Implementation of the peer support agent role in mental health
Between the 1960s and 1990s, reforms promoting deinstitutionalization and a transition to a community-centered care model took place. Groups of service users increasingly questioned their role in the care relationship and demanded a change in the model, one that recognized mental illness not only causes symptoms but also significantly limits access to a life plan (Anthony, 1993). Various alliances of service users, families, and professionals advocated for recovery -oriented systems, shared decision-making, and the creation of community services (Ostrow & Adams, 2012). There began to be a demand for a care model that recognized those affected as citizens with full rights, enabling them to explore their strengths and assume active roles in supporting others (Chamberlin, 1978). These transformations of the biomedical system require a reconceptualization of the health and disease process, a change in the way psychiatric diagnoses are perceived and treated (Higgins et al., 2020).
The role of technical people in accompaniment and mutual support (TeAM) in mental health recovery
The recovery movement, which began in the 1990s (Anthony, 1993), was influenced in part by evidence of symptomatic remission in psychosis, stemming from the pioneering Vermont study (Harding et al., 1987a, 1987b). This study concluded that complete symptomatic remission is possible even in people with supposedly chronic diagnoses such as schizophrenia. Thus, it became clear that one can lead a meaningful, or even productive, life while still experiencing symptoms (Davidson, 2016).
Recovery is defined as a personal, unique, and multidimensional process of changing attitudes, values, feelings, goals, skills, or roles that enables one to live a satisfactory and hopeful life, despite the limitations caused by the disorder (Anthony, 1993), and not as the simple disappearance of associated symptoms.
One of the distinctive elements of the recovery model is the interventions carried out by people with lived experience (Ahmed et al., 2012). Mutual aid and peer support are based on psychological theories that consider social proximity to foster motivation (Ryan & Deci, 2000). This type of support helps expand social networks by offering acceptance, support, empathy, and a sense of community, which increases hope, autonomy, self-efficacy, and the assumption of responsibilities (Bradstreet & Pratt, 2010). Specifically, through their integration into the system, the peer support agent allows individuals to assume valuable social roles.
Mutual support is a common practice in all societies, one that has developed more or less spontaneously, although it wasn't until the last century that we stopped to analyze and appreciate its importance and how necessary it is at certain times. This spontaneous practice, which once took place in public spaces and was part of daily life, has become increasingly inaccessible, just as the structures of our cities have distanced us from community life. Progress has brought us many advantages, but it has also deprived us of others.
Peer mentoring embraces the principles of equality and respect. It assumes that each person, by definition endowed with a unique individuality, can and should undergo an equally unique and singular process, without necessarily having to do it alone.
To avoid confusion about roles, it's important to clarify that this is nothing like directing, convincing, or persuading, but rather responds to the human need for belonging and recognition . It's about being and being in the company of others who understand and accept suffering as part of life's journey, without trying to silence, hide, or reject it. There are no recipes or magic formulas, but rather the understanding that each person must find their own way to cope with their discomfort, in their own time, rhythm, and manner. And that often, time is needed to speak and be heard in a safe environment, free from judgment and pressure.
Upon joining professional teams, peer support agents can perform direct or indirect support tasks (Jacobson et al., 2012). Direct support tasks may include:
- The defense of rights, providing information, support, or connection to specific resources when necessary.
- Support in the reconstruction of community life, based on horizontal relationships founded on trust and mutual respect, and knowledge of the entities and resources of the territory.
- Facilitating group activities, motivating the development of skills, socialization and improvement of self-concept and self-esteem.
Indirect tasks, broadly speaking, are related to administrative and information management, participation in team meetings and supervision, and training activities.
Among the difficulties identified in implementing this role within healthcare systems, the most notable are negative attitudes toward the recovery model among some professionals and the aforementioned role confusion. As a strategy to improve these aspects, it is recommended to establish models and practices that guide the integration of peers and help to more clearly define their functions (Gates & Akabas, 2007).
Training and awareness-raising of mental health professionals from the recovery model
Finally, another key element of the recovery model, and crucial for the successful implementation of peer support within the system, is the training and awareness-raising of mental health professionals (Gee et al., 2017; Mabe et al., 2016). A recent meta-analysis (Eiroa-Orosa & García-Mieres, 2019) found clear effects on beliefs and attitudes, while the effect on behaviors is less clear and highly heterogeneous. Progress in this area could be decisive for the integration of peer support agents.
