“Being there” takes on considerable importance amidst recognition of the substantial deleterious effects of social isolation and loneliness. In particular, presence/ “being there” may be important features of the many contributions of peer and mutual support to health and wellbeing. This study examined how peer support may enhance a sense of presence based on a) contact data for years 2015-2016 from telephonic peer support services of Rutgers University Behavioral Health Care, and b) structured interviews with peer supporters and clients of these programs. Features of peer support that convey presence include a) 24/7 availability, b) structure of peer support around shared cultural roles – e.g., “Cop2Cop,” “Mom2Mom,” rather than shared diagnoses, c) training of supporters to provide a setting for open expression of feelings, and d) structural features such as IT systems that facilitate continuity by enabling those answering a call readily to refer to previous calls. Impacts include client reports of being understood, not being judged, and being cared for through routine follow-up, even though contact such as voicemails. Managers and peer supporters should recognize the diverse organizational and processes that convey presence/ “being there” and its central importance in peer and mutual support.
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“Being there” must be among the most common clichés in discussion of social support, stressors, and human behavior. However, recent attention to the health effects of loneliness and social isolation (Holt-Lunstad, Robles, & Sbarra, 2017) suggests greater attention to what it means to be there. The influence of social isolation, being as lethal as smoking cigarettes or obesity (Holt-Lunstad, Smith, & Layton, 2010; House, Landis, & Umberson, 1988), make this a serious conversation. In light of such concerns, the British government appointed a “minister for loneliness” in 2018 (Ryan, 2018).
Some papers indicate greater importance of objective social isolation (e.g., Steptoe, Shankar, Demakakos, & Wardle, 2013) and some place greater importance on experienced loneliness (Perissinotto, Holt-Lunstad, Periyakoil, & Covinsky, 2019) but there is a great amount of evidence that, alone and together, these are related to diverse effects on health risks, emotional status, morbidity and mortality. If, as Lowenthall and Haven noted over 50 years ago, those who have someone they can talk to about personal matters and call on for a favor (a simple indicator of connection) are better able to address a variety of life’s challenges (e.g., Lowenthal & Haven, 1968), then an important contributor to benefits of social support may be that fundamental connection, “being there.” Mutual support and other approaches to enhancing social support may also convey presence. Here we focus on observations and lessons learned from a telephone-based service providing individual peer support to police, veterans and other high-risk groups.
The value of simply “being there” is illustrated in the common expression, “It wasn’t anything she said or did; it was just knowing she was there.” This is common in other languages such as in Dutch, “Het was niet zozeer wat zij zei of deed, maar dat ze er voor mij was” (“It’s not necessarily about what she said or did but that she was there for me”). More simply, varied languages refer to “being there,” such as in Thai, "[for the original Thai characters, see PDF]" ("Thank You or for always being here for me”), or German, “Ich bin (immer) für Dich da” (“I am (always) there for you”; “you” in the informal), or Brazilian Portuguese, “O que importa e’ a sua presença” (“What matters is your presence”). In Mandarin Chinese, “[for the original Mandarin characters, see PDF]” (“Thanks for being by my side”) is likely to be used by younger people and in close relationships and even then, not frequently.
Similarly, implicit support that “does not involve an explicit transaction of seeking and providing” (Kim, Sherman, & Taylor, 2008) is often more acceptable in collectivist or Asian cultures than explicit emotional support. With cultural emphases on the family and harmony, individuals are reluctant to burden family or groups of which they are a part with their own, individual problems or concerns. Instead, the support of the family or group is conveyed and assumed without explicit discussion (Kim et al., 2008) and, indeed, explicit support in such cultures may be ineffective or even counterproductive.
In a qualitative study of how emotional support emerges in their work with individuals, peer supporters represented programs from three distinct geographic and cultural settings: low-income Latinos served by a Federally Qualified Health Center in Chicago, low-income, African-American women in rural North Carolina (Cummings et al., 2013), and retired, middle-class adults in Cambridgeshire, England (Simmons et al., 2015). Across these three settings, peer supporters identified implicit support as important (Kowitt et al., 2015). Examples included showing interest and concern through attending a support recipient’s art exhibit, “giving hugs,” praying for/with people, group walks, talking about family, and playing cribbage with one another.
