Why We Hire Peer Specialists For Housing First Programs
By Sam Tsemberis, Ph.D.
CEO Pathways Housing First
James Zenner, LCSW
Supervisor and Peer Support Specialist
The purpose of this module is to provide information about the roles and services of the peer specialists on Housing First teams. After reading this module you will be able to answer the following questions:
- What qualifies one as a peer specialist?
- What is the role of peer specialists on Housing First teams?
- What kind of training and supervision do peers require?
- How do peers complement the knowledge and services of HF teams? and
- What is the role of peers in supporting community integration?
The terms peers, peer specialist, peer support, peer support worker, and people with lived experience are used interchangeably throughout the module.
There are many reasons for hiring paid staff as peer support to be members of Housing First teams and they are not just limited to the treatment of addiction and mental health services.
In mental health services, the history of hiring peer support goes back to the 1800’s and the origins of psychiatry when hiring “recovered patients” was considered an essential component of “moral treatment” (Weiner, 1979). There was a surge of hiring in the 1920’s, at the beginning of era of inpatient milieu therapy. During this time, a major proponent of hiring peers was the psychiatrist Harry Stack Sullivan, who relied heavily on peer support staff for his milieu therapy programs because they served as excellent role models (Davidson et al., 2018).
The Housing First program also has its origins in a profound commitment to peer support. The program was developed out of a consumer directed drop-in center where half the staff was comprised of peer support (Tsemberis et al., 2005). There were several reasons for hiring people with lived experience: the program valued direct input from program participants, it fostered strong engagement and empathy skills, and it ensured the inclusion of the consumer perspective in program design and governance. Hiring peer support staff was also intended to reduce the boundaries between professional staff and program participants. Finally, hiring peer specialists created a third sector in the drop-in center community—a body of participants with a perspective and a unique voice. Peer support staff could interpret the participants’ experiences for the professional staff and explain the intentions of professional staff to the participants, simultaneously serving as role models for both groups (Tsemberis, 2015).
Peer specialists or peer support staff are individuals who, at one point, overcame a combination of obstacles or transitions in which they needed to obtain assistance and treatment to engage in personal recovery or to reintegrate back into normative social roles. Examples of such obstacles faced by individuals with lived experience or peer supports include: mental health problems, problematic substance use or abuse, incarceration, homelessness, domestic violence, physical or sexual abuse, stigma, and fear of persecution. This is not an exhaustive list as there are other traumatic events that may also be included. These are some of the conditions and challenges of what can be considered as part of one’s recovery or reintegration story.
Housing First programs should include paid staff employed as peer specialist as one of the members of the support services team. The peer specialist or peer support worker should have personal experience in having sought assistance in overcoming their obstacles and is currently in recovery from substance use, mental health problems, homelessness, or has overcome other obstacles for a period of at least one year. Those who are early in their recovery or transition should be actively seeking assistance and support due to the nature of peer support work.
It is recommended that peer support workers employed as paid staff should have completed a period of time “in recovery.” The nature of the support services provided and the content of the interactions with clients places the peer specialist very close to the very situations they were dealing with and requires peers to have a strong grounding in the skills, coping mechanisms, information, or treatments that they have used or continue to use in their recovery.
Peers can play a crucial role in helping HF teams to provide treatment and support services in a manner that is grounded in recovery principles. When working with individuals who have experienced long periods of homelessness (chronically homeless), it is often the peer support worker who can best relate to the client’s experience, and by demonstrating this understanding to the client, is able to earn the client’s trust to a profound degree.
Peer support staff understand how clients feel after they are housed and what it’s like adjusting to a new home and a new community. Peers can offer practical help with basic needs and everyday living, such as finding the right grocery store or laundromat. Providing this meaningful and practical assistance with day-to-day struggles and offering effective and sustained support is the basis of a caring and trusting relationship, and hopefully serves as a model for developing other relationships.
From the perspective of the individual experiencing homelessness, the traditional outreach offered by the formal helping professional may be perceived as “the employee is doing their job.” The person understands that this is an employee of an agency who is paid to provide a service. These employees operate in a formal and professional manner. They are bound by agency rules of conduct, agency policies and procedures, professional standards of ethics and conduct that determine what they can or cannot say to clients and how to intervene and how not to intervene. These professional and agency norms can create a certain “professional distance” and may be subtle barriers to connecting with individuals who have shunned or are mistrustful of “the system.”
The formal rules of conduct are essential in mental health and addiction treatment because the standards defining professional conduct also determine agency policies in matters of boundaries and keeping their employees and clients safe. However, to not recognize and acknowledge that these rules and professional boundaries are also barriers to informal and therapeutic connection will likely prevent these professionals from authentically connecting with those they serve. These barriers cannot be overcome unless their existence is acknowledged.
