Psychiatr Q DOI 10.1007/s11126-015-9378-y ORIGINAL PAPER
Does Stigma Towards Mental Illness Affect Initial Perceptions of Peer Providers? Elizabeth Flanagan1 • Amerigo Farina2 • Larry Davidson1
Ó Springer Science+Business Media New York 2015
Abstract Peers (i.e. people with lived experience of mental illness and/or addictions) are being hired in large numbers to offer support for people with serious mental illnesses, but little is known about how peer providers are viewed. The goal of this study was to measure reactions towards actors posed as peer providers. Half of study participants interacted with an actor portraying a psychiatrist and half interacted with an actor portraying a peer provider. Ratings such as liking, feeling comfortable, as well as time spent talking were measured. Participants did not report preferring actors in either condition and did not talk more or have less silence with actors in either condition. Participants also were equally willing to see actors portraying peer providers again in the future and recommend them to a family member. Among participants who had received mental health services, there was a trend towards viewing actors portraying peer providers as more friendly and effective. These positive initial perceptions suggest that stigma towards people with mental illness does not taint the initial perception of peer providers. Keywords
Stigma Peer providers Psychiatrists Community members
Introduction In the last decade, mental health supports provided by peers (i.e., persons with histories of mental illness and/or addiction) have emerged as a viable addition to the array of services and supports available for people with serious mental illnesses [1–5]. Hiring peer staff to provide such support is also seen as an important element of the transformation of mental
& Elizabeth Flanagan [email protected] 1
Yale Program for Recovery and Community Health, Yale University, 319 Peck Street, Building 1, New Haven, CT 06513, USA
2
University of Connecticut, Storrs, CT, USA
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health care to a recovery-orientation, which has been called for by numerous national governments and professional bodies in the United Kingdom [6], Australia [7], Canada [8], and the United States [9, 10]. However, the evidence base for peer providers is still developing. Research has shown that people with histories of mental illness can provide services that are comparable in effectiveness to those provided by mental health professionals [1, 11–14], but most evidence has not shown peer providers to be superior on a number of outcome measures (e.g., case management) [11, 13], although recent papers have found peers to be superior in reducing inpatient admission and improving recovery-oriented outcomes [1, 4, 15]. Studies have also examined the relationship of peers with their clients, finding that peers may be able to develop trusting relationships more quickly, but over time peer providers are not more effective than regular case managers [2, 16]. Little is known about how peer providers are perceived by those engaged or not engaged in mental health care. The present study examines those issues. The purpose of this experimental study was to examine in vivo how those identified as peer providers are perceived in terms of likability, effectiveness, and desire to continue care, with initial perceptions of those thought to be psychiatrists used as a comparison group. These measures were chosen since a previous study found that the common factors effective in a therapeutic relationship (i.e., positive regard, empathy, unconditionality) differentiated peer providers from regular providers at the initial stage of the therapeutic relationship [2]. Given that the general public is known to harbor negative stereotypes of persons with mental illnesses [17–21] and might therefore be afraid to receive care from a person with mental illness while typically having faith in physicians, we predicted that those thought to be psychiatrists would be rated as more likeable, effective, and desirable for returning for care.
Method This study used a between-subjects experimental design in which study participants discussed their personal problems with confederate actors they were led to believe were peer providers or psychiatrists. Deceiving study participants was necessary in order to show the effect of the role of peer providers unconfounded by the effects of other variables (e.g., race/ethnicity, interpersonal skill). This design was chosen since it could measure in vivo participants’ self-reported stigma towards actors portraying peer providers as compared to self-reported stigma towards actors portraying psychiatrists. This study was approved by the [name omitted to for blind review].
Participants Participants in this study were 65 residents in or near a mid-sized city in the Northeastern United States. The participant sample was 59 % male and the average age was 44.5 (SD = 13.6). The sample was 39 % Caucasian, 51 % African-Americans, and 10 % other races. Across all races, 15 % of the sample said they were Hispanic. 43 % of the sample had at least some college education. 49 % of the sample had received mental health services at some point during their lifetime (of those who received services: M = 7.7 years of services, SD = 9.0). 51 % had received substance abuse services (of those who received services: M = 4.3 years of services, SD = 5.6).