A remarkable study examined the benefits of minimal communications to individuals at high risk for suicide (by virtue of hospitalization for depression or suicidal precautions) but who refused or discontinued post-discharge follow-up (Motto & Bostrom, 2001). Among those who merely received periodic contact through occasional letters, initially monthly but fading to quarterly, a total of 24 over five years, rates of suicide were significantly lower (p = 0.043) than among those randomized to usual care. Suggesting that it was the contact itself that was important, its effects declined as it became less frequent. These background observations suggest the importance in peer support of the fundamental value of connection.
Peer support provided by “community health workers,” “lay health advisors,” “promotores de salud” and individuals with a number of other titles has been shown to play influential roles in health and the health care delivery system (Gibbons & Tyus, 2007; Perry, Zulliger, & Rogers, 2014; Swider, 2002; Viswanathan et al., 2010). Similarly, mutual aid and self-help organizations have been long been utilized to help people initiate and sustain health behavior changes by providing social support (Kyrouz, Humphreys, & Loomis, 2002). These groups are often centered around a shared problem, such as substance abuse, mental health disorder, or bereavement, and are usually run by people who share the problem addressed in the group.
Although there are many different approaches to providing peer or mutual support, at the core of all programs seems to be the value of presence of similar others in coping with life stressors. The Reciprocal Peer Support Model (Castellano, 2012) that guides the programs from which the present observations were drawn emphasizes Connection as the first of four tasks of peer support and, within it, “pure presence” as “at the heart of … engagement and … necessary for successful peer support” (p. 138). Similarly, Peers for Progress, an international program at the University of North Carolina-Chapel Hill, that is dedicated to promoting research in and dissemination of peer support, emphasizes five “key functions” of peer support. Three of the five reflect presence: being there or presence, social and emotional support, and ongoing availability of support (Evans, Daaleman, & Fisher, 2020; E. B. Fisher et al., 2015; E. B. Fisher et al., 2012)}.
In a previous paper (Evans, Tang, et al., 2020), we reported general evaluation of the telephone peer support services for police, veterans, and other high-risk groups provided by Rutgers University Behavioral Health Care (RUBHC). Here we extend that evaluation to include patterns of engagement in services and peers’ and callers’ responses to structured interviews to gain greater understanding of “being there” and the varied aspects of programs that convey such presence.
These data were collected as part of a general evaluation of peer support services provided by RUBHC, carried out by a collaboration between program staff at RUBHC and researchers at Peers for Progress. Three of the authors (MG, CC, DDV) are RUBHC program staff. RUBHC’s peer support telephone services are designed to provide peer support to high-risk groups including law enforcement officers (Cop2Cop), veterans (Vet2Vet), child protection workers (Worker2Worker), caregivers of those with dementia (Care2Caregiver), and mothers of children with special needs (Mom2Mom). Peer supporters are members or retired members of the identified groups (e.g., retired police officers, mothers who themselves have cared for children with special needs). Prior to contacting callers, they complete an intensive, eight-day training that covers reciprocal peer support (Castellano, 2012), competence in relating to the sub-cultures served in the programs, behavioral health training and recovery principles, peer communication skills, managing crisis and emergent situations, peer support principles, self-care and ongoing support. The services are designed for populations who are exposed to vicarious or secondary trauma and/or are vulnerable to behavioral health problems. After completing general training, peer supporters undergo more specialized training for their particular sub-population. Call frequency and length are determined based on caller needs and availability, as was the overall length of the peer support relationship.
