I need you to write a 6 page paper ( the first page need to be 200 word abstract and then there needs to be a 5 page literature review, which you have to compare and contrast all the dataand sources

Keywords Peer services· Recovery· Community treatment· Mental illness· Substance abuse Introduction Peer recovery services are one option in treating individuals with mental health issues. These services may serve as an alternative to inpatient institutional care and have implica- tions for health policies, as the number of inpatient programs and psychiatric beds in the United States has decreased (Chaimowitz 2011). Unfortunately, these decreases have occurred without a structured transition to community-based treatment. One solution to improve outcomes for people with mental health problems (MHPs), and to help reduce state costs, involves recovery centers and their associated peer support services. This option has been acknowledged at the national level. In 2003, the President’s New Freedom Commission on Mental Health recommended a transition to recovery ser - vices for people with MHPs (Sledge et al. 2011 ). Many peer programs have been created in recent decades (Gold- strom etal. 2006; Moran and Russo-Netzer 2016); however, research supporting the eectiveness of peer services has not kept up with the development of such services (David- son etal. 2006). Accordingly, more research on the e cacy of peer recovery services is required (Nestor and Galletly 2008). The purpose of the current study is to address the eectiveness of peer services in a recovery center in a rural area in a Western state, referred to as the “Center” from here on. Changes in recovery capital, quality of life, general well- ness, as well as the perceptions of peer mentors regarding the services they provide, are examined.

The recovery process for mental health involves helping individuals feel like they belong in their communities and assisting them in establishing an identity distinct from their mental illness (Davidson etal. 2007). Recovery centers are premised o this model, and they present as a low-cost alter - native to conventional outpatient and inpatient mental health treatment as they are, in part, operated by consumers of men- tal health services (Brown and Townley 2015). As such, vol- unteers are, themselves, in later stages of their recovery and can assist others. Additionally, these programs are eective in promoting feelings of community and empowerment, and using peer providers helps better engage others seeking recovery (Brown and Townley 2015). Many recovery cent- ers oer peer support, which Yanos, Primavera, and Knight ( 2001) found helps protect against mental health relapse.

* Melissa A. Kowalski [email protected] 1 Department ofCriminal Justice, The College At Brockport, State University ofNew York, 350 New Campus Drive, Brockport, NY14420, USA Vol:.(1234567890) 1 3 569 Community Mental Health Journal (2020) 56:568–580 The evidence on recovery centers is mostly positive (Ahmed etal. 2015; Brown etal. 2003; Davidson etal. 2006; Felton et al. 1995; Gidugu et al. 2015; Hutchinson et al.

2006; Kemp and Henderson 2012; Kennedy 1990; Lewis etal. 2012; McDiarmid etal. 2005; Mowbray etal. 1998; Nestor and Galletly 2008; Resnick and Rosenheck 2008; Rivera etal. 2007; Roberts etal. 1999; Sledge etal. 2011; Solomon 2004). These centers may become increasingly important as states continue to encounter healthcare reform and budget crises (Whitley etal. 2012). However, the path to reform is not unobstructed. Many centers lack standardized services, clear goals, and/or quality assurance. Moreover, recovery centers may result in harm to some individuals, who may be further isolated from the community and who may become service-dependent (Whitley etal. 2012). Thus, more research is needed to ascertain whether peer recovery services have more benets than they do costs. Recovery peer mentors are individuals recovering or who have recovered from a mental illness and who provide services to others currently suering from a mental illness (Moran and Russo-Netzer 2016). The use of peer mentors is supported by social learning theory, as mentors act as positive role models for mentees (Solomon 2004). Social comparison is also relevant, in the sense that mentees may interact better with peer mentors than they do with mental health professionals because of the shared experience men- tors and mentees have regarding mental illness. Peer mentors are not completely without professional skills. It is typical for peer mentors to undergo training about the recovery model (Ahmed etal. 2015). Yet, the best advan- tage peer mentors have is their own experiential knowledge of mental illness (Nestor and Galletly 2008). Moreover, mentees’ ability to self-identify with their mentors is criti- cal, as this identication cannot be created by other mental health providers (Sells et al. 2008). Additionally, Rivera etal. (2007) found that peer mentors are about as equally eective as professional mental health providers. Davidson etal. (2006) came to a similar conclusion after reviewing four studies that used randomized controlled trials. Across the studies, there were scarce dierences between care pro- vided by peers and non-peers. In short, peer services may oer a good complement to traditional professional services but may not be e cacious enough to completely replace professional services (Gidugu etal. 2015).

As such, there is no clear evidence to suggest that peer mentors are more eective than professional mental health providers (Solomon 2004). Nonetheless, peer recovery ser - vices are attractive to many individuals with mental illness because they are dissatised with the conventional mental health system (Whitley etal. 2012). Positive outcomes asso- ciated with peer services for mentees include improved psy - chological and social adjustment (Rivera etal. 2007; Rob- erts etal. 1999), recovery (Felton etal. 1995), self-esteem (Kennedy 1990), condence, social interaction, lifestyle, motivation, and attitude (Kemp and Henderson 2012). Peer services are also associated with fewer psychiatric symptoms (Rivera etal. 2007) and a decreased likelihood of re-hospi- talization (Sledge etal. 2011). However, Brown etal. (2003) found that recovery services may detrimentally impact mentees because they may experience lowered self-esteem.

