner B, Wagner M, et al. Erfahrungen in Deutschland aus der Sicht von Peer Begleiter*innen und Trainer*innen. Sozialpsychiatrische Informationen. 2021;51(3):15-18. doi: 10.1486/SI-2021-03_15.
https://doi.org/10.1486/SI-2021-03_15....

Nordic countries: Scandinavia and Finland

Although implementation in these countries has materialized mainly in the 2010s, the five Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) have an extensive network of peer support workers and officially recognized training programs. In general, in all countries of the region, training and recruitment is done through independent organizations, but the peer support workers are integrated into social services and mental health care networks.

In Denmark there have been initiatives since the 90s, although until the 2010s there were no pilots of global implementation experiences in the most populated areas.⁸⁰80. Korsbek L. How to Recover? Recovery in Denmark: A Work in Progress. Journal of Recovery Mental Health. 2017;1(1):25-33. In 2014, an extensive mapping of peer support service providers in all regions of the country was published,⁸¹81. Socialstyrelsen. Peer-støtte i Danmark - et foreløbigt overblik [Internet]. 2014 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/2s9puw56 .
https://tinyurl.com/2s9puw56... and in 2018 a proposal for a common training framework was made.⁸²82. Peer-partnerskaberne i Region Midtjylland, Region Hovedstaden RS, Peer-Netværket Danmark. Oplæg til fælles ramme for peeruddannelser i Danmark [Internet]. 2018 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/mpjvp8ye .
https://tinyurl.com/mpjvp8ye... In addition, an ambitious statewide support program has been implemented among young people experiencing anxiety and depression.⁸³83. Lauridsen S, Nielsen MBD, Kusier AO, Cloos CØ, Jensen MP, Andersen S, et al. Implementing a peer-to-peer, self-management intervention for young people with depression and anxiety in Denmark. BMC Psychology. 2022;10(1):1-13. doi: 10.1186/s40359-022-00777-w.
https://doi.org/10.1186/s40359-022-00777...

Finland introduced in 2009 the mandatory participation of experienced experts and peer support workers in the planning and development of services as one of the main objectives of its National Mental Health and Substance Abuse Plan.⁸⁴84. Jones M, Pietilä I. “The citizen is stepping into a new role”-Policy interpretations of patient and public involvement in Finland. Health & Social Care in the Community. 2018;26(2):e304-e311. doi: 10.1111/hsc.12520.
https://doi.org/10.1111/hsc.12520.... In addition, the Open Dialogue model, which originated in the Finnish region of Lapland, but has been widely disseminated internationally in recent years, has included the inclusion of peer support workers in the teams.⁸⁵85. Kemp H, Bellingham B, Gill K, McCloughen A, Roper C, Buus N, et al. Peer support and open dialogue: Possibilities for transformation and resistance in mental health services. En: Beyond the psychology industry. Cham: Springer International Publishing; 2020. p. 49-67. Iceland, the smallest both in size and population (just 370,000 inhabitants), has been fully dedicated to peer support since the early 2000s, with its own training program that is being strengthening with Dutch and Estonian partners in the context of the Erasmus+ Peer Support+ project.⁸⁶86. Hugarafl. A mental health peer support training course [Internet]. 2021 [citado 10 oct 2022]. Disponible en: https://tinyurl.com/ymh5krsb.
https://tinyurl.com/ymh5krsb...

Since 2012, Norway has also had national guidelines supporting the introduction of peer support. With official training academies in several regions, a needs mapping,⁸⁷87. Odden S, Kogstad R, Brodahl M, Landheim A. Opplærings- og veiledningsbehov hos erfaringskonsulenter. [Internet]. 2015 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/a7dhu4au .
https://tinyurl.com/a7dhu4au... ⁾ a handbook for proper hiring,⁸⁸88. Weber AK, Frahm Jensen MJ. Brukeransettelser. Håndbok for virksomheter som ønsker å ansette personer med egenerfaring innen psykisk helse- og rusfeltet. [Internet]. 2016 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/4b5rv52u .
https://tinyurl.com/4b5rv52u... a network for the defense of interests and organization of activities,⁸⁹89. Erfaringsentrum. Nettsiden for erfaringskonsulenter - Erfaringssentrum [Internet]. 2021 [citado 10 oct 2022]. Disponible en: Disponible en: https://erfaringssentrum.no .
https://erfaringssentrum.no... and a solid implementation through municipal funding, Norway is a country with a solid commitment to professionalized peer support with levels of impact on the care system comparable to veteran countries such as Canada.⁹⁰90. Mulvale G, Wilson F, Jones S, Green J, Johansen KJ, Arnold I, et al. Integrating mental health peer support in clinical settings: Lessons from Canada and Norway. Healthcare Management Forum. 2019;32(2):68-72. doi: 10.1177/0840470418812495.
https://doi.org/10.1177/0840470418812495...