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Procedure The roles of peers and psychiatrists for this study were played by community members recruited from a local newspaper. In order to study the effect of peer providers and minimize effects because of demographic differences of actors, Caucasian males between the ages of 40 and 60 were recruited to act as peer providers and psychiatrists. A total of three actors were used in this study to play these parts. Actors received a half-day training during which they were told about the procedures of the study and its hypotheses. They also received training in basic clinical skills such as reflective and non-directive listening, making summary statements, and body posture to convey interest and warmth. They roleplayed these techniques and were told that some of the most effective elements of a therapeutic alliance are warmth, genuineness, and unconditional positive regard. Study participants were recruited through an advertisement in the same local newspaper used to recruit actors. The advertisement asked for participants in a study of ‘‘what makes a good mental health clinician.’’ Interested persons phoned study personnel and were told that study participants would be asked to talk about their everyday problems and give feedback about their experiences. Persons interested in participating were scheduled an appointment. When persons arrived for their appointments, they were given an information letter describing the procedures, risks, and benefits of the study and were asked to give their written informed consent to participate. Study participants were randomly assigned to either Condition A (i.e., actor portraying a peer provider) or Condition B (i.e., actor portraying a psychiatrist). First, study participants were asked to read a paper that listed the directions for the study. The following shows the directions given to the participants in each condition: Condition A: Today you will be interacting with someone who has had a serious mental illness for the last 15 years. He has been on medication, has been in mental hospitals, and has seen many providers in outpatient settings in an effort to manage his illness. He has decided to become a peer provider of mental health services in order to be able to use his personal experience to help others. Condition B: Today you will be interacting with a licensed psychiatrist who has had 15 years of experience treating people with mental illness, and who graduated third in his class from an Ivy League school. He has worked on inpatient units, in outpatient settings, and has managed the medication of numerous patients. He decided to become a mental health clinician out of a deep desire to help those less fortunate. All participants were then given the same additional instructions: that the researchers were interested in the process of therapy, that participants were asked to talk about their own problems, to stay in the role of the patient and focus on themselves and limit the conversation to the true things that bothered them. Participants were asked not to inquire about the other person’s background or personal experience. Participants were told they would interact with the other person for exactly 10 min and then they would be asked how things went and how much they liked interacting with the other person. After reading the instructions, the participants talked with the actor portraying the ‘peer’ or ‘psychiatrist’ for 10 min about his/her problems. These interactions were audio-taped. Then, the participant filled out questionnaires about their interactions. Participants were asked to rate how much they liked the person they interacted with, what their ability was, how effective they thought they were, how friendly they were, how uncomfortable they were, how much they would like to see this person again, and how likely they would be to
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recommend that a friend or family member see this person for care. Then participants were asked to provide demographic information, were fully debriefed about the procedures of the study, and were paid $50 for their participation. As a manipulation check, the actors were asked what condition they thought the participant was in (i.e., was the participant told the actor was a peer provider or a psychiatrist?). Actors guessed correctly no more often than was predicted by chance (49 %, v2 test for independence = 0.0, p = .97).
Results The dependent variables in this study were the ratings the participants gave the actors, how much time each person spent talking during the 10 min interaction, and the amount of silence in the interaction. Four study participants were dropped from the analysis because their interview did not last at least 10 min. Table 1 shows the participant ratings for the actors across the two conditions. Participants gave high ratings on a scale of 1–7 to the actors portraying both a psychiatrist and a peer, except the ratings for ‘‘uncomfortable,’’ were close to the center of the scale and had larger standard deviations. For none of the ratings were differences found between ratings of actors thought to be psychiatrists versus those thought to be peers (all p [ .05). The effect size calculations showed that some of the effect sizes were small (i.e., actors portraying peers seen as more effective, d = .35, being more uncomfortable with actors portraying psychiatrists d = .25, being more likely to recommend an actor portraying a peer provider to a friend of family member d = .31). Two coders were trained to use stopwatches to document the amount of time each person spent speaking in the 10 min interaction until there was 90 % agreement across coders. Independent sample t test analyses in SPSS showed no differences in the average time spent talking in the 10-min interview across the two conditions. On average, participants did not talk more to actors they thought were psychiatrists (M = 342.03 s,
Table 1 Average ratings participants gave to the interviewers across the two conditions (range 1–7) Dependent variable
‘‘Psychiatrist’’ N = 33
‘‘Peer Provider’’ N = 28
t test
How much did you like the clinician you interacted with?
6.7 (SD = 0.6)
6.7 (SD = 0.8)
t(59) = -0.09, p = .93, d = .01
What do you think the clinician’s ability was?
6.4 (SD = 0.8)
6.5 (SD = 1.0)
t(59) = -0.59, p = .56, d = .16
How effective do you think the clinician was?
6.3 (SD = 0.9)
6.6 (SD = 0.8)
t(59) = -1.38, p = .17, d = .35
How friendly was the clinician?
6.9 (SD = 0.3)
6.9 (SD = 0.8)
t(59) = 0.15, p = .88, d = .04
How uncomfortable were you during this interaction?
3.1 (SD = 2.5)
2.5 (SD = 2.3)
t(59) = 0.97, p = .34, d = .25
How much would you like to talk to this clinician again about your problems?
6.3 (SD = 1.2)
6.5 (SD = 1.3)
t(59) = -0.40, p = .69, d = .10
How likely would you be to recommend that a friend or family member see this person for therapy?
