Barriers to and Facilitators of Implementing Peer Support Services for Criminal Justice–Involved Individuals

Peer support services are provided by individuals with lived experience of mental health conditions who draw on their own recovery to provide support to others (1). A rapidly growing subset of peer services is forensic peer support (FPS), which serves individuals with mental health conditions who are involved in the criminal justice system (2–5). FPS uses peer support workers who draw on their dual lived experience of mental health conditions and involvement in the criminal justice system to provide support services to others with a similar history (4). Despite the growth of such programs, little information is available to inform the development of best practices for adopting, implementing, and sustaining these programs. In this article, we explore the unique factors serving as barriers to and facilitators of the implementation of community-based FPS services.

Peer Support Services and Implementation

Peer support workers report a wide range of activities and skills, including sharing recovery stories; helping with goal setting; completing wellness-related tasks; conducting advocacy; supporting integrated care; providing crisis support; facilitating groups; building community; and providing vocational, housing, and benefits assistance (6, 7). Although evidence of clinical effectiveness of peer services has been mixed (8–11), such services have been associated with increased hope, recovery, empowerment, and quality of life (8, 11, 12). The broader mental health peer support workforce has undergone rapid expansion over the past decade, with most states now supporting Medicaid reimbursement for individual peer support services (13).

As the peer workforce expands, there is an increasing need to identify and address factors related to service implementation. Current literature on the implementation of peer support services draws heavily on the perspectives of peer specialists themselves (14–20). Peer workers’ perceptions of barriers to implementation include stigma; negative attitudes among nonpeer workers; confusing role boundaries; lack of resources, compensation, and role clarity; inadequate policies; and organizational impediments (14). A recent systematic review identified 14 independent influences on peer support implementation, including organizational culture (reported in 53% of reviewed articles), training (42%), role definition (40%), staff willingness and ability to work with peer workers (34%), and resource availability (21%) (16). Efforts have been made to understand factors related to the implementation of peer support services in unique settings, including the U.S. Department of Veterans Affairs (VA), the Veterans Health Administration (VHA), and integrated care settings (18–20). These studies have found implementation barriers similar to those observed in more general peer support settings. However, far less is known about FPS implementation.

FPS

Individuals with mental health conditions are overrepresented at all stages in the criminal justice system. Diagnosis of a major mental illness in the year before an arrest is associated with a 50% increase in the odds of a jail sentence for individuals arrested for misdemeanors (21). Approximately half of state prison inmates have a diagnosable mental illness, including 29% with a serious mental illness (22). Rates of serious psychological distress among probationers and parolees are two to three times higher than among individuals in the general population (23). FPS is designed to service this large and hard-to-reach population (2–5). Although FPS is similar to peer mentoring, an increasingly common feature of the criminal justice system in the United Kingdom and elsewhere (24, 25), FPS typically requires lived experience of a mental health condition.

FPS services have been studied in three U.S. states: Ohio (26), Texas (27–29), and Pennsylvania (3, 30). Peer specialists in the Texas reentry program support incarcerated individuals through the reentry process from county jails, focusing on relationship building and entry into community-based care (29). In-jail FPS specialists in Pennsylvania work with individuals 90 days before their release, and community-based FPS specialists are paired with reentering citizens during their release into the community to create and implement recovery-oriented service plans (30). In Ohio, FPS specialists are based in a psychiatric hospital (26).

FPS workers’ lived experience of criminal justice system involvement is a critical component of the work (28, 31). Barrenger et al. (31) have found that workers sharing their lived experiences forms the very basis of FPS work, resulting in engagement, priority of relationships, instillation of hope, and provision of alternative services. However, structural barriers related to housing and health care impede FPS specialists’ ability to address client needs (28). FPS work has indicated impacts on recidivism, arrests, criminal planning, and criminal acts, although not on behavioral health, housing, or employment outcomes (27, 30).

RE-AIM Framework and the Current Study

The RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework (32–34) is used to evaluate public health interventions along five dimensions: reach, effectiveness, adoption, implementation, and maintenance. It has been used to understand peer service implementation (18). Our study data did not speak to the first two dimensions; therefore, we drew exclusively on the final three. “Adoption” refers to representativeness and patterns in settings that adopt innovative changes. “Implementation” assesses individual and program-level adherence and fidelity (32). “Maintenance,” or long-term sustainability, is the extent to which these changes become part of standard organizational practice (34).

