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Home arrow Language & Literature arrow The open door : homelessness and severe mental illness in the era of community treatment
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“Peer SupportThe Consumer as a Member of the Mental Health Team

The belief that people with mental illness could support one another predates the deinstitutionalization era. In the late 1940s, six people treated at Rockland State Hospital in New York met as patients and began to share stories and participate together in hospital activities. After leaving the hospital, they continued their relationships, naming their group “We Are Not Alone,” believing they could offer one another support in achieving recovery and meeting life’s challenges. Their typical meeting place was on the steps of the New York Public Library until 1948, when, with the help of supporters, they were able to purchase a building in Manhattan’s Hell’s Kitchen area. The Fountain House “clubhouse” was founded with the goal of supporting recovery and changing the social perception of mental illness (www.fountainhouse.org/about/history).

“Peers” or “consumers” have been widely employed in outreach and case management programs for homeless people. To date, however, there has not been a single controlled trial of care provided by peers that has dealt with a sample of people with mental illness who were homeless at baseline. Peers with histories of living successfully with serious mental illness have, however, achieved a prominent place in contemporary mental health service programming in general. Perhaps because they have experience with mental illness and have achieved a measure of recovery through treatment, they are uniquely able to provide support and empathy to individuals coming to terms with similar challenges (Chinman et al., 2014; SAMHSA, 2011). Peers can assist in the development of coping and problem-solving strategies that can lead to successful self-management of a person’s vulnerabilities, encourage engagement in treatment, and help the individual access housing and support in the community (Chinman et al., 2014). Peer roles have been added to standard care, case management, and assertive community treatment teams, and peers have been placed in existing case manager positions where they function in typical case management roles. They have also been trained to deliver specified program curricula, such as the Wellness Recovery Action Plan (Copeland, 1997). Peer support training and certification programs have been developed in many locations to facilitate reimbursement through Medicaid.

In an assessment of the evidence for the efficacy of peer support for people with serious mental illness, Chinman et al. (2014) noted that many studies had methodological limitations and that outcomes were mixed for adding peer support to existing services and peers in existing roles. Of the six randomized controlled trials of peers added to existing services, Sledge et al. (2011) reported that patients with multiple hospitalizations who had access to usual care plus a peer mentor had fewer hospitalizations and hospital days than patients in a usual-care control group. Two other randomized controlled trials found that patients assigned to assertive community treatment teams with peers had better short-term treatment engagement (Sells et al., 2006), lower rates of non-attendance at appointments, and greater participation in structured activities compared to patients assigned to assertive treatment teams without peers (Craig et al., 2004). The additional three randomized controlled trials produced no advantages for peer support added to existing programs (Chinman et al., 2014). In the studies of peers in existing roles, outcome of assertive community treatment staffed by peers compared to assertive community treatment without peers revealed no differences in homelessness or arrests, but greater hospitalizations and emergency department visits were observed in the standard assertive treatment group (Chinman et al., 2014). A Cochrane systematic review (Pitt et al., 2013) of 11 randomized controlled trials of consumer providers of care for adult mental health clients reported no adverse outcomes. The authors concluded that the involvement of consumer providers in mental health teams produces no better or worse psychosocial or symptomatic outcomes than those achieved by mental health professionals in similar case management roles.

 
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