6.1 (SD = 1.5)
6.5 (SD = 1.2)
t(59) = -1.20, p = .24, d = .31
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SD = 38.65) than to actors they thought were peers (M = 336.93 s, SD = 51.22; t(59) = 0.44, p = .66, d = 0.11). On average, actors who were thought to be psychiatrists did not talk more (M = 72.24 s, SD = 36.93) than actors thought to be peers (M = 76.89 s, SD = 49.50; t(59) = -0.42, p = .68, d = 0.11). Finally, there was not more silence when participants thought they were speaking with a psychiatrist (M = 5.73 s, SD = 3.33) than when they thought they were speaking with a peer (M = 6.18 s, SD = 3.32; t(59) = -0.53, p = .60, d = 0.14). Across both conditions, participants talked substantially more than actors and there was very little silence. Because peer providers are theorized to be especially engaging when working with persons with mental illnesses, we analyzed the time spent talking and the ratings participants gave to the actors just for those study participants who reported having received mental health services in the past. Table 2 shows these data. As was found across all participants, people who had received mental health services in the past gave very high ratings to actors regardless of condition and ratings of being uncomfortable were in the middle of the scale. Also important about these data is that the ratings for the actors thought to be peers generally had smaller standard deviations than the ratings for the actors thought to be psychiatrists, meaning that there was more consensus in how much the participants liked the peer providers. Last, these data show two trends (p \ .10) of these participants viewing actors thought to be peer providers as more friendly and effective than actors thought to be psychiatrists. In fact, for all of the positive questions, the ratings for actors thought to be peers were higher than the ratings for actors thought to be
Table 2 Average time spent talking and ratings of interviewers for people who had previously received mental health services ONLY (range 1–7) Dependent variable
‘‘Psychiatrist’’ N = 16
‘‘Peer Provider’’ N = 14
t test
Time spent talking – Interviewer, in seconds
63.44 (SD = 34.65)
55.79 (SD = 31.18)
t(28) = 0.63, p = .53, d = .23
Time spent talking—Participant, in seconds
350.19 (SD = 36.84)
359.21 (SD = 31.66)
t(28) = -0.71, p = .48, d = .26
Silence, in seconds
6.38 (SD = 3.36)
5.00 (SD = 2.80)
t(28) = 1.21, p = .24, d = .44
How much did you like the clinician you interacted with?
6.6 (SD = 0.8)
6.9 (SD = 0.4)
t(28) = -1.31, p = .21, d = .46
What do you think the clinician’s ability was?
6.4 (SD = 1.0)
6.6 (SD = 0.6)
t(28) = -0.91, p = .37, d = .32
How effective do you think the clinician was?
6.3 (SD = 0.9)
6.8 (SD = 0.4)
t(28) = -1.80, p = .09, d = .62
How friendly was the clinician?
6.8 (SD = 0.4)
7.0 (SD = 0.0)
t(28) = -1.86, p = .08, d = .61
How uncomfortable were you during this interaction?
3.5 (SD = 2.6)
3.4 (SD = 2.7)
t(28) = 0.08, p = .94, d = .03
How much would you like to talk to this clinician again about your problems?
6.2 (SD = 1.6)
6.6 (SD = 0.7)
t(28) = -0.97, p = .34, d = .35
How likely would you be to recommend that a friend or family member see this person for therapy?
6.1 (SD = 1.6)
6.6 (SD = 0.6)
t(28) = -1.12, p = .27, d = .15
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psychiatrists. Effect size calculations showed that effect sizes were close to moderate for liking more actors portraying peer providers d = .46, actors portraying peer providers being seen as more effective d = .62, and actors portraying peer providers being seen as more friendly d = .61.
Discussion In this study, participants reported generally high regard for actors they thought to be peer providers and actors they thought to be psychiatrists. Our hypotheses were not supported in that study participants were not more uncomfortable with and did not dislike more those described as having a mental illness (i.e., those described as peer providers). Instead, across all participants, small to moderate effect sizes were found showing preference for those thought to be peer providers for several variables (e.g., actors portraying peers seen as more effective), although these differences were not significant. Larger effect sizes demonstrating preference for those thought to be peer providers were found for study participants who had previous received mental health services, with the preferences for those thought to be peer providers approaching significance for ratings of friendliness and effectiveness. Stigma towards those with mental illnesses found in previous studies [20– 22] was not elicited in this experimental situation. Interesting are the trends found when examining the half of the sample who had previously received mental health services for whom there was a trend towards them seeing the peer providers as more effective and more friendly. Across all positively valenced items, they rated actors portraying peer providers more positively and there was higher agreement in their positive ratings, as evidenced in the smaller standard deviations for these ratings. In addition, there were trends towards significance and moderate effect sizes in rating actors portraying peer providers as more effective and friendly. These results all suggest there might be more positive attitudes towards peer providers than psychiatrists among people receiving mental health services. Given these positive attitudes, it is possible that peer providers could be helpful in increasing engagement and retention and improving continuity of care for people with mental health conditions. Even if the trends towards preferring actors portraying peer providers are not interpreted, the very high ratings for both actors portraying peers and psychiatrists show that previous experience in mental health settings did not breed dislike for either peer providers or psychiatrists in this study. Limitations to this study include: first, it is possible that null results were found because the manipulation in this study was not strong enough rather than because there are not true difference in how study participants perceive those thought to be psychiatrists and those thoughts to be peer providers. Second, the experimental comparison among those who had received mental health services had low power given the small sample size, so it is possible there might be true differences in initial perception that could have been detected with a larger number of participants, as suggested by the moderate effect sizes that were found. Finally, given that this study is a simulated experimental manipulation, it is possible these results do not describe the initial perceptions of peer providers and psychiatrists in the real world. Despite these limitations, these results at the very least show positive regard towards those thought to be peer providers from study participants. A practical implication of these results is that they suggest that peer providers in mental health settings would initially be viewed positively by those seeking and engaged in treatment.