This article drew data from a community-partnered, mixed-methods study of FPS in Pennsylvania. Previous work with these data has revealed that there are far fewer employed FPS specialists than individuals trained in FPS (3). FPS positions are often short term, and many trained FPS specialists have never personally been in the criminal justice system (3). These findings highlight the need to understand barriers to and facilitators of service adoption, implementation, and sustainability. Although the original study was not designed to assess implementation, here we drew on and extended the initial programmatic report by focusing on FPS implementation factors emerging from qualitative data. Our aim was to identify and describe barriers to and facilitators of FPS adoption, implementation, and sustainability.

Methods

Study Sample

Six peer organizations across the state of Pennsylvania distributed an online survey for peer specialists with FPS training. In total, 117 community-based peer specialists completed the survey, including 25 FPS specialists and 19 individuals who had previously worked as FPS specialists. Fewer than two-thirds of survey participants reported lived experience of criminal justice system involvement; 96% reported having ever used mental health care services. Current or past FPS participants with past criminal justice system involvement were invited to complete an in-person interview; additional interviews were conducted with other randomly selected respondents. Nine interviewees were currently employed as FPS specialists and seven had previously been employed as FPS specialists. All interviewed peer specialists (N=37) reported a past mental health condition and involvement in the criminal justice system. Peer specialist participants were 26–72 years old (mean=50 years). Twenty peer specialists identified as White, 14 as Black, and two as Latinx. Seventeen identified as female.

Stakeholders were recruited through community collaborators, Internet searches, cold calling, and snowball sampling. The large majority of recruited stakeholders expressed interest in study participation. Stakeholders (N=14) included peer program supervisors and coordinators, directors of advocacy organizations, activists, and a prison administrator. Stakeholders were employed in a variety of settings, including mental health advocacy organizations (N=3), local mental health departments (N=3), and regional consumer-run organizations (N=4). Five stakeholders were past peer specialists, three had facilitated FPS trainings, and two had developed FPS training curricula. Nine identified as female, and five worked in Philadelphia. To maintain confidentiality, stakeholder race and age were not reported. Written informed consent was obtained from all participants. The study was approved by the Northeastern University Institutional Review Board.

Study Design and Setting

Semistructured interviews with stakeholders (N=14) and FPS-trained peer specialists (N=37) (3) were conducted between July and November 2016 as part of a larger mixed-methods study of FPS in Pennsylvania. The community-based participatory research–informed design included collaboration with peer specialists at two different organizations throughout the research process, including input on project design, recruitment, and initial interpretation of the results. Pennsylvania developed one of the nation’s first statewide FPS training curricula in 2010. FPS programming in the state began through a cooperative project funded by the Office of Mental Health and Substance Abuse Services and the Pennsylvania Commission on Crime and Delinquency in 2011 (35). FPS specialists in Pennsylvania work in several settings (including state hospitals, jails, prisons, courts, and the community) and with individuals across multiple stages of criminal justice system involvement (35).

Data Collection

The first author (W.E.A.) conducted all interviews in person from July through November 2016. Most interviews were completed in 1–1.5 hours. Respondents were compensated with a gift card. The interview protocol was developed with the interview protocol refinement (IPR) framework (36). Both authors conducted the first three of the four-phase IPR process: aligning interview questions with research questions, constructing inquiry-based conversation, and receiving feedback and piloting the protocol. Although the interview guides differed somewhat for stakeholder and peer respondents, each guide contained implementation questions, including “How did FPS specialists come to be part of this organization/community?” “How has the field developed and changed in your organization . . . community . . . Pennsylvania . . . the United States?” “What concerns do you have about the field and its development?” “What will happen to the FPS workforce in the coming years?” and (for those not currently employed in FPS) “Why are [you] no longer employed in FPS?”

Data Analysis

Interviews (N=51) were recorded and transcribed verbatim by a professional transcription service and reviewed for accuracy by the first author (W.E.A.). The first author conducted coding of all transcripts, and the second author (A.K.L.) coded select interviews to confirm reliability. Both authors met to compare the double-coded interviews and discuss and clarify disagreements until reaching a consensus. Cases were defined by demographic and occupational variables.