Quantitative Evaluation of Caller and Call Data
As part of a general program evaluation, two years of caller and call data (2015-2016) from four of the RUBHC telephone peer support programs (Cop2Cop, Mom2Mom, Vet2Vet, and Worker2Worker) were analyzed. These data were collected as a routine part of providing telephonic peer support services. Date and time of call and peer supporter fielding the call were recorded. All contacts were documented including voicemails. Due to the confidential nature of many of these services, demographic information about the callers was not routinely collected. Data were analyzed utilizing StataSE, version 14.2 (College Station, TX).
Qualitative Interviews with Peer Supporters and Callers
A sample of 10 peer supporters and 12 callers from five of RUBHC’s peer support programs (Care2Caregiver, Cop2Cop, Mom2Mom, Vet2Vet, and Worker2Worker) completed semi-structured in-depth telephone interviews between November 15, 2017 and February 9, 2018. The interviewer (ME) was a doctoral research assistant at the University of North Carolina paid by subcontract from RUBHC for the purpose of the evaluation. She had previous contact with some of the peer staff through several project meetings but had no supervisory relationship with them and had no contact with callers other than through the present interviews. Potential interviewees were chosen randomly from the pool of callers and peer staff who received or provided support between January 1, 2015 and December 31, 2016, the same time period included in the quantitative call data. The telephone interview guide for peer supporters covered training they receive, support they provide, workflow processes, and thoughts on how services could be improved. For callers, interviews focused on expectations of peer support prior to engaging with the programs, support received, any benefits or drawbacks of participating, and thoughts on how services could be improved. Interviews were recorded, transcribed, and independently analyzed by two coders (ME and PT) using inductive identification of themes following standard procedures (Boyatzis, 1998) and utilizing Atlas.ti. Coders each read through the transcripts, jointly developed a codebook with 25 codes that captured important information in the data and applied these codes to each transcript. All coding discrepancies were resolved through consensus at research team meetings. After organizing the data in this way, coders again read through the transcripts and code reports to identify emerging themes.
Over the two-year period from January 1, 2015 – December 31, 2016, the four programs accounted for a total of 64,786 contacts with a total of 5,616 callers. Of these, 49% were phone calls and 51% voicemails. Disaggregated by program, Cop2Cop accounted for 15,494 contacts with 1,132 callers, Mom2Mom – 27,227 contacts with 2,088 callers, Vet2Vet – 14,883 contacts with 1,436 callers, and Worker2Worker – 7,182 contacts with 960 callers. On average over this two-year period, each caller received a total of 11.5 contacts, split evenly between calls (5.8) and voicemails (5.8). Across programs, average number of calls ranged from 3.1 in Worker2Worker to 6.4 in Vet2Vet.
Consistent with the objective that the peerline provide straightforward information or referral regarding a specific problem, 15% of callers had one contact and 22% just one or two. Excluding this pattern of use to gain a clearer sense of callers’ connection to the peerline, the average number of contacts among the 78% with more than two contacts was 14.4, with an average of 7.1 calls and 7.4 voicemails. These numbers suggest the peer services provided are of value to members of these high-risk groups in that over three quarters remain engaged over a substantial number of contacts.
Ways in Which Peer Support Conveys Presence
Table 1 (to see Table 1, download the PDF version to access the complete article, including Tables and Figures) includes the ways in which RUBHC programs convey presence. These include the availability of peer support around the clock, communicating security and comfort that a lifeline exists if one needs it, “just knowing there is someone out there that (sic) cares” [Caller8].
Presence is also communicated by calls nearly always answered by a live person, not an answering system. At the same time, emotionally reassuring continuity of care is supported by IT systems that provide access to detailed notes of previous conversations so that the peer supporter for example answering the phone at 2 am can pick up where the primary peer supporter left off.
Peer supporters identified being “trained to listen” [Peer2] as a key part of providing support to their clients and a safe space for the unfiltered expression of negative emotions. They help their clients to problem-solve, offering suggestions but not judgment. If services exist to help with the problem, the peer supporter will provide referrals. Responsiveness, being able often to provide same-day referrals to clients in need enhances the sense that the peer supporter cares about their wellbeing. Additionally, providing encouragement and affirmation that the client is doing the best they can also conveys acceptance and promotes resilience.
