Strategies and Lessons Learned for Supporting and Supervising Peer Specialists

Abstract

As peer-delivered services are increasingly embedded within behavioral health organizations, there is a need to identify practices that facilitate supervision and support of peer providers. We present supervision strategies and lessons learned that emerged during a large pragmatic trial in three supportive housing agencies that examined a peer-delivered healthy lifestyle intervention for people with serious mental illness. Strategies included access to multiple supervisors, formal and informal support, acknowledgement of lack of role clarity, on-going role negotiation, a collaborative approach to troubleshooting challenges, explicit emphasis on peer specialists’ value, and linking peer specialists to opportunities for mutual support and professional development.

Introduction

Peer specialists in mental health have rapidly increased into a workforce of over 30,000 individuals across the United States (1). Peer specialists are individuals who self-identify as having a mental illness and/or as recipients of mental health services who use their personal experience of recovery, often combined with specialized training, to support others (1, 2). Studies have demonstrated the effectiveness of peer-delivered services, finding improved outcomes for both the people they support and peer specialists themselves (2, 3). However, significant challenges persist as peer specialists navigate organizational and workforce contexts, including role confusion, lack of supervision, limited professional development, and peer specialist roles not being perceived as integral to, and valued within, organizations (2–5). As peer specialist roles become increasingly ubiquitous, organizations need to address these key areas to better support the work of peer providers.

This column aims to expand our understanding of supervision strategies that can improve the support available to peer providers embedded in mainstream behavioral health service settings. We report strategies used as part of a pragmatic trial evaluating the effectiveness and implementation of a peer-led healthy lifestyle intervention for people with serious mental illness in three supportive housing agencies across two states (6). We identified these practices through semi-structured qualitative interviews with the study’s four peer specialists and five supervisors, as well as on-going discussions reflecting on our collective experiences working with and supporting peer specialists over four years. We describe the project context and structure and discuss how specific strategies facilitated 1) role clarity, 2) supervisor responsiveness and flexibility, 3) peer value and input, and 4) peer staff development.

Project Context: Partnership, Intervention, Peer Specialists, and Supervisory Structure

The project was conducted collaboratively by a university research team and three supportive housing agencies that served as the community sites, operating in two states. The partnership between the agencies and research team focused on co-learning, community capacity building, and team building. An implementation study phase prior to the clinical trial allowed the research team to explore and understand each supportive housing agency’s context (including experience with peer-delivered services), build staff buy-in, identify stakeholder roles, and develop a communication infrastructure and operating procedures tailored to each agency. This also allowed agencies’ to become familiar with the strengths and potential challenges of working with an external research team. To build community capacity, the project embedded resources within the supportive housing agencies, including staffing, training, and funding. All peer specialists delivering the project intervention, along with several research assistants, were employed by their respective supportive housing agency, paid for by grant funding, trained by the research team, and jointly supervised. The project also engaged in team building across all partners by having frequent meetings, troubleshooting challenges while also sharing success stories, and having project retreats. The project sustained a focus on co-learning throughout, utilizing an iterative approach to intervention adaptation and peer supervision that combined the input of all partners, as well as having partners identify and participate in dissemination activities and initiate new collaborations (e.g., applying for new grants).

As part of the pragmatic trial, peer specialists delivered the Peer-Led Group Lifestyle Balance (PGLB), a 22-session, year-long manualized intervention, adapted from the Diabetes Prevention Program that aims to help people achieve weight loss through improvements in diet and physical activity (7). Peer specialists hired for the project were certified in peer-delivered services within their state, had a diagnosis of serious mental illness (e.g., schizophrenia, bipolar disorder) and, though not required, had personal experience with chronic health conditions or challenges with weight, which they shared extensively when working with participants (8). Peer specialists completed a two-day GLB certification training followed by additional training consisting of individual session coaching (e.g., group facilitation skills), applying intervention concepts in their own lives (e.g., healthy food substitutions), and conducting mock sessions (9). Peer specialists delivered individual and group sessions in participants’ residences and/or supportive housing agency offices, recorded participant attendance and weight, provided feedback on participants’ food logs, completed agency documentation (e.g., progress notes), and helped participants access other staff for non-PGLB services (e.g., housing, budgeting support).

