Peer-Facilitated Decision Making in Mental Health: Promises, Pitfalls, and Recommendations for Research and Practice

Examples of peer-delivered decision support interventions were identified within the literature on shared decision making and decision support for people with serious mental illnesses. We did not perform an exhaustive review of peer-facilitated decision support interventions for this population, because such review was beyond the scope of this article. The included interventions, discussed below, are not necessarily the only ones that exist but provide examples of the formalized role of peer support workers in supporting decision making.

The most well-established and extensively researched of these peer support interventions is Deegan’s CommonGround (23–30), which combines digital technology and peer support to help individuals prepare for psychiatric medication consultations. In this intervention, peer support workers are primarily responsible for assisting individuals in using a software program that provides education about recovery and elicits individuals’ perspectives about their mental health and questions and concerns about medication. Educational materials within the program also contain video vignettes from peers about their recovery experiences. Finally, peer support workers are available to the individuals after their medication consultations to provide any additional support needs identified during the meeting (e.g., assistance with using wellness tools) (23).

Inspired by this process, the Choices About Healthcare Options Informed by Clients Experiences and Expectations (known as Choice) project of Simmons and colleagues (31) evaluated the impact of an online decision support tool and engagement with a peer support worker during the intake process at a youth mental health service. Peer support workers (young people with lived experience of mental health challenges) greet participants in the waiting area before their first appointment and assist them in using the decision support tool. The tool gathers information about participants’ preferences for treatment and provides education about treatment options available at the service. It includes prompts for the youths to discuss with their intake clinician the potential benefits and risks associated with each option. Peer support workers are also available after participants’ appointments to provide further support.

Metz and colleagues (32) developed an intervention, called SDM-Digital Intake (known as SDM-DI), to foster shared decision making during the intake process within outpatient clinics about the management of depression, anxiety, or personality disorders. The intervention consists of digital e-health modules designed to gather information about the service user’s treatment needs and preferences, routine monitoring of clinical outcomes, and interactions with peer support workers for assistance in completing the e-health modules and preparing for the intake session.

A self-management and collaborative care planning intervention for chronic mental illness, developed by Lawn and colleagues (33), involves a comprehensive assessment of strengths and barriers to self-management, a clinician- and service user–developed care plan created on the basis of this assessment, and partnership between the peer educators and case managers in delivering a self-management skills group. Peer support workers are also available to provide education and encouragement to the service users as they work with their clinicians during care planning.

Paudel et al.’s (34) shared decision–making model also consists of a group intervention that encourages participants to set recovery goals, educates them about psychiatric medications, and provides support from a peer worker and assistance from a nurse with accessing information about medications. The aim of the Paudel et al. intervention is to prepare individuals to engage in shared decision making about medication with their psychiatrist. Peer support workers ask participants about their preferences related to medication and share their personal experiences in decision making about medication and negotiating and communicating with treatment providers.

Munson and colleagues (35) tested an intervention, Just Do You, that aims to improve treatment engagement among young adults with serious mental illnesses. This two-session intervention targets key variables relevant to decision making (e.g., beliefs about the advantages and disadvantages of engaging in treatment) through expressive art activities, personal narratives, psychoeducation, and motivational interviewing. The intervention is cofacilitated by clinicians and peer support workers. Peer support workers share their lived experiences, encourage self-acceptance and trust of providers, and promote a belief in the service user’s ability to communicate with providers about treatment decisions. The peer workers also provide mentoring and check-ins, answer questions, and build relationships with the participants between the intervention meetings.

Taken together, the findings of these studies have demonstrated that peer support workers may facilitate decision making in several ways. In these peer-facilitated interventions, peer support workers ask service users about their goals and preferences, assist them with using decision support tools, share their own stories related to decision making and self-advocacy, enhance motivation, facilitate access to information and resources, support effective communication with treatment providers, and provide follow-up support.