Following up after the initial phone call may be viewed by program managers and peer supporters as mere due diligence, however, this follow-up appeared to be much appreciated by clients. They reported being surprised when their peer supporter called to check in with them, as this had not been their experience with other providers. Reaching out helps to enhance trust and convey commitment; “I don’t think she’s ever going to give up on me. She always checks up on me” [Caller6]. In spite of the client using the vernacular “checks up” and mindful that “checking up on me” may suggest surveillance, peer supporters are encouraged to avoid any sense of surveillance but to follow-up emphasizing the connection that has been made and the peer supporter’s caring about and wanting to know how the client is doing.
In addition to these features of how peer support is introduced and provided, peer supporters are also part of a comprehensive approach to the client’s problems, supervised and trained to work in an integrated structure. Peer supporters indicated that this helps clients feel both the ability to connect with someone “like me,” as well as the security of knowing that sound professional services are available through the channel of the peer.
Standing as backdrop to all of these, the simple existence of the programs and use of them by substantial numbers of those to whom they are offered both confirms the rationality of needing such support and conveys a sense of availability of support to those who may never directly contact the programs.
Shared Identity and Culture as Basis for Presence
RUBHC structures its peer support programs around culturally defined groups, police officers, military veterans, or mothers with children with special needs, rather than around diagnostic groups, e.g., those with depression. That is the shared lived experience of the peer supporter is culture, not diagnosis. This communicates that the peer supporter will have “walked in my shoes” and understand not just the problems an individual may be having, but the circumstances and cultural setting of the military, police, etc. that may shape those problems. The program descriptions and names, “Cop2Cop,” “Mom2Mom” and the like make clear that clients will speak to someone with whom they share important sources of identity and concern. While reducing stigma and isolation, the presence of similar others also establishes a base for rapport that may facilitate the impact of even brief communications, like a voicemail. Indeed, the very fact that a program was developed for “my group,” veterans, police, etc. communicates a recognition and acceptance of the fact that those in the group have particular needs or challenges, reducing stigma associated with using the service. It also contributes to trust. One peer supporter noted that “a lot of combat veterans, they have some issues, like I do… but once they find out that I’m a combat veteran…I’ve seen it all…they bond with me, trust me” [Peer7].
Defining services culturally rather than diagnostically also conveys that no one gets turned away from this service; there is no entry criterion other than being a police officer, veteran, mother of a child with special needs, etc. As a result, people call in with a range of presenting issues with which they are seeking assistance, and the peer supporters are trained to refer clients to a variety of care, services, or community resources.
Building rapport based on a shared lived experience also conveys a sense of credibility, in that callers trust advice and perspectives they are given because they come from someone with a similar life experience. In the words of one client, the advice given to her by the peer supporter was trusted because “she has a special needs kid also, so she will think what I think.” Credibility, trust and rapport are also suggested by peer supporters’ reporting being supported by their clients, creating a reciprocal peer support relationship.
Peers supporters also understood the busy schedules of their clients since they too shared a lived experience. They understood that, rather than not wanting to talk, clients described their engagement with their peer supporter as highly determined by their chaotic schedules and noted that when they were not able to answer the phone, “it wasn’t for lack of interest, it was the whirlwind thing” [Caller1]. Peer supporters also sent emails and cards to maintain presence with their clients. This varied and reliable follow-up conveys presence and provides reassurance that support is available should it be needed. Table 2 (to see Table 2, download the PDF version to access the complete article, including Tables and Figures) includes quotations from clients and peer supporters illustrating key features of presence.
Key Features of the Process of Engagement
Prior to calling, clients reported not knowing what to expect. This reflects a broader challenge: defining peer support. With many different definitions or versions of peer support it is no wonder that clients may be unclear about what they will receive.
