On a February day 15 years ago Paul Bradford took himself to a local emergency room. Bradford felt agitated and confused; he and his wife thought he needed professional help. To his surprise, two large men came into the waiting room, grabbed him by the arms and hustled him into a treatment room. Petrified, Bradford asked his wife to stay with him, but he says the security guards forced her out, tied him to a gurney and gave him a sedative that knocked him out for 18 hours. He awoke in a locked ward, where he was kept for more than two weeks.

Bradford's doctor diagnosed him with manic depression. Although he has not had an episode since this incident, the care he received as a psychiatric patient left permanent scars. “The experience of mistreatment,” he says, “was far more of a trauma to me than the mental illness.” Instead of forcible psychiatric treatment, Bradford believes what he really needed was someone to comfort him through the terrors of his psychosis and help him get some restful sleep.

His experience made him so angry that he abandoned a career as a computer programmer with a $75,000-a-year salary for an entry-level position as a mental health peer counselor, where at first he made less than $12,000 for part-time work. Still, delivering the kind of care he wishes he had received has been therapeutic. “It was the smartest move I ever made,” says Bradford, now a full-time peer specialist at a psychiatric firm.

Peer specialists such as Bradford have been providing mental health care since the early 1990s, when a few community health centers started hiring former patients who had spontaneously been counseling their peers. These former patients (who also go by “peer counselors” or “peer supporters”) act as coaches, advisers and mentors to people who are struggling or facing hospitalization.

Although peer specialists encountered a lot of hostility in the early days and their acceptance is still mixed, they are now a routine part of mental health care. In several states, Medicaid reimburses for their services, and most major mental health providers have at least one peer specialist on staff. Yale University psychologist Larry Davidson, who has studied this practice, says that peer specialists seem “to provide a pathway for people who would otherwise not have engaged in care and who would otherwise not have benefited from the treatment.” And in the process, the presence of peer specialists challenges the traditional model of mental health treatment.

First, do no harm

When peer specialists first began to participate in care, many clinicians doubted their benefits. Therapists worried that allowing people with mental health diagnoses to coach others was unsafe. Health care workers feared that peer specialists lacked sufficient training and might even be a bad influence on those in treatment, teaching people how to evade the system.

Early investigation allayed some of these fears, finding no significant downside to peer specialists. Gradually some researchers even found benefits—for both patients and peers. In a 1998 six-month pilot study in Pennsylvania, 10 severely mentally ill people who had peer counseling in addition to intensive case management experienced fewer crises and were significantly less likely to be hospitalized than 51 other individuals who received only intensive care. People with peer counselors also reported better quality of life and improvements in their physical and emotional well-being.

In addition, counseling seemed to help the peers themselves. This is perhaps not surprising, given the fact that helping a fellow sufferer is a long-established principle of many recovery approaches focused on addiction, such as Alcoholics Anonymous. In a 1991 study 15 people who served as peer specialists for two years spent only two days during that time period as hospitalized patients—a rate far lower than most people that are diagnosed with serious mental illness. Indeed, the satisfaction that individuals in recovery can obtain from helping others informally often prompts them to pursue part- or full-time positions as peer specialists.

Bolstered by these early findings, the movement quickly took off. Experts at the International Association of Peer Supporters estimate that there may now be some 12,000 peer specialists in the country.

Unanswered questions

Today peer specialists coach people receiving treatment in three basic ways: as an addition to existing services, as substitutes for clinical staff and instructors, and as teachers. In different settings the nature of their involvement varies. Typically a case manager will assign peer support to individuals who they believe could benefit from someone's guidance. Yet much about their role remains undefined.

A qualitative investigation from 2014 by researchers at the Center for Health Policy and Research at the University of Massachusetts Medical School suggested that this ambiguity could be problematic. The team interviewed 44 peer specialists, 14 of their supervisors and 10 people diagnosed with mental illness whom a peer specialist was counseling. The specialists described themselves as being in a position to bond with a client and aid in recovery by sharing common experiences.