The role of peers is to expand and complement the capability of the teams support services. Peers are often willing and able to work with a flexibility that is beyond the traditional definition of services and service hours. It is not unusual for peer support workers to be more attuned to the needs of the people they are serving and less to how agency policy or procedures serve a purpose. This can become a source of conflict about agency policies, labor practices, liability, and questions of boundaries and ethics about what is defined as appropriate caring for clients.
Agency and professional barriers limiting the role of peer support
An example of how the work of a peer support worker can challenge team and agency practices:
The peer support worker saw a client served by the HF team on the weekend because the client wasn’t home during the regular 9 to 5 team hours. The agency had a policy against seeing clients outside work hours. The policy was to ask clients to call the local municipal crisis line. The client called the peer on her mobile phone and stated that he was having thoughts of killing himself. The peer spoke to the client on the phone for a while and the client was calmer but asked the peer to meet for a coffee to discuss what had triggered the crisis. The peer agreed.
When the peer reported this exchange during the team meeting on Monday the team leader had a startled and somewhat emotional reaction. He reminded the peer of the agency policy regarding after hours calls – use the crisis number. He informed her that he doesn’t want her visiting clients on the weekend because he was uncertain about what that meant about boundary issues and even less sure what it meant about overtime pay. The peer had not thought of getting paid or their time card. The peer was instructed that in the future to please advise the client to call emergency services or take themselves to the emergency room.
This example illustrates the point that it is not sufficient to simply hire peer support staff and then follow the same format for the team’s and agency’s support services policy. Agency policies must also be adapted to support the work of peer support which expands and extends traditional services. The team and the agency must modify or adopt policies and procedures to allow for the flexibility that peer support services can provide so that the work of peers can be better aligned with the needs of clients.
The reason that it is recommended that peer support specialists be integrated into the Housing First support services team is exactly because they can provide other types of support and services. They can provide other team members with insights about the needs for support from the service recipients’ perspective and thereby improve the quality of care provided by the team. The peer can provide team members with insight into the experience of being homeless, being evicted, feeling suicidal, and managing day-to-day life while in the throes of all that turmoil. Peers can also assist the team in problem solving obstacles to engage clients, especially those that distance themselves from traditional treatment providers
Properly integrated peer support can assist the team with providing a consumer lens to a trauma-informed approach. During team meetings and case conferencing, peer specialists can help raise awareness by pointing out how stigma, fear, and professional bias interferes with seeing the client clearly. There may be socioeconomic, educational, and ethno-racial differences between team members and the clients served and the peer may be able to offer some sensitivity in noting these differences. Additionally, the peer’s presence and participation in the ordinary chores of team work serves every day as a powerful reminder to both team members and clients that recovery is possible.
Peer support specialists should be trained and certified in their specialty. In addition, they should receive the core training about Housing First like every other team member. Training must also focus on issues of maintaining boundaries in the contexts of engagement and building authentic and trusting relationships with clients. Special attention should be given to how best to disclose that they have direct lived experience as well as experience as a recipient of services.
Peer support specialists should be trained to develop and learn how to use their own “recovery story”. No two recovery stories are the same despite many similarities that have a connective and relatable quality that makes its use effective.
The recovery story begins with a peer’s difficult times including the moment they felt most hopeless. During the certification process, trainers work to teach the peer specialist that the “hopeless place” is not a place to spend a lot of time but tell just enough of the story to demonstrate to those they are working with that they have been in their place and understand where they are. Most of the recovery story should be spent discussing how peers overcame their issues, how they tapped into their own strengths, and about the skills they had to develop, etc. It is not advice giving but is more rooted in modeling and relatability.
Agency support needed when hiring peers
Employing and maintaining peer support staff can be a time-consuming task. Organizations who have not employed peer support in the past sometimes struggle with developing policies to address the kind of accommodations needed to successfully hire and support peers in order to retain them. Hiring previous consumers or current consumers of an organization’s services is one common practice for recovery-oriented organizations. There are advantages and disadvantages to this approach.
Another area to be cognizant of is that an agency may hire peers but may not have someone who has experience supervising and supporting peers. Peer support is an entirely different discipline which requires different knowledge and skills. Traditional social service providers must recognize peer support as a discipline requiring special supervision and support.
Many problems can be prevented by hiring a supervisor with experience with peers and an understanding of the role of peer support. Such a supervisor will avoid the all too common pitfall of allowing clinical staff to use the peer specialist as assistant case managers or assistants to the case managers. This is when peers are delegated the bulk of the team’s practical chores such as transporting clients, searching for apartments to rent, assisting with moving in or moving out, and other mundane tasks.
If such practices are allowed by the team leader, the peer support workers can begin to feel like they are subordinate to other staff members and this can diminish the positive impact of their “peer approach” for the team and the clients. Peers may be vulnerable to adopting a more subservient, less effective role. This kind of negative team culture can also create conflict for the team.
