A community-based peer support service for persons with severe mental illness in China

A community-based peer support service for persons with severe mental illness in China Background: Peer support services for patients with severe mental illness (SMI) originated from Western countries and have become increasingly popular during the past twenty years. The aim of this paper is to describe a peer service model and its implementation in China, including the model’s feasibility and sustainability. Methods: A peer support service was developed in four Chinese communities. Implementation, feasibility and sustainability were assessed across five domains: Service process, service contents, peer training and supervision, service satisfaction, and service perceived benefit. Results: Service process: 214 peer support activities were held between July 2013 and June 2016. No adverse events occurred during three years. Each activity ranged from 40 to 120 min; most were conducted in a community rehabilitation center or community health care center. Service content: Activities focused on eight primary topics—daily life skills, social skills, knowledge of mental disorders, entertainment, fine motor skill practice, personal perceptions, healthy life style support, emotional support. Peer training and supervision: Intensive training was provided for all peers before they started to provide services. Regular supervision and continued training were provided thereafter; online supervision supplemented face to face meetings. Service satisfaction: Nineteen consumers (79.2%) (χ (1) = 12.76, p <0. 001) were satisfied with the peers and 17 consumers (70.8%) (χ (1) = 8.05, p = 0.005) expressed a strong desire to continue to participate in the service. Fourteen caregivers (93.3%) (χ (1) = 11.27, p = 0.001) wanted the patients to continue to organize or participate in the service. Service perceived benefit: Six peers (85.7%) (χ (1) = 3.57, p =0.059) reported an improvement of working skills. Ten consumers (41.7%) (χ (1) = 0.05, p = 0.827) reported better social communication skills. Six caregivers (40%) (χ (1) = 1.67, p = 0.197) observed patients’ increase in social communication skills, five (33.3%) (χ (1) = 1.67, p = 0.197) found their own mood had been improved. Conclusions: Peer support services for patients with SMI can be sustainably implemented within Chinese communities without adverse events that jeopardize safety and patient stability. Suggestions for future service development include having professionals give increased levels of support to peers at the beginning of a new program. A culturally consistent peer service manual, including peer role definition, peer training curriculum, and supervision methods, should be developed to help implement the service smoothly. Keywords: Severe mental illness, Peer support, Community, China * Correspondence: maning@bjmu.edu.cn Peking University Sixth Hospital; Peking University Institute of Mental Health; Key Laboratory of Mental Health, Ministry of Health (Peking University); National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fan et al. BMC Psychiatry (2018) 18:170 Page 2 of 10 Background The World Health Organization (WHO) Consultation Peer support services are designed to bring together documents the promise of peer support as an effective ap- people with similar life experiences, culture, living envi- proach to chronic disease management and health promo- ronments, social status, concerns, and daily challenges [1]. tion [17]. However, there is no widely accepted or This commonality promotes mutual respect, and it en- standardized model for the operation of peer support ser- ables sharing of information, practical strategies and on- vices [18]. For example, peer support services in Roches- going support that are critical to sustained behavior ter, NY, USA, are usually provided for a long-term change [1]. Within the field of mental health services, peer duration and their contents are flexible. However, in New service providers are individuals who have lived experi- Zealand, peer run recovery houses are widely developed. ence with mental illness, and who are willing to provide The recovery house is an alternative to inpatient care in modeling and support to other individuals with mental ill- an acute psychiatric unit. It provides 24-h support, super- ness [2]. Now regarded as a hallmark of recovery-oriented vision and treatment [19]. In Australia, there is a Certifi- care [3], peer support services emphasize the importance cate IV Mental Health Peer Work as the minimum entry of personal interests and strengths as foundations of re- requirement for employment in peer support services, and covery, rather than psychopathology and treatment con- their training content is relatively fixed [19, 20]. siderations [4]. As for the format of peer service among patients with The benefits of peer support service are multifaceted, SMI, Davidson summarized it into three types: informal including benefits for peers (providers of peer support), (naturally occurring) peer support, peer-run programs, consumers (receivers of peer support), the healthcare sys- and the employment of service recipients as service pro- tem, and society as a whole [5, 6]. Peers’ benefits include viders within traditional mental health programs [21]. self-efficacy resulting from the experience of helping Service duration can be long or short, and services can others [7], and earning money [8]. In addition, providing be located in the community or in hospitals. The con- peer support services can promote peers’ communication tent is varied, including activities such as disease and skills, improve emotional and verbal expression, and in- health education, social communication and daily life crease social functioning [9]. All of these benefits contrib- skills, and vocational support. Peer positions are often ute directly to the recovery process. The effects upon voluntary, and peers are typically selected by profes- consumers with severe mental illness (SMI) are broad and sionals based upon their communication skills, under- include not only clinical benefits, such as fewer hospitali- standing of mental illness, personal responsibility and zations or psychiatric symptoms, but also personal and compassion, and level of clinical stability. In addition, emotional benefits such as feelings of understanding, re- professionals generally supervise peers during the deliv- spect and trust [10, 11]. Peer support can also improve ery of support services [22]. Peer services currently oper- consumers’ social functioning and quality of life [12]. Peer ate in several countries including the United States [23], support services are able to benefit healthcare systems and the United Kingdom [24], Australia [25], Germany [4], society as a whole. Peers, as healthcare service providers, Brazil [26], New Zealand, and Canada [27]. The experi- can enrich mental health service teams while providing ences of these countries have also proved that the oper- additional support to clinicians. In addition, since peers ation of peer services should be consistent with local communicate with patients more often, they can function customs, values, and resource availability [28]. as important bridges between doctors and patients [13]. China, with its population of 1.3 billion, has more than Peer support can also reduce social discrimination against 13 million persons suffering from psychotic disorders persons with SMI. By demonstrating that people with SMI (hereafter labeled serious mental illness; SMI), based on can recover and work, peer service providers are able to an estimated prevalence of mood disorders was 6.1%, promote social understanding and acceptance, decrease anxiety disorders was 5.6%, substance abuse disorders social stigma and fear, and decrease patients’ feelings of was 5.9%, and psychotic disorders was 1.0% [29]. At the shame and isolation [14]. end of 2014, there were only 25,307 psychiatrists (1.85/ Many studies have reported the importance of peers as 100,000 population) and 51,571 psychiatric nurses (3.77 positive role models of recovery and hope for con- /100,000 population) [30], very few psychotherapists and sumers, caregivers and professional staff members alike social workers, and almost no mental health occupa- [9, 15, 16]. Consumers as well as their caregivers become tional therapist. Outpatient mental health services for more positive and confident about themselves and their persons with SMI are offered primarily in large psychi- future, while peers can also help consumers like them- atric hospital clinics, where one psychiatrist often sees selves better, believe in their own potential more and 50–100 patients per day, with pharmacotherapy being achieve their goals [9]. With regard to professional staff, the primary mode of treatment. If peers joined the men- they are able to see things differently and use other ap- tal health workforce and assisted in providing rehabilita- proaches to clients in specific situations [15]. tion services, this strategy could enrich the scope of Fan et al. BMC Psychiatry (2018) 18:170 Page 3 of 10 service and be beneficial to maintain patients’ good con- Table 1 Numbers of peers and consumers enrolled in each community by