Clients often called because they needed immediate help, had a pre-identified problem, and desired concrete advice and direction. They hoped to talk with someone who is objective and experienced and often wished to remain confidential. Program managers maintained that it is important also that clients talk to a live person. Peer supporters reported that the time for them to establish rapport with a new client ranges from one to four phone calls.
Peer supporters identified three patterns of client contact. One is characterized by a need for urgent and specific help with something. This may include, however, resistance to recommendations of professional treatment, leading the peer supporters to address this resistance before facilitating referral. A second pattern centers on a need for time to talk about what’s going on, including concerns that are related to both behavioral health problems and problems and issues specific to the cultures of police, veterans, etc.
In a third pattern, callers want to be “checked up on.” It is probably better to describe these as seeking ongoing follow-up and support (E.B. Fisher, Brownson, & O’Toole, 2007) and to be “checked in with” (E. B. Fisher et al., 2009), rather than being “checked up on” with its connotations of surveillance and even mistrust. Such occasional “checking in with” may provide ongoing support for those with enduring challenges such as parenting a child with special needs, or those who have dealt with a problem but who need still to be encouraged to sustain their coping with it. Also, consistent with the theme of this paper, the knowledge that someone is interested in me and keeping track of me conveys support and may combat isolation (Kowitt et al., 2015).
The Simplicity of Being There – Voicemail
Program managers and peer supporters may often interpret voicemails that do not lead to live contact as failed efforts. This makes sense if one thinks of live exchange as a necessary component of support and as voicemails useful merely for arranging such live exchange. From the perspective of “being there,” however, voicemails may take on a different status. Even when clients are unable to be reached by phone, the simple act of leaving a voicemail to check in with them does not go unnoticed. Peer supporters understand that their clients often have erratic schedules and are not always able to get to the phone. For example, one peer supporter related continuing to follow up with a particular client because, “she really cannot get to the phone, but when she gets to the phone she’s really grateful for that phone call, so I make note of never closing her case because I know she really enjoys getting my voicemails and when she is able to pick up she really enjoys being able to talk to me” [Peer6].
As portrayed in Figure 1(to see Figure 1, download the PDF version to access the complete article, inlcuding Tables and Figures), a substantial portion of total contacts across programs are voicemails, ranging from an average of 4.4 voicemails per client in Worker2Worker (relative to 3.1 phone calls), to an average of 7.5 voicemails in Cop2Cop (relative to 6.2 calls). Over all programs, clients average 5.8 voicemails and 5.8 calls, so that voicemails constitute 50% of all contacts. Because of their prominence, RUBHC provides guidance and model “scripts” to guide but not prescribe voicemails so they are personal messages, not simply a “call me back” voicemail or an “automated or customer service” message.
Respondents expressed appreciation that someone recognized they deserved extra support and thanks for the program being created. A Cop2Cop staff member reported calling an isolated officer who was often in crisis on his birthday and wishing him a happy birthday. The client called back saying the peer supporter was the only person who remembered his birthday and that it had a profound effect on him.
A major pitfall we have recognized and avoided is callback messaging that portrays follow-up calls as checking up on a client to see if they used an offered referral, made an appointment, etc. Often the populations served may struggle to get to appointments or comply so a “follow-up” call to “check up” risks making the peer supporters the “appointment police,” leading clients not to want to answer further calls. When voicemails do not suggest holding clients accountable but rather emphasize the connection that has been made and that “I care about how you are doing this week and am interested in speaking to you more,” clients are far more likely to call back and stay connected in the future.
Benefits of Presence
As many other studies have shown, peer support is related to a wide range of benefits (E. B. Fisher et al., 2017; Perry et al., 2014). Here we focus on the benefits clients of the RUBHC programs reported that seemed especially tied to the simple presence of peer support. Clients reported reduced feelings of isolation and loneliness along with relief of stress, peace, energy, and joy. Some noted a sense of clarity and reassurance, feeling as though they were “oxygenated again” [Caller1]. The normalization of clients’ experiences, “making the abnormal normal,” was also identified as a positive effect of simply participating in peer support. The peer support relationship helped them to make sense of life situations and gain a clearer perspective. This extended beyond simple presence to facilitate subsequent re-framing threats and challenges and problem solving to cope better with their circumstances.
