The Department of Veterans Affairs (VA)—the largest integrated health system in the world—is implementing recommendations from the President's New Freedom Commission for the care of people with serious mental illness (1). The commission's 2003 report concluded that to improve access to care and quality of care, systems need to be more recovery oriented and services need to be of high quality and consistent with evidence-based practices.

To operationalize the commission's report, VA created an action agenda (2) and a mental health strategic plan (MHSP) (3). The MHSP calls for use of peer support within VA—that is, veterans with serious mental illness helping each other. As of early 2008, peer support services in the VA range from orienting new patients entering programs, to providing support for emotional and social needs, to teaching skills and knowledge necessary to manage symptoms in order to live, work, learn, and socialize in the community. A specific peer support recommendation in the MHSP (3) is to "Hire veterans as Peer/Mental Health Para Professionals." Such paraprofessionals are often called consumer-providers (CPs), in contrast with traditional staff—that is, individuals who are not publicly identified as having a mental illness. Like addiction treatment counselors who themselves have experienced addiction, CPs draw upon their lived experiences to share "been there" empathy, insights, and skills. They serve as role models, inculcate hope, engage patients in treatment, and help patients access supportive programs, peers, and community resources (4,5,6).

In 2005 VA began funding CP positions across its national health care system. By August 2007 (when the focus groups were held) a total of 91 had been hired. By April 2008 (the most recent figures), 123 had been hired. Research on non-VA CP initiatives has shown that the way in which CP employment is initially implemented—that is, how CPs are incorporated into clinical teams—can affect their success (4,7,8,9,10,11,12,13,14). Diffusion-of-innovation theory states that many factors unrelated to the soundness of an innovation will have an impact on the degree to which the innovation is adopted and implemented (15). Thus it is advisable when implementing an innovation—in this case, CPs in VA—to be cognizant of a broad range of relevant implementation factors. At a recent VA conference, four focus group discussions were conducted with CPs and their direct supervisors about their early CP experiences. This article presents the focus group results along with an overview of CP employment history in VA. The discussion section addresses issues that planners may want to consider when employing CPs in clinical settings.

Peer support groups were the first patient-led service and have reduced inpatient utilization (16,17), substance use, social isolation (18,19), and symptoms (20). Nonetheless, professionals often do not know about these groups or refer patients to them. Patients often do not know about them, may feel uncomfortable attending, or may drop out prematurely (21,22,23,24,25). Adding CPs to existing clinical teams, therefore, is an alternative, proactive way to offer peer support.

CPs can address patient- and system- level factors that contribute to poor outcomes among persons with serious mental illness. Many people with serious mental illness have few social contacts (20), have low self-efficacy regarding their disorder, and see treatment as irrelevant (26). CPs have helped patients make friends, gain hope, and become more involved in their own treatment (27,28). At the system level, many patients with serious mental illness do not receive evidence-based treatments (29). CPs' knowledge and example can help patients better utilize services and encourage traditional staff to take recovery seriously and to redouble efforts to make promising practices available (6,8).

To date, three randomized controlled trials and three quasi-experimental trials (all outside VA) have compared patient outcomes of CP-inclusive services and traditional services (27,28,30,31,32,33,34). CP-inclusive services yielded at least equivalent, and in some cases superior, patient outcomes, including improved social functioning and better self-care (4,5). Other research, also outside VA, has focused on the challenges of introducing CPs (4,7,8,9,10,11,12,13,14); these studies have primarily revealed role confusion—that is, a lack of clarity about what CPs are supposed to do or how they are supposed to act—and unequal treatment—that is, lower wages for CPs, lack of a viable career path, less supervision and support, exclusion from treatment team meetings, and lack of access to medical records. Although these findings are important, the studies involved small numbers of clinical teams or were conducted in one city or state. This study is the first to examine VA's CP initiative and builds on previous studies by including more CPs on more teams from across the United States.

VA was an ex-officio participant on the President's New Freedom Commission and fully supported the commission's recommendations. VA then developed its own action agenda (2), which yielded similar recommendations. Work groups of VA mental health experts then developed VA's MHSP, which was completed, vetted, and approved by the Secretary of Veterans Affairs in 2004 (3). Most of its elements recommended evidence-based practices to address previously unmet needs. However, the MHSP included CP services despite limited evidence about their effectiveness, because other well-regarded recovery-oriented mental health systems incorporate them. VA's Office of Mental Health Services (OMHS) was tasked with operationalizing the MHSP nationally.

