The Mental Health Commission of Canada defines peer support as "a supportive relationship between people who have a lived experience in common … in relation to a mental health challenge or illness … related to their own mental health or that of a loved one" (Sunderland et al. 2013: 11). In Ontario, a key resource for peer support is the Ontario Peer Development Initiative (OPDI), which is an umbrella organization of mental health Consumer/Survivor Initiatives (CSIs) and peer support organizations across the province of Ontario. Member organizations are run by and for people with lived experience of a mental health or addiction issue and provide a wide range of services and activities within their communities. The central tenet of member organizations is the common understanding that people can and do recover with the proper supports in place and that peer support is integral to successful recovery. Nationally, Peer Support Accreditation and Certification Canada has recently been established. The relatively new national organization focuses on training and accrediting peer support workers. This paper focuses on a range of diverse peer support groups and CSIs that operate in London and surrounding areas.

Peer Support in Region

A review of peer support programs in the South West Local Health Integration Network (LHIN) identified eight programs that were publically funded through the South West LHIN and operated by a CSI. The programs were assessed against promising practice criteria for peer support identified in the literature. The majority of South West LHIN peer support models used by CSIs were based on an informal peer support model or a walk-in centre. In addition, some of the programs also used a formal/intentional peer support model. However, since intentional peer support was often reported in the absence of formal matching (i.e., formal matching being a key element of formal peer support), it may be possible that the identification to a formal/intentional peer support model was used more broadly than intended. Table 1 below (Sunderland et al. 2013) denotes a spectrum of peer support models that range from friendship to clinical care. Peer support models used in the South West LHIN were more aligned to the friendship end of the spectrum of models (see Table 2) (Mings and Cramp 2014). The eight programs are identified by number only within the chart. In addition, most of the beneficiaries of peer support were identified through word of mouth, outreach and community referrals. In some instances, referrals were made by mental health professionals where some linkages were established, the majority of which were not formalized. The Transitional Discharge Model (TDM) research study implemented in the London area provided interactions between some of the CSIs and mental healthcare professionals and service organizations.

The major gap in the South West LHIN was the relative absence of peer support programs in workplace and clinical settings (e.g., community or hospital), although, with the introduction of the TDM studies, several partnerships had resulted between CSIs and professional services in hospitals. Once the two-year study grant (funded through the Council of Academic Hospitals of Ontario [CAHO]) came to an end, there were concerns that this type of model would not be sustained, despite positive health and system outcomes.

CONNECT for Mental Health

One example of a group providing peer support is CONNECT for Mental Health Inc. CONNECT is a non-profit peer support organization run by and for individuals who have been affected by mental illness. It was founded in 2007 by Michelle Solomon, who was driven by her own experiences with mental health issues and her own need for peer support. As a student nurse, Michelle started a group at the Fanshawe College Student Union, sharing her story and letting others know they were not alone. Her strong vision was to create a peer support organization in London. This was supported by other consumer/survivors, and in 2011, CONNECT became an official non-profit organization.

CONNECT's vision is to promote sustainable systems of support that enable individuals affected by mental illness to thrive and maintain wellness in the community. To do this, CONNECT embarks on a three-fold mission: 1) supporting individuals affected by mental illness, 2) educating a wide audience on relevant mental health topics, and 3) providing outreach to the community to help decrease stigma and promote early intervention of mental health disorders.

CONNECT focuses on engaging youth and young adult populations and maintaining face-to-face contact with individuals in the community. Meetings occur at the local library or coffee shop and in community spaces. There is an emphasis on "getting into action for mental health," where individuals are encouraged to be active participants and experts in their own recovery. Volunteers offer emotional support, support that encourages positive coping and self-management of mental illness. To date, CONNECT has more than 50 volunteers who offer both group and one-to-one peer support services. Volunteers are recruited through venues such as Kijiji and social media websites and are then trained in peer support through CONNECT and OPDI's peer support core essentials program.