Taken together, these results indicate that peer recovery ser - vices are mostly benecial for mentees, but certain concerns remain to be addressed. Peer mentors may also benet from peer services by way of improved self-esteem (Brown etal. 2003), personal rela- tionships (Mowbray etal. 1998), well-being (Resnick and Rosenheck 2008), job satisfaction (Hutchinson etal. 2006; Nestor and Galletly 2008), condence (McDiarmid etal.

2005), hope, empowerment, and social engagement (Ahmed etal. 2015). More tangible outcomes include lowered risk of hospitalization (Hutchinson etal. 2006; McDiarmid etal.

2005 ), maintenance of psychiatric health (Ahmed et al.

2015), and stable employment (Hutchinson et al. 2006).

Yet, peer mentors may be detrimentally aected by their interactions with mentees. For example, Ahmed etal. (2015) discovered that peer mentors experienced emotional stress from aiding others, di culty maintaining personal wellness, and work stress. Peer services have also been devalued by professional mental health providers (Chinman etal. 2002).

More explicitly, mental health professionals may not view experiential knowledge as particularly useful (Hodges and Hardiman 2006).

Con icting research on the e cacy of peer recovery services indicates a need for more research. This need is particularly relevant considering the lack of evidence-based status for peer services (Davidson etal. 2006) despite grow - ing utilization of such services. This study contributes to the recovery research by assessing the eectiveness of services as well as interviewing peer mentors to understand their experiences and the process of providing services. Methodology This study assesses the eect of peer recovery services in the Center via a mixed-methods design, and the results may help better elucidate the impact of peer services on mentees, in addition to the process behind services, as described by mentors. Although extant research has considered the eec- tiveness of peer recovery services, the current study expands upon such research in several ways. First, the Center diers from others in its state, as it has taken steps to assess the eect of its services, and it is in the process of becoming more integrated in its community through a plethora of out- reach programs. Moreover, unlike many other recovery cent- ers, it is not a liated with any organization and is centrally 1 3 570 Community Mental Health Journal (2020) 56:568–580 located in a downtown business district. The Center has implemented three surveys to analyze peers’ recovery, qual- ity of life, and wellness. The surveys are administered every three months as well as when a person enters and leaves the program. Peer mentors’ perceptions of the services they pro- vide and whether they feel they are accepted in their roles as a pseudo mental health provider are also assessed. Mentors’ perceptions of their role in addition to the eectiveness of the Center build upon observed outcomes in the quantitative analyses to better gauge the overall eectiveness, perceived or documented, of the Center. Research questions include:

1. Do peer services improve recovery capital, quality of life, and/or general wellness?

2. What are recovery peer volunteers’ perceived goals of peer services?

3. What are sources of satisfaction and stress for recovery peer volunteers?

4. How do recovery peer volunteers perceive their work environment?

5. How do recovery peer volunteers perceive the eective- ness of peer services?

Sampling Procedure and Measurement As of the Center’s most recent report at the time of the study, 108 people had undergone peer recovery services.

Only subjects with responses to all items on a survey are included in this study. Three peer mentors were additionally recruited for interviews. Surveys are analyzed to look at peer mentors’ recovery capital, quality of life, and wellness. The Center routinely administers the Assessment of Recovery Capital (ARC), the World Health Organization Quality of Life Assessment-BREF (WHOQOL-BREF), and a Wellness Self-Assessment. Scores on the three surveys are compared across time, as measured by the number of times the surveys have been administered.

Cloud and Graneld (2008) dene recovery capital as the resources, internal and external, an individual utilizes to initiate and maintain recovery. The ARC quanties recovery capital, which can then be used to examine progression in recovery (Groshkova etal. 2013 ). The ARC has 50 items representing ten sub-scales that measure recovery strength.

A higher score indicates greater recovery capital. Groshkova etal. (2013) conducted a conrmatory factor analysis on the ARC and found concurrent validity, acceptable test–retest reliability, and that the ARC discriminates amongst respond- ents who are in later stages of recovery compared to those in earlier stages. Quality of life is relevant to this study, as such factors may result in vulnerability to substance use (Foster etal.

2000) and recovery eort (Laudet 2011). The WHOQOL- BREF has 26 items that assist in creating a quality of life prole (World Health Organization [WHO] 1996). The scale has four domains, including physical, environment, social, and psychological. A higher score signies a better quality of life. Skevington etal. (2004) investigated the psychomet- ric properties of this scale and discovered it has good to excellent reliability. This scale is valid across cultures and has good internal consistency and discriminant validity.

The third survey is a Wellness Self-Assessment, which examines general physical well-being and includes items measuring environment, employment, and stress. The assessment has 39 items, and the psychometric properties have not yet been investigated. However, it is anticipated that respondents’ general well-being may in uence their recovery process. Data for the present study was granted on the condition of anonymity; accordingly, it was not pos- sible to access o cial records regarding mental health or substance abuse/dependence histories. Neither identifying information nor contact details for survey respondents or interviewees was collected either. Although this lack of measurement limits the generalizability of the study, I felt it was important to ensure anonymity to avoid deterring indi- viduals from seeking out the Center’s services. Such caution is warranted in light of stigma and shame surrounding MHPs and service-seeking, an issue the interviewees commented on (see below). This study also includes semi-structured interviews with peer mentors to learn more about the processes and mecha- nisms underlying peer services, as there is a lack of research regarding how mentors use their experiences to help men- tees recover (Davidson etal. 2006). These interviews may also help reveal whether providing services are more ben- ecial than they are not for mentors. The research has been mixed on this issue (Ahmed etal. 2015; Brown etal. 2003; McDiarmid et al. 2005; Resnick and Rosenheck 2008).