Finally, Sweden also has an official training and recruitment model⁹¹91. Nationell Samverkan för Psykisk Hälsa introducerar peer support i Sverige. Metod Handbok: Riktlinjer för utbildning, implementering och anställning inom peer support [Internet]. 2018 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/muxtaj6x .
https://tinyurl.com/muxtaj6x... promoted by the organization of service users the Swedish Partnership for Mental Health (NSHP for its acronym in Swedish) that has advocated for a project to integrate the figure in the health system since 2016.⁹²92. Grim K, Bergmark M, Argentzell E, Rosenberg D. Managing peer support workers in Swedish mental health services-A leadership perspective on implementation and sustainability. Journal of Psychosocial Rehabilitation and Mental Health. 2022;1-25. doi: 10.1007/s40737-022-00311-6.
https://doi.org/10.1007/s40737-022-00311...

French-speaking European countries: France, Belgium, and Switzerland

The panorama in French-speaking countries is very heterogeneous.⁹³93. Gardien E, Héas S, Laval C. L’accompagnement par les pairs: Une approche transversale aux champs de la santé, de la santé mentale et du handicap: Actes de la journée d’étude EXPAIRs 2018. Actes la journée d’étude EXPAIRs [Internet]. 2019 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/2s47rb3e .
https://tinyurl.com/2s47rb3e... ^,9494. Demailly L. Les pratiques des médiateurs de santé-pairs en santé mentale. Rhizome. 2020;75-76(1):37-46. doi: 10.3917/rhiz.075.0037.
https://doi.org/10.3917/rhiz.075.0037.... France has several training programs in different regions.⁹⁵95. Demailly L, Bélart C, Déchamp LeRoux C, Dembinski O, Farnarier C, Garnoussi N, et al. Le dispositif des médiateurs de santé pairs en santé mentale: une innovation controversée [Internet]. 2014 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/3t4mdta6 .
https://tinyurl.com/3t4mdta6... There are several accredited training programs with recognition throughout the country, such as the Médiateur de Santé/Pair program carried out by the World Health Organization French Collaborating Center for Research and Training in Mental Health (CCOMS Lille), or the university degrees of the Université Paris 8 (Vincennes - Saint-Denis) and Université Paris 13 (Bobigny), Université Grenoble Alpes, Aix-Marseille Université or Université Claude Bernard Lyon 1.⁹⁶96. Maugiron P. Les différentes modalités qui déterminent l’accompagnement par les pairs. Pratiques en Santé Mentale. 2020;66(3):20. doi: 10.3917/psm.203.0020.
https://doi.org/10.3917/psm.203.0020.... Other options include non-profit organizations such as the Solidarités Usagers Psy care network.

The training program of the WHO collaborating center is one of the most complete at the international level and had a pilot phase where a number of aspects were considered, from contracting and recruitment to the subjective experiences of peers and their teams.⁹⁵95. Demailly L, Bélart C, Déchamp LeRoux C, Dembinski O, Farnarier C, Garnoussi N, et al. Le dispositif des médiateurs de santé pairs en santé mentale: une innovation controversée [Internet]. 2014 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/3t4mdta6 .
https://tinyurl.com/3t4mdta6... The training is carried out in two phases, both lasting one year. The first consists of a certified university program and the second involves the integration into teams through internships. The theoretical phase is carried out by the Université de Lille and training sessions are held in three regions. Practical training involves the 16 adult psychiatry services that host mediators/health partners in training. Enrollment for training is subject to incorporation into one of these 16 departments, so that participants in this program have a two-year professional contract, in the form of renewable fixed-term contracts. As part of that training, peers do full- or part-time internships and work alongside a team professional.

