Peer Wellness Coaches for Adults With Mental Illness
With the groundswell of attention on mental health recovery and consumer-centered care, consumer providers in mental illness (or “peers”) are working in various mental health settings. However, there has been too little information regarding introduction of peers into treatment settings. Our group has developed a comprehensive program to hire, train, place, and support peers as wellness coaches.
As wellness coaches, peers support an online weight management curriculum specifically for the cognitive needs of people with serious mental illness. The curriculum is accessible to consumers via the Web and via interactive kiosks in the clinic. Kiosks are similar to those used for self-service airport check-ins and feature touch-screen interaction. The interface provides audio to read the questions aloud to the patient while the text appears on the screen and provides pictures and text for response options. The kiosk prints a color report that patients and others can use to advocate for services during the clinical encounter and to track progress.
Coaching through the curriculum is delivered by peers in person for the first session and then weekly by phone for six months. The coaching is strengths based and uses motivational interviewing principles. This clinical service—weight management education supported by peer coaching—is delivered as part of a comparative effectiveness trial in a usual care setting.
In selecting peers, we recruited adults with lived experience with mental illness and experience as a consumer provider or health navigator. It was important to assess applicants’ willingness to learn and practice new skills and to receive ongoing supervision. The five peers who were hired had notable personal strengths and remarkable stories of recovery, but they lacked computer skills and recent employment.
We developed a peer coaching manual that includes information about the online weight management program, coaching session content and techniques, and procedural roles and responsibilities (available from the authors). This manual was designed to support consistent delivery of services across peers. Peers received didactic training in the manual and experiential training in coaching. Experiential training started with peers joining a master therapist for live coaching sessions and then leading these sessions. When the master therapist considered peers ready to coach independently, peers began to deliver the curriculum themselves. We found that the training period lasted, on average, five months, which was longer than expected. The skills needed to deliver high-fidelity coaching required considerable cognitive flexibility to switch effectively between the manualized coaching protocol and each consumer’s weekly diet and exercise status update. There was much discussion and practice focused on balancing the educational material with variable progress by the consumers. As well, each peer’s lived experience, which is highly personal, could not be part of the manual but was important to incorporate into the curriculum.
Once peers were ready to deliver services, individual supervision was provided weekly. Supervision includes time for both clinical issues and professional development. In addition, a master therapist is available on a daily basis for emergent issues. Clinical supervisors audit two coaching sessions a week to rate fidelity and emphasize benchmarks for session content. Without exception, supervision proved to be a challenge to peers at first; adjusting to considerable feedback on their coaching style and content of their calls was a process. Substantial time was spent understanding each peer’s lived experience. Any facilitated reshaping of personal experiences so that they could be used effectively in the coaching relationship was, at times, emotional and difficult for the coaches but possible in all cases. Peers’ skills, experience, caseload, and job responsibilities are regularly addressed in supervision.
Since the program’s inception in March 2012, 74 of 81 enrolled consumers have engaged in the wellness program; many have lost considerable weight. Consumers have commented that their coach “understands me” and “sticks with me whether or not I’m losing weight.” Consumers who have dropped out have typically reported financial barriers related to affording healthy foods. None of the consumers have reported that they were leaving the program due to their peer coach. Peers have reported feeling empowered by their capacity to support and motivate consumers in regard to weight issues. Various challenges have also been acknowledged by peers, including working with difficult consumers and following the coaching manual. Peers reported that it is helpful to have “a peer team that works really well together, where we can bounce ideas off each other and talk to each other if we have a hard call.”
Delivering best practices while capitalizing on peers’ experience is not easy but is worth the effort. Peers extend the treatment team by engaging and supporting consumers who might not have participated in a program delivered solely by clinicians. Employing peers also allows for a mutual learning environment between clinicians and consumer providers. Clinicians involved in training and supervision of peers should anticipate effort proportional to the peer’s presenting skills and mental health recovery. Although approaches to peer services vary, our experiences may inform a framework for those considering peer services.
