Peer support - cheaper and just as effective as CBT

April 29, 2011

Train ordinary people to be more compassionate and psychologically helpful to each other. They could do as good as job as CBT therapists for depression and anxiety, argues psychotherapist Nicky Forsythe

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I first became fascinated by the power of what I will call ?educated peer support? when I was training as a therapist in 1998.  Just a few months into an experiential group training, twenty-four of us had learned the essential skills of self-awareness, separating feelings from facts, articulating our inner experience, and providing the therapeutic experience of what is called ?accurate empathy? to one other. 

I remember wondering, dumbfounded, why I had not been taught these simple and life-changing skills earlier. 

It quickly became clear that, armed with this simple battery of skills, the group became an enormous resource to one another. Many of us set up peer support groups, some of which are still going strong after more than ten years.  As someone with experience of mental distress, I have found these groups a cornerstone of my continued well-being.

Reflecting on this after many years of my own therapy, I realised that these support groups had been as psychologically helpful as any other intervention I had experienced, and this tallies with a great deal of research into the  nature of the benefits experienced from therapy.

My personal experiences, research interviews  I have conducted with a hundred or so therapy users, and the academic literature, converge on some striking points. 

• Firstly, the effectiveness of therapy boils down to some very simple ingredients of all therapies  ? known as the ?common factors? ?  such as warmth, genuineness and rapport between the client and a concerned other.  Repeatedly, research comparing the effectiveness of different therapies has yielded ?the dodo bird verdict?:  all therapies have a beneficial effect, despite their sometimes radically different theories and practices, and because of these ?common factors? (Duncan et al, 2004, p. 32).  It has been speculated that the idea of the potency of therapies? special techniques is kept alive mainly to preserve the status and legitimacy of the therapy profession (Bergin & Garfield, 1994).

• Secondly,  despite practitioner attachments and beliefs, there is little evidence that quantity of therapist training or acquaintance with theory correlate with better therapy outcomes.  Indeed, there is plenty of evidence that ?paraprofessionals? ? people with no formal therapy training - can deliver as good ?therapy? outcomes as seasoned psychotherapists (Christensen & Jacobson, 1994).

• Thirdly, while special training may not be crucial to effective psychological helping, nevertheless having an empathic confidante or confidantes is critical to mental well-being.  The Government?s Foresight report on building mental capital (2008) and Halpern?s work on Social Capital (2005) are amongst many authoritative sources who conclude that having confidants is a critical part of what helps us (and society) stay sane. 

"It is a well-established fact that levels of social support ? in particular, the presence of close confiding relationships, are closely connected to psychological well-being? (Cooper 2008,  p. 75).  In fact overall, many have argued that the effectiveness of therapy itself can be boiled down to having an experience of confiding through the ?right kind? of talk.  It is reasonable to think then that: ?It is talking which cures and not particular therapeutic schools and their preferred techniques.? (Howe, 2004).

These findings led me to ask some questions.

What if the therapy enterprise has unhelpfully packaged up, commoditised,  jargonised and established a monopoly over the domain of restorative talk, rendering it inaccessible to all but a minority of the 16% of the general population estimated to suffer from the symptoms of common mental health disorders (Government Office for Science 2008)?

Could therapy work if you pared it down to its most parsimonious form ? just skilled  talking and listening?

Does therapy need to be as expensive as it is ? the cost resting, as it does, on the lengthy trainings and income needs of professionals?

Would it be possible to bypass experts (at least for mild mental health issues) and train ordinary people to be more compassionate and psychologically helpful to each other?

Would a model such as this actually be more desirable in terms of empowering people and conferring the proven psychological benefit of giving to other people?

I decided to test the hypothesis that a battery of simple skills might be enough for people to offer valuable emotional support to one another, so I started to develop an educative programme where people could learn the skills of understanding and talking about their own inner world and feelings,  and listening helpfully to others. 

This evolved into Talk for Health, a group programme I eventually developed and piloted with sponsorship from British Telecom (I am grateful to our sponsor Adrian Hosford , support from my colleague Simon Confino, and to Spectrum, the therapy training institute where the idea was born and shaped).

The content and approach of Talk for Health was further shaped with advice and input from a variety of experts in therapeutic talk including Gerard Egan,  Andrew Bailey, Professor David Howe of UEA, Scott Miller PhD, and colleagues Tim Foskett and Jill Sluman. 

It was a seven-session group programme based on skills and practices which have good evidence behind them in terms of their capacity to build well-being.  It taught people how to share their inner experience, and listen and respond helpfully to others? sharing.