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Psychiatr Q Acknowledgments Support for this research was provided by Grant #K01 MH079128-02 from the National Institute of Mental Health to Elizabeth Flanagan, PhD. Conflict of interest The authors have no conflicting interests to disclose.
References 1. Chinman M, George P, Dougherty RH, et al.: Peer support services for individuals with serious mental illnesses: Assessing the evidence. Psychiatric Services 65:429–441, 2014. 2. Sells D, Davidson L, Jewell C, et al.: The treatment relationship in peer-based and regular case management for clients with severe mental illness. Psychiatric Services 57(8):1179–1184, 2006. 3. Sherman PS, Porter R: Mental health consumers as case management aides. Hospital & Community Psychiatry 42(5):494–498, 1991. 4. Sledge WH, Lawless M, Sells D, et al.: Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations. Psychiatric Services 62(5):541–544, 2011. 5. Solomon P: The working alliance and consumer case management. Journal of Mental Health Administration 22(2):126–134, 1995. 6. National Institute for Mental Health in England. NIMHE guiding statement on recovery, 2005. 7. Australian Health Ministers’ Advisory Council. A national framework for recovery-oriented mental health services: Policy and theory, 2013. 8. Mental Health Commission of Canada. Towards recovery & well-being: A framework for a mental health strategy for Canada, 2009. 9. New Freedom Commission on Mental Health. Achieving the promise: Transforming mental health care in America. Rockville: DHHS Pub. No. SMA-03-3832, 2004. 10. U.S. Department of Health and Human Services: Transforming mental health care in America: Federal action agenda: First steps. Rockville, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2005. 11. Davidson L, Chinman M, Kloos B, et al.: Peer support among individuals with severe mental illness: A review of the evidence. Clinical Psychology 6(2):165–187, 1999. 12. Davidson L, Chinman M, Sells D, et al.: Peer support among adults with serious mental illness: A report from the field. Schizophrenia Bulletin 32(3):443–450, 2006. 13. Solomon P: Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal 27(4):392–401, 2004. 14. Solomon P, Draine J: The state of knowledge of the effectiveness of consumer provided services. Psychiatric Rehabilitation Journal 25(1):20–27, 2001. 15. Repper J, Carter T: A review of the literature on peer support in mental health services. Journal of Mental Health 20(4):392–411, 2011. 16. Solomon P: The efficacy of a consumer case management team: 2-year outcomes of a randomized trial. Journal of Mental Health Administration 22(2):135–146, 1995. 17. Denenny D, Bentley E, Schiffman J: Validation of a brief implicit association test of stigma: Schizophrenia and dangerousness. Journal of Mental Health 23(5):246–250, 2014. 18. Hamilton S, Lewis-Holmes E, Pinfold V, et al.: Discrimination against people with a mental health diagnosis: Qualitative analysis of reported experiences. Journal of Mental Health 23(2):88–93, 2014. 19. Martin JK, Pescosolido BA, Tuch SA: Of fear and loathing: The role of ‘disturbing behavior’ labels, and causal attributions in shaping public attitudes toward people with mental illness. Journal of Health and Social Behavior 41:208–223, 2000. 20. Pescosolido BA, Monahan J, Link BG, et al.: The public’s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health 89(9):1339–1345, 1999. 21. Phelan J, Link B, Stueve A, Pescosolida B: Public conceptions of mental illness in 1950 and 1996: What is mental illness and is it to be feared? Journal of Health and Social Behavior 41(2):188–207, 2000. 22. Link BG, Cullen FT, Frank J, Wozniak JF: The social rejection of former mental patients: Understanding why labels matter. American Journal of Sociology 92:1461–1500, 1987.
Elizabeth Flanagan, PhD is an Assistant Professor at the Yale Program for Recovery and Community Health in the Department of Psychiatry, Yale School of Medicine. Dr. Flanagan’s received a career award
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Psychiatr Q from the NIMH to study stigma in mental health settings. Her research program investigates stigma and discrimination towards people with mental illness, especially in mental health and primary care settings. She has also developed an anti-stigma intervention called ‘‘Recovery Speaks’’ where people with mental illness tell their recovery stories, how they contribute to their communities, and what was helpful to them (and not helpful) in their recovery. This intervention has been found to reduce stigma in primary care providers, behavioral health providers, high school and college students, and future healthcare professionals. Dr. Flanagan also researches healthcare disparities, the politics of the DSM, and the subjective experience of mental illness. Amerigo Farina, PhD was an Emeritus Professor at the University of Connecticut, Department of Psychology. He died in November 2014. He had a 40 year career using experimental methods to study the characteristics of stigma and reduction methods. Highlights from his career include Social Stigma: the psychology of marked relationships co-authored with Edward Jones et al. Larry Davidson, PhD is a Professor at the Yale School of Medicine. He is an international leader in the recovery movement and has published multiple articles that establish the evidence base for recovery oriented services, including peer support. He has investigated processes of recovery in psychosis, using peer support and other social engagement strategies in engaging people with co-occurring disorders and/or who are homeless into care, the development of qualitative and participatory research methods, the development and evaluation of innovative, community-based psychosocial interventions, and the promotion of collaborative relationships between people with behavioral health disorders and their healthcare providers. Much of this work has been oriented toward articulating a disability and civil rights perspective on psychiatric disorders, attempting to create an array of pathways into community life for people with psychiatric disabilities.