The interview guide was formed by deductively compiling themes found in the recovery literature. Open-ended ques- tions during the interviews also allowed for other themes to emerge. Interviewees were recruited via the Center’s Pro - gram Director, who asked all peer mentors if they would volunteer for an interview with the researcher. At the time of the study, there were six peer mentors. Three peer mentors volunteered, representing 50% of the mentor population for the Center. Analysis Plan Three repeated measures analyses were conducted to exam- ine how subjects’ responses to the ARC, the WHOQOL- BREF, and the Wellness Self-Assessment change over time, as substantial level two clustering (peer level) was evident following the calculation of an intraclass correlation. Linear regressions were also performed to assess how the overall scores from the surveys relate to each other. I hypothesized 1 3 571 Community Mental Health Journal (2020) 56:568–580 that peers would have improved recovery, quality of life, and wellness over time.

For the qualitative analyses, I enlist a thematic analysis to examine transcribed interviews (see Braun and Clarke 2006) and look for themes discovered deductively through examin- ing the literature in addition to themes that emerge induc- tively from the data. I analyzed the interviews until I reached saturation, and no further themes emerged. The study was approved by the Washington State University’s Institutional Review Board. The author has no known con ict of interest in performing this study and certies responsibility for the study. Below, qualitative results are integrated with quantita- tive ndings to detail the perceived and observed eective- ness of the Center.

Results Repeated measures analyses for the three surveys revealed marginally signicant results for the ARC but statistically nonsignicant results for the WHOQOL-BREF and Well- ness Assessment. For these latter two surveys, change in scores were in the anticipated direction. The repeated meas- ures model is shown only for the ARC. Furthermore, analy - sis of the interviews identied several themes, in line with previous research, including goals of peer support services, qualities of peer providers, peer services as an alternative to professional services (Solomon 2004), a lack of value and support for peer services, personal growth for peer providers (Brown etal. 2003), relapse in recovery, peer provider sat- isfaction (Hutchinson etal. 2006; Nestor and Galletly 2008) and stress (Ahmed etal. 2015), the need for these services, and eectiveness of peer services (Brown and Townley 2015 ). Themes not deduced from the literature emerged, including dening recovery, volunteer identication and duties, a lack of resources, and training and education as a pathway to employment.

Interviewee demographics are not included, as such descriptions could result in interviewee identication. How - ever, all interviewees had either self-reported substance abuse and/or mental health diagnoses. As Fig. 1 shows, there were six overarching themes and 15 sub-themes. Several of these themes relate to the surveys and are discussed in the context of the relevant survey. However, rst context regard- ing the services provided by the peers and Center, as they were discussed in the interviews, is provided. Context of Services De ning Recovery Identifying recovery is an overarching theme that subsumes all other themes. Recovery is an ongoing process, and inter - viewees agreed that recovery is ambiguous. Interviewees dened recovery spontaneously, and they all emphasized how personalizing support was essential. One interviewee described recovery as a “personal journey” (Interviewee #1), while another stated, “If you believe you are in recovery, you’re in recovery” (Interviewee #2). The third interviewee discussed how recovery involves control over his/her men- tal health and substance abuse issues while engaging with the community. Consequently, there are several paths to recovery.

De ning Peer Support Services Interviewees were asked about the goals of their work, as well as qualities peer mentors should have. Two other Fig. 1 Deduced and emerged themes in peer support services 1 3 572 Community Mental Health Journal (2020) 56:568–580 sub-themes emerged during this line of questioning: vol- unteer identication and volunteer duties. Taken together, these sub-themes provide a scene for what happens at the recovery center.

Goals of Peer Support Services Overall, the recovery center has a mission statement that peer mentors are meant to adhere to. The mission statement was brought up by two of the interviewees generally, but neither of them mentioned specic wording. The statement is as follows:

…The Center is a private, non-prot organization serv - ing people who are in recovery from alcohol and other drug use or mental health disorders. It is a partnership between people in recovery, family members, allies and local organizations who respect the dignity and equality of all people and who are dedicated to pro- moting healthy communities.

Interviewees discussed dierent components of the mission statement, except for family and local organizational involve- ment in the recovery process. One interviewee mentioned the importance of the community and how peer mentors work with mentees so mentees can be reintegrated into the community (Interviewee #3). Again, the goals for working with mentees are not delineated clearly because recovery varies across people. Accordingly, the level of guidance peer mentors oer depends on the mentee’s needs. With this indi- vidualization in mind, it is di cult for the Center to develop set guidelines for how mentors should support all people seeking help.

Qualities of Peer Providers I elicited responses regard- ing interviewees’ perceptions of what qualities mentors should have. The responses were diverse, from empathy and patience (Interviewee #1) to being a good listener (Inter - viewee #2). Yet, all interviewees agreed that having life experience is vital. In fact, having this experience is one requirement for becoming a volunteer (Interviewee #3).

Interviewees also accentuated how this life experience dif- ferentiated peer mentors from mental health professionals.

Volunteer Identity Another theme that emerged includes how mentors viewed themselves. One interviewee saw him- self/herself as a friend to mentees (Interviewee #2) while another made it clear that he/she was not a friend (Inter - viewee #1). This construction of self in working with men- tees related to how peer mentors do their work and how their identity connects to their perceptions of professionalism.