year dition. It could also compensate for the lack of profes- sional personnel in the long run. Role in each Year χ test of difference Community This project was started in 2013 with the aim of estab- 2013 2014 2015 2016 lishing a community-based peer support service model Peer χ (9) = 10.30, p = 0.326 for patients with SMI. No peer-based services existed in Tuanjiehu 5 5 4 4 China at the time when we began the project. The pro- Maizidian 2 2 2 2 ject had the goal of demonstrating feasibility and sus- Xiangheyuan –– 44 tainability, while also assessing whether the program Jingsong –– 22 would be associated with adverse patient events. In this paper, we described the implementation of a peer sup- Total 7 7 12 12 port service in China. Consumer χ (9) = 27.73, p = 0.001 Tuanjiehu 10 11 14 14 Methods Maizidian 13 13 14 15 Participants Xiangheyuan –– 10 11 A peer support service was developed in four communi- Jingsong –– 10 10 ties located in the Chaoyang district of Beijing: Tuanjiehu, Maizidian, Xiangheyuan, and Jinsong. Peer support was Total 23 24 48 50 initiated in July 2013 in Tuanjiehu and Maizidian, and in the other two communities in August 2015. All peer service providers were recommended by (seven of peers, eight of consumers) from 15 families community doctors and evaluated by a research team had been recruited in this study. The project proposal psychiatrist. Peers who agreed to participate in were sub- was reviewed and approved by Peking University Sixth sequently utilized if they met the following inclusion cri- Hospital Ethics Committee, and all peers and consumers teria: Diagnosed with schizophrenia or bipolar disorder provided written informed consent. which was recoded from their medical record provided by community doctors; age between 18 and 60 years old; Procedure stable at least 6 months, being adherent with medications After the recruitment of peers and consumers, pre-service according to patients’ and family members’ report, and interviews with peers, consumers and their caregivers were having insight about their disease which was assessed conducted by a research assistant. The pre-service inter- through individual interviews conducted by psychiatrists; views were aimed to find out consumers’ needs in order to no drug or alcohol abuse; no severe medical illness; and make our service contents meet their demands. As long as having good social functioning which was assessed by the peers have received the intensive pre-service training, they personal and social performance scale (PSP), more than were able to provide service. Apart from the intensive 50 scores in PSP is required [31]. All participating peers pre-service training that each peer was required to attend, were expected to be compassionate and willing to help peers were supervised during the whole service course. others. Applicants with strong practical skills (e.g., cook- During the first year of the service, community doctors and ing, drawing) were preferred. clinical psychologists provided direction to peers before All peers participated in intensive pre-service training. and after each peer support activity, and the psychiatrist Once they finished training, posters were placed in di- provided guidance and support to community doctors and verse community locations to recruit patient-recipients clinical psychologists. Beginning in July 2014 (the second (i.e., consumers); others came to the program based on year), community doctors offered non-scheduled “as the recommendation of community doctors. Each poten- needed” supervision which mainly depended on peers’ tial consumer was evaluated by the team psychiatrist, needs, while the clinical psychologists and psychiatrist of- using the following inclusion criteria: diagnosed with fered group supervision every six weeks. After they had ac- schizophrenia or bipolar disorder; age 18–60 years old; cumulated a year of experience, peers were able to prepare stable at least 3 months; no drug or alcohol abuse; and and organize session and training activities themselves; no severe medical illness. their credibility as service providers was well-established We recruited 12 peer providers and 50 consumers by among consumers. In addition, two social workers were in- 2016 (see Table 1). One peer in Tuanjiehu community volved in this program beginning in March 2016, and they quit in 2015, expressing concerns about too much pres- provided assistance before and after activities upon requests sure working as a peer. The caregivers of peers and con- by the peers. These social workers also participated in sumers were also recruited if they were willing to be group supervision. Along with face to face supervision, we contacted for the follow-up evaluation. Fifteen caregivers also provided online supervision. A WeChat group was Fan et al. BMC Psychiatry (2018) 18:170 Page 4 of 10 built which included peers, community doctors, social Service perceived benefit [9, 15] workers, clinical psychologists and psychiatrists. Feedback on the perceived impact of providing or re- An evaluation had been conducted among the peers, ceiving service was collected through brief structured consumers, and their caregivers from the first two com- face to face interviews conducted by a research assistant munities in December 2014, the evaluation concluded with peers, consumers as well as their caregivers. The the service satisfaction and effectiveness. peers and consumers were asked if organizing and par- ticipating in the service had any benefit to their im- Measures provement of skills or mood. The caregivers were also We examined implementation and feasibility of the asked if the peer support service could improve their community-based peer support service model for pa- own mood or quality of life. All the questions were sup- tients with SMI in China from five aspects – service posed to be answered with yes or no. process, service content, peer training and supervision, service satisfaction, and service perceived benefit. Data analysis All the forms as well as audio and literal records were Service process [32] recoded by three graduate students independently. De- Measures of service process included the number of ac- scriptive and inferential statistics analyses were used. tivities, frequency, average session time, and format of Continuous variables were reported as means ± SD and each activity. Peers were required to fill in a were tested for normality with the Shapiro-Wilk test. self-compiled form called “Activity Process Form” each Mean differences were tested by independent samples time after the service being provided. The form included t-tests. Discrete variables were reported as N’s and per- the date, start and end time of each activity, as well as centages. Chi-square tests were used to examine differ- the format of each activity. The forms had to be ences. Analyses were performed with SPSS 19.0 for well-preserved by each peer and submitted to the project Windows. manager every six weeks. Results Service content [33] Peer and consumer participants Measures of service content included the activity topics The numbers of peers and consumers enrolled in each and the proportion of each. These were also tested by community by year are shown in Table 1. There was a “Activity Process Form” which contained the aim and significant increase in consumers while non-significant theme of each activity as well as consumers’ feedback. It in peers. Demographic information pertaining to peers was also required to be filled in after each service and and consumers is shown in Table 2. The mean ages of submitted every six weeks. peers and consumers were 40.2 and 48.3, respectively. All peers and consumers were patients with SMI, most Peer training and supervision [9] of them were diagnosed with schizophrenia. There was Multi-background supervisor group was constituted by no significant difference between peers and consumers community doctors and professionals including psychia- apart from age, working status and diagnosis. Peers were trists, clinical psychologists and social workers. The younger, less likely to be unemployed than consumers, measures of peer training and supervision included the and less peers had diagnoses of schizophrenia. contents of issues identified which were summarized from the training schedule and textbooks, audio and lit- Service process eral supervision records. A total of 214 peer support sessions were delivered from July 2013 to June 2016. One peer session means that Service satisfaction [9, 18] peer met with consumers once and conduct activities or Semi-structured face to face interviews were con- support service in groups. There was no report of vio- ducted by a research assistant to measure the service lence, self-harm, or other potentially adverse events. The satisfaction from the perspectives of consumers and number of sessions for each community by every their caregivers. The consumers were asked if they 6-month period is shown in Fig. 1. The numbers among were satisfied with the peers and if they were willing different communities and time period yielded statistical to continue to participate in the peer support ser- significance (χ (15) = 48.75, p < 0.001). During the first vice. The caregivers were asked if they wanted the 