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Does Stigma Towards Mental Illness Affect Initial Perceptions of Peer Providers? Elizabeth Flanagan1 • Amerigo Farina2 • Larry Davidson1
Ó Springer Science+Business Media New York 2015
Abstract Peers (i.e. people with lived experience of mental illness and/or addictions) are being hired in large numbers to offer support for people with serious mental illnesses, but little is known about how peer providers are viewed. The goal of this study was to measure reactions towards actors posed as peer providers. Half of study participants interacted with an actor portraying a psychiatrist and half interacted with an actor portraying a peer provider. Ratings such as liking, feeling comfortable, as well as time spent talking were measured. Participants did not report preferring actors in either condition and did not talk more or have less silence with actors in either condition. Participants also were equally willing to see actors portraying peer providers again in the future and recommend them to a family member. Among participants who had received mental health services, there was a trend towards viewing actors portraying peer providers as more friendly and effective. These positive initial perceptions suggest that stigma towards people with mental illness does not taint the initial perception of peer providers. Keywords
Stigma Peer providers Psychiatrists Community members
Introduction In the last decade, mental health supports provided by peers (i.e., persons with histories of mental illness and/or addiction) have emerged as a viable addition to the array of services and supports available for people with serious mental illnesses [1–5]. Hiring peer staff to provide such support is also seen as an important element of the transformation of mental
& Elizabeth Flanagan [email protected] 1
Yale Program for Recovery and Community Health, Yale University, 319 Peck Street, Building 1, New Haven, CT 06513, USA
2
University of Connecticut, Storrs, CT, USA
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health care to a recovery-orientation, which has been called for by numerous national governments and professional bodies in the United Kingdom [6], Australia [7], Canada [8], and the United States [9, 10]. However, the evidence base for peer providers is still developing. Research has shown that people with histories of mental illness can provide services that are comparable in effectiveness to those provided by mental health professionals [1, 11–14], but most evidence has not shown peer providers to be superior on a number of outcome measures (e.g., case management) [11, 13], although recent papers have found peers to be superior in reducing inpatient admission and improving recovery-oriented outcomes [1, 4, 15]. Studies have also examined the relationship of peers with their clients, finding that peers may be able to develop trusting relationships more quickly, but over time peer providers are not more effective than regular case managers [2, 16]. Little is known about how peer providers are perceived by those engaged or not engaged in mental health care. The present study examines those issues. The purpose of this experimental study was to examine in vivo how those identified as peer providers are perceived in terms of likability, effectiveness, and desire to continue care, with initial perceptions of those thought to be psychiatrists used as a comparison group. These measures were chosen since a previous study found that the common factors effective in a therapeutic relationship (i.e., positive regard, empathy, unconditionality) differentiated peer providers from regular providers at the initial stage of the therapeutic relationship [2]. Given that the general public is known to harbor negative stereotypes of persons with mental illnesses [17–21] and might therefore be afraid to receive care from a person with mental illness while typically having faith in physicians, we predicted that those thought to be psychiatrists would be rated as more likeable, effective, and desirable for returning for care.
Method This study used a between-subjects experimental design in which study participants discussed their personal problems with confederate actors they were led to believe were peer providers or psychiatrists. Deceiving study participants was necessary in order to show the effect of the role of peer providers unconfounded by the effects of other variables (e.g., race/ethnicity, interpersonal skill). This design was chosen since it could measure in vivo participants’ self-reported stigma towards actors portraying peer providers as compared to self-reported stigma towards actors portraying psychiatrists. This study was approved by the [name omitted to for blind review].
Participants Participants in this study were 65 residents in or near a mid-sized city in the Northeastern United States. The participant sample was 59 % male and the average age was 44.5 (SD = 13.6). The sample was 39 % Caucasian, 51 % African-Americans, and 10 % other races. Across all races, 15 % of the sample said they were Hispanic. 43 % of the sample had at least some college education. 49 % of the sample had received mental health services at some point during their lifetime (of those who received services: M = 7.7 years of services, SD = 9.0). 51 % had received substance abuse services (of those who received services: M = 4.3 years of services, SD = 5.6).
