Strategies and Lessons Learned for Supporting and Supervising Peer Specialists

The project was conducted collaboratively by a university research team and three supportive housing agencies that served as the community sites, operating in two states. The partnership between the agencies and research team focused on colearning, community capacity building, and team building. An implementation study phase before the clinical trial allowed the research team to explore and understand each supportive housing agency’s context (including experience with peer-delivered services), generate staff buy-in, identify stakeholder roles, and develop a communication infrastructure and operating procedures tailored to each agency. This process also allowed agencies to become familiar with the strengths and potential challenges of working with an external research team. To build community capacity, the project embedded resources within the supportive housing agencies, including staffing, training, and funding.

All peer specialists delivering the project intervention, along with several research assistants, were employed by their respective supportive housing agency, paid for by grant funding, trained by the research team, and jointly supervised. The project also engaged in team building across all partners by having frequent meetings, troubleshooting challenges while also sharing success stories, and having project retreats. The project sustained a focus on colearning throughout by using an iterative approach to intervention adaptation and peer supervision that combined the input of all partners as well as having partners identify and participate in dissemination activities and initiate new collaborations (e.g., applying for new grants).

As part of the pragmatic trial, peer specialists delivered Peer-Led Group Lifestyle Balance (PGLB), a 22-session, year-long manualized intervention, adapted from the Diabetes Prevention Program, that aims to help people achieve weight loss through improvements in diet and physical activity (7). Peer specialists hired for the project were certified in peer-delivered services within their state and had a diagnosis of serious mental illness (e.g., schizophrenia or bipolar disorder). Although not required, they had personal experience with chronic health conditions or challenges with weight, which they shared extensively when working with participants (8). Peer specialists completed a 2-day Group Lifestyle Balance certification training, followed by additional training consisting of individual session coaching (e.g., group facilitation skills), applying intervention concepts in their own lives (e.g., healthy food substitutions), and conducting mock sessions (9). Peer specialists delivered individual and group sessions in participants’ residences or supportive housing agency offices, recorded participant attendance and weight, provided feedback on participants’ food logs, completed agency documentation (e.g., progress notes), and helped participants access other staff for non-PGLB services (e.g., housing or budgeting support).

Peer specialists received support and supervision from the research team and the supportive housing agency where they were employed. All supervisors were nonpeers and had backgrounds in social work, psychology, or medicine; they also had previous experience working alongside peer specialists. Weekly structured supervision with research supervisors focused on PGLB content (e.g., session fidelity), group facilitation, attendance and scheduling, participant progress, and research documentation. At least monthly structured supervision with supportive housing agency supervisors focused on participant interactions and care coordination, workplace integration, agency documentation, and support with self-care (e.g., reminders to use vacation time). Research and agency supervisors conducted joint weekly calls with peer specialists to troubleshoot participant engagement, assist with job skill development (e.g., managing schedules), clarify roles, and navigate agency and research team contexts. Informal supervision occurred spontaneously via phone and text and was generally initiated by peer specialists, who were highly mobile and frequently working at sites not colocated with supervisors.

In this column, we described supervision strategies that helped support peer providers embedded within traditional behavioral health settings. Although these strategies emerged in the context of a pragmatic trial, lessons can be applied more broadly because they address critical challenges facing the peer workforce. Strategies included having access to multiple supervisors; offering frequent formal and informal support; acknowledging lack of role clarity and cultivating space for ongoing role negotiation; a collaborative approach to troubleshooting challenges and adaptations; explicit emphasis on peer specialists’ value and contributions; and linking peer specialists to opportunities for mutual support, leadership, and professional development.

These strategies may have contributed to peer specialists reporting feeling included in decision making and having their roles valued and taken seriously; moreover, we achieved high rates of staff retention, with all four peer specialists who had begun delivering the intervention remaining on the project for at least 3 years. These strategies also benefited supervisors, who described how the peer specialists had positively influenced their own practice. They noted having developed greater awareness of inequitable power dynamics with service users, having greater humility and appreciation of challenges in peer specialists’ and service users’ lives, wanting to incorporate attributes that peer specialists exhibited in their daily work (e.g., patience and enthusiasm), and using more self-disclosure.

Nevertheless, some challenges remained. Peer specialists tended to operate in organizational silos, and few strategies had been implemented to better connect them to other agency staff and embed them within other services and support structures. Greater integration may have been facilitated by, for example, supervisors helping to develop other staff at residential and program sites to serve as allies or “local” champions for peer specialists. Supervisors also found it challenging to appropriately balance direction with latitude, wanting to provide peer specialists sufficient guidance and support but not wanting to “be in their way” and stifle their approach. Related to this challenge, peer specialists would have benefited from having the support of at least one supervisor who was also a peer. Such staff could offer more nuanced advice on peer specialists’ sharing of experiences with participants and on navigating the challenge of being a group facilitator or PGLB content expert while not creating a hierarchy with participants.

Nevertheless, given nonpeer supervisors, mainstream mental health settings, and a manualized intervention, previous reports have noted practices that helped combat drift from a peer-led focus so that peers’ strengths and contributions could be preserved (9). As the peer workforce grows, a need emerges to develop and disseminate evidence-based approaches for supporting and supervising peer specialists. Lessons learned and strategies discussed in this column suggest key areas that can be further explored and targeted for development to advance the reach, impact, and value of peer specialists in behavioral health organizations.

The authors thank the individuals and community partners who participated in this study and all the research team members who helped conduct this project. The authors are indebted to Kelli Adams for her work on this study. Ms. Adams passed away during this project. Her dedication and passion for improving the health of people with serious mental illness serves as strong inspiration to continue this important work. She will be greatly missed.