As for Switzerland, apart from the EX-IN model of the German-speaking region, the French-speaking region has an incipient implementation of the figure,³²32. Sticher L, Bonsack C. Les pairs praticiens en santé mentale: une nouvelle profession en psychiatrie. Revue Médicale Suisse. 2017;13(575):1614-1616. doi: 10.53738/REVMED.2017.13.575.1614.
https://doi.org/10.53738/REVMED.2017.13.... with official training programs such as one lasting two years led by the non-profit organization Re-pairs.⁹⁷97. Re-pairs. Formation [Internet]. 2022 [citado 10 oct 2022]. Disponible en: Disponible en: https://www.re-pairs.ch/formation .
https://www.re-pairs.ch/formation... In the predominantly French-speaking Belgian regions of Wallonia and Brussels, multiple peer training and onboarding initiatives have been developed, involving a dense support network.⁹⁸98. Allart M, Lo Sardo S. La pair-aidance en Fédération WaLLonie-BruxeLLes: Etat des lieux, Guide méthodologique [Internet]. 2020 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/33faytmv .
https://tinyurl.com/33faytmv... There is a map of all organizations dedicated to peer support that includes 35 organizations at the time of this article’s publication, of which 12 are specialized in mental health.⁹⁹99. En Route, SMES. Cartographie de la pair-aidance en Belgique francophone [Internet]. [citado 10 oct 2022]. Disponible en: Disponible en: https://cartographie-pair-aidance.be .
https://cartographie-pair-aidance.be... Three local organizations (the NGO En Route, the San Martín neuropsychiatric hospital and the Namur High School) lead the aforementioned TuTo3-PAT project of the Erasmus+ program, currently in execution.

Netherlands

In the Netherlands, the national Trimbos Institute and the national mental health organization GGZ Nederland designed a professional competency profile for peer support workers in 2013. In 2015, an official training curriculum was published.¹⁰⁰100. van Erp N, Boertien D, van Rooijen S, van Bakel M, Smulders R. Basiscurriculum Ervaringsdeskundigheid. Bouwstenen voor onderwijs en opleidingen voor ervaringsdeskundigen. Utrecht: Trimbos-instituut, Kenniscentrum Phrenos; 2015. Dutch healthcare authorities are currently accrediting a recognized profession and formal position for staff working in healthcare settings.¹⁰¹101. PowerUs. The Netherlands [Internet]. [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/bdhksvrr .
https://tinyurl.com/bdhksvrr...

Romania

As discussed earlier, Romanian organizations participated and continue to participate in two of the major European projects regarding peer support, Peer2Peer (2013-2015) and TuTo3-PAT (2022-2025). Despite the success of the first, which involved training activities in Romania¹⁰²102. peer2peer. Mutual Support in Romania [Internet]. 2015 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/yvnphtp6 .
https://tinyurl.com/yvnphtp6... and the translation of the handbook into Romanian,¹⁰³103. Christie L, Smith L, Bradstreet S, Orihuela T, Conde H, Marcos S, et al. De la Egal la Egal: Curs de instruire vocatională. Edimburgo, Escocia: SRN, Fundación INTRAS, EASP, En Primera Persona, Pro mente Oberösterreich, LRPSM; 2015. there is no record of continuity of implementation plans.

Latin America: Argentina, Brazil, Chile

Argentina has had diverse experiences and reflections on the implementation of professionalized peer support since the early 2010s.³³33. Agrest M, Geffner N, Neistadt A, Iconicoff A, Pérez F, Minvielle M, et al. La incorporación de pares en los equipos de salud mental. En: Investigaciones y Experiencias en Salud Mental y Adicciones en Argentina. Ciudad Autónoma de Buenos Aires: Ministerio de Salud y Desarrollo Social de la Nación; 2019. p. 177-182.⁾ Examples are the NGO Proyecto Suma³³33. Agrest M, Geffner N, Neistadt A, Iconicoff A, Pérez F, Minvielle M, et al. La incorporación de pares en los equipos de salud mental. En: Investigaciones y Experiencias en Salud Mental y Adicciones en Argentina. Ciudad Autónoma de Buenos Aires: Ministerio de Salud y Desarrollo Social de la Nación; 2019. p. 177-182.^,3737. Ardila Gómez SE, Agrest M, Abadi D, Cáceres C. El aporte de los pares al trabajo en salud mental: consideraciones acerca de las relaciones entre los sistemas formales e informales de ayuda: Relato de una experiencia. Vertex. 2013;XXIV:465-471. and the Fundación Bipolares de Argentina, which carries out a training program based on the materials developed by the Peer2Peer project.¹⁰⁴104. Vinacour CA, Lago V. Programa agente de apoyo mutuo AAM de FUBIPA [Internet]. 2021 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/yc2ubenk .
https://tinyurl.com/yc2ubenk... However, there does not seem to be a clear framework for incorporation into the health system.

Another country with peer training experiences is Brazil, in which different training initiatives exist.¹⁰⁵105. Magalhães Dahl C, de Araújo Carvalho MC, Moscoso Teixeira de Mendonça J, Mitkiewicz de Souza F, Wainstok Estivil Bustos M, Fernandes de Cintra Santos J, et al. “Soy loco, pero estoy en red”: el proceso de capacitación con usuarios de servicios de Salud Mental para el trabajo de ayuda entre pares en la red de atención psicosocial de Río de Janeiro. Vertex Revista Argentina de Psiquiatría. 2013;24(112):445-454. Although there is not yet an official system of legitimization of the peer figure, some independent organizations do so at their own discretion and may or may not be connected to government agencies or other organizations that may recognize and hire peer support workers. In some states, workers are hired by government organizations. However, although the process has been initiated, a specific category is not yet available within the Brazilian occupation classification system.