Peer Support is Different
The shared lived experience aspect of peer support makes it unique from the support provided by others, including medical and mental health providers, managers and supervisors, and family and friends. Also setting peer support apart is the fact that peer supporters offered unconditional support with no judgment or expectations attached.
Clients stated that their experiences with peer support were different than experiences they had with traditional medical and mental health providers. Not viewed as “a sterile provider” [Caller1], unique advantages of a peer support relationship include the ability to connect on a personal level and receive practical, constructive advice from the perspective of someone with shared experience. In the words of one caller, “the doctor had no practical suggestions,” and “I needed somebody in the trenches to help me find ideas on ways to take care of him” [Caller1]. This lived experience perspective is different from, but complementary with, professional advice and recommendations. In other words, a doctor may tell someone what to do while a peer supporter helps them to figure out how to do it (Davis, O'Toole, Brownson, Llanos, & Fisher, 2007).
In the programs focused on occupational groups (Cop2Cop, Vet2Vet, and Worker2Worker), callers noted that they liked having someone who understood the culture of their job but was also outside of it, so they did not have to worry about potential repercussions of sharing their struggles which may not be the case with their supervisors or co-workers. Police officers, in particular, noted the confidentiality of the peer support service to be especially beneficial. Confidentiality and the option to remain anonymous provided people with jobs that often require stoicism the opportunity to be vulnerable and share openly and honestly.
Additionally, peer support is different from the support provided to callers by their family and friends. Because they have a similar lived experience to their callers, peer supporters are able to validate the experiences of their callers. For example, one peer stated that “a lot of times family members or friends don’t understand the job [of a child protection worker]” [Peer9] and a caller stated that it “really helped, that fact that he had experience in this field... `cause certain things I would talk about, he knew exactly what I was talking about” [Caller12]. These observations underscore that peer support is uniquely suited to meet the needs of those it serves.
That the 78% of callers who had more than 2 contacts with the present peer telephone support services averaged a total of 14.4 contacts over 2 years attests to callers’ valuing the continued availability of support. The qualitative findings here also attest to the value of that support’s pure presence, “being there” and its many benefits, including reducing loneliness and social isolation – [add quote about the voicemail being the only message for a birthday]. Not only is being there important in and of itself, many of the observations shared by callers and peers suggest it is necessary as a base for the other things peer support may provide (Castellano, 2012).
The observations presented here make clear that presence and “being there” are not the result only of “saying the right thing,” but rather are based on a broad range of features of the peer support programs. These include, for example, the IT resources that facilitate smooth reference to a previous call by a peer supporter answering the phone at 2 am who may never have talked to the client. They also include the arrangements that support rapid, often same-day referrals as well as the training and supervision of peer supporters. Presence is clearly a feature of programs as well as the peer supporters who implement them. When designing and implementing peer- and mutual-support programs, explicit attention should be paid to workflow processes so that they routinely provide opportunity for the communication of presence.
An explicit program plan or theory that recognizes the value of presence can lay the groundwork for providing helpful peer support services. The RUBHC peer support programs described here are guided by the Reciprocal Peer Support model emphasizing four key steps in the process of peer support: Connection & Pure Presence; Information Gathering & Risk Assessment; Case Management & Goal Setting; and Resilience, Affirmation & Praise (Castellano, 2012). Clearly the current findings are consistent with the importance of Connection & Pure Presence among these four and indeed with its place as first in order among them. The findings reported here and the experience of the RUBHC programs point to “being there” as the base on which other peer support services are built, whether they be referrals to professional services, peer supporters helping clients in pursuit of goals they set, or providing ongoing Affirmation & Praise as part of follow-up. This centrality or primacy of “being there” is reflected also in the training of RUBHC peer supporters first and foremost to connect before going on to detailed information gathering or case management tasks. Encouraging clients first to tell their stories and connect with peer supporters facilitates their being comfortable then in receiving recommendations or referrals.