It was a small pilot involving twelve people, but the results were promising.  Using Scott Miller?s therapy assessment protocol (the ORS) which measures well-being across five areas of life, nine of the twelve showed marked improvements across all five measures.  (The remaining three dropped out of the programme early and their final feedback could not be obtained).

As one participant put it: "This teaches you the skills that society often forgets to:  how to connect to your feelings and needs, how to express this authentically and appropriately, and how to adapt your communication so that others can hear you?

It was a small step but I believe that programmes such as this could offer a cheaper and more effective solution to the growing ?epidemic? of loneliness, depression and anxiety that we are experiencing in this country. 

On the other hand, relying on state-funded CBT therapy as a response to this problem is costly and, as Seligman points out in his latest work (2011), has limitations in its effectiveness.  It has doubtful lasting benefit ? its effect often ?melting? when treatment stops. 

The latest outcomes data research on the IAPT programme show a modest 52% recovery rate (Clark et al 2008), where 65% is an average recovery rate across all forms of therapy (and the effectiveness of ?placebo? ranges between 45% and 55% - Seligman 2011).  Important to note, this 52% rate was where professionals were assessing ?recovery?.  By contrast, it was reported that only around 10% of a qualitative sub sample reported that they felt better - and in my opinion it?s important to look at what service users say, as well as professional appraisals, if you really want to know what works.  

A further and substantial problem with rolling out more therapy provision is not just its modest effectiveness but the extent to which it reinforces the notion that in addressing depression and anxiety, we are ?treating illnesses?.

In a society where we have growing social inequality, fragmentation, declining spiritual practice, and a focus on material things as opposed to relationships and people, we have created conditions for an ?epidemic? of the human afflictions named depression and anxiety - as has been well documented by Halpern (2005), Layard (2006),  James (2007) and Wilkinson & Pickett (2009) amongst others.

Competitiveness and materialism reduce opportunities to connect in emotionally nutritious ways ? and ways that buffer against mental ?illness?.  We become more isolated, invest less time in relationships and don?t want to display vulnerability to others.

If our consequent angst is then diagnosed and treated as a malady, we are tackling the problem at the wrong end.  People are surely suffering from the deficiencies of society rather than from mysteriously acquired ?illnesses?, aren?t they?  The risk is that we will continue to medicalise the unhappiness which arises out of our social conditions instead of normalizing practices which promote mental health - such as empathy and emotions-talk with close confidantes.

What if we approached the problem in a different way?  Could we reintroduce to society those health-giving skills and practices of empathy and confiding, and create a growing network of people who are trained in the simple skills that enable them to give and receive effective emotional support for nothing?  Perhaps then we could address the ?epidemic?,  save money and grow a resource of essential capabilities in our society. 

Or as one of my research interviewees succinctly put it: ?Society has become too individualistic and therapy encourages that.  I don?t like the idea of people going down their own rabbit holes, it?s the wrong idea.  But I want society to be more therapeutic.  To know I?ll get a caring response if something goes wrong.?

* Nicky Forsythe is a researcher, psychotherapist, and sits on the advisory board of the Time To Change campaign against mental health stigma.

A condensed report on the Talk for Health pilot can be found on here, and a fuller report is available from . Nicky Forsythe runs a programme of free introductory Talk for Health sessions between May and September 2011.  Email for further information.

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References and further reading

Bergin, A.E. & Garfield, S.L. (1994).  Overview, Trends and Future Issues.  In Bergin, A.E. & Garfield, S.L. (Eds), Handbook of Psychotherapy and Behaviour Change  New York:  Wiley

Christensen, A. & Jacobson, N.S. (1994). Who (or What) can do Psychotherapy:  The Status and Challenge of Non-professional Therapies, in Psychological Science, 5, 8 ? 14)

Clark, D.M., Layard, R., Smithies, R., (2008).  Improving Access to Psychological Therapy:  Initial Evaluation of the Two Demonstration Sites, LSE Centre for Economic Performance

Cooper, M., (2008).  Essential Research Findings in Counselling and Psychotherapy, Sage Publications

Duncan, B.L., Miller, S.D., & Sparks, J.A. (2004).  The Heroic Client, John Wiley & Sons
Frank, J.D. & Frank, J.B., (1991).  Persuasion and Healing:  A Comparative Study of Psychotherapy, The Johns Hopkins University Press

Government office for Science, London., (2008).  Foresight Mental Capital and Wellbeing Project.  Mental Health, Future Challenges.