Chile, with experiences in research processes managed by people with lived experience of mental distress,¹⁰⁶106. Cea Madrid JC. “Locos por nuestros derechos”: Comunidad, salud mental y ciudadanía en el Chile contemporáneo. Quaderns de Psicologia. 2019;21(2):1502. doi: 10.5565/rev/qpsicologia.1502.
https://doi.org/10.5565/rev/qpsicologia.... is another Ibero-American country with experience in peer support, although apparently occasionally without coordination at the national level. There are experiences linked to non-profit organizations of associations of service users and their relatives¹⁰⁷107. Círculo Polar. Apoyo de Pares [Internet]. [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/bdyxm85t .
https://tinyurl.com/bdyxm85t... in collaboration with professional groups.¹⁰⁸108. Sociedad Chilena de Trastornos Bipolares. ¿Qué es un especialista en apoyo a pares? [Internet]. 2017 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/4s9823fa .
https://tinyurl.com/4s9823fa...

Spain

Within Spain, the main focus of this work, different experiences of training and incorporation of peer support workers can be found. Recently, a literature review was carried out regarding training experiences in peer support in mental health in Spain.¹⁰⁹109. Zabaleta González R, Lezcano Barbero F, Perea Bartolomé MV. Programas de formación para el apoyo entre iguales en salud mental en España. Interdisciplinaria Revista de Psicología y Ciencias Afines. 2021;38(2):183-198. Five peer support experiences were identified and will be explained in the corresponding geographical sections.

At the state level, the Mental Health Confederation of Spain has carried out two editions of the course “Informing in the first person,” which aims to provide tools and information to volunteer peers so that they can welcome and accompany other people with lived experience of mental distress in the organizations to which they belong. It also has an evaluation that is carried out at the end of the training and an assessment of the usefulness of the training six months after its completion.¹⁰⁹109. Zabaleta González R, Lezcano Barbero F, Perea Bartolomé MV. Programas de formación para el apoyo entre iguales en salud mental en España. Interdisciplinaria Revista de Psicología y Ciencias Afines. 2021;38(2):183-198.

We will next look more closely at the autonomous communities in which the figure of peer support worker is in the process of implementation.

Andalusia

The first peer training implemented exclusively in Spain took place in Andalusia between 2010 and 2011. It was through the project “Peer support in the Mental Health Services of Andalusia,” which was part of the Second Comprehensive Mental Health Plan of Andalusia and was coordinated by the Andalusian School of Public Health and the Andalusian Mental Health Federation.¹⁰⁹109. Zabaleta González R, Lezcano Barbero F, Perea Bartolomé MV. Programas de formación para el apoyo entre iguales en salud mental en España. Interdisciplinaria Revista de Psicología y Ciencias Afines. 2021;38(2):183-198.⁾ Also in Andalusia is the Federación En Primera Persona that supports the Peer Support Network [Red de Apoyo Mutuo] of Andalusia. The federation was involved in the Peer2Peer project⁵⁴54. peer2peer [Internet]. 2013 [citado 10 oct 2022]. Disponible en: Disponible en: http://p2p.intras.es .
http://p2p.intras.es... led by the Castilian-Leonese Intras foundation and by the Scottish Recovery Network. The training program is planned in a practical and participatory way and has a mid-term evaluation and another at the end.¹⁰⁹109. Zabaleta González R, Lezcano Barbero F, Perea Bartolomé MV. Programas de formación para el apoyo entre iguales en salud mental en España. Interdisciplinaria Revista de Psicología y Ciencias Afines. 2021;38(2):183-198. Subsequently, short-term contracts have been made through federated associations in the Andalusian Health System.¹¹⁰110. Mejías Martín Y, Ali Delgado A, Fernández Pérez E, Ruiz Rodríguez, Silvia Ramírez Esteban M. Opinión de los profesionales sobre un programa de apoyo mutuo. En: Afianzando los cuidados enfermeros en Salud Mental. Asociación Española de Enfermería de Salud Mental; 2019. p. 1235-1246.