Volunteer Duties The interviewees also discussed the duties they perform; they agreed that part of what they do is external guidance for mentees. Recovery as an individu- alized process was again emphasized, as well as mentees’ willingness to be proactive about their own recovery process (Interviewee #1). One interviewee discussed his/her work in more detail than the others:

We don’t have a step-by-step rulebook or something that’s like, ‘Here, dothis’. But, it’s kind of where your mentee is and trying to nd something, you know, that matches … Ah, you know, we don’t diagnose… We don’t … We refer people if we think that’s where the person is, just like you need to know what your issue is. Okay, let’s refer you to someone that can diag- nose. Ah … We can try to help keep people motivated to work on their recovery. We can provide external accountability. We can, you know, provide some struc- ture. Ah … But, it’s vastly dependent on the person’s desire to, you know, work on their own recovery (Inter - viewee #1).

This interviewee alluded to a couple of points regarding peer mentors’ duties. First, peer mentors need to match services to mentees’ needs. Second, a mentor’s role is dierent from that of a mental health professional. For instance, mentors do not diagnose mentees but will refer them to mental health professionals as needed. Third, mentors are an external sup- port and help make mentees accountable to themselves in achieving recovery. Two interviewees (#2 and #3) further discussed how mentors help bridge a gap between the com- munity and mentees by addressing stigmatization of mental illness and drug abuse, where mentors help mentees under - stand how to live their lives without being stigmatized (Interviewee #3). Overall, these ndings provide a setting in which services are provided and which may improve recovery, quality of life, and general wellness for mentors and mentees. Assessment of Recovery Capital Forty-two subjects completed the ARC at least once, 17 nished it twice, 11 a third time, and 2 a fourth time (see Table 1). The fourth wave was not included since few sub- jects completed it. The model had a marginally good t ( x 2 = 3.50, p = 0.06), and the average starting score was about 177 points out of 250. Subjects experienced a marginal Table 1 Repeated measures of survey administration eect on ARC scores (N = 70) † p < .1, *p < .05, **p < .01, ***p < .001 ARC total score Coe cientSEz 95% condence interval Constant 177.225.3633.07*** 166.72187.72 Survey administration 5.913.160.06 † − 0.28 12.11 1 3 573 Community Mental Health Journal (2020) 56:568–580 change in their scores, with an increase of about six points for each successive administration (p = 0.06).

As displayed in Fig. 2, subjects’ xed eects ARC scores were around 172 points for the rst administration of the ARC. Over time, subjects’ ARC scores increased by the third administration of the ARC to an average score of about 187 points. The overall model was statistically signicant (p < 0.001), and the predictors explained 77% of the variance in subjects’ ARC scores (see Table 2). Subjects’ scores on the QOL sur - vey were statistically and positively related to their ARC scores. Accordingly, higher scores on the QOL are associ- ated with higher scores on the ARC (p < 0.001). Interview results also suggested that mentors and mentees experience recovery, as indicated in themes regarding outcomes of ser - vices and justication for services.

Outcome for Peer Providers There were positive and negative eects associated with providing services. Interviewees discussed personal growth, relapse, stress, and satisfaction with the work they do. For stress and satisfaction, the relationship between peer mentors and mentees was a source of both frustration and enjoyment. The direction these interactions took often depended on the mentee, where mentee success in overcoming barriers resulted in satisfaction (Interviewee #1), while other mentees intentionally tried to provoke mentors (Interviewee #2). Nev - ertheless, the interviewees appeared to have more positive outcomes than they did negative ones.

Personal Growth I sought information about peer mentors’ personal growth in providing services, as the literature sug- gested that this is one of the positive eects for peer mentors (Brown et al. 2003). The interviewees conrmed that they have grown and changed as a result of working with men- tees. All interviewees emphasized a sense of greater self- understanding and how it has been an important benet of providing services.

Relapse Relapse was one concern emphasized in the lit- erature (Ahmed et al. 2015). Not all interviewees relapsed while providing services; however, the interviewees agreed that the Center was a good place to relapse if they did since they had a support system there. One interviewee who has relapsed also described how the supportive environment at the Center helped him/her to regain and maintain recovery (Interviewee #2).

Peer Provider Stress Stress associated with providing sup- port is a concern reported by past researchers (Ahmed etal.

2015); therefore, I asked interviewees about what was stress- ful when providing services. Again, two of them (Interview - ees #1 and #2) discussed how the mentees may be a source of stress. However, not having enough training and a lack of resources was also a substantial concern.

Peer Provider Satisfaction I inquired about sources of satis- faction for mentors as peer support can be personally reward- ing (Hutchinson etal. 2006; Nestor and Galletly 2008). The interviewees conrmed this nding and discussed how it can be satisfying to see mentees overcome specic obsta- cles (Interviewee #1) and/or to help people take control of their lives again (Interviewee #3). Another rewarding aspect involves interaction with others (Interviewee #2). Volunteer - ing, itself, was a source of satisfaction, as one interviewee described it:

Give me a scale of 1 to 10, 100 … I love my job. I get to help people get through the same things I went through. I learn things every day. Every day is almost like a challenge. But I meet almost all of those chal- lenges, and in that process, I grow. I grow so much and help other people grow (Interviewee #3).