Support

CONNECT provides peer support in group settings. The longest-running program is the weekly coffee "socials," where individuals drop in to gain emotional support from others who have "been there." There is also an eight-week recovery group, started in 2012, that addresses topics that promote self-management and the exploration of tools to help prevent crises and maintain wellness. This group occurs at the local Canadian Mental Health Association (CMHA). In 2013, CONNECT started a student support group at Western University for students in need of support with mental health and school.

CONNECT partnered with Lawson Health Research Institute, London Health Sciences Centre, and OPDI in 2013 to provide transitional support to individuals being discharged from the hospital. The TDM, funded by CAHO, expanded CONNECT's provision of peer support in the community. In this program, peer coordinators have a presence on the hospital ward, offering peer support to clients and also matching clients with volunteers who further support peers in the community after their discharge. Furthermore, in 2014, St. Joseph's Health Care's Parkwood Institute invited CONNECT to offer peer support to their clients, allowing CONNECT to provide support to individuals who are in hospital for longer periods of time.

Education

As a consumer/survivor voice, CONNECT works with organizations in the community to provide education to the public on topics concerning mental illness and recovery. From 2008 to 2012, CONNECT partnered with the London Public Library (central branch) to provide workshops on various mental disorders and mental health and to raise awareness about supports. To date, CONNECT partners with organizations who want to provide information and raise public awareness on mental health.

Outreach

In addition to working with community organizations to facilitate educational events, CONNECT has an outreach team, whose purpose is to connect with the community, particularly with youth, to decrease stigma associated with mental illness, promote early intervention and connect individuals to peer support. Volunteers share their personal experience with mental illness and recovery through public speeches. Venues include Western University and other public forums in the community.

In a community that is in need of various types of support for mental health struggles, CONNECT has seen an amazing response from its residents. People are likely to open up to individuals who have "been there," and in turn, gain emotional support, which places people with lived experience in an opportune situation to help. With the proper training, mentorship and financial support, peer support can be used to help people maintain wellness. The key to starting a peer support group is to listen to the needs of individuals, work with people who share the same vision for the group and foster leadership from people who are passionate about helping others. With a dedicated team and support from the community, anything is possible.

Tips for Starting a Peer Support Group from CONNECT

Vision: Create a vision for the group. What is the group trying to achieve?

Audience: Who is the audience?

Goals: What are the needs of the group and how will you meet those needs?

Guidelines/Contract: How will people share? Is everyone expected to share? What topics will not be discussed?

Facilitation: Are the facilitators trained in peer support? Is this training evidence based?

Topics/Discussion: Will there be specific topics? Are topics evidence based? Is discussion random or structured?

Crisis Management: How will adverse events be handled to maintain the safety of the group?

Boundaries: Participants are experts on their experience and don't give advice. Use "I" language. It's social support, not clinical support.

Local Innovation and Consumer/Survivor Groups Involvement in Research

CSIs have a long involvement in research generally. This is illustrated with the involvement in the TDM. The TDM is an evidence-based approach that includes both peer support and continued involvement of inpatient staff until a therapeutic relationship has been established with the community care provider (Forchuk et al. 2013; Forchuk et al. 2007a and b). It was originally developed through a participatory action research project, including front-line hospital and community staff, consumers who were currently hospitalized as well as ones who had successfully made the transition to the community, and researchers. The pilot ward was a long-term schizophrena program, where length of stay was typically many years. The concept of providing a safety net of relationships, both professional and through a peer friendship model, was the cornerstone of what people said they needed to make a successful transition out of hospital. All 38 inpatients on the pilot ward were successfully transitioned to community care (Forchuk, Chan et al. 1998; Forchuk, Jewell et al. 1998; Forchuk, Schofield et al. 1998; Schofield et al. 1997). TDM has since been tested in a number of wards. For example, in a randomized cluster study with 26 tertiary care wards (13 implementing TDM and 13 with usual care) across four hospital sites, the length of stay on the TDM wards dropped by 116 days per person (Forchuk et al. 2005). The TDM has been replicated in many places. For instance, after a successful randomized trial on acute care wards in Scotland (Reynolds et al. 2004; Sharkey et al. 2005), where the control group was more than twice as likely to be readmitted, the Scottish parliament declared TDM a best practice. More recently, TDM was identified as a best practice by CAHO (n.d.). CAHO supported an implementation project to extend the model. Two London hospitals (London Health Sciences Centre and St. Joseph's Health Care London), OPDI and local peer support organizations were recently involved, with the Lawson Research Institute as the lead site.

