Applying lessons learned from public health crises to expand peer support specialists in youth mental health services

Abstract

COVID-19 exposed issues in our mental health system, prompting an emergency advisory from the Surgeon General on youth mental health. This Comment offers two lessons drawn from empirically supported aspects of a public health model to guide a transformation of youth mental health services: (1) the importance of recruiting local community members (peer support specialists [PSSs]) with lived experiences to promote engagement in services and (2) the necessity of expanding services to natural settings to enhance access and uptake. Examples of service models applying these lessons and illustrating how they are interrelated are provided. These initiatives are overdue in response to persistent disparities and the need to provide services across the prevention to intervention continuum.

The past four years has yielded an unparalleled focus on addressing and supporting youth mental health highlighted by the 2021 Surgeon General’s advisory calling attention to the long-standing national public health crisis of youth mental health¹. The advisory noted that these challenges are both treatable and preventable and called for widespread policy and service innovations. These concerns were exacerbated by the COVID-19 pandemic, which laid bare the inadequacies of the current mental health system for youth, and families. In truth, acknowledgement of the shortcomings of the mental health system date back more than five decades², including the failure to mitigate mental health stigma³, an insufficient focus on prevention and early intervention, and a lack of access to quality services¹. These problems are especially evident in communities impacted by poverty, given logistical and attitudinal barriers⁴. In addition, even with recent advances in telehealth⁵, a chronic shortage of licensed providers impedes access to quality services⁶.

The primary response to these issues has been a call for increased coordination across health sectors and increasing the number of mental health clinics and providers. However, even if fully enacted, these changes fail to address the social contexts that drive disparities such as stigma and structural inequities. We suggest that a more impactful approach that aligns with the Surgeon General’s call for innovation is to promote two interrelated empirically supported aspects of a public health model used to respond to COVID-19 and with a robust literature supporting their efficacy with youth and families: (1) employing community members with lived experiences as service providers⁴, and (2) basing services in community settings^7,8.

During COVID-19, residents recruited from highly impacted communities played an integral role in the public health response initially as “contact tracers” to inform residents of their risk and health status^9,10 and subsequently, when disparities in vaccine uptake across communities became apparent¹¹, as “health ambassadors” to promote mask-wearing and vaccine uptake^12,13. Another highlight of the public health response to COVID-19 was the widespread availability of the vaccines both through government subsidies to eliminate (and later reduce) costs to residents, and through their availability at easily accessible public facilities such as grocery store pharmacies, and workplaces¹⁴. These two initiatives aligned with recent advances in navigation and community outreach in public health^15–17, and the placement of health tools and services in community settings such as blood pressure cuffs in barber shops and domestic violence screening in beauty salons^7,8. In this commentary, we suggest that if concerns for youth mental health are sincere, then a similar level of resources and outreach are required consistent with effective public health campaigns. With COVID-19 still fresh in memory, we highlight research that supports these two interconnected elements of a public health campaign as especially applicable to address youth mental health.

Community members as allies: peer support specialists

Local community members with lived experiences, often called peer support specialists (PSSs), are optimally positioned to connect and build trust with youth and families and, in turn, reduce stigma and treatment disparities^4,18. PSSs are known by a variety of terms, including paraprofessionals, lay health workers (LHW), peer support specialists (PSSs), Family Partners and promotores de salud, amongst others. We use the PSS term to refer to individuals from the community with lived experiences who have no formal mental health training. Recognized as prominent members of health service teams^19,20, PSSs are unique in their capacity to empathize with clients through their shared lived experiences with the specific health issue, treatment, or community. Integrating PSSs into health teams is particularly important for marginalized communities who face a myriad of logistical and attitudinal barriers to accessing services given their shared lived experiences⁴.

PSSs have been widely deployed in global mental health, and their application in the U.S. is growing. In the U.S., PSSs have been effective members of mental health teams, specifically for stepped-care interventions, co-therapy, and case management⁴. They are also frequently recommended as ideal navigators for their ability to maximize rapport and provide a bridge to specialty services^21,22. In a study examining an early intervention program in urban schools, PSSs drew on their shared lived experiences to build rapport and a strong relationship with caregivers, and provide tangible support tailored to a caregiver’s context^23,24.

