Mental Health peer support workers

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For the first time in France, the pilot program "Médiateurs de santé / Pairs, MSP" (peer support workers in mental health) aimed to train and hire in mental health facilities people who have recovered from mental health illness. 

A first experiment was thus conducted in 2012 by the WHOCC, in 3 pilot regions, with 30 peer health mediators (see the detailed presentation of this experience below) who alternated training (with a university degree) and professional activity in a service of psychiatry.

In December 2017, a second experiment was initiated. A Bachelor of Health and Social Sciences mention "peer support workers in mental health" was thus launched by the University Bobigny Paris 13 and the WHOCC.

35 health-peer mediator positions were filled in 6 french regions in psychiatry public sectors, hospitals and social structures. 7 regional helth agency are involved. In 2020, this Bachelor keep going for the third time.

The first experimentation

Drawing on foreign experience, especially in Quebec, and adapted to the French context, this programme was designed to enhance the experiential knowledge and training of users of psychiatric services, to demonstrate the effectiveness of peer-support for people with mental disorders in France. The ambitions of the program were threefold: create a new function in the mental health care system, contribute to transform professional practices as well as occupational representations and cultures, and facilitate the recovery of both peer support workers and current patients.

Locations of the first experiment (2012):
Inter-regional: Ile-de-France, Nord Pas de Calais, Provence Alpes Côte d'Azur

Financial partnerships:
- National Solidarity Fund for Autonomy (CNSA)
- Regional health agencies (ARS) Nord-Pas-de-Calais, Ile-de-France and Provence-Alpes-Côte d'Azur
- Fondation de France

Methodological Partnership qualitative and quantitative external evaluations:

- Laboratory Clersé (Université Lille 1 / CNRS, Lille)
- Laboratory URC Eco

Activities


Individual support for peer support workers:
WHOCC via three delegates associated with the programme, maintained regular contact with all the teams throughout the experiment. Periodic visits on the 12 different premises began in the first trimester of 2012. WHOCC thus remained in constant contact with both the MSP with the teams, by phone or on locations, to prevent, reduce or solve any problems: specific missions between scheduled visits were organized if needs were expressed. This sustained monitoring continued beyond the first year of training and was still offered up until December2014.

The continuation of regional steering committees and inter-regional commitee:
These committees met three times a year until June 2014 and were led by representatives from each of the three Regional Health Agencies (ARS). Composition of these committees sought the participation of all regional actors (peer-support workers as well as various representative members of their teams). These meetings enabled to organize field players of the experiment to build common feedbacks and encouraged co-construction of the action as a research: many adjustments have indeed been made over the course of the first two years. A report of each meeting was automatically sent to all participants after a few weeks.

Regular meetings on exchanging best practices and sharing information of mutual interest
These groups had been established from the outset in the training modules. Best practices exchanges were introduced more regularly over the course of 2014. These exchanges gathered people involved and a project manager of WHOCC hired for this mission. Specifically, these meetings allow peer-support workers to present their different professional practices and to confront them with their peers’s own ways of working with patients. Those groups also made it possible to offer short training modules to peer-support workers: among the topics discussed at their special requests, an introduction to motivational counselling and group facilitation techniques presentations. These tools are presented in very practical ways, including suggestions for practical applications.

Counselling training
The possible involvement of peer support workers in the field of therapeutic patient education (TVE) became obvious as they moved on in their decision making positions. Patient education and counselling try to impact the patient's quality of life by tackling his/her relation to his/her illness, and stresses the importance of empowerment: the sense of personal competence, awareness and motivation to take action, and relations with one’s global environment. The existence of  peer support workers in mental health testifies of the possibility of recovery for patients with mental health problems. In May-June 2014, the WHO CC organized for peer support workers a 6-day training session in patient education/counselling. This training was provided by an authorized training organization and was designed in collaboration with the WHO CC  : it was to be centered on the theme of health mediation in the context of mental illness. This training enabled the acquisition of practical tools: interview models, group facilitation techniques, and formalization of data. During this training, peer support workers have also been working on efficient ways to engage in transmission of information with the members of their teams.

Experiential knowledge
It now seems important to theorize about what constitutes the specificity of health-peer mediator. Experiential knowledge is obviously plural and also comes depending on the personalities of mediators. The development work on this knowledge experience began in 2013 through a number of meetings of the mediators in all three regions and continued on 2014. They led to the emergence four specific areas

1. The absence of therapeutic distance
In the sense of the absence or reduction of the therapeutic range. Mediators say they are positioning themselves spontaneously accessible, near.

2. Bilingualism
The peer-support workers can both speak the language of health care as the patient and that it would ensure a translation assignment between the two languages. The MSP has somehow made profession of the disclosure of his illness and the affirmation of its ability to recovery and has developed a language for explaining the hazards and steps of this journey. He shares the daily care of patients with teams of other professionals while having been explicitly on the side of treated and brings a different perspective on behavior, actions or comments of patients.

3. The mutual identification
The peer-support workers’ job is to to say how he reached the stage of recovery and to testify and how it is possible to get to that stage. The patient with mental health issues, which actually means is a person who happens to be a patient at this point of his life, meets a peer in the support worker, while the peer support workers recognizes in this person fractions of who he was at some point and it’s this encounter that initially will initiate a unique dialogue.