6 months, only two communities developed peer sup- patients to continue to organize (for peers’ care- port services and the peers were not yet proficient in givers) or participate (for consumers’ caregivers) in running activities, which were organized about once the service. All the questions were supposed to be every one or two months. During the second year, ses- answered with yes or no. sions were delivered about once every two weeks in Fan et al. BMC Psychiatry (2018) 18:170 Page 5 of 10 Table 2 The demographic information of consumers and peers Characteristic Peers Consumers t test or χ test of difference N % N % Age (M ± SD) 40.2 ± 8.9 48.3 ± 8.2 t = −2.99, p = 0.004 Sex χ (1) = 2.37, p = 0.124 Male 8 66.7 21 42.0 Female 4 33.3 29 58.0 Education level χ (5) = 2.93, p = 0.711 Primary school 0 0 2 4.0 Junior high school 1 8.3 10 20.0 Senior high school 8 66.7 22 44.0 Junior college 1 8.3 8 16.0 Undergraduate degree 2 16.7 7 14.0 Postgraduate degree 0 0 1 2.0 Marital Status χ (3) = 1.32, p = 0.726 Single/never married 7 58.3 29 58.0 Married 4 33.3 11 22.0 Divorced 1 8.3 9 18.0 Widowed 0 0 1 2.0 Working status χ (1) = 5.53, p = 0.039 Yes (all part-time) 4 33.3 4 8.0 No 8 66.7 46 92.0 Diagnosis χ (1) = 10.61, p = 0.004 Schizophrenia 6 50.0 45 90.0 Bipolar Disorder 6 50.0 5 10.0 Fig. 1 The number of peer support activities in each communities by every 6 months Fan et al. BMC Psychiatry (2018) 18:170 Page 6 of 10 these two communities. During the first 6 months of 2015, one peer in Tuanjiehu quit and one peer in Maizidian asked for a temporary leave because of needing to assist his sick mother. In addition, Tuanjiehu had trouble in finding the service place because the old one could not be used anymore. Resulting in no session had been provided during this time period in Tuanjiehu com- munity. Beginning in August 2015, peer support services were started in another two communities. In 2015 and 2016, the session frequency differed among communities. It occurred once or twice each week in the first two com- munities, and once every two weeks in the newer two communities. The duration of each session ranged from 40 min to 120 min, depending on the activity theme and format for the session. The format of each activity varied depending on the topics, including group discussion, role play, personal sharing, lecture, and outdoor exercises. Most sessions were held in community rehabilitation cen- ters or community health care centers. Each session typic- ally involved at least two peers, with one leading and the other one assisting with service delivery, record keeping, and documenting consumers’ feedback. Fig. 2 The proportion of peer support activity categories Service contents On the basis of previous studies [34, 35], combining with the pre-service interviews, we summarized consumers’ Theprogram beganbypeerssharing therules of this ser- needs into eight categories: daily life skills, social interper- vice with those consumers who were referred or who sonal skills, knowledge of mental disorders, entertainment, responded to our posters. Each was asked to review and fine motor skill practice and exercise, personal perceptions sign an informed consent document as well as a service and such as self-esteem and self-confidence, healthy life style, group activity agreement before beginning the activities. and emotional support. The eight categories had been In addition, there were usually three parts for each ses- provided to peers before the initiation of peer support ses- sion. First, there were brief warm up activities, such as sions. Peers had freedom to choose which category and icebreaking games or setting-up exercises. The main ac- what specific contents they were going to afford. tivities relating to each topic then were initiated. At the Analyses of the service contents showed that each of end, peer providers or consumers would summarize the the eight categories had been addressed during the activity, followed by reciting a poem or singing a song three years’ service. Some of the session contents exam- together. Peers were required to complete documenta- ples are listed below: daily life skills study (e.g., cooking, tion for each session. Before one session’s activities, they how to use WeChat), social skills study (e.g., communi- planned and completed an “Activity Plan Form”. Upon cating with body language and facial expression, verbal completion of each session, peers completed the “Activ- communication skills), knowledge of mental disorders ity Process Form” and a “Participant List”. If any adverse (e.g., treatments for schizophrenia, recognizing disease event or behavioral emergency (e.g., poorly controlled recurrence, medications, side-effects), entertainment behavior, or problem that might require immediate at- (e.g., singing, watching movies), fine motor skill prac- tention) occurred during the session, peers were re- tice and exercises (e.g., handwriting, puzzles, physical quired to record the “Emergency Event Form” and to exercise), personal perceptions (building self-esteem submit this report to the community doctors. and self-confidence), healthy life style support (e.g., controlling your emotions, healthy diets), emotional Peer training and supervision support (e.g., sharing stories of childhood, building re- Pre-service training was provided for all peers. Training lationships with family members). The proportion of contents included the concept and theory of peer sup- each category is shown in Fig. 2.The topthree most port services, working principles and requirements (in- popular activity categories were fine motor skill prac- cluding confidentiality, boundaries, and relationships), tice and exercise (19%), daily life skills study (16%) and how to design and implement group activities, effective emotional support (15%). listening and speaking skills, how to handle emergency Fan et al. BMC Psychiatry (2018) 18:170 Page 7 of 10 situations, and how to complete the record forms. We de- Service perceived benefit veloped the training curriculum with reference of USA Service perceived benefit was only assessed among the and Australia experience [8], and integrated with extensive first two communities (Tuanjiehu & Maizidian). For discussion with potential peers during the pre-service in- peers, six (85.7%) (χ (1) = 3.57, p = 0.059) reported an terviews to better understand their knowledge and needs. improvement of working skills, four (57.1%) (χ (1) = The primary trainers were a psychiatrist and a clinical 0.14, p = 0.705) reported increase in social communica- psychologist. Pre-service training was completed in five tion skills. For consumers, ten (41.7%) (χ (1) = 0.05, p = half a day with six workshop sessions. The format in- 0.827) reported better social communication skills. For cluded coursework, group sharing and discussion, role caregivers, six (40%) (χ (1) = 1.67, p = 0.197) observed play, and storytelling. We also included the peers from patients’ increase of social communication skills, five our first two communities when we trained new peers in (33.3%) (χ (1) = 1.67, p = 0.197) found their own mood June 2015 for the second two communities. The former had been improved. shared their experiences and demonstrated how to con- duct activities as part of their presentations. Discussion With regard to the peer supervision during the whole The results of this evaluation suggest that peer support service course, while the supervision group initially func- services for persons with SMI are feasible and sustain- tioned to provide basic instruction and support related to able in China. The peer service has been in operation for conducting activities, the group subsequently focused three years, and the number of communities that devel- more upon addressing peers’ difficulties and feelings of oped peer support services has increased from two to once they had accumulated service experience. For ex- four with a significant increase of consumers. The ser- ample, some peers might feel frustrated when they did not vice has received positive evaluation and satisfaction achieve their service goals, or when they encountered con- from consumers and caregivers of both peers and con- sumers who did not listen carefully or seemed bored. sumers. Our experience can serve as a point of reference These experiences may undermine peers’ confidence, even for other areas of China where there is interest in devel- though they are related to factors other than the peers’ oping peer support services within their respective com- level of skill or experience. The overall aim of supervision munities. Although we did not establish a standardized was to build peers’ confidence as well as their work cap- model for the operation of peer support services, our acity, motivation, and self-satisfaction. work may provide a general framework upon which to In addition, face to face supervisions were supplemented build such services. with the online supervision. According to unstructured in- Several aspects of this framework are particularly import- terviews with peers and community doctors, online group ant early in the course of service development and imple- provided timely and efficient input to support both peer mentation. It is important to provide peers with extra