Shared Decision Making and Peer Support: New Directions for Research and Practice

Peer support and shared decision making (SDM) in mental health care have increasingly been framed as central to high-quality treatment of mental health conditions. Peer support interventions and SDM have some conceptual similarities; both intervention areas evolved in response to a history of coercion in psychiatric care, along with narrow treatment options, limited opportunity for self-determination, and little real choice of treatments and services. Peer support and SDM emphasize person-centered support, better person-defined outcomes, and autonomy and recovery as major goals. Therefore, integration of peer support and SDM within psychiatric services, in the form of peer-facilitated decision support interventions, is seen as a best practice.

However, outcomes of peer-facilitated decision support interventions have been largely confined to improved communication between client and provider. As a result, the uptake of these interventions has been limited (1), because, unlike clinical providers, peer support workers are not the ones involved in SDM regarding clinical treatments, which are the common form of contemporary SDM interventions and tools in mental health. The limited impact and infrequent use of peer-facilitated decision-support interventions can be attributed to the fundamental differences between peer support and SDM. These differences are often overlooked or misunderstood in research and practice. In this commentary, we discuss the challenges of using contemporary peer-facilitated decision support interventions to achieve SDM. We also offer new directions for incorporating peer support workers in SDM that will enhance their value as independent advocates via future peer-led SDM interventions for social prescribing of nonclinical services.

Challenges With Peer-Facilitated Decision Support Interventions

To understand the challenges with peer-facilitated decision support interventions, we first need to understand what SDM is and which SDM interventions are common in mental health care. SDM is a health communication process requiring at least two autonomous decision makers or advocates: a client, who draws on lived experience of mental health challenges and use of psychiatric services, and a provider, who is a knowledgeable and certified content expert for the decision at stake (2). Most evidence-based SDM interventions focus on clinical decisions, primarily in regard to psychiatric medications, and few address decisions about mental health therapies or services (1). Therefore, the nature of the SDM process makes it difficult to integrate peers, because it requires providers with clinical expertise who understand the scope and content of common SDM interventions, which is on clinical decisions. Because many peer support workers are neither certified prescribers nor mental health providers, not all have lived experience with medications or other clinical treatments (which are the main therapies at stake in common SDM interventions), and most are not involved in independent advocacy, peers often can offer only a role as decision supporters rather than as a prescriber or decision maker. Deegan’s pioneering work on CommonGround (3) is a well-known model of such peer-facilitated decision support interventions that has laid the groundwork for other models. However, the absence of peers from the discussion table when these interventions are considered, and their role as second fiddles, may explain the limited impact and poor uptake and implementation of contemporary peer-facilitated decision support interventions, as described by Thomas and colleagues (4) in a special article in this issue of the journal.

Peer-Led SDM for Social Prescribing

A new framework for integrating lived experience in SDM is needed, where peer support workers can have an equal seat at the table with real authority to contribute to decisions in their area of expertise, which is the lived experience of accessing psychiatric services and being in recovery. To achieve this goal, we must work in three directions. First, in some organizations, where demonstrated commitment has been made to authentic peer work, peers are more enabled to take on the essential role of advocate rather than feeling implicitly or explicitly coerced to align or agree with the clinician’s perspective (5). Additionally, the results of independent peer advocacy are promising. Independent peer advocates work at the behest of the person accessing services and support that person to become more active, self-confident, and self-determined during discussions with clinical providers, fitting with the fundamental principle of any SDM intervention to “eliminat[e] power asymmetries between clinician and patient” (2).

Second, following from the need for the peer role to exist within a work culture that supports authentic peer practice, SDM needs to occur within a culture that values and respects lived experience and expertise for the decision to be truly shared. Clinicians need to be trained in and understand the principles of meaningful coproduction, including sharing power, not only with peers but also with their clients (6). For many clinicians, this understanding may entail a significant philosophical shift and needs to be prioritized in ongoing and revisited learning.

Third, the field should develop new evidence-based SDM interventions that focus on social prescribing of nonclinical services (described below), where peers can fully participate as decision makers, providing advice and guidance about various services and opportunities on the basis of their lived experience. In this approach, by using lived experience, peers can help spread the word about nonclinical mental health services or provide personal examples of alternative forms of care that have helped them. This approach further ensures that the decision options provided to people who access services are not inherently biased toward a biomedical approach, thereby decreasing the risk for peers being complicit in promoting clinical treatments.

Social prescribing, an emerging concept, describes the prescription of nonclinical services in the community (e.g., housing subsidies, walking clubs, and cycling) to improve health and well-being (7). Although social prescribing is currently centered on licensed professionals in primary care settings, the decisions at stake are nonclinical per se, making social prescribing an ideal area for peer workers to flourish as shared decision makers. In social prescribing, the referral is first made from a licensed professional, who usually prescribes medical treatments, to a link worker to “coproduce a simple plan . . . based on the person’s assets, needs and preferences” (7). Link workers prescribe a nonclinical service, or refer the client to such services, after engaging in SDM with the client to elicit preferences and personal choices. The development of new peer-led SDM interventions for social prescribing of nonclinical services gives peers a central role and emphasizes the power of lived experience and the value of personal stories and experiential knowledge of living with mental illness and using psychiatric services. Peer-led SDM in social-prescribing interventions offers promise for optimizing mental health services and empowering and supporting the recovery process of peer providers and the people for whom they provide care.

Conclusions

The involvement of peer workers in SDM is more than an ethical imperative to promote recovery, eliminate coercion in psychiatric care, and enhance self-determination and choice. Peers have experiential knowledge of living with a psychiatric diagnosis. Such lived experience can include the actual impact of using psychiatric treatment and services, facing stigma and discrimination, having limited or no voice in decision making and treatment options, and ultimately discovering a personal path of healing that may include a wide range of activities beyond traditional treatments. Growing advocacy roles, along with lived experience, make peers central to SDM for nonclinical services, where their experiential knowledge is an expertise. New, exciting, and unexplored directions and opportunities to centralize, and better use, peer support lie in the development of new peer-led SDM for social-prescribing interventions, which will allow peer support workers to truly engage in SDM and to effectively support clients in their personal journeys to recovery.