Mental health challenges during the Covid-19: An experience of peer support telephone

Silvia Clementi

Catholic University of Milan, Italy

Deborah Occhi

Catholic University of Milan, Italy

CORRESPONDENCE:

Silvia Clementi

e-mail: silvia.clementi@unicatt.it

Abstract

This paper presents the experience of peer support telephone offered to people with mental health issues and their families, during the Covid-19 lockdown by «Associazione per la Salute Mentale di Vallecamonica». This association has been managing peer support in a local hospital ward for the last eight years.

Due to the Covid-19, peer supporters stopped their activities and took the initiative to ensure that patients and their families were be offered support. From March 2020, Experts by Experience were available twice a week for four hours to offer support through telephone calls. The proposal was sent to mental health service in Vallecamonica (BS) and was accepted by them. Furthermore, they were offered help to promote the project. Several social problems were identified by the patients that were primarily associated with the difficulties of managing mental illness during the lockdown.

Interviews were conducted with two peer supporters who provided help during the first lockdown. They underlined the difficulties of remote support and the possibility of being helpful to patients and their families. Based on this project, peer supporters have been further recognized, practitioners have involved them in problem solving processes and, therefore, peer support continues to be offered through telephone calls.

Keywords

Peer Support, Mental Health, Covid-19, social work, experiential knowledge.

Introduction

The promotion of relational mental health services is essential if the benefits of experiential knowledge have to be leveraged along with the technical knowledge and to ensure increased participation of citizens.

User’s mental health service can be seen from two different perspectives, and this affects the expectations of practitioners and also those of patients (Clementi, 2019).

According to the traditional perspective, patients and family members are receivers of mental health services (Benning, 2015). In this case, people are considered as objects on whom medical interventions of exclusively professional competence are applied. In this perspective, the possibility for participation does not exist and the contribution of users, is only the acceptance of the intervention of health professionals. The second perspective considers the users as producers or co-producers of services and social interventions. In this approach, the users and family members are considered to be experts of their lives (Folgheraiter, 2004).

Patients and family members, who have coped with mental health issues and have experienced the recovery path through mental health services, can help those suffering with similar health problems to be more flexible and adapt to the various problems in life. They can effective non-medical interventions with creativity and capacity for innovation (Folgheraiter, 2004). These people are known as peer supporters.

Peer support has emerged as an innovative service delivery mechanism, particularly for those who have been ill-served by traditional system of care (Hardiman, 2004, p. 432). It involves the exchange of help between individuals and can be viewed as an embodiment of the client-centered approach, as providers are inclined towards a naturally empathic relationship with the recipients. Some peer supporters are complementary to mainstream mental health services, while others are entirely consumer-run (Hodges, 2007). Peer support projects can be highly structured and may follow a proper plan or could be highly unstructured. These supports may be conducted face to face or through telephone calls (Mohr et al., 2005) and may involve people with mental illness, their care givers, or a combination of both (Bolzan et al., 2001). Thus, peer support is a complex phenomenon that has highly variable applications.

In recent times, the less-than-optimal outcomes and escalating costs for chronic conditions, including mental illness, have led to the realisation that health professionals cannot address evolving health needs on their own and that mental health consumers represent a key asset in this service environment. The ethos underlying the user-based initiatives are as follows: service users speaking and acting for themselves; having more control over their lives and the support they receive; working together to achieve change; addressing stigma and discrimination; having access to non-medicalised interventions; valuing user-controlled organisations; focusing on people’s human and civil rights; being part of mainstream society and communities; having the ability, to take on responsibilities. Another goal of peer support-based mental health intervention is to improve the quality of life and well-being of the participants.

The study presents a peer support service in a hospital which, during the Covid-19 lockdown, was able to adapt by offering peer support through telephones calls. This is a structured, individual peer support service that is recognised and promoted by practitioners.

The project «Peer supporter open the doors of the psychiatry ward»

This project was introduced in 2012 by a group of care providers and family members of the Association «Alleanza della Salute Mentale». They recognised the general need of the psychiatric patients’ family members, for peer support during the particularly critical phases in life, such as hospitalisation. Most care providers report this as a negative experience that is characterised by a strong feeling of loneliness, shame, and difficulty in asking for help to better manage mental illness.

After various meetings that were open to citizens, the practitioners of the hospital’s psychiatry department confirmed that care gives had difficulties in dealing with hospitalisation and a peer support programme needs to be introduced. This project responds to this need through a resource that has always been available in the psychiatry ward, but was not been utilised peer support, that is, the family members and patients themselves.

Based on the peer support goals identified in literature (Vaz et al., 1996; Harris et al., 1998; Sallinen et al., 2011), improving of the patients’ quality of life is the primary goal of this project.

