1. Peer Support in the UK

2. Nottinghamshire Healthcare NHS trust Employ around 60 peer support workers 8,800 members of staff Support 190,000 people every year (population of Nottinghamshire ~1.1million)

3. UK mental health task force 2016 ‘Everybody in mental health services should be able to say […] I am provided with peer support contact, with people with their own experience of mental health problems and of using mental health services. I can find peer support from people who understand my culture and identity. Peer support is available at any point in my fluctuating health – in a crisis, during recovery, and when I am managing being well’ (p.37)

4. What is Peer Support? ‘ A system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful.’(Mead, 2003) ‘Offering and receiving help, based on shared understanding, respect and mutual empowerment between people in similar situations.’ (ImROC, 2013)

5. What do Peer Support Workers do? Listen Hold hope Draw out strengths Reframe Empathise

6. ‘Over the years I met many good people who were mad like me. Their madness had taken them to a foreign land where only mad people could go to…Mental health professionals stood at the border trying to pull people out of the mad land, even the ones who wanted to stay. They knew the mad land was a bad place where people get lost, sometimes forever. But most of them had never been there. My peers showed me that the mad land, for all its perils, had some of the most enchanted scenery in the world. Like a land that has mountains and ravines, rivers and caves, blinding sun and swirling storms, the mad land could be a place of beauty as well as danger. My peers helped me to understand that I was not alone in the mad land, that there was a whole tribe of us who had been there and seen many of the same things. Things that other people did not easily understand. Things they feared and denigrated.’ (Mary O’Hagan, 2014)

7. But seriously….what do PSWs do? Support worker status (starting salary of £16,633) Part of ward and community teams Peer Health Care Assistants Part of charity organisations and community initiatives Offer practical and social support based on individual goals Can attend reviews and meetings Supporting transitions and times of ‘crisis’

8. What makes it so special?

9. 8 Core Principles Mutual Reciprocal Non-directive Progressive Inclusive Safe Recovery focussed Strengths-based (ImROC, 2013)

10. Credibility

11. “To be mildly hypocritical, if I was not well, whether with drink or alcohol or mentally unwell, if someone who hadn’t had that experience came to me and tried to help me, I’d be like ‘you have no idea what you’re talking about.’” (staff member)

12. Liminality “It’s just having that whole, being able to stand in the middle of it all, you can relate to your co- workers and your manager, you can relate to the people that use the service, but you kind of stand there in the middle. You’re kind of a bridge between the two, and it helps people get the best out of everything.” (PSW)

13. Hope ‘‘And, seeing that she has done it … is motivational. She did it … if she can do it, I can do it, you know?’’ (service user)

14. What makes it so challenging?

15. Preconceptions Myth #1 – Peer support is just a way of saving money. Myth #2 – Peers will be too fragile, they are likely to ‘break down’ at work. Myth #3 – Peers cannot be expected to conform to usual standards of confidentiality. Myth #4 – There is no difference between peer support workers and other staff who have personal experience of mental health problems. Myth #5 – The presence of peer support workers will make staff worried about ‘saying the wrong thing’.

16. More preconceptions Myth #6 – The only way to be sure of getting a job these days is to say you have a mental health problem. Myth #7 – Peers get to do all the nice things – talking to patients, taking them out, going home with them – the rest of us have to do the boring admin and medication, handing out meals, making beds etc. Myth #8 – Peers don’t know the difference between friendships and working relationships. Myth #9 – Peers will be subversive, they will be ‘anti- psychiatry’ and ‘anti-medication’. Myth #10 – Peers will take up so much time that traditional staff roles will be made much harder, not easier. Repper (2013)

17. Friend or worker? – Negotiation of relationships and boundaries between Peer Support Workers and the people they support Power – Do payment and employment in services preclude genuine peer support? Stress – Both from peer relationships and the organisation – maintaining personal wellbeing is a difficult responsibility Ward environment – intense relationships, unplanned endings, high levels of distress Challenges for PSWs

18. Accountability – Peer Support Workers may feel responsible for other people’s distress, particularly around risk – shared responsibility between the Peer Support Worker, the person they are supporting and other team members is key Distinctive role – Peer Support Workers bring a unique skills set and approach to working, so specific measures need to be introduced to define, maintain and value their role e.g. peer supervision, recovery language, recovery-focused practice Challenges for PSWs

