Peer Respites: A Research and Practice Agenda

Peer respite goals are wide ranging and include primary goals of fostering wellness, increasing meaningful choices for recovery, and creating and maintaining mutual and supportive relationships. Secondary goals include reducing emergency hospitalizations and system costs.

Short-term, individual-level domains that could lead to benefits for the service user include quality of life, housing stability, and development of social relationships and natural supports. Although explicitly nonclinical, peer respite participation may result in measurable improvements in clinical domains such as mental health functioning and symptom severity. Long-term outcomes include employment, education, and community and civic engagement, which are addressed by measures of recovery (9). Peer respites are not designed to substitute for inpatient hospitalizations; comparison of the cost of a respite day with the cost of a hospital day is therefore incongruent. Nonetheless, peer respites may avert escalation of an event to a psychiatric crisis and may therefore be associated with decreases in costly inpatient and emergency service use, including crisis support teams, crisis residential programs, and hospitalization. Understanding these relationships requires a detailed examination of cost and utilization data. Because inpatient and emergency services are financed through multiple means, accurate cost estimates may not be available in a central administrative database.

The relationship between peer respite and other mental health services use is also unclear. As respite guests experience greater stability, self-determination, and awareness of treatable conditions, they may become more engaged with services and supports, which could translate to increased short-term service utilization. Cost and service-utilization analyses should link with data on other recovery outcomes when possible.

Census within the program is critical for cost-effectiveness research and long-term sustainability. Without an adequate number of people in the program at one time, the fixed costs outweigh the variable costs, and hence the value to the community or funder. Measuring census and keeping programs at capacity through referrals and outreach contribute to defining costs. These analyses should account for additional costs and benefits, such as linkages to a larger organization or additional services (such as a drop-in center or “warm-line” telephone peer support).

Intentional Peer Support is a trauma-informed, peer-delivered training and supervision model used in many peer respites. Based on a detailed peer-developed training program, Intentional Peer Support uses reciprocal relationships to redefine help; practitioners aim to build community-oriented supports rather than create formal service relationships (10). Early work by the authors is under way to develop a set of core competencies and may be a first step toward documenting fidelity in peer respite programs.

Most peer respites’ quality improvement strategies focus on the use of satisfaction measures to understand guest perceptions. However, future quality assurance and improvement activities could more closely examine experiential components, such as promoting choice, mutual decision making, a recovery view, and human rights.

Mixed methods are appropriate for studying peer respites (11). Qualitative approaches, such as in-depth interviews, enable exploration of complex relationships between respite use and outcomes that may not be apparent through quantitative analyses of cost, service use, and survey data alone. The infusion of qualitative approaches is particularly warranted because of peer respites’ emphasis on self-defined outcomes and the need to understand guests’ perception of services and the relationship between the peer respite and other traditional crisis services. Because peer respite research is in its infancy, qualitative approaches contribute a theory of change to help in interpreting measurement. Formative process evaluations should accompany any exploration of outcomes to document challenges and lessons learned and facilitate charting program fidelity (12).

Control or comparison groups are critical for understanding what would have happened had individuals not stayed at a peer respite. Observational methods, such as asking guests to predict where they would have gone otherwise and what might have happened, are subject to reporting and recall biases. RCTs remain the gold standard for ensuring group equivalence; when an RCT design is not feasible or ethical, quasi-experimental methods also may be used (13), including propensity score matching or dynamic waitlist control designs. Longitudinal designs also are critical to understand short- and long-term impacts and to capture dose-response effects to assess whether and how peer respites affect individuals in the long term.

Peer respite research may present ethical issues or concerns. Because peer respite guests arrive in distress, primary data collection may be experienced or perceived as intrusive or may present an undue burden to guests and staff. Just as peer respite staff members work to ensure that their practices reflect the program mission, researchers, too, should ensure that activities with the program are in concordance with the ethos of mutuality and shared power. Adopting participatory research methods may help accomplish this and help to ensure that feedback from peer staff and guests informs research design, interpretation, and dissemination of results (14). This approach may present a challenge if research-funding priorities and standards in the current scientific paradigm are at odds with those of the community.