The other, secondary yet important, goals include increasing self-efficacy and the reduction of care costs (Morh et al., 2005).

According to Davidson et al. (1999), the aim of peer support is to improve the ability to cope with the concern related to a disease. Kennedy and Humpreys (1994) affirm that through peer support people primarily acquire the ability to understand their experience of illness.

Other studies (Levy, 1976; Robert et al., 1991) state that the benefits include understanding one’s situation and the reduction of social isolation and these are achieved by sharing similar life experiences. The involvement in peer support, can aid acceptance, support, understanding, empathy, and a sense of community, thereby, increasing hope and autonomy, in addition to the acceptance of personal responsibility.

This peer support project aims to assist people in filling socially esteemed roles and promotes information on «how to deal with their problem», coping strategies, and alternative perspectives, on the specific condition of life, with the intent of improving problem solving abilities (Kaufmann et al., 1995).

The peer support project, based on literature (Levy, 1976; Robert et al., 1991; e Humphreys, 1994; Davidson, 1999; Harris et al., 1998; Sallinen et al., 2011), provides three types of support as follows: emotional, informative, and practical support. The emotional and practical support within the psychiatry department has also facilitated the relationship with the hospital organisation, which at such times is perceived negatively by most family members and patients.

The goal of the project is achieved through individual peer support from care givers and patients visit hours. Initially this support was to be offered outside the psychiatry ward. However, in practice, from the beginning, peer supporters have entered the ward and they move freely between the patients’ rooms and smoking room, which is regularly used by patients and their families.

Another goal of the project is to reduce stigma. Support for patients and their families promotes the well-being of both, the peer supporters and the recipients of support. Peer supporters try to reduce the stigma associated with mental illness in the community by meeting recipients in the psychiatry ward and raising awareness through meetings held by family members outside the ward, and with other associations. Several mental health awareness events were organised by collaborating with various local administrations. These were aimed to spread a culture of mental health that is free of stigma, reduce the fear related to those with mental illness and spread awareness and responsibility.

The suspended time: peer supporters during the Covid-19 lockdown

During the lockdown, peer supporters who were already a part of the project, reconsidered the support offered to families and people with mental health issues. They were unable to accept the suffering caused by the serious social and health emergency, however, due to this emergency they were unable to offer support in the psychiatry ward.

The lockdown implied that some people were completely isolated. This led to a strong sense of loneliness and, consequently, difficulty in asking for assistance to cope during this critical situation. The intent to help families led peer supporters to redesign how support was offered. The goals remained the same, but were addressed while complying with the restrictions imposed. Remote peer support was offered through the telephone. Some peer supporters shared their telephone number with the patients. This option was shared with mental health service providers who welcomed the proposal and helped to promote it by sharing the information with patients and their families. The Association «Alleanza per la Salute Mentale» promoted this idea on social media. This telephone peer support option stemmed from past experiences of activities within the psychiatry ward. In some situations, experts by experience (E.B.E.) supported, the patients and their families for a few weeks following the patient’s discharge, through phone calls. Consequently, during the lockdown, they decided to replicate this phone support.

Remote peer support began on 23 March 2020 and has continued since then. Six peer supporters shared their phone number and were available two days in a week (Monday and Friday) for four hours a day.

A schedule was designed based on the availability of the number of peer supporters, to avoid the possibility of having to offer support throughout the day or night. This was based on the consideration that this was a difficult period for the peer supporters who are also either patients or family members dealing with mental illness themselves.

Eight people requested and used the phone peer support continuously for three months, and this included four family members and four patients. One of the four patients who utilised the peer support was hospitalised.

Topics covered with the peer support telephone

The difficulties of families and patients have been highlighted. Primarily, the following four issues emerged: parents were distressed as they were unable to visit their child hospitalised in the ward; trouble maintaining balance in the family during episodes of crisis, especially in the case of children who regularly suffer from depression; abandonment and loneliness which resulted in schizophrenic episodes; and the need to discuss coping strategies adopted by peer supporters during the lockdown.

During peer support telephone, the E.B.E. listened, shared their experiences, addressed active social services in that period, and used their experiential knowledge to help patients.

The «EBE» were able to interact with new patients during this period through phone calls and this created another method to offer support. The association is now creating a phone peer support project on a larger scale and making it available to more people, in association with mental health service providers.

During this support, for the first time, «EBE»s were called by social workers at the request of the patient, and it was acknowledged that they are capable of managing difficult situations. The team at this point comprised, the peer supporter, social worker, psychiatrist, and user. They were recognised ad a coping resource during the crisis.

What do the Experts By Experience think of this project?