help and service development. Whenever the peers experienced and support in figuring out the topic of activities and pre- challenging work situations, they could ask questions in the paring for peer support sessions at the beginning of service online WeChat group. This forum provided an opportunity delivery.It shouldberecognizedthatthe role of peersis for the professional staff to respond quickly, and it also pro- very new in China, the majority of them are lacking in ex- vided an opportunity for the other peers to express support perience and confidence. At the beginning of the project, and to give suggestions. The success of our online supervi- both the caregivers and community workers were worried sion prompted peers to build additional online peer support about the safety of service, they did not believe in peers. services. Now, three communities have their own WeChat Even the peers did not believe in themselves and they groups for peers and consumers in order to provide timely tended to avoid telling stories about themselves or sharing support for consumers. their own life experiences because of the perceived stigma and the unfamiliar environment. Therefore, we guided Service satisfaction peers to provide some entertainment or skill training activ- Service satisfaction evaluation was only conducted ities at first. It is helpful to identify community workers, among the first two communities (Tuanjiehu & such as doctors, nurses and social workers, who are willing Maizidian). Among the 24 consumers, three (12.5%) had to guide peers in preparing activity materials, and in provid- not been assessed because of personal issues. Nineteen ing on-site support as peers assume their new roles. The (79.2%) (χ (1) = 12.76, p < 0.001) were satisfied with the early availability of supportive health professionals serves to peers and 17 (70.8%) (χ (1) = 8.05, p = 0.005) expressed a alleviate stress that is commonly experienced by peers as strong desire to continue to participate in the service. they adopt the role of service provider. At the same time, it Among the 15 caregivers, 14 (93.3%) (χ (1) = 11.27, p = is important for community workers to give peers more au- 0.001) wanted the patients to continue to organize or tonomy as their proficiency increases. We came to under- participate in the service. stand, as well, that many community health workers, Fan et al. BMC Psychiatry (2018) 18:170 Page 8 of 10 including physicians, frequently have scant knowledge social workers, depending upon their local availability. about SMIs and their treatment, and about providing peer Pre-service training is particularly important for peers and support services. Mental health professionals should pro- community doctors in order to clearly understand their vide more guidance for community health workers from roles and job requirements, and also for obtaining the ne- the knowledge, skill training and supervision in helping cessary skills for providing services. The content of our peer providers. It should also be noted that the frequency pre-service training turned out to be consistent with the ex- of sessions was less during the first year in our first two perience in Hong Kong, which proved to be practical in communities. This slower initial pace allowed us to grad- non-Western context [36]. One of our peer program’snot- ually develop the necessary procedures and practices to able features is that we developed a group to provide super- support peer service provision. Our pace increased during vision, an unusual feature in China. Several community the third year period, especially as we opened a second set doctors and peers mentioned that the supervision group ef- of services and as the peers’ overall experience increased. In fectively provided support for them. As for the format of addition, after several months, the intimacy between peers supervision, we recommend combining both face-to-face and consumers also increased, then both the peers and and online formats. Face-to-face supervision is particularly community health workers became more positive about helpful for affective interactions, while online supervision is peer service. more timely and efficient. It is essential to clarify the role of “peer.” At the outset, Finally, we recommend having at least two peers for each peers reflected that they are patients too – that is, con- community, and to have both present at every session when sumers – and they initially expressed doubt that other possible. This level of peer staffing is particularly important consumers would trust and listen to them. Community for new programs. This team approach will better enable workers also commented that it was difficult for them to peers to monitor activities, and to adjust the peer role more decide how closely they should work with the peers in effectively. Peer partners can support each other in a timely providing support. Clear job descriptions and role clarifi- way before and after each session, discussing the plans and cation is necessary for both peers and community processes, sharing the job experiences, and identifying op- workers. We observed that the role of peer service pro- portunities for improvement in future support and training viders can vary according to the characteristics and needs activities. We received consistently positive feedback from of consumers and the activities planned for each session. peers and community doctors alike for having two peers These roles can include being a professional assistant, an working together by design. advocate, a supporter, and even a case manager. Despite There are some limitations in this study that need to this variability in roles, we found that their primary re- be addressed. First, according to the results, although sponsibility involved working as a role model and partner the service received positive evaluation and satisfaction in recovery for other consumers. As such, peer providers from consumers and caregivers, the perceived benefit should be prepared to provide emotional support, living still not significant. This may because some of the effect and social skills development, education, sharing of expe- have not been showed up by the evaluation or due to the riences, and encouragement. small sample size, future researches are needed to repli- We recommend offering a range of service topics as cate our study with larger sample size of peers, con- part of the peer training curriculum. In this project, sumers as well as their caregivers. Secondly, based on peers initially found it difficult to generate their own our experience, at the initiate of peer service, peers ideas for group activities, preferring that professionals tended to avoid telling stories about themselves or shar- would provide a list of topics. In the absence of such ing their own life experiences because of the perceived guidance from professionals, there is a risk that peer stigma and the unfamiliar environment. However, the providers could become somewhat overwhelmed and key idea of peer support service is that peer staff are demoralized. To minimize the risk, we recommend that trained to provide different services for which they are peers first consider carrying out activities that relate to especially well suited based on their own life experiences topics with which they are familiar. These can include and accumulated knowledge of how to live with a mental daily life skills (e.g., cooking), basic social skills (e.g., illness. So, although peers would adapt to their new roles introducing oneself), information about mental illness eventually, future research could find more effective (e.g., early warning signs of relapse), entertainment sug- ways to speed up this process. We have also conducted gestions (e.g., watching movies), and fine motor skill follow-up evaluations with quantitative combined with practice and exercises (e.g., Chinese calligraphy). qualitative measures among peers, consumers as well as It is important to provide specific training and continuing their caregivers in the four communities, the results will supervision for peers through the use of multidisciplinary be showed and discussed in another paper. Future re- groups, including psychiatrists, psychological therapists, search could also explore more long-term outcomes of community workers (especially primary care doctors), and peer support service in China. Fan et al. 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Development, reliability and acceptability of a new version of the DSM-IV social and occupational functioning assessment scale (SOFAS) to assess routine social funtioning. Acta Psychiatr Scand. 2000;101(4):323–9. 32. Weissman EM, Covell NH, Kushner M, Irwin J, Essock SM. Implementing peer-assisted case management to help homeless veterans with mental illness transition to independent housing. Community Ment Health J. 2005; 41(3):267–76. 33. Cabassa LJ, Camacho D, Vélez-Grau CM, Stefancic A. Peer-based health interventions for people with serious mental illness: a systematic literature review. J Psychiatr Res. 2017;84:80–9. 34. Blixen C, Perzynski A, Kanuch S, Dawson N, Kaiser D, Lawless ME, Seeholzer E, Sajatovic M. Training peer educators to promote self-management skills in people with serious mental illness (SMI) and diabetes (DM) in a primary health care setting. Primary health care research & development. 2015;16(2):127–37. 35. Todd NJ, Jones SH, Lobban FA. What do service users with bipolar disorder want from a web-based self-management intervention? A qualitative focus group study. Clinical psychology & psychotherapy. 2013;20(6):531–43. 36. Yam KK, Lo WT, Chiu RL, Lau BS, Lau CK, Wu JK, Wan SM. A pilot training program for people in recovery of mental illness as vocational peer support workers in Hong Kong–job buddies training program (JBTP): a preliminary finding. Asian J Psychiatr. 2016; https://doi.org/10.1016/j.ajp.2016.10.002. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Psychiatry Springer Journals