As this interviewee demonstrated, peer mentors may gain a sense of satisfaction by helping others, which can also help them grow. 17 0 175 180 185 190 AR C Fixe d Ef fects Scores 0 .5 1 1. 5 2 Time Fig. 2 ARC scores across time Table 2 Regression of QOL and wellness assessment predicting ARC (N = 37) † p < .1, *p < .05, **p < .01, ***p < .001 F = 37.21***, R 2 = 0.77 Covariates b (SE)t Constant − 10.08 (19.7)– Survey administration 5.04 (4.60)1.10 QOL total score 1.78 (0.23)7.61*** Wellness assessment total score 0.21 (0.17)1.24 1 3 574 Community Mental Health Journal (2020) 56:568–580 Justi cation of Peer Support Services The main purpose of this study was to determine the eec- tiveness of peer services. As such, I sought interviewees’ perceptions regarding recovery services. The interviewees agreed that peer services are needed and eective. Yet, they believed implementation issues hindered provision of services.

Lack of Resources All interviewees acknowledged a chal- lenge the Center faces: a lack of resources, which was viewed as interfering with provision of eective services.

Insu cient resources included: too few peer mentors, too little shared experience with mentees, not enough training, too few male peer mentors (Interviewee #1), and insu - cient funding to support more peer services (Interviewees #1 and #3). One interviewee was concerned about this lack of resources because an insu cient number of peer mentors impeded successful collaborations with the community and other agencies (Interviewee #1). This interviewee empha- sized how mentors’ work predominately benets only indi- viduals, not the community generally, due to having too few mentors. Yet, the interviewees also discussed programs that the Center plans to implement that may be more benecial to the community.

Need for Services Overall, interviewees believed peer sup- port services were necessary to help people who have been devalued or disregarded by the community. For example, So, having peer providers who have been there a little bit and can possibly say, ‘Hey, you know, you’re still valuable as our community member or as a person, and if I can, I’ll help you navigate some of this that now you’re a part of because you did something dumb or were diagnosed with an issue …’ So, I think they often come to us as a community member … And, I think we can help navigate (Interviewee #1).

In other words, peer mentors humanize people who have fallen out of favor with society and gives them back the status of being worthwhile.

Eectiveness of Peer Support Services The interviewees were in consensus about the eectiveness of peer services.

In describing the e cacy of services, interviewees again emphasized how peer services are dierent from profes- sional services. One interviewee described more in-depth why peer support services are eective:

For all of us … we’ve done it. And now we are helping somebody else do it … I’ve seen somebody go from coming in here like this to talk to me for the rst time to a year later and sometimes it’s longer than that, to seeing the person on the street, and they’ve got a smile on their face (Interviewee #2).

Furthermore, the voluntary nature of peer services may con- tribute to their eectiveness because mentees are not forced to seek treatment (Interviewees #1 and #3). Consequently, peer services may be a viable alternative for people who cannot or will not turn elsewhere for help. These services are also eective for mentors because they experience per - sonal growth and satisfaction that outweighs the negative eects of their work. The results from the ARC and the interviews suggest that peers, overall, experience improve- ment in recovery. World Health Organization Quality of Life Assessment‑BREF Forty-seven subjects took the WHOQOL-BREF at least once, 19 completed it twice, 10 three times, 3 four times, 2 ve times, and 1 six times. Subjects who were administered the survey four, ve, or six times were collapsed into one wave. The average starting score was about 85 points for the rst administration of the survey. The covariates oered a good t (p < 0.001) and explained 78% of the variance in subjects’ QOL scores (see Table 3).

Survey administrations were marginally signicant, where subjects tended to have lower QOL scores across time when controlling for Wellness Assessment and ARC total scores ( p = 0.07). Higher ARC scores were also related to higher QOL scores (p < 0.001). Although the repeated measures analysis was not statistically signicant, interviewees dis- cussed how quality of life has been improved by way of professionalism.

Professionalism I sought themes involving professionalism, as the lit- erature demonstrated potential contention between peer support and professional services (Chinman etal. 2002; Solomon 2004). All interviewees commented on peer sup- port as a supplement to professional services. Training and Table 3 Regression of ARC and wellness assessment predicting QOL (N = 37) † p < .1, *p < .05, **p < .01, ***p < .001 F = 38.52***, R 2 = 0.78 Covariates b (SE)t Constant 14.26 (8.58)– Survey administration − 3.73 (1.99)− 1.87 † ARC total score 0.36 (0.05)7.61*** Wellness assessment total score 0.08 (0.08)1.09 1 3 575 Community Mental Health Journal (2020) 56:568–580 education, as well as volunteering as a path to an occupa- tion, were mentioned spontaneously.

Peer Support Services as an Alternative to Professional Services The literature suggested that peer support ser - vices may be a feasible alternative to professional services (Solomon 2004). However, the interviewees viewed peer services as a complement to professional services, which is in line with Gidugu et al.’s (2015) ndings. Still, the interviewees perceived peer services as being benecial for some people seeking help because those people either had prior bad experiences with a professional provider or because they felt stigmatized by seeking professional ser - vices. I also inquired about how lived experiences com- pares to the work of mental health professionals, who are not required to have such experience. The interviewees thought lived experience was important, but they also acknowledged the limitations of having no formal edu - cation in mental health or substance abuse treatment.

Accordingly, there are limits to both peer and professional mental health services.

