The present Delphi study aimed at providing a framework for the effective implementation of peer support in mental health outside of the clinical setting and to establish whether this kind of peer support is capable of adding value to the recovery process. Consensus was reached for 38 statements in three rounds. The consensus on these statements is noteworthy: with one exception, all statements have a median score of 7 and over 85% of participants gave a score of 6 or 7 to each statement.
According to these statements, participants acknowledged that intentional, asymmetric peer interactions organized outside the clinical setting can be beneficial at various stages of the recovery process (at the beginning, continuously, towards the end, when returning to work), complementing clinical care. It can address different patient needs and offers added value for both the patients (empowerment and psychoeducation, hope and perspectives, support in case of difficulty, breaking isolation, empathetic listening) and the peer supporters themselves (self-esteem, reintegration).
However, for this kind of peer support to be recognized as a valid resource, participants agreed that a certain framework is needed, including logistical support (facilities), financial support (transportation or operational expenses, salary), and human resources support (integration into teams). Peer supporters should also be integrated into a network that can support them, especially in communication (raising awareness among the general public and healthcare professionals, communicating with patients with respect for privacy).
Participants found that intentional, asymmetric peer interactions organized outside the clinical setting should also be regulated, based on a job description defining the rights and duties (e.g., confidentiality) of the peer supporter and the boundaries of their role. This would improve the legitimacy, credibility, and recognition of the peer supporter among healthcare professionals (function integrated into the range of possible functions) and better identify their place when working with them. According to the participants, a clearer demarcation would protect both the patient and the peer supporter, reassure patients, employers, and other professionals, and reduce any stigma that peer supporters may still face. Additionally, it would facilitate a discussion on fair remuneration for peer supporters (establishment of pay scales). An important requirement to be able to be recognized as a peer supporter, is the idea that peer supporters should undergo training including practical elements of communication and group dynamics, ethics, networking skills, and elements related to the well-being of the peer supporter (including knowing how to set boundaries and maintain a professional distance from personal experiences). To maintain their recognition, peer supporters should also participate in peer supervision, and ongoing training.
Statements on which there was insufficient agreement highlighted some specifications. For example, it is essential to clearly define the role of the peer supporter, particularly regarding their role in the healthcare system. While participants agreed that peer support can be a complementary resource in the healthcare system, especially in addressing gaps or issues in conventional care (e.g., waiting lists, patient distrust, breakdown of communication), they emphasized that this should not be the primary role of peer supporters. According to the participants, it is the responsibility of the conventional healthcare system to address potential gaps and resolve these issues instead of relaying these problems to peer supporters. The specific added value of peer supporters lies in being a peer and this specificity should be protected.
While some sort of regulation of the term peer supporter is deemed necessary by the respondents, overly stringent requirements for becoming a peer supporter also form a potential risk. Some participants voiced the concern that stringent requirements may also lead to the exclusion of people with valuable experience. They, therefore, emphasized the importance of striking a balance between the need for regulation (especially to protect patients and peer supporters) and the preservation of the informal and accessible nature of peer support. A solution that was brought up, is to explicitly distinguish peer supporters who play an explicit role in the healthcare system from other forms of support that operate independently outside of that framework (e.g., self-help groups). All kind of support (individual or group) naturally exist and do not all need to be regulated. It is, particularly, asymmetric peer interactions organized outside the clinical setting that would benefit from regulation.
There were also divergent views regarding remuneration and training conditions. While study participants agreed that remuneration adds value and can motivate peer supporters contributing to their sense of recognition and integration into society, some participants also expressed concerns about potential additional pressure on peer supporters. They also specified that remuneration should not be the main motivation for becoming a peer supporter. Additionally, participants emphasized the importance of not remunerating all types of peer support. It is, therefore, essential to define remuneration based on the recognition of specific peer support types. Regarding training, participants agreed that training conditions should be defined for peer supporters, but they also emphasized that personal experience is crucial for peer supporters. Indeed, the authenticity of personal experience facilitates establishing connections with the patient. Personal experience is and continues to serve as the foundation for fulfilling the role of a peer supporter. Some participants, therefore, suggest adopting a balanced approach, in which personal experience is valued as much as structured training. Training should mainly focus on practical elements (e.g., communication and group dynamics), with theoretical knowledge (e.g., mental health theories, principles of psychology) addressed by other healthcare professionals. Furthermore, efforts should be made to promote communication and mutual understanding between peer supporters and conventional healthcare professionals by coordinating training in which both groups are present.
Limitations
The Delphi study has several strengths and limitations. Notable strengths include broad consultation and widespread dissemination of the call, along with the involvement of various target groups.
However, the participation rate among certain target groups, particularly patients, was rather limited. As with all iterative research designs, there is a risk of participant dropout. While it is common for 20 to 30% of participants to discontinue between rounds (Chalmers & Armour, 2019), our study saw a dropout rate of 39% between rounds 1 and 2, and 32% between rounds 2 and 3, which is slightly above the expected range. Despite this, the proportion of various expert categories was evenly distributed across rounds, suggesting no attrition bias in the outcomes. Additionally, although the interpretation of peer support was clearly defined at the beginning of the survey, it may have led to different interpretations within the diverse group of participants. The use of different terms ("peer supporters," "lived experience experts," and "peer experts") throughout the statements could have prompted varied interpretations and responses, potentially causing confusion about the different roles and types of peer support addressed in this study. Furthermore, the formal scientific approach adopted in the Delphi study, while systematic, may have resulted in some limitations. Research on patient participation in scientific research highlights the value of involvement but also underscores challenges such as the need for training and education before participation, attention to facilitating factors, and potential obstacles like individual and structural barriers and interaction issues between researchers and patients, which were less emphasized in the current study.