A community-based peer support service for persons with severe mental illness in China

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Abstract

Background: Peer support services for patients with severe mental illness (SMI) originated from Western countries and have become increasingly popular during the past twenty years. The aim of this paper is to describe a peer service model and its implementation in China, including the model’s feasibility and sustainability. Methods: A peer support service was developed in four Chinese communities. Implementation, feasibility and sustainability were assessed across five domains: Service process, service contents, peer training and supervision, service satisfaction, and service perceived benefit. Results: Service process: 214 peer support activities were held between July 2013 and June 2016. No adverse events occurred during three years. Each activity ranged from 40 to 120 min; most were conducted in a community rehabilitation center or community health care center. Service content: Activities focused on eight primary topics—daily life skills, social skills, knowledge of mental disorders, entertainment, fine motor skill practice, personal perceptions, healthy life style support, emotional support. Peer training and supervision: Intensive training was provided for all peers before they started to provide services. Regular supervision and continued training were provided thereafter; online supervision supplemented face to face meetings. Service satisfaction: Nineteen consumers (79.2%) (χ (1) = 12.76, p <0. 001) were satisfied with the peers and 17 consumers (70.8%) (χ (1) = 8.05, p = 0.005) expressed a strong desire to continue to participate in the service. Fourteen caregivers (93.3%) (χ (1) = 11.27, p = 0.001) wanted the patients to continue to organize or participate in the service. Service perceived benefit: Six peers (85.7%) (χ (1) = 3.57, p =0.059) reported an improvement of working skills. Ten consumers (41.7%) (χ (1) = 0.05, p = 0.827) reported better social communication skills. Six caregivers (40%) (χ (1) = 1.67, p = 0.197) observed patients’ increase in social communication skills, five (33.3%) (χ (1) = 1.67, p = 0.197) found their own mood had been improved. Conclusions: Peer support services for patients with SMI can be sustainably implemented within Chinese communities without adverse events that jeopardize safety and patient stability. Suggestions for future service development include having professionals give increased levels of support to peers at the beginning of a new program. A culturally consistent peer service manual, including peer role definition, peer training curriculum, and supervision methods, should be developed to help implement the service smoothly. Keywords: Severe mental illness, Peer support, Community, China * Correspondence: maning@bjmu.edu.cn Peking University Sixth Hospital; Peking University Institute of Mental Health; Key Laboratory of Mental Health, Ministry of Health (Peking University); National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Fan et al. BMC Psychiatry (2018) 18:170 Page 2 of 10 Background The World Health Organization (WHO) Consultation Peer support services are designed to bring together documents the promise of peer support as an effective ap- people with similar life experiences, culture, living envi- proach to chronic disease management and health promo- ronments, social status, concerns, and daily challenges [1]. tion [17]. However, there is no widely accepted or This commonality promotes mutual respect, and it en- standardized model for the operation of peer support ser- ables sharing of information, practical strategies and on- vices [18]. For example, peer support services in Roches- going support that are critical to sustained behavior ter, NY, USA, are usually provided for a long-term change [1]. Within the field of mental health services, peer duration and their contents are flexible. However, in New service providers are individuals who have lived experi- Zealand, peer run recovery houses are widely developed. ence with mental illness, and who are willing to provide The recovery house is an alternative to inpatient care in modeling and support to other individuals with mental ill- an acute psychiatric unit. It provides 24-h support, super- ness [2]. Now regarded as a hallmark of recovery-oriented vision and treatment [19]. In Australia, there is a Certifi- care [3], peer support services emphasize the importance cate IV Mental Health Peer Work as the minimum entry of personal interests and strengths as foundations of re- requirement for employment in peer support services, and covery, rather than psychopathology and treatment con- their training content is relatively fixed [19, 20]. siderations [4]. As for the format of peer service among patients with The benefits of peer support service are multifaceted, SMI, Davidson summarized it into three types: informal including benefits for peers (providers of peer support), (naturally occurring) peer support, peer-run programs, consumers (receivers of peer support), the healthcare sys- and the employment of service recipients as service pro- tem, and society as a whole [5, 6]. Peers’ benefits include viders within traditional mental health programs [21]. self-efficacy resulting from the experience of helping Service duration can be long or short, and services can others [7], and earning money [8]. In addition, providing be located in the community or in hospitals. The con- peer support services can promote peers’ communication tent is varied, including activities such as disease and skills, improve emotional and verbal expression, and in- health education, social communication and daily life crease social functioning [9]. All of these benefits contrib- skills, and vocational support. Peer positions are often ute directly to the recovery process. The effects upon voluntary, and peers are typically selected by profes- consumers with severe mental illness (SMI) are broad and sionals based upon their communication skills, under- include not only clinical benefits, such as fewer hospitali- standing of mental illness, personal responsibility and zations or psychiatric symptoms, but also personal and compassion, and level of clinical stability. In addition, emotional benefits such as feelings of understanding, re- professionals generally supervise peers during the deliv- spect and trust [10, 11]. Peer support can also improve ery of support services [22]. Peer services currently oper- consumers’ social functioning and quality of life [12]. Peer ate in several countries including the United States [23], support services are able to benefit healthcare systems and the United Kingdom [24], Australia [25], Germany [4], society as a whole. Peers, as healthcare service providers, Brazil [26], New Zealand, and Canada [27]. The experi- can enrich mental health service teams while providing ences of these countries have also proved that the oper- additional support to clinicians. In addition, since peers ation of peer services should be consistent with local communicate with patients more often, they can function customs, values, and resource availability [28]. as important bridges between doctors and patients [13]. China, with its population of 1.3 billion, has more than Peer support can also reduce social discrimination against 13 million persons suffering from psychotic disorders persons with SMI. By demonstrating that people with SMI (hereafter labeled serious mental illness; SMI), based on can recover and work, peer service providers are able to an estimated prevalence of mood disorders was 6.1%, promote social understanding and acceptance, decrease anxiety disorders was 5.6%, substance abuse disorders social stigma and fear, and decrease patients’ feelings of was 5.9%, and psychotic disorders was 1.0% [29]. At the shame and isolation [14]. end of 2014, there were only 25,307 psychiatrists (1.85/ Many studies have reported the importance of peers as 100,000 population) and 51,571 psychiatric nurses (3.77 positive role models of recovery and hope for con- /100,000 population) [30], very few psychotherapists and sumers, caregivers and professional staff members alike social workers, and almost no mental health occupa- [9, 15, 16]. Consumers as well as their caregivers become tional therapist. Outpatient mental health services for more positive and confident about themselves and their persons with SMI are offered primarily in large psychi- future, while peers can also