Background Peer support roles in mental health services are significantly increasing in the United Kingdom and internationally. However, there is wide variation in these roles and limited research exploring the ways in which Peer Support Workers (PSWs) are currently working. We aimed to explore: 1) the values underpinning the PSW role; 2) the distinctive features of the work that PSWs' do; and 3) the perceived impact of the PSW role. Methods We conducted semi-structured qualitative interviews with paid mental health PSWs working across a range of settings. We took a co-produced, participatory approach: interviews were carried out by researchers with lived experience of mental health conditions and data were analysed using collaborative methods, guided by general principles of thematic analysis. Results We interviewed 35 PSWs. Overarching themes identified from iterative analysis included: 1) Underpinning values: (i) Recovery is possible: fostering hope, role-modelling and encouraging change, (ii) Mutuality: sharing lived experiences to bring empathy and build connection, (iii) Person-centred approach: adapting ways of working to the individual, (iv) Empowering instead of'fixing'service users. 2) Distinctive features:The centrality of an individualised approach, facilitating recovery through sharing lived experiences and building connection. PSWs advocated for service-user needs and most worked in non-clinical ways, offering holistic, recovery-orientated support. Tensions could arise with more clinical approaches. 3) Impacts: Participants thought that peer support helped service users feel understood, leading to greater openness and facilitating recovery, although some felt that it may not be right for everyone. The role had benefits for participants' own recovery, although its emotional demands could lead to burnout. Participants felt that PSWs could bring systemic improvements to services and use their lived experience to help teams meet service user needs. Conclusion PSWs work in a range of ways, but, a unifying feature is a flexible, person-centred approach, facilitating recovery through shared lived experience. A range of potential benefits of peer work were identified for PSWs and for service users, as well as reports of positive systemic change. These could be facilitated by recovery-orientated models in services, space for shared learning with PSWs, and flexibility to incorporate PSWs'unique ways of working. Clinical trial number Not applicable.

Peer support roles within mental health services are rapidly increasing in number and scope in the UK and internationally. This paper explores the facilitators and barriers to delivering peer support effectively, as experienced by Peer Support Workers (PSWs) in a range of services and settings. We conducted semi-structured qualitative interviews with paid mental health PSWs working across a range of settings in England. We took a collaborative, participatory approach. Interviews were carried out by researchers with experience of living with and/or supporting others with mental health conditions, and for some having experience delivering peer support themselves, and data were analysed using methods guided by general principles of thematic analysis. We interviewed 35 PSWs with a range of roles that spanned a range of mental health areas, and regions. Overarching facilitators and barriers were identified including the need for roles to have flexibility with some structure and boundaries; the need for support, supervision and training to ensure PSWs are skilled in delivering the unique elements of their job; the importance of working with a strong team and leaders who support and value PSW; the complexity of working where there are tensions between the flexibility of PSW and the structures of existing healthcare systems, as well as the systemic factors such as funding, pay and progression can have an effect both on the personal experience of PSWs and on the value placed on PSWs in the wider organisation. Our findings highlight the complexity of peer support work and PSW roles, with a variety both of facilitators allowing them to carry out roles effectively and the barriers to doing so. As PSWs numbers and the scope of their roles increase, awareness of barriers and facilitators needs to inform PSW job roles, support systems and integration into teams and systems.

AIM:HOPE (National Institute for Health and Care Research Global Health Research Group on Homelessness and Mental Health in Africa) aims to develop and evaluate interventions that address the unmet needs of people who are homeless and have severe mental illness (SMI) living in three African countries in ways that are rights-based, contextually grounded, scalable and sustainable. METHODS:We will work in the capital city (Addis Ababa) in Ethiopia, a regional city (Tamale) in Ghana, and the capital city (Nairobi) and a rural county (Makueni) in Kenya to understand different approaches to intervention needed across varied settings.We will be guided by the MRC/NIHR framework on complex interventions and implementation frameworks and emphasise co-production. Formative work will include synthesis of global evidence (systematic review, including grey literature, and a Delphi consensus exercise) on interventions and approaches to homelessness and SMI. We will map contexts; conduct focused ethnography to understand lived experiences of homelessness and SMI; carry out a cross-sectional survey of people who are homeless (n = 750 Ghana/Ethiopia; n = 350 Kenya) to estimate prevalence of SMI and identify prioritised needs; and conduct in-depth interviews and focus group discussions with key stakeholders to understand experiences, challenges and opportunities for intervention. This global and local evidence will feed into Theory of Change (ToC) workshops with stakeholders to establish agreement about valued primary outcomes, map pathways to impact and inform selection and implementation of interventions. Intervention packages to address prioritised needs will be co-produced, piloted and optimised for feasibility and acceptability using participatory action research. We will use rights-based approaches and focus on community-based care to ensure sustainability. Realist approaches will be employed to analyse how contextual variation affects mechanisms and outcomes to inform methods for a subsequent evaluation of larger scale implementation. Extensive capacity-strengthening activities will focus on equipping early career researchers and peer researchers. People with lived experience of SMI and policymakers are an integral part of the research team. Community engagement is supported by working closely with multisectoral Community Advisory Groups. CONCLUSIONS:HOPE will develop evidence to support action to respond to the needs and preferences of people experiencing homelessness and SMI in diverse settings in Africa. We are creating a new partnership of researchers, policymakers, community members and people with lived experience of SMI and homelessness to enable African-led solutions. Key outputs will include contextually relevant practice and policy guidance that supports achievement of inclusive development.