Peer specialists received support and supervision from the research team and the supportive housing agency where they were employed. All supervisors were non-peers and had backgrounds in social work, psychology, or medicine, and had prior experience working alongside peer specialists. Weekly structured supervision with research supervisors focused on PGLB content (e.g., session fidelity), group facilitation, attendance/scheduling, participant progress, and research documentation. At least monthly structured supervision with supportive housing agency supervisors focused on participant interactions and care coordination, workplace integration, agency documentation, and support with self-care (e.g., reminders to use vacation time). Research and agency supervisors conducted joint weekly calls with peer specialists to troubleshoot participant engagement, assist with job skill development (e.g., managing schedules), clarify roles and navigate agency and research team contexts. Informal supervision occurred spontaneously via phone/text and was generally initiated by peer specialists, who were highly mobile and frequently working at sites not co-located with supervisors.

Support & Supervision Strategies

Role Clarity

While peer specialists were specifically hired to deliver PGLB, challenges still arose regarding role clarity and responsibilities. These included the degree to which and how peer specialists should address participants’ non-healthy lifestyle needs, balancing intervention fidelity with peer specialists’ judgement, and the relative importance of documentation tasks. Strategies adopted to address these challenges included having supervisors explicitly acknowledge and take responsibility for lack of clarity, making role negotiation an on-going discussion in supervision, and having supervisors not only assign tasks, but explicitly explain the rationale behind them. Supervisors acknowledged that adjustments to responsibilities and processes made it feel like supervisors and project staff were “building the plane while flying it,” validating frustrations associated with such an approach. While supervisors and peer specialists developed working guidelines, it was agreed that peer specialists had the expertise to make decisions on a case-by-case basis; for example, when participant stressful life events (e.g., death of family member, substance use relapse) needed to take precedence over PGLB material or group dynamics limited coverage of session content. Finally, explaining the rationale behind certain responsibilities, particularly documentation (e.g., tracking contact with participants), helped make connections between the systematic reporting of information, identification of service delivery challenges, and potential adaptations. Altogether, these strategies helped build a shared understanding of fundamental project and participant goals among supervisors and peer specialists, reducing tension regarding role clarity and allowing for nuanced discussion of how and when things would be accomplished without losing focus on an individualized and holistic approach.

Supervisor Responsiveness and Flexibility

Given that peer specialists often report feeling unsupported or receiving inadequate supervision, the project sought to facilitate access to supervisors who could provide responsive and flexible support. Strategies included having multiple supervisors and meetings, using both formal and informal approaches. While having multiple supervisors can be challenging, this strategy increased responsiveness to peer specialists’ concerns, exposed peer specialists to multiple perspectives, and provided them with intermediary support for challenges on the research or agency side. Joint supervision calls reconciled potential conflicting information or requests and bolstered a shared understanding of context and goals. Though multiple meetings required time and coordination, it ensured that peer specialists’ or supervisors’ concerns were addressed in a timely manner. While formal meetings were key, informal support offered peer specialists immediate moral and social support as they experienced challenges during the course of their day or shared successes. This informal support also provided supervisors with opportunities to better understand peer specialists’ daily work and contributed to an overall sense of teamwork.

Peer Value and Input

To guard against the common challenge of peer specialists being undervalued and not treated as equal partners and colleagues, supervisors created space for and encouraged peer input and feedback. Additionally, supervisors sought to assuage peer specialists’ hesitation to share negative feedback by framing it away from potentially reflecting negatively on peer specialists’ performance towards presenting an opportunity to change a problematic practice. A collaborative approach to problem-solving sought to convey supervisors’ willingness to not only hear about challenges, but to address them as a team with peer specialists (e.g., peer specialist calling attention to the availability of unhealthy snacks at a residence). Supervisors also highlighted each peer specialists’ specific skills and successful engagement with participants, using statements such as “I trust your judgment” to convey confidence and belief in peer specialists, particularly when they felt disheartened (e.g., low session attendance). Altogether, this fostered working relationships that conveyed an open, non-judgmental stance, and acknowledgement and responsiveness to peer specialists’ input and contributions.