help consumers like them- atric hospital clinics, where one psychiatrist often sees selves better, believe in their own potential more and 50–100 patients per day, with pharmacotherapy being achieve their goals [9]. With regard to professional staff, the primary mode of treatment. If peers joined the men- they are able to see things differently and use other ap- tal health workforce and assisted in providing rehabilita- proaches to clients in specific situations [15]. tion services, this strategy could enrich the scope of Fan et al. BMC Psychiatry (2018) 18:170 Page 3 of 10 service and be beneficial to maintain patients’ good con- Table 1 Numbers of peers and consumers enrolled in each community by year dition. It could also compensate for the lack of profes- sional personnel in the long run. Role in each Year χ test of difference Community This project was started in 2013 with the aim of estab- 2013 2014 2015 2016 lishing a community-based peer support service model Peer χ (9) = 10.30, p = 0.326 for patients with SMI. No peer-based services existed in Tuanjiehu 5 5 4 4 China at the time when we began the project. The pro- Maizidian 2 2 2 2 ject had the goal of demonstrating feasibility and sus- Xiangheyuan –– 44 tainability, while also assessing whether the program Jingsong –– 22 would be associated with adverse patient events. In this paper, we described the implementation of a peer sup- Total 7 7 12 12 port service in China. Consumer χ (9) = 27.73, p = 0.001 Tuanjiehu 10 11 14 14 Methods Maizidian 13 13 14 15 Participants Xiangheyuan –– 10 11 A peer support service was developed in four communi- Jingsong –– 10 10 ties located in the Chaoyang district of Beijing: Tuanjiehu, Maizidian, Xiangheyuan, and Jinsong. Peer support was Total 23 24 48 50 initiated in July 2013 in Tuanjiehu and Maizidian, and in the other two communities in August 2015. All peer service providers were recommended by (seven of peers, eight of consumers) from 15 families community doctors and evaluated by a research team had been recruited in this study. The project proposal psychiatrist. Peers who agreed to participate in were sub- was reviewed and approved by Peking University Sixth sequently utilized if they met the following inclusion cri- Hospital Ethics Committee, and all peers and consumers teria: Diagnosed with schizophrenia or bipolar disorder provided written informed consent. which was recoded from their medical record provided by community doctors; age between 18 and 60 years old; Procedure stable at least 6 months, being adherent with medications After the recruitment of peers and consumers, pre-service according to patients’ and family members’ report, and interviews with peers, consumers and their caregivers were having insight about their disease which was assessed conducted by a research assistant. The pre-service inter- through individual interviews conducted by psychiatrists; views were aimed to find out consumers’ needs in order to no drug or alcohol abuse; no severe medical illness; and make our service contents meet their demands. As long as having good social functioning which was assessed by the peers have received the intensive pre-service training, they personal and social performance scale (PSP), more than were able to provide service. Apart from the intensive 50 scores in PSP is required [31]. All participating peers pre-service training that each peer was required to attend, were expected to be compassionate and willing to help peers were supervised during the whole service course. others. Applicants with strong practical skills (e.g., cook- During the first year of the service, community doctors and ing, drawing) were preferred. clinical psychologists provided direction to peers before All peers participated in intensive pre-service training. and after each peer support activity, and the psychiatrist Once they finished training, posters were placed in di- provided guidance and support to community doctors and verse community locations to recruit patient-recipients clinical psychologists. Beginning in July 2014 (the second (i.e., consumers); others came to the program based on year), community doctors offered non-scheduled “as the recommendation of community doctors. Each poten- needed” supervision which mainly depended on peers’ tial consumer was evaluated by the team psychiatrist, needs, while the clinical psychologists and psychiatrist of- using the following inclusion criteria: diagnosed with fered group supervision every six weeks. After they had ac- schizophrenia or bipolar disorder; age 18–60 years old; cumulated a year of experience, peers were able to prepare stable at least 3 months; no drug or alcohol abuse; and and organize session and training activities themselves; no severe medical illness. their credibility as service providers was well-established We recruited 12 peer providers and 50 consumers by among consumers. In addition, two social workers were in- 2016 (see Table 1). One peer in Tuanjiehu community volved in this program beginning in March 2016, and they quit in 2015, expressing concerns about too much pres- provided assistance before and after activities upon requests sure working as a peer. The caregivers of peers and con- by the peers. These social workers also participated in sumers were also recruited if they were willing to be group supervision. Along with face to face supervision, we contacted for the follow-up evaluation. Fifteen caregivers also provided online supervision. A WeChat group was Fan et al. BMC Psychiatry (2018) 18:170 Page 4 of 10 built which included peers, community doctors, social Service perceived benefit [9, 15] workers, clinical psychologists and psychiatrists. Feedback on the perceived impact of providing or re- An evaluation had been conducted among the peers, ceiving service was collected through brief structured consumers, and their caregivers from the first two com- face to face interviews conducted by a research assistant munities in December 2014, the evaluation concluded with peers, consumers as well as their caregivers. The the service satisfaction and effectiveness. peers and consumers were asked if organizing and par- ticipating in the service had any benefit to their im- Measures provement of skills or mood. The caregivers were also We examined implementation and feasibility of the asked if the peer support service could improve their community-based peer support service model for pa- own mood or quality of life. All the questions were sup- tients with SMI in China from five aspects – service posed to be answered with yes or no. process, service content, peer training and supervision, service satisfaction, and service perceived benefit. Data analysis All the forms as well as audio and literal records were Service process [32] recoded by three graduate students independently. De- Measures of service process included the number of ac- scriptive and inferential statistics analyses were used. tivities, frequency, average session time, and format of Continuous variables were reported as means ± SD and each activity. Peers were required to fill in a were tested for normality with the Shapiro-Wilk test. self-compiled form called “Activity Process Form” each Mean differences were tested by independent samples time after the service being provided. The form included t-tests. Discrete variables were reported as N’s and per- the date, start and end time of each activity, as well as centages. Chi-square tests were used to examine differ- the format of each activity. The forms had to be ences. Analyses were performed with SPSS 19.0 for well-preserved by each peer and submitted to the project Windows. manager every six weeks. Results Service content [33] Peer and consumer participants Measures of service content included the activity topics The numbers of peers and consumers enrolled in each and the proportion of each. These were also tested by community by year are shown in Table 1. There was a “Activity Process Form” which contained the aim and significant increase in consumers while non-significant theme of each activity as well as consumers’ feedback. It in peers. Demographic information pertaining to peers was also required to be filled in after each service and and consumers is shown in Table 2. The mean ages of submitted every six weeks. peers and consumers were 40.2 and 48.3, respectively. All peers and consumers were patients with SMI, most Peer training and supervision [9] of them were diagnosed with schizophrenia. There was Multi-background supervisor group was constituted by no significant difference between peers and consumers community doctors and professionals including psychia- apart from age, working status and diagnosis. Peers were trists, clinical psychologists and social workers. The younger, less likely to be unemployed than consumers, measures of peer training and supervision included the and less peers had diagnoses of schizophrenia. contents of issues identified which were summarized from the training schedule and textbooks, audio and lit- Service process eral supervision records. A total of 214 peer support sessions were delivered from July 2013 to June 2016. One peer session means that Service satisfaction [9, 18] peer met with consumers once and conduct