Training and Education Training and education emerged as a theme and was viewed by interviewees as an impor - tant part of providing services. All interviewees were condent in providing services, despite having no formal education in treatment provision. Lived experiences con- tinued to be a crucial part of providing services. When asked whether lived experience or training was more help- ful, one interviewee described how both were resources to draw on when the interviewee (#1) found himself/herself decient in one or the other. The balance between training and life experiences is similar to how peer mentors viewed peer services and professional services: the lived experi- ences of mentors can be an adjunct to training they have received; both were viewed as necessary to be an eective mentor. Volunteer work wasalso perceived as a path to employ - ment (Interviewee #1). The possibility of turning training into a career was expressed by one mentor:

… I know for some people, too, the certications you can get for certied peer coach or certied peer spe- cialist … place them in a professional position. Take something with some negative in their life, the whole time, and spin it into a career prospect (Interviewee #1).

In short, peer services can improve traditional mental health treatment peers already receive, or mentors can improve their own career prospects by volunteering. In both cases, peers were able to improve their care and quality of life by participating at the Center. Wellness Self‑Assessment Thirty subjects completed the assessment at least once, while 14 subjects nished the assessment twice, and ve subjects three times. The model was statistically signicant (p = 0.001), but none of the individual predictors were (see Table 4). Across time, subjects’ scores on the ARC and QOL were not related to their scores on the Wellness Assessment. Although the Wellness Assessment does not have items related to support specically, it does include questions about relationships with others and participation in groups. These items speak to interpersonal interactions; as such, I include interviewee responses about support here because greater support may improve wellness.

Support for Services According to Chinman etal. (2002), mentors’ work is not valued due to the lack of their professional status, and men - tors may not feel supported in their work. I asked about interviewees’ perceptions regarding whether their work is valued and whether they feel supported.

Value of Peer Providers’ Work All interviewees described how their work was valued, both by the mentees they worked with and the community at large. Despite the work being di cult at times, the appreciation shown by others outweighed peer mentors’ frustration and made their work worth it.

Support Peer Providers Receive Not only was interviewees’ work valued, but they also felt supported when they needed it. This support was essential for one interviewee, who reported needing it when he/she was feeling down (Inter - viewee #2). The interviewees also reported that the com- munity was supportive of their work. Yet, despite this sup- port, one interviewee felt that the community was ignorant of peer support services:

Table 4 Regression of QOL and ARC predicting wellness assessment (N = 37) † p < .1, *p < .05, **p < .01, ***p < .001 F = 7.0**, R 2 = 0.40 Covariates b (SE)t Constant 62.45 (17.45)– Survey administration 3.40 (4.75)0.72 QOL total score 0.41 (0.40)1.04 ARC total score 0.22 (0.17)1.29 1 3 576 Community Mental Health Journal (2020) 56:568–580 I think the community is supportive … I don’t think they really know much about us … The community supports those in disadvantaged positions ... We think something should be done about that, and if you’re doing something, that’s great, but I don’t know what you do ... I think many of them don’t understand how complicated the process of recovery can be for some people (Interviewee #1).

It appears more education is needed for the community regarding the Center and the services it provides. Working with the community is part of the recovery center’s mission statement, but the Center may be limited in this endeavor due to a lack of resources (Interviewee #1). The amount of support provided by the community may change as it realizes the role the Center plays. One interviewee men- tioned how he/she has already seen support grow because of the community learning more about peer support services (Interviewee #2). Greater integration between the commu- nity and the Center may also serve to improve outcomes for peers. Discussion The purpose of this study was to examine the eectiveness of peer services in a recovery center, as past research on the e cacy of such services is ambiguous (Davidson etal.

2006). Overall, the results demonstrate that subjects experi - ence statistically signicant improvement in recovery over time. Although not statistically signicant, scores for the WHOQOL-BREF and the Wellness Self-Assessment also increased over time, indicating improved quality of life and general wellness. Furthermore, higher scores on the ARC were associated with higher scores on the WHOQOL- BREF. This nding supports past research on the concurrent validity of the ARC (Groshkova etal. 2013). Interestingly, when controlling for total scores on the ARC and Wellness Self-Assessment, subjects had a marginal decrease in their WHOQOL-BREF scores over time. Scores on the Wellness Self-Assessment were not statistically or signicantly asso- ciated with scores on either the ARC or WHOQOL-BREF. The ndings further suggest there are several themes related to peer support services in the Center. Several of the themes found in the literature, including lived experi- ence as acharacteristic of mentors (Moran and Russo-Netzer 2016); stress (Ahmed etal. 2015) and satisfaction experi- enced by peer mentors (Hutchinson etal. 2006; Nestor and Galletly 2008); personal growth (Brown etal. 2003); and the eectiveness of peer support services (Brown and Townley 2015), were conrmed. In contrast, other themes in the literature were not sup- ported by interviewees’ reports. These latter themes included peer services as a viable alternative to professional mental health services (Solomon 2004), unequal or unsupportive treatment (Chinman etal. 2002), and a lack of value in men- tors’ work. Interviewees felt supported and valued but also believed the community did not understand the Center’s ser - vices. Accordingly, community ignorance may need to be rectied for the Center to maximize its services and improve its eectiveness. Contrary to Yanos etal.’s (2001) ndings, providing peer services was not a protective factor for all mentors. One mentor (Interviewee #2) discussed how he/ she has relapsed several times since becoming a volunteer.