TDM was implemented in collaboration with OPDI on 14 wards (eight tertiary, six acute) in nine hospitals across Ontario. Peer support coordinators and volunteers/workers based out of CSIs partnered with participating hospital wards to offer the peer support component of the TDM. The average length of stay on the participating wards dropped by an average of 9.8 days, which freed up the equivalent of approximately $33 million. As well, consumers being discharged reported feeling better supported and less anxious in making the transition to the community.

Recent Regionwide Work

The South West LHIN has sponsored the development of a regional peer support strategy focusing on strengthening existing peer support models that promise practices while addressing identified gaps. This strategy is in alignment with Ontario's 10-year mental health and addictions strategy, which states, "An Ontario where all people have the opportunity to thrive, enjoying good mental health and well-being throughout their lifetime – an Ontario where people with mental illness or addictions can recover and participate in welcoming, supportive communities" (Ontario Ministry of Health and Long-Term Care 2011: 4).

A key South West LHIN peer support strategy is the development of partnerships between CSIs and mental healthcare programs in the community and in hospital. A stakeholder engagement process was used to identify the following hopes, aspirations and outcomes that stakeholders wished to achieve:

• Regionwide acceptance of peer support as a valid and effective intervention
• Availability of peer support wherever individuals are in their recovery journey – community, hospital, outpatient, work and school, as well as wherever they live in the region – urban, rural or remote locations
• Appropriate and sustainable funding to support implementation of models based on promising practices
• CSIs and mental health providers working in a true partnership – as true partners, peer supporters are part of the planning and ongoing oversight of mental health and addiction programs
• Standards for peer support practices linked with accountability
• Continuous support and improvement of existing peer support programs, while filling the gaps with new models where these are needed, such as models that include partnership with clinical agencies. Expand mandates of existing programs, where appropriate and feasible, to address gaps
• Peer support programs – no matter where they exist – in CSI or on mental healthcare teams – are part of a peer support network of sharing and learning

Areas of Focus and Goals

Stakeholders reflected on a set of promising practices identified through the literature and assessed their own peer support programs against these practices. The findings from the self-reflections, or self-assessments, of these programs were presented at an in-person stakeholder meeting. Through discussions and an exercise to rank priorities, the following four areas of focus were identified for the peer support strategy:

• Models of peer support
• Standards in training and investments in people
• Linkages and integrated processes with the mental healthcare system
• Governance and infrastructure support

The South West LHIN will be sharing the peer support strategy with our board in October 2015 to receive a motion to accept the report, recommendations and suggested next steps. Some readiness activities are already underway.

Conclusion

Peer support has a long and valued role within the London area as well as across the entire South West LIHN. The groups in the area have a strong history and are continuing to evolve to address the needs of people who experience mental health and addiction challenges. Many of the groups began as grassroots organizations. They tend to offer more informal forms of peer support. A major area of potential growth is with more formal arrangements with clinical services. An example of where this does occur is with the TDM, which encourages partnerships between psychiatric wards and consumer organizations. Some groups also have formal arrangements with the local CMHA offices, but these are often informal systems. Using evidence-based approaches, CSIs and peer support organizations in London, Ontario, as well as throughout the LHIN, are working together in partnership with others to provide strong support to individuals with mental health and addiction issues. The strong partnerships with CSIs and research have supported the evidence base, demonstrating the benefits of peer support.

Lessons Learned

• Consumer organizations that provide peer support often start as grassroots, volunteer organizations. As they grow and experience success, the need to look at funding increases. Start looking at diverse sources of funding as early as possible.
• Linkages and communication with the formal mental health system ensures that the consumer's voice is heard, provides support and increases referrals.
• Peer support organizations need to work together and provide peer support for each other. They have an unique role within the healthcare system and can provide concrete learning and assistance to each other.

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