There is an important observation to be made about performing a task with a client, completing that task, and the experience of the client and the staff member in the process of completing the task. A common example that can be used to illustrate this point is helping clients in navigating the system to obtain documentation, identification, and other requirements to apply for housing or benefits. Regular staff who assist clients through this process may complain about waiting times at social services and the myriad of barriers encountered through the process. Peer specialists who have first-hand experience with these chores understand that it is important to get the task done but may see opportunities to use the waiting time differently. They are more likely to remain with clients and aim to reduce the client’s frustration with waiting by engaging in conversations about likes and dislikes in music, sports teams, meals to cook, or get a better sense of extended family. The point is that peer supports may provide a different quality of experience doing the very same task. This provides a qualitatively different experience for the client.
Supervising peer support workers requires an approach that is grounded in positive reinforcement and accountability. It also requires supervisors to be more available for informal feedback and to provide support to the peer outside of structured supervision times. Feedback should be more personal and address the barriers and challenges faced by the peer in the workplace. It is useful to focus on what the peer specialist sees as barriers.
When discussing challenges in supervision with peers, it is very common to hear that their role is commonly misunderstood and that pieces of what they do are considered “boundary violations.” This is largely because most peers are supervised by clinicians who use the same guidelines with both traditional clinical services staff and peer support specialists—this is an often-occurring mistake.
Finally, with peer specialists there is a need for ongoing training and supervision on issues of boundaries, confidentiality, and self-care as those are typically the areas most in need of continual refreshers and education.
Peer support working in a Housing First program should have training, and if available, receive a certification in peer support work. Obtaining certification usually requires attending classes, participating in role-plays, one-on-one support, group facilitation, and ideally a field placement working directly with a multidisciplinary intensive case management (ICM) or assertive community treatment (ACT) teams or some other version of case management teams. Training should include modules on integrated dual diagnosis treatment, motivational interviewing, trauma informed care and person-centered planning to provide peers with the language and knowledge that are the core practices of their fellow teammates and their HF team. Peer specialist training should also include guidelines about peer specialists’ scope of practice, ethics, how to tell one’s recovery story, and many other related topics. This comprehensive training will help peers obtain the skills and knowledge necessary to begin employment and set the foundation for them to develop their professional identity and their own approach of how they will serve as peer supports.
In instances where the community does not have a peer training program there are online educational modules. It is also possible to hire peers and train them on the job. This will require more effort from the supervisor and team members, but the rewards are well worth the effort.
Most Housing First support services, whether they are comprised of ICM, ACT or case management, operate as teams. Team meetings are excellent opportunities for each team member to articulate their point of view about each client. The team meeting is an excellent forum for the team and the peer to educate each other about the unique perspectives of their clients’ issues. A well-supervised team meeting can also reinforce the unique role of each team member including the peer specialist.
Providing Housing First support services is difficult work. There is a high industry-wide turnover rate and how to avoid burnout is a regular topic of discussion. In this regard, the use of teambuilding events on a regular basis (such as hosting a lunch or potluck for all staff born that month, going to a game, going bowling or participating in other social or recreational activities) can provide a break from the intensity and exhaustion of the week’s work and help staff members connect with each other outside of client care to mitigate stress, strengthen team cohesion, and establish mutual support.
Peers working in Housing First are highly effective with outreach, being able to work with a person who is still homeless to resolve some of the ambivalence of getting off the street. Peers are often excellent in times of crisis and in developing rapport and trust at the client’s low point. Once clients are housed, the rapport can help a peer support intervene and influence a person to consider and make healthier lifestyle decisions either by directly discussing troublesome behavior or indirectly by serving as a recovery role model.
Research on the effectiveness of peer support: how and why it works
This section provides a brief review of several studies on the effectiveness of peer support and the ways in which peer support operates in conjunction with traditional treatment. It expands the scope of peer support to include findings for the effectiveness of peer support for other chronic illnesses.
In a recent article by Davidson and colleagues (2018) numerous studies were reviewed on the effectiveness of peer support. That article cited a report by the Institute of Medicine that examined several studies on the use of peer support in a wide range of illnesses and chronic conditions such as asthma, cancer, diabetes, obesity, hypertension and others. The report, citing further evidence from the World Health Organization, concludes that peer support should be promoted as, “a key part of health, health care, and prevention around the world” (Institute of Medicine, 2012).
Taken together, these studies provide insights into exactly how peer support works and why it is effective.