BACKGROUND:Peer workers are people with personal experience of mental distress, employed within mental health services to support others with similar experiences. Research has identified a range of factors that might facilitate or hinder the introduction of new peer worker roles into mental health services. While there is mixed evidence for the effectiveness of peer worker delivered interventions, there are no studies exploring how implementation might be associated with effect. METHODS:This was a qualitative comparative case study using data from interviews with 20 peer workers and their five supervisors. Peer workers delivered peer support for discharge from inpatient to community mental health care as part of a randomised controlled trial. In the trial, level of participant engagement with peer support was associated with better outcome (hospital readmission). Study sites with higher levels of engagement also had higher scores on a measure of fidelity to peer support principles. We compared data from sites with contrasting levels of engagement and fidelity using an analytical framework derived from implementation theory. RESULTS:In high engagement-high fidelity sites, there was regular work with clinical teams preparing for working alongside peer workers, and a positive relationship between staff on inpatient wards and peer workers. The supervisor role was well resourced, and delivery of peer support was highly consistent with the intervention manual. In low engagement-low fidelity sites peer workers were employed in not-for-profit organisations to support people using public mental health services and in rural areas. Supervisors faced constrained resources and experienced barriers to joint working between organisations. In these sites, peer workers could experience challenging relationships with ward staff. Issues of geography and capacity limited opportunities for supervision and team-building, impacting consistency of delivery. CONCLUSIONS:This study provides clear indication that implementation can impact delivery of peer support, with implications for engagement and, potentially, outcomes of peer worker interventions. Resourcing issues can have knock-on effects on consistency of delivery, alongside challenges of access, authority and relationship with clinical teams, especially where peer workers were employed in not-for-profit organisations. Attention needs to be paid to the impact of geography on implementation. TRIAL REGISTRATION:ISRCTN registry number ISRCTN10043328, registered 28 November 2016.

Aim In South Africa and other low- and middle-income countries (LMIC), personal recovery for people with a severe mental health condition (SMHC) is hampered by lack of community-based support. This paper describes the development of a non-specialist and peer-facilitated recovery intervention (PRIZE) intended as an adjunct to psychiatric care. Methods Intervention development was guided by the MRC framework for complex interventions. Evidence review was followed by 43 in-depth interviews exploring desired recovery outcomes of people with lived experience and caregivers, and 15 interviews with service providers. Thematic analysis guided development of a theory of change and evaluation framework. District stakeholder mapping, engagement and feedback was undertaken to explore acceptability and feasibility of recovery groups facilitated by trained peers (people with lived experience of SMHC or carers). Results Intervention components are described in line with the GUIDED framework. Formative work identified expressed recovery needs and led to a theory of change based on building self-esteem, reducing social isolation, and improving responses to financial instability, substance use and medication difficulties. The intervention was based on sharing experiences and coping strategies. It incorporated two phases of mutual support groups comprising people with SMHC and caregivers. An auxiliary social worker-led phase (9 weekly sessions) was followed by a supported peer-led phase (12 weekly sessions). The planned didactic psychosocial rehabilitation intervention evolved into an intervention designed to support individuals’ recovery journeys, grounded in values of building hope, opportunity and control, and harnessing strengths. This required training to realign the practice of auxiliary social workers accustomed to a traditional helping role towards an empowering role. Particular attention was given to processes for supportive supervision and mentorship. Conclusion The involvement of district stakeholders and potential participants resulted in a tailored, context-specific intervention with potential to contribute to evidence for community-based, task-shared, peer-led and recovery-focused interventions in LMIC.

Purpose This study aims to investigate how British Pakistani people talk about their social identity, in the context of mental health, and how this shapes their experiences and perceptions of care delivered by the National Health Service, UK. Design/methodology/approach Eight narrative interviews were conducted among members of the Pakistani community living in a city in the UK. The data were analyzed using a narrative analysis approach using “social identity” as a theoretical lens. Findings Considering Pakistani service users as a single social entity, and responding with generic approaches in meeting their mental health needs, may not be helpful in achieving equitable treatment. Study participants reject a simple conceptualization of race and ethnicity and how a response based upon stereotypes is woefully inadequate. The study revealed that people from one ethnic or national background cannot be assumed to have a fixed social identity. Originality/value This study broadens understanding of how people from a single ethnic background may construct and view their social identities markedly different to others from the same ethnic group. This has implications for service providers in understanding how their clients’ social identity is treated and understood in practice.