VA funding of the MHSP, which began in 2005, led to the creation of a new federal category of mental health provider: the peer support technician (PST), a VA term for CP. This involved obtaining the necessary approvals, describing job duties and drafting position descriptions, setting grade and salary levels, and establishing the primary funding mechanism. Administered by OMHS, this program solicited proposals from all VA Veterans Integrated Service Networks (VISNs) (regions) for implementing various recovery-oriented practices, including hiring CPs. Many VISNs responded, with diverse proposals.

VA leadership supported local VA medical centers' hiring of CPs in numerous ways. VA developed a centralized general position description for all sites to use. National VA leaders established regular conference calls for both CPs and their supervisors, with parallel national e-mail Listservs, to facilitate ongoing dialog and problem solving. VA funded national trainings and helped sites secure local training. Supporting these efforts was the fact that some local VA facilities had introduced peer services before the approval of the MHSP and the CP initiative. For example, some sites had paid providers who were functioning in a CP role through grants and other funding sources. Another example was Vet-to-Vet, a psychoeducational peer support group tailored to veterans, utilized in some local VA mental health systems (35). A national conference was held in Memphis in November 2005 to further inform VA about early, field-based peer support efforts, which suggested that CPs could address gaps in VA mental health services that promoted recovery.

Within VA, CP services are provided in a variety of mental health programs under the supervision of an appropriate mental health care provider. Services are delivered in group and individual formats. Several sites use CPs in VA's intensive case management program, which focuses on community-based visits. All CPs employed by VA have position descriptions based on a national template and modified at each facility to reflect the specific duties of the individual position.

Integration of CP positions into existing VA services is just beginning. Therefore, a training conference held in Chicago in August 2007 provided an opportunity to explore these early experiences with the goal of informing and optimizing CP implementation.

The conference

The three-day conference, "Evolving Roles of Peers in VA Mental Health," was designed to provide training to newly hired CPs and their supervisors. Held in Chicago in August 2007, it provided information about the recommendations of the President's New Freedom Commission and the VA MHSP, skills important for CPs (recovery-fostering skills, group facilitation, role modeling, appropriate self-disclosure, and use of supervision), and issues of incorporating CPs into clinical teams (navigating dual relationships, developing relationships with existing staff, and conducting appropriate hiring practices).

Data source and procedures

Data were gathered about CPs' and supervisors' experiences through four focus groups held as part of the official conference. A standard-question guide was used in all groups (36,37,38). Focus groups were used because they encourage exploration of the uniformity of group opinion (39), allow participants to interact, and help identify outliers (40). Ninety-three individuals—59 recently hired VA CPs and 34 supervisors—attended the conference. All were randomly assigned to a group. Thus it is assumed that there were roughly equivalent numbers of CPs and supervisors in each group. The groups were not mandatory, but on the basis of group leaders' reports, it is assumed that all CPs and supervisors attended. All groups were held at the same time. Each individual participated in only one group.

Each group was led by one VA CP and one traditional VA staff person. Groups lasted 90 minutes and included 20 to 25 participants. In each, a note taker created the data by taking detailed notes on the entire session, including responses to questions, discussions, interactions, and group dynamics (41). This study was exploratory and designed to yield only information for program improvement within VA's CP initiative, not conclusions generalizable to all CPs. Therefore, written consent and institutional review board approval was not obtained. However, all participants were informed that their participation was voluntary and anonymous.

Measures

Group leaders guided the focus groups according to a protocol based on one used in a previous study that investigated stakeholder attitudes toward the future use of CPs (4). That protocol was then adjusted to ask about actual experiences rather than expectations. The five main questions for each group were related to positive and negative impacts of a CP's services, CPs' experiences in joining a team, duties and roles of CPs, supports that were or would be helpful for CPs, and barriers to current or future CP implementation.