The data were analyzed in two steps. First, we conducted a thematic analysis (37) of both inductive and deductive codes, beginning with an a priori template of codes based on theoretical frameworks and research aims, followed by emerging codes. The codebook consisted of codes applicable to all interviews and codes used exclusively for stakeholder or peer transcripts. Analyses were conducted iteratively with qualitative NVivo for Mac software, by linking codes and subcodes to specific textual segments and with multiple codes frequently attached to the same text. Implementation factors emerged as important themes during the initial thematic analysis. Therefore, a second analysis step was taken to clarify these themes; interview transcripts were deductively recoded by using directed content analysis (38, 39). The first author recoded all applicable text (extracted sections based on the thematic analysis coding) by using three a priori codes and subcodes based on the RE-AIM model. The results reported below focus on barriers to and facilitators of the adoption, implementation, and maintenance of FPS, highlighting differences from general peer services when appropriate.

Results

Adoption

Table 1 summarizes the results. Participants involved in the successful introduction of FPS services identified buy-in from sympathetic gatekeepers in the criminal justice system as a central facilitator. A program manager who was integral to launching FPS services in his community described the process:

As illustrated by the quote, service introduction requires buy-in from mental health system gatekeepers and recovery-oriented gatekeepers in local criminal justice system facilities. Funding is a barrier to FPS service introduction in ways that differ from funding-related barriers to other peer support services. Peer support services are Medicaid reimbursable in 41 states (40), including Pennsylvania. A main challenge with implementing FPS is that many incarcerated individuals in Pennsylvania are not eligible for Medicaid; individuals released from incarceration frequently encounter barriers to enrolling (or reenrolling) in Medicaid: “When we talked to the warden, he was very open about the idea of peer support within. . . . But then the barrier came of ‘who’s going to pay for it?’” (participant 045). Therefore, even when recovery-oriented gatekeepers exist, lack of access to traditional peer support–funding mechanisms presents a substantial barrier to the initial adoption of FPS.

Implementation

Two factors present significant barriers to FPS implementation: the philosophical divide between peer support and the criminal justice system and FPS specialists’ criminal justice histories. The philosophical mismatch between recovery-oriented peer support services and the criminal justice system impedes successful FPS service implementation. The recovery paradigm emphasizes individual self-determination, hope, and connection (41), values that are central to peer support. Conversely, participants described the criminal justice system as punitive and dehumanizing. This philosophical divide further compounded the inherent challenge of cross-system collaboration. “What ends up happening is we get all these people at the table . . . everybody’s ego gets involved. ‘We’re the Pennsylvania Department of Corrections, and we want your program to do this!’ Then you have the mental health advocates, ‘We want it to do this!’” (participant 023). Respondents reported that philosophical divides and organizational power struggles obstructed service implementation.

Moreover, a history of criminal justice system involvement restricts the hiring of individuals qualified to provide FPS. Although shared lived experience is a fundamental value of peer-delivered services, respondents reported that lived experience of criminal justice system involvement can be a substantial formal and informal barrier to employment. Peer specialists are frequently restricted from working in facilities where they were previously incarcerated. One peer respondent shared that

As a result of these barriers, some organizations are hiring FPS specialists without a history of criminal justice system involvement, thus abandoning the fundamental peer principle of experiential knowledge (42). As a program director admitted, “We have not hired people because they couldn’t go in the jail. It defeats the purpose in a way” (participant 021).

Maintenance and Sustainability

Many long-term facilitators of FPS sustainability are similar to those most important for services adoption: funding and buy-in. Here, we discuss the role of nonpeer FPS coworkers in the criminal justice system and the limitations of grant funding. Although buy-in from high-level recovery-oriented gatekeepers is required for the introduction of FPS services, service delivery sustainability also requires relationship building with workers on the ground within the criminal justice system. As one FPS specialist remarked, “It’s not so much the people at the top that you’ve got to build the rapport with. It’s the people that do the day-to-day work” (participant 033). Although gatekeeper buy-in facilitates service introduction, peer specialists’ rapport with on-the-ground workers (including correctional officers) has an impact on how well the specialists deliver services. On-the-ground criminal justice system workers sometimes discriminate against FPS workers on the basis of their personal history of justice system involvement and philosophical differences between recovery and punitive paradigms.