Castile-La Mancha

The Castile-La Mancha autonomous community was pioneer in integrating the professional figure of experts by experience in the labor market. Since 2018, the Expert by Experience project of the Fundación Sociosanitaria de Castilla-La Mancha has existed at the autonomic level.¹¹¹111. Casas Toral LA, López Antón L, Carrasco Ramírez O, Nieto-Moreno M, García-Heras S. Profesional experto por experiencia en salud mental. En: XXVII Jornadas Estatales Salud Mental AEN. Madrid: Asociación Española de Neuropsiquiatría; 2017. The objective of the project is to integrate people with lived experience of mental distress as professionals within the Psychosocial and Occupationa Rehabilitation Centers’ teams. A training program has been implemented that has led to hiring through the Extraordinary Plan for Employment in Castile-La Mancha. It should be noted that the training program has a final phase of supervision of the peer support workers hired by the Psychosocial and Occupational Rehabilitation Centers.¹⁰⁹109. Zabaleta González R, Lezcano Barbero F, Perea Bartolomé MV. Programas de formación para el apoyo entre iguales en salud mental en España. Interdisciplinaria Revista de Psicología y Ciencias Afines. 2021;38(2):183-198.

Castile and Leon

This autonomous community joined the European project Peer2peer⁵⁴54. peer2peer [Internet]. 2013 [citado 10 oct 2022]. Disponible en: Disponible en: http://p2p.intras.es .
http://p2p.intras.es... through the Intras Foundation. This organization has continued to carry out training activities both in Castile and Leon and in other communities such as Andalusia or the Balearic Islands. In addition, since 2016 the Castile and Leon Mental Health Federation has carried out a Personal Assistant course. Although personal assistance is not only based on peer support, this course consists of theoretical-practical job training and instruction that follows a peer support model. The training also has a final evaluation.¹⁰⁹109. Zabaleta González R, Lezcano Barbero F, Perea Bartolomé MV. Programas de formación para el apoyo entre iguales en salud mental en España. Interdisciplinaria Revista de Psicología y Ciencias Afines. 2021;38(2):183-198.

Recently, organizations from Burgos have participated in the training program ¡ACOMPAÑAME!, in which organizations from Navarre and Madrid have also participated, validated by an international panel of experts and implemented since 2019. As novel elements, the course includes virtual reality, robotics, and an evaluation of the program by the facilitator and as well as the participants. In addition, it has two evaluation sessions: an initial one, which evaluates the cognitive situation of the participants and formalizes their participation in the course; and a final one, which repeats the initial psychometric tests in addition to evaluating the knowledge acquired.¹⁰⁹109. Zabaleta González R, Lezcano Barbero F, Perea Bartolomé MV. Programas de formación para el apoyo entre iguales en salud mental en España. Interdisciplinaria Revista de Psicología y Ciencias Afines. 2021;38(2):183-198.

In this territory, contracts have been made through the Intras foundation using the professional category of caregiver through special employment centers.¹¹²112. Fundación INTRAS. ARTMO BENE [Internet]. 2018 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/55474uyc .
https://tinyurl.com/55474uyc...

Catalonia

Catalonia is the only territory that has a concrete implementation plan,¹¹³113. Consell Assessor en Salut Mental i Addiccions. Programa suport entre iguals a Catalunya [Internet]. Barcelona: Generalitat de Catalunya, Departament de Salut; 2018 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/y2hc79p4 .
https://tinyurl.com/y2hc79p4... although it has not been put into operation yet. There is experience in the implementation of a figure called health worker in environments such as prisons or addictions care, with competencies very similar to those considered in this work for peer support workers.¹¹³113. Consell Assessor en Salut Mental i Addiccions. Programa suport entre iguals a Catalunya [Internet]. Barcelona: Generalitat de Catalunya, Departament de Salut; 2018 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/y2hc79p4 .
https://tinyurl.com/y2hc79p4... ^,114114. Educadors socials de centres penitenciaris. Programa Compartim de gestió del coneixement del Departament de Justícia: Agents de salut a l’àmbit penitenciari [Internet]. 2011 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/3vjujtf8 .
https://tinyurl.com/3vjujtf8... ⁾ There is also a certain tradition of accompaniment groups combining mutual aid and peer support.¹¹⁵115. Bardají-Mauri Á, Casacuberta-Martí S, Eiroa-Orosa FJ. La figura del técnico de apoyo entre iguales en Cataluña: de la experiencia a la esperanza. En: Avances en Psicología Clínica. Granada: Asociación Española de Psicología Conductual; 2017. p. 1034-1045. In 2017, for the first time, a training of peer support trainers was organized and evaluated by the Universitat de Barcelona through a Marie Skłodowska Curie project.²²22. Sanchez-Moscona C, Eiroa-Orosa FJ. Training mental health peer support training facilitators: a qualitative, participatory evaluation. International Journal of Mental Health Nursing. 2021;30(1):261-273.