Halpern, D. Social Capital, Polity Press 2005

Howe, D., (2004).  On Being a Client, Sage Publications

James, O., (2007).  Affluenza, Vermilion Publishers

Layard, R. (2006).  Happiness:  Lessons from a new science, Penguin

McLeod, J. (2009)  An Introduction to Counselling, Open University Press, pps 470 ? 474

Seligman, M., (2011).  Flourish, Nicholas Brealey Publishing

Wilkinson, W. & Pickett, K., (2009).  The Spirit Level:  Why More Equal Societies Almost Always Do Better, Allen Lane

Wittchen, H. and Jacobi, F. (2005) Size and burden of mental disorders in Europe ? a critical review and appraisal of 27 studies.  European Neurophsychopharmacology, 15, 357 ? 76

Read also:
Feb 2, 2011: Government extends psychological therapies programme - four-year action plan launched by care minister Paul Burstow
Dec 3, 2010: Peer support reduces NHS mental health costs but improves outcomes - new report highlights possible increased role of service users
Nov 16, 2010: NHS psychological therapists enable four in 10 people to recover - study on Improving Access to Psychological Therapies programme states 44% of 12,388 people who completed their cognitive behavioural therapy (CBT)-based intervention benefited significantly.
Nov 18, 2009: Eight out of 10 people recover after CBT, reports study - new research claims effectiveness for government's psychological therapies programme
March 19, 2009: CBT "does not work? says high-profile clinical psychologist - Oliver James accuses government ministers of being "downright dishonest? on depression cure claim

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My 24 years as nurse confirms relationship matters, not theories

From: Peter Kaan, Staff Nurse, Cotehele, Adolescent Unit, Plymouth
Date: May 3, 2011

As the years go by, and I accumulate experience (24 years now) as a nurse on in-patient psychiatric units, the more convinced I am that it is the quality of the relationship that matters, not the therapist's/nurses theories.

So I obviously believe that nurses can be just as good (and caring, and effective, etc) as therapists of any other description.

I am not against theory, and believe rather that nurses (and members of all caring professions) should read - and read widely - so that their commitment and compassion are well supported by learning. But ultimately - and this is always later confirmed by patients/clients - what counts for most is the quality of the rapport that is built up (which has hope and honesty and a genuine willingness to help as main ingredients). So I agree with the whole thrust of Nicky Forsythe's good article. My only reservation is with the notion (articulated in the article's sub-heading) that people can be trained to be more compassionate. Skills and techniques - these can probably be taught, but compassion? Is that not innate? It's either there, or it isn't.

NB So much of this article reminded me of the work of David Smail (e.g. "Taking Care - An Alternative To Therapy").

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Peer support helped my recovery

From:, Buddy Scheme Co-ordinator, Borough Green, Kent
Date: May 3, 2011

I am passionate about peer support. It was an important factor in my recovery journey. To be supported by another service user who has been in the same dark place and who has recovered gives people not only the hope that they can and will recover but they also gain so much from that person's experience.

We will be promoting peer support at our Peer Support Conference in Kent in July to service users and staff of the Kent and Medway Partnership Trust.

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Peers support is essential

From: Susan Hohman, Faciltator of Peer Support Group in Bennington, Vermont, USA
Date: May 6, 2011

There's no doubt about the power of peer support. I have been involved in this group for four years and I have seen some major improvements in peers that were made via the group over the therapies the individuals were receiving.

This is not to say that therapy is not necessary, but that peer support is essential as well. Who knows better than a peer what another peer is going through and who has better information that could help.

In our group - we happen to be affiliated with the Depression Bipolar Support Alliance - our motto is "we have been there. We can help." How true that is. We are not discussing theories when we meet, we are discussing true life situations and what works and what doesn't. It is enormously helpful to draw on another peer's experience rather then set out on a course of action where you don't know anyone who ever tried it. And then go back the next week and be able to evaluate h ow it worked and get immediate feed back.

Peer support is so valuable, and so underrated. It is at least as important as any other tool in our tool box:along with medication, therapy, exercise, proper nutrition, and healthy life style choices.

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GPs should offer peer support

From: Service user (anonymous), UK
Date: May 10, 2011

Over 20 years ago I had group therapy sessions and they were pretty effective, especially when they continued after the professional left and we no longer felt observed.

When hospitalised I have always felt that I missed out on a lot of beneficial talk that went on the smoking room - the main focus for peer support on the wards. People quickly learn it is SAFE to be open, warm and empathetic in an environment where all are vulnerable. Some of my hospital friendships are still going strong, providing mutual support.

My goodness, Nicky also suggests that the patients should be a part of assessing their recovery and it comes across as radical in this article. Well, I have always felt only partly listened to by professionals.

I think every GP's surgery should have peer support groups available, sometimes as an adjunct to medication and counselling, sometimes not, depending on the individuals need.

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