The researchers also found, however, that peers were unsure of their place in the system—and supervisors did not know how to guide the peer specialists in their charge. Although many states have certification requirements, no national standards exist for training or evaluating peer counselors. Such ambiguity heightens the tension between people who have long been a part of treatment and these relative newcomers.

The nebulous nature of the peer specialist's role has led some advocates to question whether mental health agencies might abuse this system. Activist and filmmaker Sera Davidow, director of the peer-run Western Massachusetts Recovery Learning Community, suspects that peer specialists are increasingly hired to be coercive voices in the treatment process. She believes that conventional treatment providers rely on peer supporters to earn the trust of and draw information from reluctant clients.

Another unresolved question involves cost. Peer specialists could either add to the expense of mental health care by teaching people how to use more services or save money by preventing hospitalizations. Most peer supporters are part-time staff employed by a health care provider, and they may earn anything from zero to $70,000 a year. And in certain cases, peer support is being used to provide cheaper care than offered via a traditional specialist.

As a result, evaluating the overall efficacy of peer care is difficult. A 2013 review from the Cochrane collaboration, a nongovernmental organization that evaluates medical research, explored the use of peers working in professional roles or whose services were added to traditional treatments. Across 11 experiments, they found no significant differences in most measures of success between people who had worked with peer specialists and study participants who did not have peer support. Yet these findings may reflect the fact that the methodology of the studies, according to the reviewers, was of “moderate to low” quality, with many studies failing to control for the possibility of bias in the subjects' reporting.

In 2014 a group of researchers led by Matthew Chinman of the U.S. Department of Veterans Affairs came to a more positive conclusion. Although their review of 20 studies also uncovered research weaknesses, Chinman and his colleagues found that in most cases, adding peers to traditional services delivered more benefits than traditional services alone. The advantages included reduced hospitalization, better social functioning and improved quality of life. Peers who led six- or eight-session classes generally helped their participants with recovery, job readiness, communication and assertiveness, according to four studies considered in the review.

The contradiction between these reviews underscores the pressing need for more rigorous research and perhaps clearer guidelines for the practice of peer specialists. In the interim, it seems clear that peer specialists are not dangerous to the patients whom they serve—although they may pose a challenge to the status quo of mental health treatment.

Treatment revolution

Sitting in the meeting room of an old Masonic Lodge, Bradford leans forward and asks his client: “What was the most important information that you needed to know?” He is interviewing a woman recovering from profound depression. The two are surrounded by some 20 people who make up her care team, assessing how they had done now that her treatment was nearing its end. Bradford sticks out compared with most of the doctors and specialists. He is physically bigger than the others, and in contrast to the measured, quiet manner of most of the “professionals” in the room, he speaks loudly and with greater urgency and passion.

His presence in the circle—and the patient's—illustrates a paradigm shift in treatment. Until a few years ago, Prakash Ellenhorn, the psychiatric firm where Bradford works, had not thought to include patients in such meetings about their care. But once a peer specialist became part of the team, including the client seemed logical, according to the firm's co-founder, psychotherapist Ross Ellenhorn. Peer specialists such as Bradford forced the rest of the staff to confront a tendency toward us-versus-them thinking about clients, Ellenhorn says.

Even if much about peer specialists still needs to be standardized, the movement could nonetheless encourage a wholesale rethinking of the way mental health care is delivered and even how people think about mental health. People who are diagnosed with mental illness often get the message that they are permanently damaged and, in some sense, beyond recovery. Peer specialists by definition contradict that hopelessness and the stigma it entails. They have bounced back enough to be able to help others.

Even at an enlightened place such as Prakash Ellenhorn, Bradford must still occasionally remind his professional colleagues that their clients experience the mental health system differently than they do. Although doctors and health workers are often ready to declare victory when they have been able to alleviate a client's unusual behavior, Bradford knows from experience that their job is unlikely to be over. “You can't just say, ‘You've stopped howling at the moon, so I'm satisfied,’” he declares. “They have to have a life worth living.”