On a number of occasions, we have written in the pages ofMHSI about the discriminatory nature of the 1983 Mental Health Act (Perkins and Repper, 2014, 2018). On 4th October 2017, then Prime Minister Theresa May announced an independent review of the Act, specifying that this should address what can be done to reduce compulsory detention and the disproportionately large number of Black people detained under the Act. We argued that:

On the question of vulnerabilityThe COVID-19 pandemic has led to a resurgence of the word "vulnerable" and the concept of "vulnerable people".Within the Government's COVID-19 strategy three groups of "vulnerable people" are defined (HM Government, 2020, p. 51):

INTRODUCTION:In the period shortly after discharge from inpatient to community mental health care, people are at increased risk of self-harm, suicide, and readmission to hospital. Discharge interventions including peer support have shown potential, and there is some evidence that community-based peer support reduces readmissions. However, systematic reviews of peer support in mental health services indicate poor trial quality and a lack of reporting of how peer support is distinctive from other mental health support. This study is designed to establish the clinical and cost effectiveness of a peer worker intervention to support discharge from inpatient to community mental health care, and to address issues of trial quality and clarity of reporting of peer support interventions. METHODS:This protocol describes an individually randomized controlled superiority trial, hypothesizing that people offered a peer worker discharge intervention in addition to usual follow-up care in the community are less likely to be readmitted in the 12 months post discharge than people receiving usual care alone. A total of 590 people will be recruited shortly before discharge from hospital and randomly allocated to care as usual plus the peer worker intervention or care as usual alone. Manualized peer support provided by trained peer workers begins in hospital and continues for 4 months in the community post discharge. Secondary psychosocial outcomes are assessed at 4 months post discharge, and service use and cost outcomes at 12 months post discharge, alongside a mixed methods process evaluation. DISCUSSION:Clearly specified procedures for sequencing participant allocation and for blinding assessors to allocation, plus full reporting of outcomes, should reduce risk of bias in trial findings and contribute to improved quality in the peer support evidence base. The involvement of members of the study team with direct experience of peer support, mental distress, and using mental health services, in coproducing the intervention and designing the trial, ensures that we theorize and clearly describe the peer worker intervention, and evaluate how peer support is related to any change in outcome. This is an important methodological contribution to the evidence base. TRIAL REGISTRATION:This study was prospectively registered as ISRCTN 10043328 on November 28, 2016.

Where is peer support going?Peer support is not new.For as long as people have used mental health services, people diagnosed with mental health challenges have provided support to each other and peer led groups and services have become widespread in many parts of the world (see, e.g.Chamberlin, 1978; O'Hagan, 2014).Today, numerous local peer support initiatives exist, many peer support and peer led groups have developed within voluntary sector organisations.For example, Bipolar UK[1] and the Hearing Voices Network[2] have long seen peer support as a core part of their business and a core part of Mind's 2012-2016 strategy is to ensure that "Everyone in England and Wales with mental health problems can access peer support by 2016" (Mind, 2013, p. 1).More recently, Mind's Peer Support in the Community programme 2018-2021 aims to establish ten Community Peer Support Hub Networks, with each Hub supporting 60 local peer support leaders and groups.In addition, a range of on-line peer support opportunities have developed [3].

Background Mental health recovery narratives are a core component of recovery-oriented interventions such as peer support and anti-stigma campaigns. A substantial number of recorded recovery narratives are now publicly available online in different modalities and in published books. Whilst the benefits of telling one's story have been investigated, much less is known about how recorded narratives of differing modalities impact on recipients. A previous qualitative study identified connection to the narrator and/or to events in the narrative to be a core mechanism of change. The factors that influence how individuals connect with a recorded narrative are unknown. The aim of the current study was to characterise the immediate effects of receiving recovery narratives presented in a range of modalities (text, video and audio), by establishing the mechanisms of connection and the processes by which connection leads to outcomes. Method A study involving 40 mental health service users in England was conducted. Participants were presented with up to 10 randomly-selected recovery narratives and were interviewed on the immediate impact of each narrative. Thematic analysis was used to identify the mechanisms of connection and how connection leads to outcome. Results Receiving a recovery narrative led participants to reflect upon their own experiences or those of others, which then led to connection through three mechanisms: comparing oneself with the narrative and narrator; learning about other's experiences; and experiencing empathy. These mechanisms led to outcomes through three processes: the identification of change (through attending to narrative structure); the interpretation of change (through attending to narrative content); and the internalisation of interpretations. Conclusions This is the first study to identify mechanisms and processes of connection with recorded recovery narratives. The empirically-based causal chain model developed in this study describes the immediate effects on recipients. This model can inform selection of narratives for use in interventions, and be used to support peer support workers in recounting their own recovery narratives in ways which are maximally beneficial to others.