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Procedure The roles of peers and psychiatrists for this study were played by community members recruited from a local newspaper. In order to study the effect of peer providers and minimize effects because of demographic differences of actors, Caucasian males between the ages of 40 and 60 were recruited to act as peer providers and psychiatrists. A total of three actors were used in this study to play these parts. Actors received a half-day training during which they were told about the procedures of the study and its hypotheses. They also received training in basic clinical skills such as reflective and non-directive listening, making summary statements, and body posture to convey interest and warmth. They roleplayed these techniques and were told that some of the most effective elements of a therapeutic alliance are warmth, genuineness, and unconditional positive regard. Study participants were recruited through an advertisement in the same local newspaper used to recruit actors. The advertisement asked for participants in a study of ‘‘what makes a good mental health clinician.’’ Interested persons phoned study personnel and were told that study participants would be asked to talk about their everyday problems and give feedback about their experiences. Persons interested in participating were scheduled an appointment. When persons arrived for their appointments, they were given an information letter describing the procedures, risks, and benefits of the study and were asked to give their written informed consent to participate. Study participants were randomly assigned to either Condition A (i.e., actor portraying a peer provider) or Condition B (i.e., actor portraying a psychiatrist). First, study participants were asked to read a paper that listed the directions for the study. The following shows the directions given to the participants in each condition: Condition A: Today you will be interacting with someone who has had a serious mental illness for the last 15 years. He has been on medication, has been in mental hospitals, and has seen many providers in outpatient settings in an effort to manage his illness. He has decided to become a peer provider of mental health services in order to be able to use his personal experience to help others. Condition B: Today you will be interacting with a licensed psychiatrist who has had 15 years of experience treating people with mental illness, and who graduated third in his class from an Ivy League school. He has worked on inpatient units, in outpatient settings, and has managed the medication of numerous patients. He decided to become a mental health clinician out of a deep desire to help those less fortunate. All participants were then given the same additional instructions: that the researchers were interested in the process of therapy, that participants were asked to talk about their own problems, to stay in the role of the patient and focus on themselves and limit the conversation to the true things that bothered them. Participants were asked not to inquire about the other person’s background or personal experience. Participants were told they would interact with the other person for exactly 10 min and then they would be asked how things went and how much they liked interacting with the other person. After reading the instructions, the participants talked with the actor portraying the ‘peer’ or ‘psychiatrist’ for 10 min about his/her problems. These interactions were audio-taped. Then, the participant filled out questionnaires about their interactions. Participants were asked to rate how much they liked the person they interacted with, what their ability was, how effective they thought they were, how friendly they were, how uncomfortable they were, how much they would like to see this person again, and how likely they would be to
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recommend that a friend or family member see this person for care. Then participants were asked to provide demographic information, were fully debriefed about the procedures of the study, and were paid $50 for their participation. As a manipulation check, the actors were asked what condition they thought the participant was in (i.e., was the participant told the actor was a peer provider or a psychiatrist?). Actors guessed correctly no more often than was predicted by chance (49 %, v2 test for independence = 0.0, p = .97).
Results The dependent variables in this study were the ratings the participants gave the actors, how much time each person spent talking during the 10 min interaction, and the amount of silence in the interaction. Four study participants were dropped from the analysis because their interview did not last at least 10 min. Table 1 shows the participant ratings for the actors across the two conditions. Participants gave high ratings on a scale of 1–7 to the actors portraying both a psychiatrist and a peer, except the ratings for ‘‘uncomfortable,’’ were close to the center of the scale and had larger standard deviations. For none of the ratings were differences found between ratings of actors thought to be psychiatrists versus those thought to be peers (all p [ .05). The effect size calculations showed that some of the effect sizes were small (i.e., actors portraying peers seen as more effective, d = .35, being more uncomfortable with actors portraying psychiatrists d = .25, being more likely to recommend an actor portraying a peer provider to a friend of family member d = .31). Two coders were trained to use stopwatches to document the amount of time each person spent speaking in the 10 min interaction until there was 90 % agreement across coders. Independent sample t test analyses in SPSS showed no differences in the average time spent talking in the 10-min interview across the two conditions. On average, participants did not talk more to actors they thought were psychiatrists (M = 342.03 s,
Table 1 Average ratings participants gave to the interviewers across the two conditions (range 1–7) Dependent variable
‘‘Psychiatrist’’ N = 33
‘‘Peer Provider’’ N = 28
t test
How much did you like the clinician you interacted with?
6.7 (SD = 0.6)
6.7 (SD = 0.8)
t(59) = -0.09, p = .93, d = .01
What do you think the clinician’s ability was?
6.4 (SD = 0.8)
6.5 (SD = 1.0)
t(59) = -0.59, p = .56, d = .16
How effective do you think the clinician was?
6.3 (SD = 0.9)
6.6 (SD = 0.8)
t(59) = -1.38, p = .17, d = .35
How friendly was the clinician?
6.9 (SD = 0.3)
6.9 (SD = 0.8)
t(59) = 0.15, p = .88, d = .04
How uncomfortable were you during this interaction?
3.1 (SD = 2.5)
2.5 (SD = 2.3)
t(59) = 0.97, p = .34, d = .25
How much would you like to talk to this clinician again about your problems?
6.3 (SD = 1.2)
6.5 (SD = 1.3)
t(59) = -0.40, p = .69, d = .10
How likely would you be to recommend that a friend or family member see this person for therapy?