4. Body of knowledges
Mental health peer support workers highlight the fact that patients do have a knowledge that evolves with time and growing experience, as any other professional, and it could be very wise to keep precise tracks of this particular body of knowledge : “when we are patient, we also learn to know ", explained one peer. Patients are not simply in denial (which, by the way, is also a form of "knowledge").The therapeutic alliance is built step by step within the process of this exchange of individual practices.
In this section of the global report, we will address the two evaluation studies carried out on the peer support workers program (PSW program).

Qualitative study evaluation of the PSW program carried out by the CLERSE team

Qualitative evaluation research was finalized and published in September 2014.
Lise Demailly, Claire BELART Catherine DéChamp Le Roux, Olivier Dembinski, Cyril Farnarier, Nadia Garnoussi Jeremiah Soulé, with the participation of Damien Cassan "A peer support workers  in mental health program : a controversial innovation”. Final Report of the qualitative evaluation research on the experimental program 2012-2014. September 2014 - Lille University CLERSE_CNRS. Scientific Officer: Lise Demailly

Report Outline

1st part:  history, objectives and specifics of the program
2nd part : overview and results

I- study premises and integration models
II- causes and outputs of MSP leaving their positions
III- practices and activities developed by the MSP
V- effects on  teams
VII- meetings between MSP and users

Third Part: suggestions for the future

Conclusions on assessment / suggestions

The experimental program peer support workers in mental health was a controversial initiative, ambitious in its in institutional break with the existing situation, which has demonstrated its feasibility (its ability to federate institutional and professional energy), its ability to generate within psychiatric services debates about diseases and treatments. She made actual progress in the development of social approaches in the context of a biopsychosocial care, and argued in favor of the role of access to employment in the mental health recovery. It stands out as a truly innovative program which was supported by an external research feature.

However, the program showed weaknesses concerning implementation modalities, which turned it on many levels into a somewhat costly and difficult operation. New modalities for the implementation of such a project in the future should be tested, and some recommendations have been drafted by the qualitative team.  The evaluative team does not advocate for a generalization of the program at this point but suggests continuing a research process on new areas of the countries. 

Several aspects remain unclear but will probably be clarified in the process: the mode of professionalization of PSW, their professional ethics and conduct orientation, their symbolic and practical position towards the psychiatric institution.

PSW program quantitative evaluation

Regarding this study, the data processing will be done by Urc Eco Ile de France. Data collection is done by the WHO CC.
The main objective is to assess the contribution of a follow-up lead by PSW for users, in levels of internalized stigma, quality of life and overall functioning. The secondary objective is to test the contribution of the OSW follow-up of users according to the diagnostic category (psychotic disorders / mood disorders / other disorders).
The study is based on the comparison of three groups over three different periods (T0, T6 and T12):
- Group 1: users who have not been followed up by a PSW before inclusion in research
- Group 2: Users followed in control areas
- Group 3: Users followed by PSW and for which this monitoring began before the start of the evaluation (by July 2013).

The PSW program as an experiment is completed and finalized since June 30, 2014.

The qualitative assessment is finalized and the report of the research team of CLERSE is available, but the quantitative assessment including the study called "STIGMA" required an extension until June 2015, mainly due to the delayed recruitment of project managers in the 3 regions, as well as to the low number of inclusions at baseline.

The table below shows the original timetable for STIGMA study and the updated schedule with regard to the need for an extension until the end of June 2015.

 

Initial implementation phases Calendar

New timetable envisaged

Outreach medical teams

1 to December 30, 2012

1 January 2013 - 30 June 2013

participants inclusion phase

January 2013 - June 30, 2013

July 1, 2013 - June 30, 2014

End of longitudinal follow-up phase

1 June 30, 2014

June 30, 2015 or July 30, 2015

Data analysis and report writing

July 2014 - April 2015

July 2015 - December 2015

Numbers of inclusions

Inclusion of users followed by a PSW from July 2013 (group 1)
Group 1 affects all users whose follow-up by a PSW started from as early as their inclusion in the quantitative research.
Distribution of effective inclusions in group 1 (November 2014):

 

T0

T6

T12

Eligible in theory

145

116

102 *

Refusal and missed appointment

28

35

4

Inclusions done

116

56

16

Estimated 06/2015

116

81

98


 * The estimated figure for T12 is higher than the T6 to be carried out taking into account the missed appointments, impossibilities to collect T6 for various reasons (not compatible mental health,  patient unreachable, appointments not honored, interruption of care, change of institution, patient not in the right district,  patient deceased).

 

Inclusion of users followed by a PSW before the start of the study (group 3)

Group 3 concerns all users whose follow-up by PSW began before the start of the study. Inclusion in this group implied an identification of eligible users, to be able to organize information channels and following inclusions in the research.
Distribution of effective inclusions in group 3 (November 2014):

 

Population included users after 6 months of follow-up
(T6 / T12)

 Population included users after 12 months of follow-up (T12)

Eligible in theory

134

128

Refusal and missed appointment

75 T6 / 24 T12

70

Inclusions done nov 2014

22 T6 / 10 T12

22

Estimated

59 T6 / 110 T12

58 T12

Inclusion of users treated in control districts (group 2)

Group 2 concerns all users treated in areas not working with PSW :  9 institutions agreed to participate in the study as control sites. These institutions are located within the four regions of the PSW program (2 in Nord-Pas-de-Calais and 2 in Ile-de-France). Inclusions began in 8 schools. To date, 249 users were included in this group.

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