Yet, like Yanos etal.’s (2001) ndings, this same interviewee found coping strategies to be an important part of regaining recovery. Past research has been contradictory regarding whether peer or professional services are more eective. Gidugu et al. (2015) suggested peer services are not a feasible replacement to professional services. In contrast, other researchers have found that peer services are either equally eective (Rivera etal. 2007; Davidson etal. 2006) or more eective (Solomon 2004). The interviewees agreed that peer services are best as a supplement to professional services but can be more benecial if people do not want to seek profes- sional services. Findings for peer mentors’ relapse while providing peer services were mixed. Moreover, the idea of “recovery” did not match past research. Interviewees could not pinpoint an exact denition because recovery varies for each person seeking it. Nebulous descriptions of recovery t the nature of the services (i.e.

individualized) they provide. Again, as one interviewee (#2) described it, “if you believe you are in recovery, you’re in recovery”. Recovery is subjective and relies heavily on each person’s perception of his or her own change. Also, inter - viewees’ reported goals varied, again due to the ambiguous nature of the recovery process. This vagueness may be a contributing factor in why recovery centers often lack clear goals or standardized services (Whitely etal. 2012). How - ever, uniform practices and goals may be too restrictive for the recovery process. Additionally, in discussing the qualities of peer provid - ers, two more themes emerged in the form of identication and volunteer duties. One mentor (Interviewee #1) was clear in dierentiating himself/herself from mental health professionals and clarifying that he/she is not a friend to mentees but a motivator and source of accountability for mentees. This nding supports the literature since recipro- cal accountability is an aspect of peer-run organizations (Lewis etal. 2012). In terms of duties, mentors provide guidance to mentees (Interviewees #1 and #2), but this support is dierent from the help mental health profession- als provide because mentors rely much more on their lived experiences (Interviewee #1). This last point resonates with Solomon’s (2004) description of social comparison 1 3 577 Community Mental Health Journal (2020) 56:568–580 and how mentees may do better with peers than with pro- fessionals because of shared experience.

Furthermore, peer mentors are typically trained in recovery and helping others (Ahmed et al. 2015). The sub-theme of training emerged but was a key factor in how mentors viewed themselves as competent. When asked whether training or life experience was more use- ful, one mentor (Interviewee #1) responded that both are necessary and can be used to complement one another if a mentor is decient in either. This result is akin to Nestor and Galletly’s (2008) claim that experiential knowl- edge is the key advantage peer mentors have over mental health professionals. Moreover, this training could result in employment for mentors. However, peer mentors may face a barrier in the way of unequal treatment in the work - place. Mental health professionals do not view experiential knowledge as valuable (Hodges and Hardiman 2006). Yet, the interviewees reported that they were treated equitably at the Center, suggesting that these mentors’ experiences are appreciated. A sub-theme emerging from the interviews is that men- tor–mentee interactions may result in stress or satisfac- tion for peer mentors. This theme is not in the recovery research; nonetheless, mentors appeared to value these interactions much more than they did not. Moreover, mentors may better understand recovery and themselves because of these interactions (Interviewee #1). The inter - viewees described a lack of resources, including concerns about continued funding for the Center, not having enough time, having too few male mentors, and not having enough training. Despite insu cient resources, the interviewees expressed a positive outlook about peer services. As discussed by mentors, peer services help people regain their connections to the community without the stigma of a diagnosis or professional help-seeking. These results are similar to Brown and Townley’s (2015) ndings that peer programs help promote a sense of community and that mentors are successful in engaging others who seek recovery. Overall, the eectiveness of peer services partly derives from how they are dierent from professional mental health services (Interviewees #1 and #3) because mentors have the lived experience and can relate to mentees (Solomon 2004; Nestor and Galletly 2008; Sells etal. 2008). Apart from benetting mentees, peer services may also be eec- tive for mentors because they learn more about recovery (Interviewee #1), may develop a new support system if they relapse (Interviewee #2), and/or may gain employment fol- lowing their volunteer work. Additionally, satisfaction men- tors gain from their work outweighs stress or other negative outcomes they experience. It remains to be seen how the community will benet from these services because the Center is still in its infancy. Future Research This study contributes to the recovery research by lling a gap about recovery services in a rural area. Yet, there is more work to be done to determine the overall eective - ness of these services and their impact on the community and other systems (e.g., the medical and criminal justice systems). Further research could examine why mentees choose peer support services either in addition to or in place of professional services. It would also be benecial to learn more about how the community perceives peer support services. Exploring these views could eventu- ally help bridge the gap between the Center and the com- munity. The same could be done with policymakers who decide whether the Center should receive funding. It is essential to know what these decision-makers expect so the Center can either inform them about the limitations of what they are expected to do or so the Center can work towards fullling these expectations. This research could also be repeated with more recovery centers to determine whether the same themes emerge. Additionally, a longer follow-up period could be assessed. As part of this follow- up, research could look at whether mentors become sta or nd work somewhere else in the helping eld to conrm whether volunteering is a pathway to employment and to examine whether mentors and/or mentees relapse.

Limitations This study was exploratory in nature and is not intended to make any causal inferences regarding the e cacy of peer recovery services. I conducted the study under certain constraints, and limitations must be addressed by future research to further support evidence for the ndings dis- covered here. First, I was not able to interview every peer mentor in the Center, resulting in a convenience sample of peer mentor volunteers. Consequently, participants may not be representative of all peer mentors at the Center.

