What Is Peer Support (PS)?

Peer support (PS) is embedded in national mental health policy in many countries (World Health Organization, 2021). A PS relationship is co-created between a service user and a PS worker. The relationship involves the PS worker offering recovery support and hope, based on common experiences (Davidson et al., 2012). The relationship is characterised by mutuality and connection. Mutuality involves joint sharing of experiences and coping strategies with the intention of supporting the other (Fortuna et al., 2019). Connection means emotional engagement with another person who is important and supportive, which enhances a sense of belonging and wellbeing (Blanch et al., 2012). A defining feature of the PS role is to share parts of the PS worker’s own story, to facilitate these relational processes of mutuality and connection and to act as a visible role model of recovery. This expectation differentiates PS from other professional groups. Nurses, psychiatrists, psychologists and other members of the multidisciplinary team sometimes choose to use therapeutic self-disclosure in the course of especially psychological therapies, but sharing of one’s own story is not a defining feature of any of these professional roles.

Evidence Base for Mental Health PS

Mental health PS has a robust evidence base (Mutschler et al., 2021). A meta-analysis synthesising 19 randomised controlled trials (RCTs) of one-to-one PS identified its effectiveness for recovery, empowerment and working alliances (White et al., 2020). Likewise, a meta-analysis based on eight RCTs for group PS reported the intervention was effective for recovery and psychiatric symptoms (Lyons et al., 2021). A systematic review about digital PS, where live or automated support is offered using technology, reported that digital PS was feasible, acceptable and effective (Fortuna et al., 2020). Qualitative evidence also supports the effectiveness of PS work. A meta-synthesis, integrating evidence of 27 qualitative studies about adult mental health, revealed that service users perceived their PS worker as a role model, which helped them feel more hopeful and motivated about their recovery (Walker & Bryant, 2013). Another qualitative meta-synthesis evaluated evidence of 34 studies identified that PS helps to reframe service user identity through mutual relationships and appropriately sharing the PS worker story (MacLellan et al., 2015). A qualitative longitudinal study found that PS work changes fear into hope, using a shared experience between a PS worker and a service user as a primary asset (Simmons et al., 2020). Furthermore, PS has high applicability and is effective for diverse populations, contexts and mental health outcomes, used for older adults, youth, LGBTQ + people, persons with disabilities, those in a forensic context and in low- and middle-income countries, among others (Borthwick et al., 2020; Moran et al., 2020; Shalaby & Agyapong, 2020; Williamson & Durcan, 2020).

How Peer Support Works

Several theories have been proposed to explain the mechanisms of how PS improves mental health, such as love labour, strength-focused social and practical support and lived experience (Watson, 2019). A prominent theory is social comparison theory (SCT). SCT is based on the assumption that people have an inherent need to evaluate themselves by comparing with others (Watson, 2019). Seventy-eight percent of participants in one study reported comparison was the most effective to maintain a high level of quality of life (Graham Beaumont & Kenealy, 2004). SCT identifies two forms of social comparison: upward and downward (González-Nuevo et al., 2021). Upward comparison may occur when working with a PS worker who has recovered from a similar challenge, which may result in the service user feeling more hopeful that they too can overcome the challenge. Downward comparison may occur when the PS worker has undergone more serious challenges than the service user, which may result in the service user believing that their own challenges are not as difficult, leading them to feel better about their circumstances.

However, a SCT-based understanding of PS work can inadvertently cause harm to service users. PS workers selectively emphasise aspects of their narratives in their work, with the aim of maximising benefit for the service user (Mancini, 2019). A SCT-informed PS worker may selectively present more adversity-based aspects of their narratives to support downward comparison or the more recovery-based aspects to support upward comparison. Although this can benefit the service user, an implication of emphasising different experiences may also be that connection is less supported. Without connection, a service user may feel inferior or self-critical from comparing with their PS worker who has overcome a similar problem. This is conceptualised in the comparison process of the self-evaluation maintenance model, where the closer the relationship gets, the more one’s self-evaluation suffers (because of the enhanced inferiority or self-criticism), leading to various harms including a withdrawal from the relationship (Tesser, 1988). Recent studies reported that social comparison is associated with negative outcomes such as loneliness and anxiety (Arnold et al., 2021; Jiang & Ngien, 2020; Kotera et al., 2022; Lee, 2020; Verduyn et al., 2020). A SCT perspective can highlight differences between a PS worker and a service user, conflicting with mutuality and connection—the key components of a PS relationship (Davidson et al., 2012). A theoretical understanding of PS work needs to be aligned with these key components.