19. Love labour There will never be enough money to pay back a person for that part of themselves that they give. I don’t know of any other job actually, that a person has to give something that intimate and that important to that person, than peer support. (PSW manager; Scott, 2011, pp.173)

20. Challenges for the organisation Unclear roles We didn't really know how it was going to work. There were a lot of mixed feelings amongst staff. We didn't know. Was she going to be another member of staff, a colleague, or were we going to have another service user (PSW) we didn't know how it was going to work out. Staff member “Each service has a different way of what they think peer support is so there's no clear definition of what our job actually entails.” PSW

21. Role Clarity Role clarity significantly predicts job satisfaction for PSWs (Davis, 2013) It is has been identified as crucial for successful implementation alongside a supportive organisational culture (Gillard et al., 2014) Lack of clarity and structure are significant barriers undermining peer support (Gates, 2007; Gillard, 2013) The role of management to provide routine structures for support and working practice has been frequently stressed (e.g. Chinman et al, 2006)

22. Challenges for the organisation Should PSWs be employed in statutory services? PSWs subject to medical paradigm, outcomes, throughput, clustering, restraint, medication, sectioning

23. How can we make it work?

24. Training Core Content Introduction to peer support and recovery Active listening skills Wellness planning Use personal stories of recovery to support others Peer support boundaries Working through setbacks and challenges Use of recovery focused language Strengths spotting

25. International good practice 1.Training for Peer Support Workers and the staff they will be working with 2. Clear role descriptions understood by Peer Support Workers and staff they are working with 3. Specific codes of conduct for Peer Support Workers 4. Arrangements for support for mental health made on an individual basis 5. Create supervision structures to support wellbeing and development 6. At least two Peer Support Workers employed in each team 7. Develop a career structure with promotion opportunities

26. What makes it so worth it?

27. Benefits to people using services Overall, RCTs indicate that PSWs have the potential to bring a range of benefits to those receiving support, including: increased self-esteem and confidence improved problem solving skills increased sense of empowerment improved access to work and education more friends, better relationships, more confidence in social settings greater feelings of being accepted and understood (and liked) reduced self stigmatisation greater hopefulness about their own potential more positive feelings about the future. Most commonly the inclusion of peers in the workforce produces the same or better results in a range of outcomes when compared with services without peer staff (Davidson et al., 2012; Repper & Carter, 2010; Bradstreet, 2006).

28. “It's like someone's switched a light on, or clicked their fingers.” (service user) “If it hadn't been for my peer support worker I wouldn’t have been able to get here today because I had major issues getting far from the house. And because she'd been dragging me out the house, I've built the confidence to get here today. I've been in the house for virtually 9 years but she's been getting me out and mixing in the community…she's also got me on a course on Fridays” (service user)

29. Benefits to the PSW Peer Support Workers feel empowered in their own recovery journey (Salzer & Shear, 2002) Have the opportunity to transform their ‘illness story’ into a ‘recovery story’ PSWs have greater confidence and self-esteem (Ratzlaff et al., 2006) and a more positive sense of identity They feel less self-stigmatisation, have more skills, more money and feel more valued (Bracke et al., 2008).

30. “I’ve loved it from day one. I’d say I feel more free than I’ve ever felt before I’m more free to be me, nothing’s hidden. I’ve had a mental health condition my whole life, even some of my friends didn’t know about it, and professionally I’ve had some quite high up jobs and it’s always been hidden. And I’m in a workplace now where nothings hidden whatsoever and it’s really freeing.” (PSW)

31. Benefits to Staff teams The introduction of peer workers is a powerful way of driving forward a recovery-focused approach within a team. (Repper, 2013) Just as peer workers provide hope and inspiration for others experiencing mental health problems, they challenge stigmatising attitudes and provide inspiration for all members of the team. Peer workers also facilitate a better understanding between people providing the service and those using it (Repper & Watson, 2012).

32. I've found her own experience of living with OCD has been really invaluable in supporting the service users …without her help, support and knowledge, I'd have had a much more difficult time. (staff)

33. Benefits to the Organisation Adding peer support workers to care pathways shortens lengths of admission and reduce re- admission rates leading to significant cost savings (Reynolds, 2004; Forchuk, 2007; Lawn, 2008) PSWs bring about significant reductions in hospital bed use among the people they support, leading to financial savings which are well in excess of their pay costs- a ratio of between 3 and 4:1 (Trachtenberg et al., 2013).

34. A letter from a warrior

35. Thank you Emma.Watson@nottshc.nhs.uk