In addition to presenting a barrier to initial service adoption, insufficient funding also is a barrier to long-term service sustainability. Medicaid, as discussed above, is the most common funding mechanism for peer services in Pennsylvania, but it is difficult to use for FPS. Therefore, several regional organizations secured grant funding to implement and operationalize FPS services in their area. Indeed, community-based FPS services in Pennsylvania appear to be funded primarily through nonsustainable mechanisms such as grants. However, unlike Medicaid, grant funding runs out. Once the grant terminates, the program often does too. According to a peer supervisor (participant 047), FPS specialist roles are “so limited that they’re not making what I would mark as a significant impact because the only way you get into that role is through grant funding,” which is only short term. One ex-FPS specialist explained that FPS employment was too precarious. He had been laid off as a result of FPS program closure after a grant ran out. Although a second grant was later obtained and the organization offered to hire him back, he declined in order to stay in a secure Medicaid-funded position.

Discussion

Peer Support Implementation and FPS

Drawing on the RE-AIM framework, we used these findings to build on the existing FPS literature to better understand FPS implementation and expand the scope of inquiry to include its adoption and maintenance. Although much peer support implementation literature has focused specifically on service implementation, Shepardson and colleagues’ article on implementing peer support in integrated settings in the VHA found that stakeholder buy-in and visibility are crucial factors in adoption and that evidence of success facilitates service sustainability (18). Data from the present study agree with these authors’ findings. Buy-in by criminal justice system stakeholders was critical to FPS adoption and implementation. Funding presents a substantial barrier to the initial adoption of specialized services, as has been the case with the VA (20) and now with FPS.

Organizational culture and staff willingness and ability to work with peer workers were two factors identified in a recent systematic review of peer support implementation (16) as playing a significant role in FPS services implementation. This observation maps neatly onto our findings that the chasm between recovery and punitive paradigms is a substantial barrier to FPS implementation, upheld by on-the-ground criminal justice system workers resistant to working alongside peer specialists.

FPS in Context

Our findings reflect and extend recent research on policy barriers to mental health services for people involved in the criminal justice system. Although peer services are reimbursable by Medicaid, many individuals involved in the criminal justice system are not covered by Medicaid. Medicaid coverage varies among states: 31 states temporarily suspend Medicaid enrollment for enrolled inmates during their time in correctional facilities, and 19 states, including Pennsylvania, terminate coverage altogether (43). Medicaid coverage termination for incarcerated individuals impedes continuity of care on release into the community (44) as well as the development and sustainability of FPS services.

It is also critical to address the formal and informal barriers to employment faced by individuals with a criminal history in gaining peer employment. Lived experience is fundamental to the principles of all peer support provision (42). Studies of FPS have indicated that workers’ lived experience of criminal justice system involvement is the very basis for reentry services (28, 31). Yet lived experience of the criminal justice system can be a barrier to FPS employment. Policy changes aimed at removing barriers to employment for ex-offenders, including employment in criminal justice settings, are needed to facilitate peer employment opportunities.

Conclusions

Our findings provide important knowledge needed to support the continued growth and success of FPS services. On the basis of the evidence presented here, we propose three main strategies. First, more research assessing both recovery and criminal justice–focused outcomes related to FPS programming is needed to bolster limited existing evidence (27, 30), increase stakeholder buy-in, and broaden funding potential. Second, funding stability and sourcing need to be addressed, which may include new joint or blended funding models across mental health and criminal justice sectors. For example, the Pennsylvania Department of Corrections supports a Certified Peer Specialist Program in which incarcerated individuals are trained and employed in state prisons (45). Finally, the results of the present study, along with the substantial literature on the broader implementation of peer support related to stigma and role confusion (14, 16), suggest that criminal justice system employees be trained and introduced to peer workers before service implementation. Despite the barriers we have identified here, substantial evidence indicates that FPS services are increasingly being adopted, implemented, and sustained throughout the United States (27, 30, 31) and will continue to expand.