Analyses

Data analysis consisted of organizing the typed notes to summarize participant responses to the focus group questions and allowing additional categories to emerge consistent with grounded theory analysis (42,43). First, for each group two doctoral-level researchers independently organized the notes according to the five main questions. We then compared and discussed our respective sortings. A few passages had been put under different topics. We discussed our respective rationales and decided together where each of these notes (line or phrase) belonged. A few cases were resolved by putting the passage under multiple topics. Second, one researcher collapsed the sorted notes across groups to make one document containing all data, sorted by the guide's questions and subquestions. Then the other reviewed and further refined this overall data document, grouping some specific points under broader ones to streamline the data.

We discussed these revisions, and there were no disagreements with the changes. In addition, all group leaders reviewed and held discussions about a summary of the results and suggested edits to improve the accuracy and reliability of the data. Finally, as is customary in focus group analysis, this data summarization was shared with participants (42). All conference participants were invited to attend one of two conference calls; 12 participated in the first and another 14 in the second. During each call, participants were invited to comment on the summary's completeness and accuracy. Minor revisions were suggested and then made by the two coders. The results presented here are a summary of the final document.

Positive and negative effects

Many participants stated, on the positive side, that CPs helped the entire team become more patient centered and that most patients trusted and related to CPs more readily than traditional staff, which facilitated patient engagement and satisfaction. In addition, some said that CPs organized and led new services, such as peer support and illness management groups. Some also observed that CPs empowered patients to be more outspoken about pursuing their own goals. Finally, participants said that CPs were often role models to patients and traditional staff, encouraging both groups to be hopeful and action oriented in regard to recovery. One CP said, "We don't just bring the hope, we bring the proof that it [recovery] works."

Participants said that the CP's perspective was often educational for staff and motivating for patients. Some reported that CPs had suggested useful, veteran-oriented coping strategies and tools to patients and had facilitated increased patient engagement in services. Participants commented that the mixed role of peer and employee allowed CPs to act as liaisons between staff and patients, helping each to better understand the other. Finally, some participants commented that CPs often have a better understanding than traditional staff of community resources that are not part of VA.

Responses about negative impacts of programs focused on disruptions of usual work patterns, because adding CPs meant that team operations needed to be reorganized to some degree. Some described CPs as not having a work space, desk, telephone, or computer access. Traditional staff told of not knowing how to "fit in" the CP at first. Further, some staff described fears of or experiences with CPs working "beyond their job" by intruding onto other staff's professional ground, overstepping their roles, or portraying their own recovery as the only blueprint to recovery. Participants said that their initial concerns largely dissipated once the CP was on staff and became a familiar coworker. However, some supervisors noted that some "traditional-minded" staff had ongoing difficulty accepting CPs. They found that discussing the benefits associated with CPs and having CPs trained and certified has helped these individuals understand and accept the CPs' role.

CPs' experiences joining a team

All stakeholders—CPs, traditional staff, and patients—experienced initial discomfort and challenges when CPs joined the teams. Many CPs reported that the role was initially ambiguous, which made them anxious about demonstrating their value. Many wanted more guidance, role definition, and time with good supervisors when they started. Several CPs said that they were "walking on eggshells" at first, consciously working hard to counteract staff's initial fears. Most said that being the team's only CP made entrée more stressful. When more than one CP was on a team, they provided peer support to each other.

Many CPs found the transition from "patient" to "staff" challenging, especially if they were working at the same facility from which they had received or were currently receiving services. CPs said the role change complicated their relationships with other patients; for example, friends had unrealistic expectations about what the CP's new position could do for them or resented the CP's success. Also, CPs sometimes became coworkers with a former or even current mental health provider. Several had to change providers to avoid these boundary problems. Some CPs, especially those in rural areas, said that alternative providers were sometimes unavailable. Finally, disclosure of one's mental illness also complicated the transition; it is private information, but it also is what makes one a "peer."

A few CPs reported experiencing overt wariness, paternalism, and even insensitive comments from a few co-workers or patients. One focus group discussed the fact that when a CP calls in sick, traditional staff often mistakenly conclude that the CP had had a psychiatric relapse. Another CP reported that some staff were afraid that the CP would "take away" their patients. Some CPs reported that some patients were nervous about working with "a crazy person," questioning the CP's abilities because most don't have formal training. Despite occasional skepticism from patients, most CPs and supervisors said that patients usually embraced CPs as veterans who "know what it's like" to have mental health problems.