Mirroring the mobilization of community members as COVID-19 contact tracers and vaccine ambassadors^9,10, so too can a community-wide mobilization of adults and youth, including PSSs, support children’s well-being^20,25,26. For example, a home-visiting program for American Indian teen mothers led by PSSs led to greater parenting knowledge, lower drug use for mothers, and improved behavior for children²⁷. Similarly, in a program of research in high poverty urban communities^25,26, PSSs were essential members of social service teams to promote parent involvement in their child’s schooling and assist caregivers to address stigma and provide case management support to the child and family. Importantly, PSSs have Medicaid billing authority in many states²⁸, thereby providing a sustainable financial base. Given the advantages of PSS engagement in services, the lack of their wide-spread utilization in the U.S. mental health system is a missed opportunity for service reform¹⁸ (see Table 1 for examples).

Table 1.

Roles for a Peer-Support Specialist in a Public Health Framework of Mental Health Services

Level	Setting	Role	Examples
Universal	• School •Community Based Organization	• Liaison between family and school •Family advocate •Support engagement in school or community activities	Mehta et al. (2019) Lakind et al. (2019) Rusch et al. (2018) Gustafson et al. (2018)
Targeted	• School •Community Based Organization •Community Mental Health	• Liaison between family, school, and community-based organization (e.g., mental health team) •Client support during activities (e.g., classroom support) •Family advocate •Support engagement in school or organization activities (e.g., homework routines, classroom behavior; sports)	Atkins et al. (2015) Atkins et al. (2017)
Intensive	• Community Mental Health •Hospital health care system	• Liaison between family and health-care system •Support family skill building •Family advocate	Olin et al. (2010) Pollock et al. (2022)

Unpacking PSS impact: social networks and the role of relationships

A social network lens can help elucidate the mechanisms underlying the success of PSS-provided services and offer information on how integrating into a client’s social network can increase engagement in mental health promoting programs and services. We highlight two social network processes, social proximity and boundary spanning, to understand the success of PSSs in engaging families in mental health promoting services and to provide potential targets for intervention.

Social proximity

The shared experiences and perceived similarities to clients, described as social proximity²⁴, place PSSs in a nearly unique position to build trust with families and reduce negative attitudes and stigma²⁹. In the case of PSSs who are members of a mental health team, PSS endorsement of mental health services as acceptable and valued can influence client attitudes and increase the likelihood of trust of the system and adoption of services. For example, PSSs outreach to engage and sustain involvement in a school-based parenting intervention showed unique patterns of parental engagement and an increased number of parenting skills practiced across the school year³⁰.

Boundary spanning³¹

PSS providers have a unique capacity to act as a boundary spanner between families, service settings and other providers^23,26. Specifically, when employed by health care facilities, their dual alignment with the communities they serve and the health care setting allows them to connect these often-disparate worlds and thereby enhance the cultural competence of services³². Within this relationship, the PSS provides bridging social capital, which occurs when a client’s network allows them to connect with multiple otherwise disconnected groups (e.g., mental health providers, other organizations) to support their access to new and novel information^29,33.

Advancing these social network processes requires establishing collaborative working relationships between the PSS and members of the mental health or social service team, providing clear roles for each, and actively promoting engagement strategies to manage family disruptions and barriers to care^34,35. In addition, as described by Gustafson and Torres³⁶ several steps in research, policy, and practice are critical to effectively move these models forward. Key steps include the development of robust training and supervision models that provide ongoing support to address the complexity of supporting one’s peers; expanding reimbursement and payment models to ensure equitable compensation and stable employment; and academic–community partnerships that elevate PSSs’ perspectives throughout program development, implementation, and evaluation. In addition, it is important to monitor these processes to ensure that PSSs can access supervision and support critical for their role as respected team members with opportunities for career advancement.

Natural settings to support youth mental health

As noted, the response to COVID-19¹⁴ illustrated the value of expanding services beyond the health care system into community settings^7,8. When applied to youth mental health care, a commitment for prevention and early intervention services in neighborhood schools³⁷, after-school settings³⁸, and youth-serving community-based organizations³⁹, can decrease reliance on clinic-based services by promoting healthy youth development, catching problems early, and reserving specialty care for high-need cases. An additional advantage to these settings is the presence of key adults (e.g., teachers, coaches who often act as PSSs), to, in effect, expand the mental health workforce supporting youth with trusted members of the community^19,38. This also positions them to reduce stigma and support engagement in services¹⁸. Similar to the support provided to PSSs, non-health professionals can benefit from support provided by specialty mental health staff given high levels of stress and burnout³⁵.