There are currently two accredited training programs. One is organized by the Associació Emilia, derived from the aforementioned European project of the same name,⁵⁰50. CORDIS. Empowerment of Mental Illness Service Users: Lifelong Learning, Integration and Action [Internet]. 2022 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/yar8fbz4 .
https://tinyurl.com/yar8fbz4... in the institute for vocational training Bonanova as optional units within the official program of Technician in Care for People in Situation of Dependency. This training is carried out in year-long cycles and is recognized as part of an official program. Additionally, the Universitat Central de Catalunya and local health providers such as Althaia and Osonament carry out a training originally organized by professionals for service users¹¹⁶116. Prat Vigué G, Cano Prieto I, del Río Sáez R, Vilanova Masana R, Simó Algado S. Training Peer Support Workers in Mental Health Care: A Mixed Methods Study in Central Catalonia. Frontiers in Psychiatry. 2022;13:1-14. doi: 10.3389/fpsyt.2022.791724.
https://doi.org/10.3389/fpsyt.2022.79172... and has initiated collaborations with first person organizations to give it continuity.

As for recruitment, some health provider organizations have initiated contracts establishing agreements with first person non-profit organizations, through figures such as accompaniment technician, initially designed for the labor integration of people with disabilities.

Catalonia has become, along with Australia,¹¹⁷117. Tisdale C, Snowdon N, Allan J, Hides L, Williams P, de Andrade D. Youth Mental Health Peer Support Work: A Qualitative Study Exploring the Impacts and Challenges of Operating in a Peer Support Role. Adolescents. 2021;1(4):400-411. doi: 10.3390/adolescents1040030.
https://doi.org/10.3390/adolescents10400... England,²⁵25. Ballesteros-Urpí A. El suport mutu (peer support) en salut mental i la seva aplicabilitat en infants i adolescents. Educació Social. 2020;(75):47-63. Denmark⁸³83. Lauridsen S, Nielsen MBD, Kusier AO, Cloos CØ, Jensen MP, Andersen S, et al. Implementing a peer-to-peer, self-management intervention for young people with depression and anxiety in Denmark. BMC Psychology. 2022;10(1):1-13. doi: 10.1186/s40359-022-00777-w.
https://doi.org/10.1186/s40359-022-00777... and Quebec,¹¹⁸118. East-Richard C, Cellard C. Pair-aidance à l’adolescence. En: Franck N, Cellard C, (eds). Pair-aidance en santé mentale: Une entraide professionnalisée. Elsevier Masson; 2020. p. 163-172. a pioneer in the implementation of mental health peer support in child and youth populations. Currently, a pilot project is being implemented within the Children’s and Youth Day Hospital of the Psychiatry Service of the Hospital Clínic de Barcelona.²⁵25. Ballesteros-Urpí A. El suport mutu (peer support) en salut mental i la seva aplicabilitat en infants i adolescents. Educació Social. 2020;(75):47-63. The project proposes mutual aid groups with the collaboration of adult peer support workers who experienced mental distress in their youth.

Basque Country

In the Basque Country, the existence of specific training programs is unknown. However, a member of the Asociación Guipuzcoana de Familiares y Personas con Problemas de Salud Mental [Guipuzcoan Association of Relatives and People with Mental Health Problems] (AGIFES) has participated in the European Peer2Peer project⁵⁴54. peer2peer [Internet]. 2013 [citado 10 oct 2022]. Disponible en: Disponible en: http://p2p.intras.es .
http://p2p.intras.es... and the association has incorporated peers with categories such as instructor, common in leisure services.

Madrid

The Fundación Manantial, a provider of large-scale rehabilitation services including a now-defunct Early Care Unit project based on open dialogue,¹¹⁹119. Seikkula J, Alakare B, Aaltonen J. Open dialogue in psychosis I: an introduction and case illustration. Journal of Constructivist Psychology. 2001;14(4):247-265. doi: 10.1080/10720530125965.
https://doi.org/10.1080/10720530125965.... has been a pioneer in the incorporation of peers in the region. A position of expert by experience was incorporated using the professional category of educator. This incorporation was not maintained when the unit was absorbed by the Madrid Health Service. Currently, La Porvenir,¹²⁰120. La Porvenir - Equipo De Trabajo [Internet]. 2021 [citado 10 oct 2022]. Disponible en: Disponible en: https://laporvenir.org .
https://laporvenir.org... a newly created non-profit organization, has a peer on staff. Additionally, Madrid organizations have been part of the training program ¡ACOMPAÑAME! (see Castile and Leon),¹⁰⁹109. Zabaleta González R, Lezcano Barbero F, Perea Bartolomé MV. Programas de formación para el apoyo entre iguales en salud mental en España. Interdisciplinaria Revista de Psicología y Ciencias Afines. 2021;38(2):183-198. and recently training courses have been organized by public mental health centers.¹²¹121. Rosillo Herrero M, Alonso Martos V. La experiencia del apoyo mutuo en los Centros de Rehabilitacion Psicosocial (CRPS), el “programa mentor” del servicio. Norte de Salud Mental. 2018;15(59):103-114.^,122122. Centro de Salud Mental Miraflores. Curso de Formación Agente de Apoyo Mutuo [Internet]. [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/4umh3j5b .
https://tinyurl.com/4umh3j5b... .