Despite initial anxieties, most CPs came to be valued with time, familiarity, and better definition of their niche. For example, one CP said that when she recently applied for vacation time, colleagues joked that she could not be spared for even a week. Several other CPs reported being sought out when other staff had difficulty assisting a patient. Only a few CPs reported that they did not feel like a team member or that staff continued having unrealistic expectations of their role.

Duties performed by CPs

Because focus group participants hailed from diverse programs, the CP roles that they discussed varied. Many were involved in direct patient services with a recovery focus. These services included assisting with or conducting new patient orientation; leading many types of groups (support, illness management, 12 step, and social or quality of life); completing intakes, screenings, and treatment planning with patients and staff; helping patients find housing; and accompanying patients to community activities. Many CPs mentioned advocating on behalf of patients to get needed services. Some CPs described less clinical duties, such as providing patient transportation, assisting patients with basic daily needs, or being a "clerk" for the program. In all the focus groups, participants emphasized the CP role as loosely defined or unclearly communicated. One person even said that the CP's job was "anything anyone asks us to do." Some said that the flexibility this fuzziness afforded was beneficial and empowering, but most CPs and supervisors alike called for more role definition.

Supports helpful to CPs

CPs said that they would have liked more training, supervision, and discussion about the content and process of their jobs and about self-care and role and boundary issues. Supervisors concurred. Both said that it would be helpful for CPs to shadow existing staff and to be told that it is OK to make and learn from mistakes. They also felt that teams with CPs should discuss difficult situations ahead of time ("What should we do if… ?") and have access to the experiences of other CPs and sites employing CPs, including resources, policies, procedures, and lessons learned.

Barriers to CP implementation

In addition to the needs discussed above, participants mentioned three barriers to further incorporating CPs within VA. First, many said that human resources personnel at their site did "not know what to do with a CP position," leading to lengthy challenges getting positions approved, posted, and filled. Second, some said that administrators at their site "seem to find recovery … a new concept" and so were less able to help with administrative challenges related to CPs. Third, a number of CPs stated that they were poorly compensated. Many participants speculated that this might be because the CP role is new or not fully valued or that human resources personnel are unclear how the position fits into VA. Others felt that CPs do not have a clear path for professional growth or promotion. Participants also noted that professional competencies some CPs bring with them (such as being a social worker) are not factored into grade and salary levels because, although valuable for CP roles, they are not part of the job requirements.

According to the focus groups, CPs in VA perform a wide range of case management and patient support duties and help their teams become more recovery oriented and patients participate more fully in their own treatment. Such duties are consistent with those described in multiple reports about CPs outside VA (27,28,30,31,32,33,34). CPs and traditional staff both reported some challenges and concerns regarding CPs' initial entrée. These concerns have been reported previously both inside (4) and outside VA (7,10). However, most CPs came to be valued by staff and patients with time, familiarity, and increased role clarity. This was often facilitated by CPs' assertiveness in demonstrating their utility and defining their role and by supportive attitudes of supervisors and other staff.

Several barriers to employing CPs were discussed by the focus groups, including lack of understanding of the CP job by human resources personnel, inadequate value placed on CPs by administrators, inadequate wages, and lack of a well-defined job path. Although the finding about human resources was new, the other barriers have been noted in other reports about the experiences of CPs (7,10,11,13). Many theories of diffusion predict similar challenges when innovations are introduced. For example, Rogers' (15) diffusion-of-innovation theory posits that an innovation is less embraced when it competes with, and has no perceived advantages over, existing routines.

Recommendations for employing CPs

On the basis of these data and the CP literature (4), the following recommendations are offered to improve the process of employing CPs in new places. First, CPs, traditional staff, and administrators need to be adequately prepared. Staff should be prepared to address potential dual roles and to incorporate CPs within their team's mandated mission. Training and actively involving staff in establishing the parameters of the CP's role has demonstrated some success in preparing traditional staff and thereby reducing their concerns and resistance (44). A readiness assessment of the team that the CP would join—via focus groups, surveys, or informal discussions with staff and leadership—could be conducted to better plan training and specific preparation steps needed. Previous research has recommended assessing and improving readiness conceptualized in this manner (12). Although hiring CPs has been viewed as making the care around them more recovery oriented (8), several authors have commented that part of becoming ready to accept CPs involves changing the entire culture toward a recovery orientation in which the utilization of CPs is one component (7,12,13,45).