6.1 (SD = 1.5)
6.5 (SD = 1.2)
t(59) = -1.20, p = .24, d = .31
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SD = 38.65) than to actors they thought were peers (M = 336.93 s, SD = 51.22; t(59) = 0.44, p = .66, d = 0.11). On average, actors who were thought to be psychiatrists did not talk more (M = 72.24 s, SD = 36.93) than actors thought to be peers (M = 76.89 s, SD = 49.50; t(59) = -0.42, p = .68, d = 0.11). Finally, there was not more silence when participants thought they were speaking with a psychiatrist (M = 5.73 s, SD = 3.33) than when they thought they were speaking with a peer (M = 6.18 s, SD = 3.32; t(59) = -0.53, p = .60, d = 0.14). Across both conditions, participants talked substantially more than actors and there was very little silence. Because peer providers are theorized to be especially engaging when working with persons with mental illnesses, we analyzed the time spent talking and the ratings participants gave to the actors just for those study participants who reported having received mental health services in the past. Table 2 shows these data. As was found across all participants, people who had received mental health services in the past gave very high ratings to actors regardless of condition and ratings of being uncomfortable were in the middle of the scale. Also important about these data is that the ratings for the actors thought to be peers generally had smaller standard deviations than the ratings for the actors thought to be psychiatrists, meaning that there was more consensus in how much the participants liked the peer providers. Last, these data show two trends (p \ .10) of these participants viewing actors thought to be peer providers as more friendly and effective than actors thought to be psychiatrists. In fact, for all of the positive questions, the ratings for actors thought to be peers were higher than the ratings for actors thought to be
Table 2 Average time spent talking and ratings of interviewers for people who had previously received mental health services ONLY (range 1–7) Dependent variable
‘‘Psychiatrist’’ N = 16
‘‘Peer Provider’’ N = 14
t test
Time spent talking – Interviewer, in seconds
63.44 (SD = 34.65)
55.79 (SD = 31.18)
t(28) = 0.63, p = .53, d = .23
Time spent talking—Participant, in seconds
350.19 (SD = 36.84)
359.21 (SD = 31.66)
t(28) = -0.71, p = .48, d = .26
Silence, in seconds
6.38 (SD = 3.36)
5.00 (SD = 2.80)
t(28) = 1.21, p = .24, d = .44
How much did you like the clinician you interacted with?
6.6 (SD = 0.8)
6.9 (SD = 0.4)
t(28) = -1.31, p = .21, d = .46
What do you think the clinician’s ability was?
6.4 (SD = 1.0)
6.6 (SD = 0.6)
t(28) = -0.91, p = .37, d = .32
How effective do you think the clinician was?
6.3 (SD = 0.9)
6.8 (SD = 0.4)
t(28) = -1.80, p = .09, d = .62
How friendly was the clinician?
6.8 (SD = 0.4)
7.0 (SD = 0.0)
t(28) = -1.86, p = .08, d = .61
How uncomfortable were you during this interaction?
3.5 (SD = 2.6)
3.4 (SD = 2.7)
t(28) = 0.08, p = .94, d = .03
How much would you like to talk to this clinician again about your problems?
6.2 (SD = 1.6)
6.6 (SD = 0.7)
t(28) = -0.97, p = .34, d = .35
How likely would you be to recommend that a friend or family member see this person for therapy?
6.1 (SD = 1.6)
6.6 (SD = 0.6)
t(28) = -1.12, p = .27, d = .15
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psychiatrists. Effect size calculations showed that effect sizes were close to moderate for liking more actors portraying peer providers d = .46, actors portraying peer providers being seen as more effective d = .62, and actors portraying peer providers being seen as more friendly d = .61.
Discussion In this study, participants reported generally high regard for actors they thought to be peer providers and actors they thought to be psychiatrists. Our hypotheses were not supported in that study participants were not more uncomfortable with and did not dislike more those described as having a mental illness (i.e., those described as peer providers). Instead, across all participants, small to moderate effect sizes were found showing preference for those thought to be peer providers for several variables (e.g., actors portraying peers seen as more effective), although these differences were not significant. Larger effect sizes demonstrating preference for those thought to be peer providers were found for study participants who had previous received mental health services, with the preferences for those thought to be peer providers approaching significance for ratings of friendliness and effectiveness. Stigma towards those with mental illnesses found in previous studies [20– 22] was not elicited in this experimental situation. Interesting are the trends found when examining the half of the sample who had previously received mental health services for whom there was a trend towards them seeing the peer providers as more effective and more friendly. Across all positively valenced items, they rated actors portraying peer providers more positively and there was higher agreement in their positive ratings, as evidenced in the smaller standard deviations for these ratings. In addition, there were trends towards significance and moderate effect sizes in rating actors portraying peer providers as more effective and friendly. These results all suggest there might be more positive attitudes towards peer providers than psychiatrists among people receiving mental health services. Given these positive attitudes, it is possible that peer providers could be helpful in increasing engagement and retention and improving continuity of care for people with mental health conditions. Even if the trends towards preferring actors portraying peer providers are not interpreted, the very high ratings for both actors portraying peers and psychiatrists show that previous experience in mental health settings did not breed dislike for either peer providers or psychiatrists in this study. Limitations to this study include: first, it is possible that null results were found because the manipulation in this study was not strong enough rather than because there are not true difference in how study participants perceive those thought to be psychiatrists and those thoughts to be peer providers. Second, the experimental comparison among those who had received mental health services had low power given the small sample size, so it is possible there might be true differences in initial perception that could have been detected with a larger number of participants, as suggested by the moderate effect sizes that were found. Finally, given that this study is a simulated experimental manipulation, it is possible these results do not describe the initial perceptions of peer providers and psychiatrists in the real world. Despite these limitations, these results at the very least show positive regard towards those thought to be peer providers from study participants. A practical implication of these results is that they suggest that peer providers in mental health settings would initially be viewed positively by those seeking and engaged in treatment.
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Psychiatr Q Acknowledgments Support for this research was provided by Grant #K01 MH079128-02 from the National Institute of Mental Health to Elizabeth Flanagan, PhD. Conflict of interest The authors have no conflicting interests to disclose.