Although the research designs of the aforementioned studies precluded isolating the effects of peer support within these multifaceted interventions, the results of these studies indicate promising decision-making and health outcomes. As reported by a recent systematic review of shared decision-making interventions for individuals with serious mental illnesses (36), these outcomes include enhanced patient-centered communication (24), increased treatment engagement and health care service use (26, 35), improved symptoms and recovery attitudes (30, 32), greater perceived shared decision making (31, 32), reduced decisional conflict (31, 34), and increased self-management and functional outcomes (33). These findings suggest that decision support interventions that are delivered fully or partially by peer support workers may confer several benefits to service users, at least among people experiencing serious mental illnesses in high-income countries, where these studies took place.

Besides the findings of the studies described above, literature on the power of lived experience perspectives has suggested additional benefits associated with peers serving in decision support roles. For example, the voices of those with lived experience, including peer support workers, can inform systems transformation to better support service users’ dignity, self-determination, and empowerment (37). As part of the decision support process, peer support workers can use their personal experience of decision making, as well as their observations about supporting others in these efforts, to identify and help reduce barriers associated with the mental health system, such as concern about the ability of service users to participate in decision making. This support may entail sharing their success stories and advocating for others to have the opportunity to make autonomous treatment choices. Furthermore, the sharing of lived experience may help peer support workers to achieve a level of credibility and connection with service users that is qualitatively different from that of mental health service providers without such lived experience (38). As peer support workers share their stories about their health care and recovery choices and experiences with service users, they are likely to simultaneously build the trusting relationships needed to support the service users with their own decision making and recovery.

The opportunity to deliver decision support may also have a positive impact on the peer support workers themselves. According to Salzer and Shear (39), the helper-therapy principle indicates that peer support workers may benefit in several ways from serving as helpers, including experiencing greater perceived interpersonal competence, equality in the peer-to-peer relationship, gains in personal knowledge, and social approval. In a qualitative study of how peer support workers benefit from serving in these roles, Salzer and Shear (39) found support for all of the benefits identified by the helper-therapy principle, as well as gains in personal recovery, professional growth, and other job-related benefits. In the case of peer-facilitated decision support, peer support workers may gain a sense of accomplishment from helping others to make choices about their health care and recovery and by empowering them to advocate for their preferences. Peer support workers also may grow in their own knowledge and skills related to decision making and may feel fulfilled by developing mutually beneficial relationships with service users. Furthermore, as proposed by Fiddian-Green and colleagues (40), sharing personal stories related to decision making may help peer support workers make sense of their own experiences, promote a sense of mastery and self-efficacy, and aid in the formulation of goals and plans for future decision making. Finally, hiring and training peer workers to deliver decision support interventions could lead to increased role clarity for peer support workers employed in mainstream mental health settings, where role confusion has been a prevalent issue for the workforce (41).

Although there are many possible benefits to peer support workers serving in decision support roles, several potential challenges also exist. Across the aforementioned studies of peer-facilitated decision support interventions, implementation barriers were largely related to resourcing issues, team integration, professional stigma toward peer support workers, and poor uptake of peer support services (27, 32, 33, 42). Although these issues do not appear to be specific to peer-facilitated decision support, and have been reported in other studies more broadly focused on peer support (43–45), they indicate potential obstacles to the implementation of these services.

Other research has identified challenges more closely related to the provision of decision support by peers. In a qualitative study of barriers to and facilitators of supporting service users’ participation in shared decision making (17), peer support workers reported experiencing conflict between their roles as advocates and expectations of management, and they felt challenged by power dynamics that placed decision-making authority in the hands of clinicians. Extrapolating on these findings, we surmise that peer support workers may be expected to persuade those they support to make specific choices (e.g., those that align with clinicians’ preferences), which runs counter to foundational principles associated with peer support, such as person-centeredness, voluntary participation, and respect for alternative worldviews (46). Peer support workers may also be put in positions of giving treatment advice or providing information beyond their expertise to persuade service users to make the decisions the clinicians believe are in the service users’ best interests. A complementary qualitative study (47), conducted with mental health nurses, has highlighted concerns about the potential for the sharing of lived experience to create undue influence and to undermine decision making. These concerns have been echoed by sentiments within the literature on personal narratives (48, 49) that urge caution when using such narratives to support decision making, because of their persuasive power, potentially biasing effects, and ability to spread misinformation. These possible pitfalls associated with peer-facilitated decision support require careful attention and have implications for training and supervision, as discussed below.