Valencia

Since 2019, the non-profit association ASIEM has had a peer support team.¹²³123. ASIEM Salud Mental Valencia. Equipo humano [Internet]. [citado 10 oct 2022]. Disponible en: Disponible en: https://asiem.org/equipo-humano .
https://asiem.org/equipo-humano... This team carries out, on the one hand, tasks of accompaniment and monitoring of service users of the public mental health network and, on the other, training tasks for its own members.¹²⁴124. ASIEM Salud Mental Valencia. En primera persona: expertas en salud mental [Internet]. III Premios Buenas Prácticas. 2020 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/5n7wm92r .
https://tinyurl.com/5n7wm92r... .

Portugal

Portugal has an incipient program for the implementation of peer support in mental health for which a document of practical guidelines has been developed.¹²⁵125. Campos F, Sousa A, Rodrigues V, Marques A, Queirós C, Dores A. Directrices prácticas para programas de apoyo entre personas con enfermedad mental. Revista de Psiquiatría y Salud Mental. 2016;9(2):97-110. doi: 10.1016/j.rpsm.2014.06.002.
https://doi.org/10.1016/j.rpsm.2014.06.0...

Peer support as a development tool

Apart from the UPSIDES consortium, which is already implementing training and incorporation projects in India, Tanzania and Uganda,¹²⁶126. Nixdorf R, Nugent L, Aslam R, Barber S, Charles A, Gai Meir L, et al. A multinational peer support intervention: the UPSIDES pilot phase. Advances in Mental Health. 2022;20(1):2-14. doi: 10.1080/18387357.2021.2020140.
https://doi.org/10.1080/18387357.2021.20... other international projects such as the World Health Organization’s QualityRights are committed to peer support as a tool to strengthen poorly resourced mental health care systems.¹²⁷127. Pathare S, Kalha J, Krishnamoorthy S. Peer support for mental illness in India: An underutilised resource. Epidemiology and Psychiatric Sciences. 2018;27(5):415-419. doi: 10.1017/S2045796018000161.
https://doi.org/10.1017/S204579601800016... ^,128128. World Health Organization. Peer support mental health services: promoting person-centred and rights-based approaches (Guidance and technical packages on community mental health services: promoting person-centred and rights-based approaches). Geneva: World Health Organization; 2021.

DISCUSSION

Peer support in mental health is a tool that has shown to have multiple benefits in the recovery process of people with lived experience of mental distress. Recently, progress has also been made in the scientific demonstration of its efficacy.⁴⁶46. Smit D, Miguel C, Vrijsen JN, Groeneweg B, Spijker J, Cuijpers P. The effectiveness of peer support for individuals with mental illness: systematic review and meta-analysis. Psychological Medicine. 2022;1-10. doi: 10.1017/S0033291722002422.
https://doi.org/10.1017/S003329172200242... However, in the Ibero-American environment, peer support work is still at an early stage of implementation.

The analysis carried out indicates that the German-speaking countries and Canada offer the most homogeneous training and incorporation programs. In the case of anglophone countries and France, non-profit organizations are usually in charge of training programs, sometimes in alliance with academic institutions, although it is possible to later incorporate peers into health systems using loosely defined labor categories. The situation in Latin America, although incipient, is encouraging, with formal experiences in Argentina, Brazil, and Chile, and likely many other informal ones. In Spain, the implementation of peer support is also in different phases in each autonomous community. Andalusia, Castile-La Mancha, Catalonia and Valencia have more or less stable training programs and the number of people hired is increasing. However, in Basque Country or Madrid, there are no defined training programs and hirings are isolated.