activities or Semi-structured face to face interviews were con- support service in groups. There was no report of vio- ducted by a research assistant to measure the service lence, self-harm, or other potentially adverse events. The satisfaction from the perspectives of consumers and number of sessions for each community by every their caregivers. The consumers were asked if they 6-month period is shown in Fig. 1. The numbers among were satisfied with the peers and if they were willing different communities and time period yielded statistical to continue to participate in the peer support ser- significance (χ (15) = 48.75, p < 0.001). During the first vice. The caregivers were asked if they wanted the 6 months, only two communities developed peer sup- patients to continue to organize (for peers’ care- port services and the peers were not yet proficient in givers) or participate (for consumers’ caregivers) in running activities, which were organized about once the service. All the questions were supposed to be every one or two months. During the second year, ses- answered with yes or no. sions were delivered about once every two weeks in Fan et al. BMC Psychiatry (2018) 18:170 Page 5 of 10 Table 2 The demographic information of consumers and peers Characteristic Peers Consumers t test or χ test of difference N % N % Age (M ± SD) 40.2 ± 8.9 48.3 ± 8.2 t = −2.99, p = 0.004 Sex χ (1) = 2.37, p = 0.124 Male 8 66.7 21 42.0 Female 4 33.3 29 58.0 Education level χ (5) = 2.93, p = 0.711 Primary school 0 0 2 4.0 Junior high school 1 8.3 10 20.0 Senior high school 8 66.7 22 44.0 Junior college 1 8.3 8 16.0 Undergraduate degree 2 16.7 7 14.0 Postgraduate degree 0 0 1 2.0 Marital Status χ (3) = 1.32, p = 0.726 Single/never married 7 58.3 29 58.0 Married 4 33.3 11 22.0 Divorced 1 8.3 9 18.0 Widowed 0 0 1 2.0 Working status χ (1) = 5.53, p = 0.039 Yes (all part-time) 4 33.3 4 8.0 No 8 66.7 46 92.0 Diagnosis χ (1) = 10.61, p = 0.004 Schizophrenia 6 50.0 45 90.0 Bipolar Disorder 6 50.0 5 10.0 Fig. 1 The number of peer support activities in each communities by every 6 months Fan et al. BMC Psychiatry (2018) 18:170 Page 6 of 10 these two communities. During the first 6 months of 2015, one peer in Tuanjiehu quit and one peer in Maizidian asked for a temporary leave because of needing to assist his sick mother. In addition, Tuanjiehu had trouble in finding the service place because the old one could not be used anymore. Resulting in no session had been provided during this time period in Tuanjiehu com- munity. Beginning in August 2015, peer support services were started in another two communities. In 2015 and 2016, the session frequency differed among communities. It occurred once or twice each week in the first two com- munities, and once every two weeks in the newer two communities. The duration of each session ranged from 40 min to 120 min, depending on the activity theme and format for the session. The format of each activity varied depending on the topics, including group discussion, role play, personal sharing, lecture, and outdoor exercises. Most sessions were held in community rehabilitation cen- ters or community health care centers. Each session typic- ally involved at least two peers, with one leading and the other one assisting with service delivery, record keeping, and documenting consumers’ feedback. Fig. 2 The proportion of peer support activity categories Service contents On the basis of previous studies [34, 35], combining with the pre-service interviews, we summarized consumers’ Theprogram beganbypeerssharing therules of this ser- needs into eight categories: daily life skills, social interper- vice with those consumers who were referred or who sonal skills, knowledge of mental disorders, entertainment, responded to our posters. Each was asked to review and fine motor skill practice and exercise, personal perceptions sign an informed consent document as well as a service and such as self-esteem and self-confidence, healthy life style, group activity agreement before beginning the activities. and emotional support. The eight categories had been In addition, there were usually three parts for each ses- provided to peers before the initiation of peer support ses- sion. First, there were brief warm up activities, such as sions. Peers had freedom to choose which category and icebreaking games or setting-up exercises. The main ac- what specific contents they were going to afford. tivities relating to each topic then were initiated. At the Analyses of the service contents showed that each of end, peer providers or consumers would summarize the the eight categories had been addressed during the activity, followed by reciting a poem or singing a song three years’ service. Some of the session contents exam- together. Peers were required to complete documenta- ples are listed below: daily life skills study (e.g., cooking, tion for each session. Before one session’s activities, they how to use WeChat), social skills study (e.g., communi- planned and completed an “Activity Plan Form”. Upon cating with body language and facial expression, verbal completion of each session, peers completed the “Activ- communication skills), knowledge of mental disorders ity Process Form” and a “Participant List”. If any adverse (e.g., treatments for schizophrenia, recognizing disease event or behavioral emergency (e.g., poorly controlled recurrence, medications, side-effects), entertainment behavior, or problem that might require immediate at- (e.g., singing, watching movies), fine motor skill prac- tention) occurred during the session, peers were re- tice and exercises (e.g., handwriting, puzzles, physical quired to record the “Emergency Event Form” and to exercise), personal perceptions (building self-esteem submit this report to the community doctors. and self-confidence), healthy life style support (e.g., controlling your emotions, healthy diets), emotional Peer training and supervision support (e.g., sharing stories of childhood, building re- Pre-service training was provided for all peers. Training lationships with family members). The proportion of contents included the concept and theory of peer sup- each category is shown in Fig. 2.The topthree most port services, working principles and requirements (in- popular activity categories were fine motor skill prac- cluding confidentiality, boundaries, and relationships), tice and exercise (19%), daily life skills study (16%) and how to design and implement group activities, effective emotional support (15%). listening and speaking skills, how to handle emergency Fan et al. BMC Psychiatry (2018) 18:170 Page 7 of 10 situations, and how to complete the record forms. We de- Service perceived benefit veloped the training curriculum with reference of USA Service perceived benefit was only assessed among the and Australia experience [8], and integrated with extensive first two communities (Tuanjiehu & Maizidian). For discussion with potential peers during the pre-service in- peers, six (85.7%) (χ (1) = 3.57, p = 0.059) reported an terviews to better understand their knowledge and needs. improvement of working skills, four (57.1%) (χ (1) = The primary trainers were a psychiatrist and a clinical 0.14, p = 0.705) reported increase in social communica- psychologist. Pre-service training was completed in five tion skills. For consumers, ten (41.7%) (χ (1) = 0.05, p = half a day with six workshop sessions. The format in- 0.827) reported better social communication skills. For cluded coursework, group sharing and discussion, role caregivers, six (40%) (χ (1) = 1.67, p = 0.197) observed play, and storytelling. We also included the peers from patients’ increase of social communication skills, five our first two communities when we trained new peers in (33.3%) (χ (1) = 1.67, p = 0.197) found their own mood June 2015 for the second two communities. The former had been improved. shared their experiences and demonstrated how to con- duct activities as part of their presentations. Discussion With regard to the peer supervision during the whole The results of this evaluation suggest that peer support service course, while the supervision group initially func- services for persons with SMI are feasible and sustain- tioned to provide basic instruction and support related to able in China. The peer service has been in operation for conducting activities, the group subsequently focused three years, and the number of communities that devel- more upon addressing peers’ difficulties and feelings of oped peer support services has increased from two to once they had accumulated service experience. For ex- four with a significant increase of consumers. The ser- ample, some peers might feel frustrated when they did not vice has received positive evaluation and satisfaction achieve their service goals, or when they encountered con- from consumers and caregivers of both peers and con- sumers who did not listen carefully or seemed bored. sumers. Our experience can serve as a point of reference These experiences may undermine peers’ confidence, even for other areas of China where there is interest in devel- though they are related to factors other than the peers’ oping peer support services within their respective com- level of skill or experience. The overall