- Role definition and time and effort: Persons with chronic illnesses spend about 6 hours every year in a health professional’s office, while spending the remaining 8,760 hours of the year living with and trying to manage their health conditions (Davidson et al., 2018). In psychiatry, this ratio is likely much less. Whether it is diabetes or mental illness, helping someone to live well with a serious illness is different from treating the illness, and it takes a different investment of time and effort. Simply put, people living with serious mental health conditions need more assistance and support than can be provided by mental health or health professionals alone (Fischer et al., 2018). Peers can assist participants with all manners of conditions, to engage in self-care, and to navigate complex health systems.
- I’ve walked in your shoes: Peer support works to engage persons with mental illnesses to establish meaningful lives and to understand the challenges of prejudice and stigma associated with mental illness. There are also the stigmatizing current conditions or histories of homelessness, incarceration, and hospitalization that are often barriers to program participants receiving welcoming and respectful receptions by providers, their community, or people they seek out to socialize. Because peer support workers have walked in their shoes, they are especially expert in establishing and maintaining caring and meaningful relationships with program participants. And since peers have made some gains in successfully integrating back into community after overcoming similar challenges, peers can provide the support and skills needed for reconnecting with families or others in the community.
- Shifting the focus from illness to wellness: Peer support workers can provide valuable firsthand experience and knowledge to assist those with similar conditions in managing their own health. The focus of peer support is shifted away from the illness and treatment to health promotion and well-being. In another context this would be considered a form of “strengths-based” case management. Peer support works with program participants to develop a lifestyle that is functional and satisfying. This broadens the focus of support beyond symptom reduction and symptom management to improvement in quality of life. Peer support can also include group peer support: evidence has consistently found that support groups are beneficial for addressing a variety of chronic illnesses—especially groups related to maintaining self-management regimens.
- Expanding and complimenting treatment: Peers are not a substitute for treatment or traditional services, but rather are a complement to these services. Peer support can be provided directly with face-to-face contact or remotely by telephone, text, or email. Peers provide the follow up support that accompanies treatment and encourages maintaining medication and treatment compliance, learning to read and self-monitor symptoms, identifying and avoiding triggers, and coping with other challenges. Peers are integral members that complement and expand the scope of services provided by the support services team.
- Peer support as social support: Social support has been demonstrated to be a protective factor of health, where social isolation—which may be a consequence for persons living with complex chronic illness— can significantly worsen a person’s condition. Peer support (both individual and group) can serve an important role in providing social support and improving outcomes. In many instances program participants have lost contact with families and they have few if any social supports. Some of the participants’ network members may still be homeless, and thus ties have been severed after the person is housed. With few or no other supports, the role of the peer and other team members is vitally important, especially in the early months and first year after exiting homelessness.
- Peer support and recovery: Peers provide positive role models for self-management of similar clinical conditions and challenges. Recovery requires active participation from participants and some degree of active mastery over chronic conditions. Peer support is collegial, interactive, and participatory. The interactive and mutual support dimension of peer support relationships can serve as an essential building block to develop the confidence needed for self-management and recovery.
After someone is housed, is where the role of the peer really expands. Peers are excellent at community integration work. If recruited with prior homelessness experience as a requirement, peer support know firsthand the significance of the transition from streets to housing and what that transition is like. Peers can help clients (and fellow team members) manage expectations about how much and how quickly life changes after housing and also help clients to develop the life skills needed for successful tenancy. Peers can address needs for socialization and support during that critical period of 6-12 months after a person is housed in order to prevent them from falling out of housing.
Many things that most people take for granted (how to order one of the new coffees, going to a movie, getting a library card, using the new machines at the laundromat, how to research questions on the internet, etc.) peers do not take for granted because they have faced these challenges themselves. They can be more attuned and know where to take the conversation around exploring new social activities, hobbies, and opportunities that provide a sense of purpose and belonging to one’s community.
As mentioned earlier, peer support is a completely different discipline that interacts with clients with a much different perspective about what help may be needed and how to provide it. Peer support, when empowered to play a full role on the HF team, can provide the team with a “consumer’s view” of how they are doing.
Peers should be looking for a person’s strengths, needs, abilities, and preferences for how the team assists the person. Peers can help participants write recovery plans, but through the lens of lived experience. This allows the peer to truly be an advocate for the people they serve and be the voice of the client in team meetings when their clients aren’t available. Some disciplines consult on medication, clinical indications, wound care; peers are the team’s consultant on homeless culture, addiction culture, and coping with mental illness. They can provide the team with an ongoing understanding of what it is like to overcome these obstacles to keep the team rooted in empathy and focused on recovery.
Davidson and his colleagues provide a fitting conclusion to this module:
“Persons in recovery from mental illnesses have insider knowledge of what it takes to have a life well lived with mental illness… based on the credibility and trustworthiness fostered by their lived experience, their passion to give back, and their dedication to making recovery a reality for others who suffer with mental illness, peers specialists can also make invaluable contributions to better outcomes by advocating for, transforming, expanding, and providing effective mental health services.” (Davidson et al., 2018)
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