The origin of the recovery model in anglophone countries, the conceptual basis of the profession of peer support workers, in addition to the inclusion of these practices in one of the main global mental health programs,¹²⁸128. World Health Organization. Peer support mental health services: promoting person-centred and rights-based approaches (Guidance and technical packages on community mental health services: promoting person-centred and rights-based approaches). Geneva: World Health Organization; 2021. could lead one to think that these types of practices are just another type of neocolonialism. Clear arguments in favor of this idea are that Western values have permeated both the model and the profession since its origins and neoliberal impulses have conditioned its implementation.¹²⁹129. Mcwade B. Recovery-as-Policy as a Form of Neoliberal State Making. Intersectionalities: A Global Journal of Social Work Analysis, Research, Polity, and Practice. 2016;5(3):62-81. However, we find it necessary to emphasize that, in a world in which professional mental health practices have long been globalized, following a marked pattern of neocolonialism and decontextualization, being the main exponent the Diagnostic and Statistical Manual of Mental Disorders, the possibilities of establishing dialogues between expert and lay knowledge must be taken advantage of by the movements of people with lived experience of mental distress and their relatives. These opportunities should promote a critical training of people who aspire to carry out professionalized peer support to ensure that they can problematize their new professional identity from an intersectional perspective.

Limitations

One of the major limitations of this study is the possibility that projects and experiences with more capacity to disseminate the results of their evaluations, as well as those that have participated in international consortia, are overrepresented. While it is true that the objective of this work has been to collect information on professionalized peer support, whose institutional implications often leave a digital footprint, it is possible that grassroots initiatives whose funding originates in the social economy or are developed on a voluntary basis may be underrepresented.

Recommendations in the context of its implementation in Catalonia

Considering the international evolution and the current panorama in Spain, we can draw some conclusions and offer some recommendations for the implementation of the figure in Catalonia.

Regarding the legitimization of the training received by people with experience as workers, in the short term, a competency unit could be created within the procedures for evaluating and accrediting professional skills acquired through work experience or non-formal channels.¹³⁰130. Ministerio de Educación y Formación Profesional. Acreditación de Competencias [Internet]. 2021 [citado 10 oct 2022]. Disponible en: Disponible en: https://tinyurl.com/93k3c6ff .
https://tinyurl.com/93k3c6ff... In the long term, we believe that an ideal scenario would be the creation of an official training cycle with health care recognition. Finally, for the proper integration of the peer support figure in the system, in any new accreditation process it is very important to establish synergies between training programs and already-established recruitment schemes, and to ensure the participation of promoters of this figure in possible commissions for future development, in addition to the involvement of representatives of recognized health professions.

Regarding the incorporation of peer support workers, it can currently be carried out directly with healthcare providers or non-profit organizations external to health systems, including organizations managed by people with lived experience of mental distress. This is possible through contractual categories that do not require specific professional or university training. However, the incorporation by providers of the National Health System has limitations derived from the Law on the Regulation of Health Professions and the little flexibility of the autonomic systems in terms of the professions whose hiring is permitted. In the short term, without losing sight of the fact that the ideal situation is the integration into the health system, a possible option would be for healthcare providers to subcontract non-profit organizations external to the system and for them to be the ones that offer a direct contract to the peer support workers. Of course, another possibility is incorporating people who have previously been trained as health workers, although this would require people to reveal their lived experience. By way of illustration, in countries with greater implementation of these figures, such as the United States, it is common for medical or nursing staff with lived experience of mental distress to coordinate teams of peer support workers. This facilitates the legitimization by the rest of the professionals of these institutions, although such a scenario is far removed from the horizontality sought by peer support.

ACKNOWLEDGEMENTS

We would like to thank the following members of the International Recovery and Citizenship Collective for their contributions on the different systems of training and incorporation of peer support workers: Jean-Francois Pelletier from the University of Montreal (Quebec, Canada), Chyrell Bellamy, Graziela Reis and Larry Davidson from Yale University (United States), Gillian MacIntyre from the University of Strathclyde (Scotland, United Kingdom), Henning Pettersen from the Innlandet University (Norway), Matthew Jackman Australian member of the Global Peer Network in Mental Health, Helen Hamer from the University of Auckland (New Zealand), Eve Gardien from the Université Rennes 2 (France) and Walter Oliveira from the Universidade Federal de Santa Catarina (Brazil). We would also like to thank Ramona Hiltensperger and Bernd Puschner from the UPSIDES project for their generous contributions. Regarding the contributions at the Spanish level, we thank Rus Moreno and Silvia Parrabera from the Fundación Manantial (Madrid), María José Reviriego Moreno from the Mental Health Center of Alcobendas and San Sebastián de los Reyes, Mikel Merino from AGIFES (Basque Country), María Alcalde from the Federación en Primera Persona (Andalusia), Guillermo Pastor from the Asociación Caleidoscopio (Castile and Leon), Santiago Casacuberta and Albert Piquer from the Associació Emilia and the Federació Veus (Catalonia) and Eulàlia Porta and Jordi Blanch from the Mental Health and Addictions Master Plan of the Catalan government.

References

Publication Dates

History