However, random sampling was not feasible. Of more concern, respondents knew the nature of the study and that I was seeking to learn about the eectiveness of peer services, so their responses may have been biased in that they may have overemphasized the positive outcomes of peer services. However, I attempted to learn about both negatives and positives of services during the interviews, and the surveys were utilized to produce more information about the potential eectiveness of the Center. Although the survey data oered much information regarding peers’ outcomes, the in-depth interviews with mentors resulted in more meaningful data that helped to clarify how the 1 3 578 Community Mental Health Journal (2020) 56:568–580 Center could facilitate successful recovery in peers who utilized services.

Furthermore, the sample sizes for the quantitative anal - yses were relatively small. Another concern is the attrition rate; mentees are not required to nish peer services. As of the Center’s latest reportwhen the study was conducted, 24 peers either left the program, entered an inpatient pro- gram, or were in jail. Additionally, characteristics of sub- jects and amount of service utilization were not measured, as that information was not released in order to protect peers’ condentiality and respect the anonymity of the Center’s environment. Moreover, service utilization is not measured by the Center, as peers are encouraged to visit the Center whenever they feel they need the support of other peers. Services utilized may also not be easily meas- urable, as “utilization” could involve a call with a mentor, meeting for coee, playing chess, doing yoga, or other activities not traditionally dened as treatment. Informa- tion regarding demographics and service utilization could help better explain what specic peer characteristics as well as what dosages of services most impact the outcomes examined above. However, the overarching intent of the current study was not to examine how individual charac- teristics or how amount of service contributed to changes in recovery capital, quality of life, and general well-being.

Rather, trends in change for these outcomes were evalu- ated with the goal to assess whether the recovery center is having an impact on peers’ outcomes across time in a rural area. Additionally, the reliability, validity, and credibility of the results may present as a concern. I took several steps to address these issues. To establish reliability for the qualita- tive aspects of this study, I focused on consistency in the interviews by utilizing an interview guide to ensure all inter - viewees were asked the same questions regarding deduced themes. Brink (1991) has proposed consistency as a test of reliability for qualitative work. Although considered a weak form of validity (Long and Johnson 2000), the interview guide also demonstrates face validity, as it was developed following deduced themes from the literature regarding the eectiveness of peer recovery services. Moreover, each interview transcript was rated the same way to reduce measurement error, and I transcribed both notes taken during the interview and recorded the inter - views as an alternative option of data recording to improve reliability and validity for the single interviews conducted with mentees (Brink 1991). I also attempted to falsify the data by looking for discrepant evidence (Maxwell 1996 ) for deductively deduced themes. Throughout this rereading and revalidating process, it became clear that some of the themes I originally identied as separate issues overlapped with others. I was able to better construct themes following continued review of the literature to verify whether what peer mentors reported aligned with past research.

Furthermore, I attempted to ensure credibility in the results via establishing trust with respondents andinter - viewing them in a setting familiar to them (e.g., the Center) as well as being sensitive to their life-styles and histo- ries. These decisions were intended not only to develop a rapport with respondents but also to better understand a fuller narrative regarding the Center (views of mentees), attempting to improve content validity (Halls and Stevens 1991). I further attempted to improve credibility pertain- ing to the Center’s eectiveness via triangulation (Halls and Stevens 1991), wherein I examined quantitative sur - veys regarding peer mentees’ outcomes and qualitative interviews involving peer mentors’ perceived eectiveness of the Center within a very specic context: a centrally located peer recovery center in a rural community. For instance, the surveys had close-ended questions, which may mask information about why someone responded the way he or she did. The surveys limit researcher bias, but the context for answers could be critical to understanding how peer recovery services benet or are detrimental to respondents. For this issue, the interviews helped to reveal these processes. Other attempts made to improve the rigor and valid- ity of the study included engaging in both personal and interpersonal re exivity (Hesse-Biber and Leavy 2006) throughout the data collection and analysis process to bet- ter understand any biases I may have had and any situ- ational dynamics between myself and interviewees that may have aected knowledge creation regarding the eec- tiveness of the Center. Additionally, the results were pre- sented to the Program Director of the Center as a member check (Lincoln and Guba 1985) to gain additional insight regarding the Center and the ndings. I also performed peer debrieng (Robson and McCartan 2016) by discuss- ing my analysis, themes, and conclusions throughout data analysis with a colleague familiar with the Center and its operations. This process, along with the re exivity I engaged in, resulted in dropping or merging themes found to be irrelevant. Another limitation of this study is that it is based solely on peers from one peer recovery center in a rural area. This is an understudied population requiring more research in order to better comprehendthe peer recovery process for individuals with MHPs or substance use issues in a rural community. The very nature of the Center—its location in a central area within a rural community—makes the present study unique but also limits any ability to generalize these ndings outside of the Center. Although ndings here can- not be generalized elsewhere, they may serve as a compari- son for other peer recovery centers that may be established in rural communities in the future. These areas certainly 1 3 579 Community Mental Health Journal (2020) 56:568–580 warrant further study and would benet from inclusion of more respondent information.

Conclusion This study is one of the rst to examine the eect of peer support services in a rural area. There is preliminary evi- dence that subjects’ recovery improved over time. The ndings also re ect some of the di culties peer mentors face but also the benets they derive from their work. The ndings provide insight for policymakers, who may make funding decisions for recovery centers. It is imperative we heed the stories of these ndings and not rely solely on the numbers of those who have relapsed or fail to attain recov - ery because, as the ndings show, peer mentors provide a service that is utilized and contributes to the well-being of the community.

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