The role of peer support agent at the international level
North American countries, pioneers in implementing peer support worker roles, such as Canada and the United States , now have training programs and defined recruitment processes (Kaufman et al., 2012). Training is mostly provided by organizations run by experienced professionals. Recruitment is handled by specialized agencies, using job categories that do not require the same licenses as other healthcare professions.
Similarly, in other English-speaking countries such as the United Kingdom, Australia, and New Zealand, peer support is already a recognized profession. Although the role is usually integrated within their healthcare systems, non-profit organizations collaborate with them for training and recruitment. These countries also have specific professional categories and job opportunities both in the non-profit sector and in mental health services.
In the case of German-speaking countries ( Germany, Austria, and Switzerland ), there is an entity, EX-IN, that centralizes training. The curriculum was developed collaboratively by mental health service users and professionals, researchers, and trainers from six European countries (Hegedüs et al., 2021). This standardization of training has facilitated the recruitment of trained professionals within the healthcare systems of these countries.
In France, the role is also widely implemented, although very heterogeneously in terms of both training and hiring practices. Of particular note is the training program offered by CCOMS Lille , a partner of the United Nations (UN), which lasts two years and includes internships contingent upon employment at one of the 16 participating mental health services, thus providing participants with a paid professional contract.
In Latin America, there is a growing interest in peer support, which takes the Anglo-Saxon recovery model as a reference point and combines it with more locally rooted approaches, such as the liberation pedagogy of Brazilian Paulo Freire (1965). However, there is no defined framework for its integration into healthcare systems.
Finally, there is an initiative that promotes the exchange of experiences between European, African, and Asian countries. The UPSIDES network ( Using Peer Support in Developing Empowering Mental Health Services ) has established an international community for research and practice in peer support (Puschner et al., 2019).
The role of peer support agent in Spain
In Spain, implementation experiences are, with some nuances, still in their initial stages.
The Andalusian Federation of Mental Health Associations – In the First Person – has been a pioneer in implementing this role. This organization was involved in the Leonardo da Vinci peer2peer project ( Peer2peer , 2013), led by the Intras Foundation and the Scottish Recovery Network . Hiring has been carried out through associations and the Andalusian Health Service in cities such as Granada, Motril, Málaga, and Almería. In some cases, the professional category of caregiver has been used for hiring through sheltered workshops. Subsequently, the Intras Foundation also facilitated job placements in Castile and León, following the same training model.
The Castilla-La Mancha Sociosanitary Foundation 's Expert Project, a regional initiative, has been another pioneering experience. Training programs have been conducted that have led to hiring through the Extraordinary Employment Plan in Castilla-La Mancha since 2016.
In Catalonia, there is already a tradition of peer support and mutual aid groups (Bardají-Mauri et al., 2017). In 2017, a peer support trainer training project was carried out, organized and evaluated by the University of Barcelona (Sanchez-Moscona and Eiroa-Orosa, 2021). Currently, two accredited training programs coexist, involving third-sector organizations, such as the Emilia Barcelona Association, and service providers such as Althaia and Osonament . Hiring has been carried out through job roles such as support technician, initially conceived for the field of employment integration.
Madrid, for its part, has the Manantial Foundation, a rehabilitation services provider that pioneered peer support in the region. They opted for the educator category, with a salary equivalent to that of an occupational therapist. La Porvenir ( La Porvenir - Equipo De Trabajo , 2021), a non-profit organization, also has a peer support agent on its team.
Finally, in the Basque Country, the Gipuzkoa Association of Families and People with Mental Health Problems (AGIFES ) has carried out a recruitment of agents.
Conclusions and recommendations
Professional peer support has proven to have numerous benefits in the recovery process. However, this professional role is still in the early stages of implementation. Considering international trends and the current situation in Spain, we offer some insights to facilitate its implementation in our country.
In the short term, peer recruitment can be carried out legally and directly by healthcare providers or non-profit organizations. However, direct integration into the National Health System is subject to limitations under the Law on the Regulation of Healthcare Professions. In this context , one possible option would be for healthcare providers to subcontract non-profit organizations to deliver the service and manage human resources.
In the long term, an ideal scenario for the certification of the professional figure could involve the creation of an official training cycle with health recognition , or at least the possibility of accessing the evaluation and accreditation of the professional skills acquired through experience (Ministry of Education and Vocational Training, 2021).
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