Peer Professional Development

Given that peer workforce challenges include few opportunities for professional growth, the project created opportunities for peer specialists to expand their knowledge and skills, and also make broader contributions to the project and field. Peer specialists led the development of formal intervention adaptations, facilitated Community of Practice calls (i.e., monthly mutual learning exchanges among project staff), and attended and presented at conferences and trainings. Intervention adaptation relied on a peer specialist identifying session problem areas and initiating deliberation of changes, while a supervisor assisted with operationalizing and documenting adaptations. Community of Practice calls, led by each peer specialist on a rotating basis, were initiated upon recognition that supervisors led all other agendas and formal meetings. For these calls, one peer specialist led agenda development, in consultation with the others, and facilitated the meeting. Supervisors’ roles were limited to logistical support and tips on agenda development, as well as responding to requests for input during the call. These calls helped peer specialists connect with each other regarding their experience of supporting PGLB participants, normalize challenges, share resources, and discuss managing their own wellness. Peer specialists also initiated informal mutual support calls that were solely attended by them. Finally, peer specialists attended conferences and additional trainings, and with supervisor support, developed and presented a presentation of their PGLB work at a peer conference. These experiences provided peer specialists with platforms to develop new areas of competency, access mutual support, assume leadership roles, share their expertise to influence practice, and network.

Discussion

This column described supervision strategies that helped support peer providers embedded within traditional behavioral health settings. While these strategies emerged in the context of a pragmatic trial, lessons can be applied more broadly since they address critical challenges facing the peer workforce. Strategies included having access to multiple supervisors, offering frequent formal and informal support, acknowledging lack of role clarity and cultivating space for on-going role negotiation, a collaborative approach to troubleshooting challenges and adaptations, explicit emphasis on peer specialists’ value and contributions, and linking peer specialists to opportunities for mutual support, leadership, and professional development. These strategies may have contributed to peer specialists’ reporting feeling included in decision-making, having their roles valued and taken seriously, and high rates of staff retention, with all four peer specialists who had begun delivering the intervention remaining on the project for at least three years. These strategies also benefitted supervisors, who described how the peer specialists had positively influenced their own practice. They noted having developed greater awareness of inequitable power dynamics with service users, having greater humility and appreciation of challenges in peer specialists’ and service users’ lives, wanting to incorporate attributes that peer specialists exhibited in their daily work (e.g., patience, enthusiasm), and using more self-disclosure.

Nevertheless, some challenges remained. Peer specialists tended to operate in organizational silos and few strategies had been implemented to better embed them within other agency staff, services, and support structures. Greater integration may have been facilitated by, for example, supervisors helping to develop other staff at residential and program sites to serve as peer specialists’ allies or champions “locally.” Supervisors also found it challenging to appropriately balance direction with latitude, wanting to provide peer specialists sufficient guidance and support, but not wanting to “be in their way” and stifle their approach. Related, peer specialists would have benefitted from having the support of at least one supervisor who was also a peer. Such staff could offer more nuanced advice on peer specialists’ sharing of experiences with participants as well as navigating being a group facilitator/PGLB content expert while not creating a hierarchy with participants. Nevertheless, given non-peer supervisors, mainstream mental health settings, and a manualized intervention, previous reports have noted practices that helped combat drift from a peer-led focus, so that peers’ strengths and contributions could be preserved (9). As the peer workforce grows, there is a need to develop and disseminate evidence-based approaches for supporting and supervising peer specialists. Lessons learned and strategies discussed in this column suggest key areas that can be further explored and targeted for development to advance the reach, impact, and value of peer specialists in behavioral health organizations.

Highlights.

• Peer specialists are increasingly part of the workforce of behavioral health organizations.

• Challenges persist with organizations being able to provide adequate support and supervision for peer specialists.

• Supervision practices can be implemented to bolster role clarity, supervisor responsiveness and flexibility, peer value and input, and peer professional development.