Second, although many authors have commented that training is critical (4,10), the best training package for CPs must be determined. The types of training available for CPs inside and outside VA vary greatly, ranging from 30 hours to 28 weeks (46). Given the nascent state of evidence of the effectiveness of CPs, it is difficult for those who need training to know which training package would lead to the best outcomes. Reviewing the most effective topics, formats, and duration for CP training across existing sites—for example, through expert panels—would begin to shed light on this area.

Third, it would be prudent for systems contemplating use of CPs to establish a system of continuous quality improvement. This infrastructure would serve two purposes simultaneously. It would provide organizations with a system for evaluating how well CPs are performing and influencing patient outcomes. It would also allow standardized data to be aggregated to further develop a knowledge base regarding best practices in CP employment, including hiring, training, service delivery, supervision, and outcomes. These findings could be systematically disseminated though a variety of mechanisms, including practice collaboratives (47), brief reports, and conferences.

Limitations and future research

Some limitations of the current study should be noted. First, focus groups yield exploratory data, not conclusive results, and thus these findings should be interpreted with caution. Second, use of the conference as the vehicle for data collection resulted in groups that were larger than traditional focus groups and use of multiple facilitators. However, the opportunity to hear the experiences of 65% of all VA-employed CPs from across the United States and their supervisors outweighed the drawbacks of deviating from usual focus group procedures. Related to that limitation, sampling of traditional staff (that is, supervisors) was not as representative as was the CP sample and may reflect some bias; those who traveled to the conference more likely had favorable attitudes toward CPs than those who were not in attendance. Fourth, patients were not involved in the groups. Doing so could have provided additional insights into the use of CPs in these settings.

In addition to research on services that CPs currently provide, more prospective research is needed in which key aspects of CP services are purposefully tested. For example, prospective studies should assess different training options, different CP roles, placement of CPs in different settings, whether the CP is also a veteran (with or without combat experience), and the impact of these variations on patient outcomes. Also, although there is a small amount of literature that suggests positive impacts on CPs themselves—enhanced self-esteem, social approval, interpersonal competence, employment, and recovery (48,49,50)—much more can be done in this area. Finally, research should provide additional opportunities for providers to describe the challenges they experience employing CPs. CPs should not be looked upon as a panacea that will address all the challenges of facilitating recovery within public-sector mental health care but as one more resource to accomplish that goal. More research can help to elucidate the parameters within which CPs can be most effective.

Hiring and employing CPs involves several challenges. Improving CP implementation would be beneficial for several reasons. First, CPs have the potential to supplement usual mental health services and facilitate recovery of individuals with serious mental illnesses. Evidence of their direct impact on patient outcomes is mixed; difficulties encountered in employing CPs have made conclusions about their ultimate impact difficult to discern. Many CPs are already being hired and employed in and outside VA, and administrators need to fully understand the challenges and commitment in time, energy, and resources necessary to effectively utilize this type of peer support. This study distilled the comments of VA-hired CPs and their supervisors about their early experiences. These discussions produced useful insights into how best to manage the employment of CPs, both locally and nationally. This information could be useful to mental health managers in promoting the recovery of patients with serious mental illness.

Work on this article was supported in part by grant IIR 06-227, PEers Enhancing Recovery (PEER), from the Health Services Research and Development Service, Department of Veterans Affairs. The authors thank the Department of Veterans Affairs (VA) Employee Education System and the VAs Office of Mental Health Services for sponsoring and conducting the conference, "The Evolving Roles of Peers in VA Mental Health." They thank Brian Anderson, Darla French, M.S.W., Laurie Harkness, Ph.D., C.P.R.P., Greta Mankins, M.B.A., and Deborah Dorsey, M.Ed., for their work on the conference that led to the development of this article. They also thank the consumer-providers and their supervisors for attending and taking part in the focus groups described here. Any opinions expressed are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

The authors report no competing interests.