Background Mental health recovery narratives are stories of recovery from mental health problems. Narratives may impact in helpful and harmful ways on those who receive them. The objective of this paper is to develop a change model identifying the range of possible impacts and how they occur. Method Semi-structured interviews were conducted with adults with experience of mental health problems and recovery (n = 77). Participants were asked to share a mental health recovery narrative and to describe the impact of other people’s recovery narratives on their own recovery. A change model was generated through iterative thematic analysis of transcripts. Results Change is initiated when a recipient develops a connection to a narrator or to the events descripted in their narrative. Change is mediated by the recipient recognising experiences shared with the narrator, noticing the achievements or difficulties of the narrator, learning how recovery happens, or experiencing emotional release. Helpful outcomes of receiving recovery narratives are connectedness, validation, hope, empowerment, appreciation, reference shift and stigma reduction. Harmful outcomes are a sense of inadequacy, disconnection, pessimism and burden. Impact is positively moderated by the perceived authenticity of the narrative, and can be reduced if the recipient is experiencing a crisis. Conclusions Interventions that incorporate the use of recovery narratives, such as peer support, anti-stigma campaigns and bibliotherapy, can use the change model to maximise benefit and minimise harms from narratives. Interventions should incorporate a diverse range of narratives available through different mediums to enable a range of recipients to connect with and benefit from this material. Service providers using recovery narratives should preserve authenticity so as to maximise impact, for example by avoiding excessive editing.

Based on the work of such people, we have written about the intrinsically discriminatory nature of mental health legislation in the pages of Mental Health and Social Inclusion (Perkins and Repper, 2014).In particular, current mental health legislation in England and Wales denies those diagnosed with a mental disorder the rights accorded other citizens in two primary ways.First, unlike any other citizen who may be a danger to themselves or others, it allows people diagnosed with a "mental disorder" to be detained because they might commit an offence.On civil rights grounds, UK law does not permit this sort of preventative detention for anyone else who are at risk of causing harm to others, like, habitual spouse abusers or those who are drunk and may drive dangerously.Again, those deemed to have "mental disorders" are denied the rights accorded to other citizens:Justice requires that all people posing equal risk should be equally liable to preventive detention (Szmukler in Szmukler and Weich, 2017, p. 1).Second, as Szmukler (in Szmukler and Weich, 2017) describes, two sets of rules exist for involuntary treatmentone for psychiatry and one for the rest of medicine:[…] having one law for decisions about physical illness and another for mental illness is anomalous, confusing and unjust (

WHAT IS KNOWN ON THE SUBJECT?: Risk assessment and management in mental health services are contested and perceived as problematic by both professionals and service users. There is substantial emphasis on risk as a core component of professional practice. However, recovery for people with mental health problems emphasizes self-determination which seems to conflict with risk management. A critique is emerging of risk assessment and management. However, there is a lack of empirical evidence which seeks to explore how professionals manage the conflicts between recovery orientated practice and risk management. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper reports on qualitative research which highlights people with mental health problems are objectified and frequently associated with the potential for harm. Risk dominates the work of mental health professionals and undermines individualized care. Service users are subject to increased surveillance and medication as a result. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Service users' subjective experiences need to be prioritized in mental health care by renewed focus on the relationship between professionals and service users. Mental health professionals should question the centrality of risk to their practice. ABSTRACT: Introduction The emergence of recovery, alongside significant focus on risk management, creates potential for conflicting influences in mental health care. Although evidence has critiqued risk assessment, there is a lack of research that seeks to explore how professionals make decisions within these apparently incompatible agendas. Aim To explore how practitioners, experience potential tensions arising from delivering recovery-orientated care and enforcing containment. Method This paper reports on a case study inquiry, using interviews with mental health professionals and observations in an acute ward and an assertive outreach team. Results Risk governed the practice of mental health professionals to such an extent it defined how service users were understood and treated. Service users were constructed as objects of risk, first by being objectified and secondly by creating a link between that object and harm. Discussion Hilgartner's (1992, Organizations, uncertainties and risk (pp. 39-53). Boulder, CO: Westview Press) theory of risk explains how risk dominates the identity of people with mental health problems at the cost of recovery. This results in increased monitoring, surveillance and medication to enact control. Implications for practice To undermine the dominance of risk, professionals should reconnect with the subjective experiences of people with mental health problems and challenge the acceptance of risk as central to their role.