As the above studies indicate, peer-facilitated decision support interventions have yielded promising outcomes, but we also note a clear need for additional research in this area. For instance, studies designed to understand the unique contributions of peer support to decision-making outcomes are necessary. Many of the interventions discussed in this article included components other than peer support—such as decision support tools—that may have affected decision making. Furthermore, several interventions were cofacilitated by peer support workers and clinicians. Studies that may be especially useful are those designed to assess the relative utility of various components of multielement interventions and include mixed-methods approaches exploring whether and how various aspects of peer support influence decision making. This research could examine mechanisms of action, as well as which peer support core values or principles are most useful in the context of peers facilitating decision making. Additionally, the impact of peer-facilitated decision support on service users and on peer support workers themselves merits further investigation. According to the literature, service user outcomes of interest may include decisional conflict, perceived shared decision making, treatment engagement, and clinical and functional outcomes, whereas peer supporter outcomes may focus on professional and personal growth, self-efficacy, and job-related benefits.

Because the studies of peer-facilitated decision support interventions discussed in this article were conducted in high-income countries, their findings may not generalize to the global population of individuals with serious mental illness. Research is needed on how interventions could be tailored to meet the specific needs of racial, ethnic, and cultural minority populations or could be reimagined through culturally appropriate participatory methods if the current approaches are not culturally appropriate (50, 51). This tailoring may be accomplished through modifications to the interventions themselves (e.g., translation of decision support tools), reconceptualization of decision support for different cultural groups (e.g., family decision making), new models of peer support (e.g., having one peer support worker and one community elder providing decision support to an extended family), or greater representation among intervention providers. Because peer work is one role that typically has fewer barriers to entry (at least in terms of required educational and training credentials), it offers a pathway to increased diversity and relevance of the mental health workforce.

Further integration of the literature on personal narratives with that of peer support would also benefit the field. Although a body of research has been established on how narratives influence medical and health-related decision making (52, 53), comparatively little of this research exists in the mental health field, and even less has been conducted in the context of peer support. This is an important and surprising gap given the frequency with which peer support workers share their personal experiences as part of their work with service users (4). As recommended by Mancini (54), an application of narrative methods and theory is needed to better understand the nuances of peer practices. We affirm and extend this recommendation by adding that narrative research should be used to inform studies of the influence of peer support on decision making. This research may also be useful for establishing best practices related to the sharing of lived experience to facilitate decision making.

The potential pitfalls identified here point to several practical implications for peer-facilitated decision support. First, peer support workers may need additional training in how to strategically share their experiences in a way that aids decision making. Although broader training programs for peer support workers in storytelling and self-disclosure exist (55), the extent to which these approaches apply to decision-making discussions is not clear. Because personal narratives can be used for many purposes (e.g., to engage, inform, model, or comfort) (56), peer support workers should receive instruction in how to craft their stories in alignment with what they hope to accomplish by sharing them. They should also be made aware of the persuasive power that personal stories have and should be encouraged, as appropriate, to acknowledge experiences that differ from their own.

Second, supervisors and fellow team members may require training in how to support the role of a peer in facilitating decision making. As suggested by Gates and Akabas (43), improving nonpeer staff attitudes toward peers and enhancing peer integration on the treatment team may be accomplished by making it clear what the peer role is and how it contributes to the mission of the agency. Because peer roles vary widely across localities, states, and organizations, this training should be tailored to the specific expectations of peers in the local area. Training should also include education about the foundational principles of peer support (46) and how these principles may align or conflict with expectations of how peers may promote decision making. Supervisors and team members may also benefit from training and consultation in shared decision making to foster greater involvement of service users, and others, in the decision-making process. Professional development opportunities in this area may help to rectify perceived power imbalances between clinicians and those with lived experiences in decision-making discussions.

The literature cited in this study points to peer-facilitated decision support as a promising approach in need of further study. We have offered several future directions for research and practice, including seeking a better understanding of the specific impacts of peer support within multielement decision-making interventions, investigating how peer-facilitated decision support influences service user and peer worker outcomes, and developing training programs for peer workers, supervisors, and coworkers to support the unique role of peers in facilitating the decision-making process. As such, we hope to encourage further development and more widespread implementation of peer-based services in this important area.