aim of supervision munities. Although we did not establish a standardized was to build peers’ confidence as well as their work cap- model for the operation of peer support services, our acity, motivation, and self-satisfaction. work may provide a general framework upon which to In addition, face to face supervisions were supplemented build such services. with the online supervision. According to unstructured in- Several aspects of this framework are particularly import- terviews with peers and community doctors, online group ant early in the course of service development and imple- provided timely and efficient input to support both peer mentation. It is important to provide peers with extra help and service development. Whenever the peers experienced and support in figuring out the topic of activities and pre- challenging work situations, they could ask questions in the paring for peer support sessions at the beginning of service online WeChat group. This forum provided an opportunity delivery.It shouldberecognizedthatthe role of peersis for the professional staff to respond quickly, and it also pro- very new in China, the majority of them are lacking in ex- vided an opportunity for the other peers to express support perience and confidence. At the beginning of the project, and to give suggestions. The success of our online supervi- both the caregivers and community workers were worried sion prompted peers to build additional online peer support about the safety of service, they did not believe in peers. services. Now, three communities have their own WeChat Even the peers did not believe in themselves and they groups for peers and consumers in order to provide timely tended to avoid telling stories about themselves or sharing support for consumers. their own life experiences because of the perceived stigma and the unfamiliar environment. Therefore, we guided Service satisfaction peers to provide some entertainment or skill training activ- Service satisfaction evaluation was only conducted ities at first. It is helpful to identify community workers, among the first two communities (Tuanjiehu & such as doctors, nurses and social workers, who are willing Maizidian). Among the 24 consumers, three (12.5%) had to guide peers in preparing activity materials, and in provid- not been assessed because of personal issues. Nineteen ing on-site support as peers assume their new roles. The (79.2%) (χ (1) = 12.76, p < 0.001) were satisfied with the early availability of supportive health professionals serves to peers and 17 (70.8%) (χ (1) = 8.05, p = 0.005) expressed a alleviate stress that is commonly experienced by peers as strong desire to continue to participate in the service. they adopt the role of service provider. At the same time, it Among the 15 caregivers, 14 (93.3%) (χ (1) = 11.27, p = is important for community workers to give peers more au- 0.001) wanted the patients to continue to organize or tonomy as their proficiency increases. We came to under- participate in the service. stand, as well, that many community health workers, Fan et al. BMC Psychiatry (2018) 18:170 Page 8 of 10 including physicians, frequently have scant knowledge social workers, depending upon their local availability. about SMIs and their treatment, and about providing peer Pre-service training is particularly important for peers and support services. Mental health professionals should pro- community doctors in order to clearly understand their vide more guidance for community health workers from roles and job requirements, and also for obtaining the ne- the knowledge, skill training and supervision in helping cessary skills for providing services. The content of our peer providers. It should also be noted that the frequency pre-service training turned out to be consistent with the ex- of sessions was less during the first year in our first two perience in Hong Kong, which proved to be practical in communities. This slower initial pace allowed us to grad- non-Western context [36]. One of our peer program’snot- ually develop the necessary procedures and practices to able features is that we developed a group to provide super- support peer service provision. Our pace increased during vision, an unusual feature in China. Several community the third year period, especially as we opened a second set doctors and peers mentioned that the supervision group ef- of services and as the peers’ overall experience increased. In fectively provided support for them. As for the format of addition, after several months, the intimacy between peers supervision, we recommend combining both face-to-face and consumers also increased, then both the peers and and online formats. Face-to-face supervision is particularly community health workers became more positive about helpful for affective interactions, while online supervision is peer service. more timely and efficient. It is essential to clarify the role of “peer.” At the outset, Finally, we recommend having at least two peers for each peers reflected that they are patients too – that is, con- community, and to have both present at every session when sumers – and they initially expressed doubt that other possible. This level of peer staffing is particularly important consumers would trust and listen to them. Community for new programs. This team approach will better enable workers also commented that it was difficult for them to peers to monitor activities, and to adjust the peer role more decide how closely they should work with the peers in effectively. Peer partners can support each other in a timely providing support. Clear job descriptions and role clarifi- way before and after each session, discussing the plans and cation is necessary for both peers and community processes, sharing the job experiences, and identifying op- workers. We observed that the role of peer service pro- portunities for improvement in future support and training viders can vary according to the characteristics and needs activities. We received consistently positive feedback from of consumers and the activities planned for each session. peers and community doctors alike for having two peers These roles can include being a professional assistant, an working together by design. advocate, a supporter, and even a case manager. Despite There are some limitations in this study that need to this variability in roles, we found that their primary re- be addressed. First, according to the results, although sponsibility involved working as a role model and partner the service received positive evaluation and satisfaction in recovery for other consumers. As such, peer providers from consumers and caregivers, the perceived benefit should be prepared to provide emotional support, living still not significant. This may because some of the effect and social skills development, education, sharing of expe- have not been showed up by the evaluation or due to the riences, and encouragement. small sample size, future researches are needed to repli- We recommend offering a range of service topics as cate our study with larger sample size of peers, con- part of the peer training curriculum. In this project, sumers as well as their caregivers. Secondly, based on peers initially found it difficult to generate their own our experience, at the initiate of peer service, peers ideas for group activities, preferring that professionals tended to avoid telling stories about themselves or shar- would provide a list of topics. In the absence of such ing their own life experiences because of the perceived guidance from professionals, there is a risk that peer stigma and the unfamiliar environment. However, the providers could become somewhat overwhelmed and key idea of peer support service is that peer staff are demoralized. To minimize the risk, we recommend that trained to provide different services for which they are peers first consider carrying out activities that relate to especially well suited based on their own life experiences topics with which they are familiar. These can include and accumulated knowledge of how to live with a mental daily life skills (e.g., cooking), basic social skills (e.g., illness. So, although peers would adapt to their new roles introducing oneself), information about mental illness eventually, future research could find more effective (e.g., early warning signs of relapse), entertainment sug- ways to speed up this process. We have also conducted gestions (e.g., watching movies), and fine motor skill follow-up evaluations with quantitative combined with practice and exercises (e.g., Chinese calligraphy). qualitative measures among peers, consumers as well as It is important to provide specific training and continuing their caregivers in the four communities, the results will supervision for peers through the use of multidisciplinary be showed and discussed in another paper. Future re- groups, including psychiatrists, psychological therapists, search could also explore more long-term outcomes of community workers (especially primary care doctors), and peer support service in China. Fan et al. 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BMC PsychiatrySpringer Journals

Published: Jun 4, 2018

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