A key component to expanding services into natural setting is integrating PSSs into these settings to build trust, bridge across systems, and expand the workforce^23–25. PSSs can implement services and act as boundary spanners in these settings, providing increased access to crucial information and services to underserved families^25,29. Below we provide examples of expanding care into natural settings, and the critical role of PSSs in this expansion to support healthy youth development and access to services.

Early intervention and coordination with community mental health

Perhaps most prominent in a public health approach is a focus on prevention and early intervention to reduce the need for more intensive care. The school-based intervention noted earlier²⁵ teamed social workers and PSSs from nearby community agencies with parents and teachers to support engagement in schooling for children with disruptive behaviors disorders. Evidence for the program’s effectiveness as an early intervention was high participation by families in services and increased academic engagement and social skills of children, with effect size estimates on mental health outcomes as high or higher than prominent evidence-based models²⁵.

Navigation to access care

We are currently studying a PSS-led model of service navigation to reduce disparities in accessing care among ethnic minority children experiencing urban poverty based on models with adults⁴⁰. In this model, PSSs provide both emotional support (e.g., empathy, acknowledging service system frustrations) and informational support (e.g., knowledge of social services and problem-solving barriers) to help families navigate the mental health and social service system. By connecting regularly with families through personalized contacts (e.g., texting, home visits, phone calls), PSSs can leverage their knowledge of local culture and context to support the initiation and ongoing engagement in mental health services^23,24.

Conclusion

The recent attention to persistent and pervasive mental health concerns for youth presents an urgent opportunity for substantial system changes¹. As noted by the Surgeon General in referring to the accelerating youth mental health crisis, “It would be a tragedy if we beat back one public health crisis only to allow another to grow in its place” (p.4)¹. In a dysfunctional mental health system such as exists in the U.S., more money and providers in isolation is an insufficient solution. While it is true that more specialty providers are needed to meet the needs of youth with high-acuity challenges, simply scaling the existing traditional mental health service model will fall short of addressing long-standing barriers and disparities in care⁴¹. We propose that for funding and workforce development to effectuate change, they must be paired with an approach that capitalizes upon existing community strengths through advancing PSSs role in services and embedding services in readily accessible non-health care settings. Using a social network lens, we highlight how social proximity (i.e., shared community membership) and boundary spanning (i.e., connecting otherwise disconnected groups of key members of marginalized communities) can build strong trusting relationships to advocate for and empower families, act as a bridge between disparate systems, enhance trust in existing services as needed, and provide essential support and resources for children and families across the spectrum of universal, targeted, and intensive services (Table 1).

We also propose that it is imperative that these teams move beyond siloed health care facilities and integrate services into familiar and accessible settings for youth and families. Specifically, mental health organizations and teams need to broaden their scope from a clinical service model (e.g., one-on-one sessions, groups) to supporting settings (e.g., schools) and setting goals (e.g., education) that are critical to positive youth development⁴². As we have reviewed, community members with lived experiences who are part of a health care team integrated into non-health settings can reduce persistent disparities in mental health care and provide support to youth in the settings most meaningful to their development. Further, this moves us toward a system that centers mental health promotion and wellness, values that are aligned with the assets and strengths of diverse communities.

We are not naïve to the difficulties of mental health reform given financial incentives to maintain a clinic-based model of care as the primary mental health service model⁴³. However, we are optimistic regarding the ability to effect these changes as they build on existing models that used billable Medicaid services, and is consistent with recommendations to broaden the scope of funding through Medicaid waivers⁴⁴. We are also acutely aware of the impact of current federal initiatives to restrict community services and public health. Perhaps, paradoxically, this can provide even greater incentive to combine efforts and work across systems on behalf of youth and families. If ever there was a time for bold change and reimagining health care to meet urgent needs, it is now.

Author contributions

T.G. and M.A. wrote the main manuscript text. E. G., D.R., and J.N provided substantive comments, text, and edits to the main document. All authors reviewed the manuscript.

Data availability

No datasets were generated or analysed during the current study.

Competing interests

The authors declare no competing interests.