References 1. Chinman M, George P, Dougherty RH, et al.: Peer support services for individuals with serious mental illnesses: Assessing the evidence. Psychiatric Services 65:429–441, 2014. 2. Sells D, Davidson L, Jewell C, et al.: The treatment relationship in peer-based and regular case management for clients with severe mental illness. Psychiatric Services 57(8):1179–1184, 2006. 3. Sherman PS, Porter R: Mental health consumers as case management aides. Hospital & Community Psychiatry 42(5):494–498, 1991. 4. Sledge WH, Lawless M, Sells D, et al.: Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations. Psychiatric Services 62(5):541–544, 2011. 5. Solomon P: The working alliance and consumer case management. Journal of Mental Health Administration 22(2):126–134, 1995. 6. National Institute for Mental Health in England. NIMHE guiding statement on recovery, 2005. 7. Australian Health Ministers’ Advisory Council. A national framework for recovery-oriented mental health services: Policy and theory, 2013. 8. Mental Health Commission of Canada. Towards recovery & well-being: A framework for a mental health strategy for Canada, 2009. 9. New Freedom Commission on Mental Health. Achieving the promise: Transforming mental health care in America. Rockville: DHHS Pub. No. SMA-03-3832, 2004. 10. U.S. Department of Health and Human Services: Transforming mental health care in America: Federal action agenda: First steps. Rockville, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2005. 11. Davidson L, Chinman M, Kloos B, et al.: Peer support among individuals with severe mental illness: A review of the evidence. Clinical Psychology 6(2):165–187, 1999. 12. Davidson L, Chinman M, Sells D, et al.: Peer support among adults with serious mental illness: A report from the field. Schizophrenia Bulletin 32(3):443–450, 2006. 13. Solomon P: Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatric Rehabilitation Journal 27(4):392–401, 2004. 14. Solomon P, Draine J: The state of knowledge of the effectiveness of consumer provided services. Psychiatric Rehabilitation Journal 25(1):20–27, 2001. 15. Repper J, Carter T: A review of the literature on peer support in mental health services. Journal of Mental Health 20(4):392–411, 2011. 16. Solomon P: The efficacy of a consumer case management team: 2-year outcomes of a randomized trial. Journal of Mental Health Administration 22(2):135–146, 1995. 17. Denenny D, Bentley E, Schiffman J: Validation of a brief implicit association test of stigma: Schizophrenia and dangerousness. Journal of Mental Health 23(5):246–250, 2014. 18. Hamilton S, Lewis-Holmes E, Pinfold V, et al.: Discrimination against people with a mental health diagnosis: Qualitative analysis of reported experiences. Journal of Mental Health 23(2):88–93, 2014. 19. Martin JK, Pescosolido BA, Tuch SA: Of fear and loathing: The role of ‘disturbing behavior’ labels, and causal attributions in shaping public attitudes toward people with mental illness. Journal of Health and Social Behavior 41:208–223, 2000. 20. Pescosolido BA, Monahan J, Link BG, et al.: The public’s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health 89(9):1339–1345, 1999. 21. Phelan J, Link B, Stueve A, Pescosolida B: Public conceptions of mental illness in 1950 and 1996: What is mental illness and is it to be feared? Journal of Health and Social Behavior 41(2):188–207, 2000. 22. Link BG, Cullen FT, Frank J, Wozniak JF: The social rejection of former mental patients: Understanding why labels matter. American Journal of Sociology 92:1461–1500, 1987.
Elizabeth Flanagan, PhD is an Assistant Professor at the Yale Program for Recovery and Community Health in the Department of Psychiatry, Yale School of Medicine. Dr. Flanagan’s received a career award
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Psychiatr Q from the NIMH to study stigma in mental health settings. Her research program investigates stigma and discrimination towards people with mental illness, especially in mental health and primary care settings. She has also developed an anti-stigma intervention called ‘‘Recovery Speaks’’ where people with mental illness tell their recovery stories, how they contribute to their communities, and what was helpful to them (and not helpful) in their recovery. This intervention has been found to reduce stigma in primary care providers, behavioral health providers, high school and college students, and future healthcare professionals. Dr. Flanagan also researches healthcare disparities, the politics of the DSM, and the subjective experience of mental illness. Amerigo Farina, PhD was an Emeritus Professor at the University of Connecticut, Department of Psychology. He died in November 2014. He had a 40 year career using experimental methods to study the characteristics of stigma and reduction methods. Highlights from his career include Social Stigma: the psychology of marked relationships co-authored with Edward Jones et al. Larry Davidson, PhD is a Professor at the Yale School of Medicine. He is an international leader in the recovery movement and has published multiple articles that establish the evidence base for recovery oriented services, including peer support. He has investigated processes of recovery in psychosis, using peer support and other social engagement strategies in engaging people with co-occurring disorders and/or who are homeless into care, the development of qualitative and participatory research methods, the development and evaluation of innovative, community-based psychosocial interventions, and the promotion of collaborative relationships between people with behavioral health disorders and their healthcare providers. Much of this work has been oriented toward articulating a disability and civil rights perspective on psychiatric disorders, attempting to create an array of pathways into community life for people with psychiatric disabilities.
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