Interviews were conducted with two Experts By Experience (E.B.E.) who offered the most telephone peer support during this period. Interviews indicate that E.B.E felt useful during phone calls. The initial calls made to patients and their families were followed up by other calls or messages and, thereby, the support continued over this period.

The E.B.E felt gratified by this new experience. They felt useful and important. According to the interviewees, people benefited from this support.

I felt good, it is a part of me. Being able to provide support by listening to people, even during this lockdown, has helped me and made me feel useful. I am happy to be able to give others a moment of relief (Interview n. 1).

The interviewees primarily identified positive elements of this new form of support and did not mention any negative aspects. However, they highlighted the following limitations, that are associated with physical distance.

• Lack of physical contact: during peer support it may be useful to hold a patient’s hand or hug them. However, this is not possible while offering telephone support.
• Loss of non-verbal communication: gestures, facial expression, and expressions cannot be observed on the phone.
• Connectivity issues: sometimes the line gets disconnected during a call and peer supporters have to call back.

If you can see each other, you can also see the expression. People’s faces communicate a lot. Not seeing all of this is not a bad thing, but it is more of a lack. Seeing each other, face to face, while offering such support, means making people understand that you are truly interested. For example, if the patient nods, it means he understands us. This is missing on the phone, though it is more difficult, it is better than nothing (Interview n. 2).

Despite these limitations, phone calls allow peer supporters to offer support to patients and their families. It helps them feel less lonely. An interviewee stated:

From this support I understood how lonely people felt during this period. There was a person who told me that he felt alone even when he was with his family and that he was happy to hear from me once a week. He reported that he felt better, since he had someone he could talk to about his disease and knows what it means to live with mental illness (Interview n. 2).

Respondents know that this remote peer support will continue for a sustained period of time. They believe that they will soon start making video calls, and when spring arrives, they will start meeting the patients and their families outdoors, in public parks, while wearing a mask and maintaining social distance.

An important aspect for the interviewees is the ability to offer immediate help for patients and families who request for it. «People with mental illness cannot wait» (Interview n. 1).

Discussion and conclusion

Based on this experience, peer supporters have acquired further recognition from families and services. Practitioners have better understood the role of peer support in mental health. It has been acknowledged that with peer support it is possible to adopt a recovery-oriented approach and build mental health services oriented not only towards cure, but also care. Furthermore, it has been established that during a pandemic due to the lack of formal resources, these serviced naturally depend on informal resources, such as peer supporters, who are considered experts and were able to promote empowerment and provide support.

Mental health professionals predominantly believe that to ensure quality services, payment has to be involved as free projects are usually of poor quality and do not last for long. However, this free project indicates that peer support represents an important help for families, patients, and also for practitioners. During the lockdown, practitioners did not stop the project, rather they collaborated with peer supporters to advertise telephone support and even referred patients to peer supporters to encourage collaborative problem solving. Due to their presence in the Vallecamonica hospital’s psychiatry ward, the right to health, that is enshrined in the Italian regulations and considered the superior purpose of the entire health system, the peer supporters finally commanded respect. Peer support experiences can be used to gain the attention of policymakers to provide support for such projects. This project, which started from a shared need by psychiatry services, could become the object of a decision-making process and open a policy window (Kingdon, 1995), and thus, become a part of the agenda of local public health policies.

The application of a recovery-oriented service system entails challenges to enhance both, experiential and technical knowledge. To conceptualise recovery-oriented practice, mental health services need to consider both of these and recognise the role of peer supporters.

Social policy goals should aim to enhance personal resources, and not just address problems. They should believe in the change that is possible and promote the spread of experiential knowledge.

The Covid-19 pandemic is different from the political and organisational challenges that mental health services have previously dealt with, as there is no known time frame for when this pandemic will end. Many patients and their families have suffered and continue to so as they are isolated in their homes, left to care for their needs and that of their families’. Furthermore, the practitioners and clients have to balance the risks arising from social isolation and that of contracting the virus. This new landscape can, therefore, also provide a more «symmetric relationship» in terms of interaction and understanding between the care manager and the client, where the exploration to find solutions for the situation based on the needs could be done on more equal terms (Nilsson & Olaison, 2020).

Through this project, peer support has emerged as an important way to help manage mental illness. However, to ensure that the peer support intervention has a positive impact, the involvement of practitioners is required. Since service users, as both recipients and providers of peer support them. Furthermore, this attempt to implement a peer support telephone project has highlighted the need to collate evidence regarding the relationship between peer support and recovery.

The Covid-19 pandemic has led to the introduction of alternative ways to offer peer support for those with mental health issues and their families, in Vallecamonica. During the lockdown, the practitioners collaborated with E.B.E. and laid the foundations for the co-production of relational mental health services.

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