Common Humanity

Common humanity (CH) supports connection and mutuality (Gilbert & Leahy, 2007). CH is an experience in which we acknowledge that suffering is a part of human life and that other people experience similar suffering to our own (Ling et al., 2020). A person with strong awareness of CH does not think they are alone in their life challenges, but are aware that similar challenges happen to other people. They accept that humans are imperfect; therefore, challenges connect them with other humans who are also imperfect, rather than isolate them. This awareness can create resistance to any arising feelings of isolation, shame and inadequacy. Experiencing CH allows us to recognise that suffering and personal weaknesses are part of our shared humanity (Kim, 2017). A CH perspective is that all humans are the same in their desire for happiness and the avoidance of discomfort, and this recognition helps us to focus on the sameness between self and others, rather than on the differences. In difficult circumstances, CH helps us replace the experience of isolation with feelings of normalisation and connectedness (Alasiri et al., 2019). CH is highly relevant to PS work because CH connects individuals with others in life challenges (connection) by recognising the challenges as shared experience (mutuality).

CH has an empirical evidence base. In a randomised controlled trial (RCT) of socially anxious young adults (n = 63), a CH intervention reduced anxiety and increased self-warmth among socially anxious adults (Slivjak et al., 2022). A RCT involving 75 healthcare workers found that watching a CH-focused video increased compassion among workers (Ling et al., 2020). In another RCT, CH-focused writing increased compassion and life satisfaction among 83 German university students (Dreisoerner et al., 2021). Moreover, CH is an essential component of compassion, which helps us regulate emotions by activating our parasympathetic nervous system (Kim et al., 2020). CH is associated with resilience and quality of life (Dreisoerner et al., 2021; Kotera et al., 2021; Wilkes et al., 2022), which are targeted in the core practices of PS work (Stratford et al., 2019).

We propose CH provides a useful lens through which to understand how a PS relationship may help service users. Increased awareness of the concept of CH may empower a PS worker to support a sense of connection in the PS relationship through emphasising their sameness with their peers and normalisation of their experiences. The emphasis on the sameness and normalisation are aligned with the guiding values of PS work including equality, understanding and shared experience (Stratford et al., 2019). The service user may feel that their PS worker is alongside them in their recovery journey and that there is nothing wrong with themselves (it is a part of being human), reducing negative feelings of isolation, shame and inadequacy (Dreisoerner et al., 2021). In contrast with the SCT mechanism which emphasises the difference between a PS worker and a service user, the CH mechanism highlights the sameness between them, reducing the likelihood that the service user will feel inferior or self-critical.

Understanding PS as a relationship-supporting experience of CH has implications for clinical research and practice.

Research Implications

For research, the CH lens highlights the potential role of emotional self-regulation in understanding how mental health PS benefits service users. CH helps activate our parasympathetic nervous system, contributing to our emotional self-regulation (Kim et al., 2020). The impact of PS on emotional self-regulation has not been researched to date. Future research could evaluate the impact of PS on emotional self-regulation in the service user. This would extend PS evaluative research in two ways. First, the use of standardised patient-rated outcome measures such as the Self-Compassion Scale (Neff, 2003) or the Forms of Self-Criticising/Attacking & Self-Reassuring Scale (Gilbert et al., 2004) to assess emotional self-regulation would assess CH-related outcomes. Second, biological indices such as heart rate variability (measured using a portable electrocardiogram device) can be used to assess the parasympathetic functioning associated with emotional self-regulation (Kim et al., 2020). The development of observable biological indicators of PS impact would complement current evaluation approaches which are based primarily on self-report measures and service use data.

Practice Implications

Understanding how CH is experienced can help a PS worker to support the experience of CH in the service user they work with. For example, understanding of CH could influence how the PS worker tells their story. As noted, a SCT-informed PS worker may present more challenging aspects of their narratives to support downward comparison or more successful aspects to support upward comparison. Highlighting these differences can inadvertently make the service user feel inferior or self-critical. By contrast, a CH-informed PS worker may emphasise aspects of their narratives relevant to normalisation of the service user’s difficulties and to points of similarity and connection with the service user. This distinction between comparison-based PS and connection-based PS is potentially important because there are pathways to benefit arising from connection-based approaches which do not arise from comparison-based approaches. For example, connection-based emotional self-regulation more stably supports good mental health than comparison-based approaches that entail the need to be better than others (Neff & Vonk, 2009). Understanding of CH may help a PS worker to offer more connection-based use of their own story.