Peer Support Specialists Partnering with Clinicians: Outpatient Psychotherapy

Outpatient psychotherapy is the most common mental health intervention, used by more than 50 million people in the US each year.  When done well, it can be very effective at addressing a range of mental illnesses and helping with life problems and general quality of life.

 However, there are several key challenges in therapy.  Many people who need it don’t participate or wait a long time.  When they do participate, a large percentage dropout before they gain any benefit.  For example, large reviews of the research find dropout rates of 32-67% (Maggio, Molgora & Oasi, 2019).  In therapies that focus on addressing trauma and anxiety, dropout rates are particularly high.

 When researchers look closely as the causes of these problems (Maggio, Molgora & Oasi, 2019; Suárez-Delucchi, Keith-Paz, Reinel, Fernandez, & Krause, 2022), they find several recurring themes: 

1.     New clients have low trust in therapists.  Clients that drop out of treatment often report feeling low levels of trust in psychotherapists.  Specifically, they report low trust that the therapist understands them or is listening to them.  Some of this distrust is actually part of the mental illnesses that they are seeking help for.

 2.     Problems in communicating and agreeing on goals. Clients report that poor communication, and disagreement about goals for the therapy are part of why they dropout. 

 3.     Clients misinterpret actions and intentions of the therapist. Some mental illnesses involve patterns of misinterpreting the actions of other people.  It is not surprising then that clients do this in therapy, and those misinterpretations can lead to problems.

4.     Therapists misinterpret actions and intentions of the client.  It is also common that therapists don’t fully understand some clients and may misunderstand their actions.  This can lead to disagreement and dropout.

 5.     Low levels of hope by the client that therapy can benefit them.  Most clients enter psychotherapy after they’ve unsuccessfully tried to solve their “problems” on their own.  Hopelessness is often present and is a key factor in why clients dropout or don’t participate fully.

Peer Support Specialists are well positioned to help address these specific problems.  Consider the advantages of having psychotherapy being provided by a therapist in collaboration with a Peer Support Specialist who meets separately with the client to enhance the work done in therapy.  That Peer Specialist adds some key advantages to the therapy: 

• They model success.  They provide concrete evidence that therapy works and that the client can do what is needed to achieve success.  In this way, they increase the client’s hopefulness and confidence, and thus their engagement.

•  They add credibility and trust to the treatment.  Peer Support Specialists are usually granted initial credibility due to their personal experience with recovery.  By being part of the psychotherapy team, they add this credibility to the treatment.

•  They can enhance communication.  Peer Support Specialists can watch for communication problems between the therapist and the client and take steps to prevent or reduce their impact.  These steps include correcting misconceptions, translating communication that is not being understood, and calling for corrective action when communication has actually broken down.

•  They can collaborate/“tag team” with the therapist.   Adding a Peer Support Specialist who is providing collaborative peer counseling adds a second provider to the care.  They can work with the therapist in ways that are referred to as “tag teaming”, which includes (1) reinforcing messages to the client, (2) alternating messages when they are more likely to be heard from either the therapist or the Peer Support Specialist, and (3) coordinating interventions to improve impact.

•  They can extend the work of the therapist.  This could include efforts to help clients apply what they are learning in therapy to their daily live, help completing and fully understanding homework tasks, and help taking steps that involve actions in the community. 

•  They can help encourage compliance.  Clients often have difficulty with attendance and completion of psychotherapy tasks.  Peer Support Specialists can help encourage attendance and completion of tasks in a way that maximizes the impact of the therapy.

•  They can help clients recognize when it is time to end psychotherapy.  Some clients have difficulty terminating the therapy.  They may feel anxious about leaving the support of the therapist.  They may have challenges building a fully supportive life that allows them to move out of treatment.  Peer Support Specialists can be key in helping clients build that supportive and successful life and then recognize when it is time to end treatment.

How to get started:

1.     Find a psychotherapist you can work with, and who understands your role.  This will be a close working partnership and so you want to find someone that you trust and respect and who will trust and respect you.

 2.     Start talking with them about how you will work together.  This will take some time to figure out and so you will need to begin a dialogue that will cover all of the key elements of your work together.

 3.     Figure out how you will get paid.  There are some funding sources that support the work of Peer Support Specialists and many that do not yet recognize it.  Be practical in your planning so that you can sustain this work. 

 4.     Try it with a few clients.  I try to “pilot” any new effort that I want to do but am unfamiliar with.  Work with your partner to pilot your collaborative effort with 2-3 clients.  Pick those clients carefully, selecting those most likely to benefit from the collaboration.  After you provide that support, ask those clients for feedback, listening carefully for what worked and what can be improved.

 5.     Implement lessons learned and move forward.

 6.     Publicize your collaborative work.  There are clients who will be particularly interested in trying psychotherapy that has integrated peer support.  Let them know about what you are doing and share it with other therapists and Peer Support Specialists.

REFERENCES

 Maggio, S., Molgora, S., & Oasi, O. (2019). Analyzing psychotherapeutic failures: A research on the variables involved in the treatment with an individual setting of 29 cases. Frontiers in Psychology, 10, 433125.

 Suárez-Delucchi, N., Keith-Paz, A., Reinel, M., Fernandez, S., & Krause, M. (2022). Failure in psychotherapy: A qualitative comparative study from the perspective of patients diagnosed with depression. Counselling Psychology Quarterly, 35(4), 842-866.

KEY WORDS: Peer Support Specialist, Recovery, Peer Support, Outpatient Mental Health, Psychotherapy, Peer Support Training, Peer Support Certification, Peer Support Jobs