A shared lived experience provides a solid base from which connection and presence can be built. Peer support services are unique because the advice and assistance given is informed by practical experience, not professional training or knowledge. These observations make clear that this shared lived experience lends credibility to the advice given and often allows for rapport to quickly develop between peers and clients. Peer support operates in a complementary manner to other services, where peers can assist in implementing recommendations of professionals, as well as referring clients to professional services or support groups they are aware of or have had personal experience with.
Reliable follow-up is a powerful tool for communicating presence. As noted in the findings, a peer supporter identified a common pattern of calls as centered on wanting to be “checked up on,” referring to wanting peer supporters to continue to keep in contact and communicate availability. A peer support program for low income mothers of children who were eligible for Medicaid and had been hospitalized for asthma was successful in engaging 89.6% of the mothers and reducing their children’s subsequent hospitalizations by 50% relative to controls (E. B. Fisher et al., 2009). Resembling the present findings, the “Asthma Coaches” reported that mothers were surprised and gratified when Coaches called back in several weeks as they said they would to “check in” with them. The Asthma Coaches felt it was indicative of their non-demanding but persistent approach to mothers that they talked of “checking in with them,” rather than “checking up on them.”
An important aspect of reliable follow-up that should not be minimized or discounted is the role of voicemail. Voicemail messages that focus on the connection made and communicate continued concern for the client are meaningful in and of themselves to clients and should not be viewed simply as “missed connections” or attempts to schedule contact.
As noted in the Introduction, the present study focuses on peer support provided by trained peers to individuals by telephone. But valuing presence is not unique to peer support. A recent study of participants in online support communities for those dealing with self-harm identified five “therapeutic affordances,” first listed among which was “connection, the ability to make contact with others who self-harm for the purposes of mutual support and in so doing reduce feelings of loneliness and isolation”(Coulson, Bullock, & Rodham, 2017).
Although some of the procedures such as the IT systems supporting 24/7 coverage may be different, many of the features of being there identified apply as well to mutual support groups as well as other channels of social support. Shared cultural identity and experience, emphases on acceptance, validation of experience, encouragement and affirmation, ongoing availability of support (e.g., the ability of most members to find an Alcoholics Anonymous meeting anywhere in the world), along with the simple existence of programs all convey the presence of others who will be there. Among the characteristics noted in the Results related to “Peer Support is Different,” most would apply also to mutual support programs, although the protection of confidentiality, so important to groups like police, may be easier to guarantee in supervised, individual support than in some mutual support approaches. Additionally, although some mutual support or self-help programs may see fit to follow strict limits on who may join or how they may participate, they may accept a variety of reasons for joining and varied patterns of attendance or may encourage varied shared activities as ways of providing flexible accessibility, again to convey presence and availability of someone to “be there.”
Although not reported in the present findings, experience of the RUBHC managers suggests that the connection established between peer supporters and clients may often include a “trauma bond” such as when a client who has successfully dealt with suicidal impulses attributes that success to the peer supporter and that relationship. This suggests a range in the communication of presence, from a simple voicemail to helping a client turn back from suicide. But the quotation at the start of this paper, “that those voicemails resulted in one less dead Marine” suggests also that simple actions along that range may have effects far more profound than their simplicity may suggest.
Qualitative and quantitative data from the telephone peer support services of RUBHC add support and broader illumination of the importance of “being there” in peer support interventions. Clients’ as well as peer supporters’ observations describe the importance of shared cultural experience, of a nonjudgmental and accepting atmosphere, of support that makes little demand on clients doing something to earn or maintain services but largely takes them as they are, and, as in the case of voicemail, maintains contact and communicates caring and availability even when clients, for any of many reasons, go for extended periods without utilizing services. In terms of quantitative data, average contacts per client were almost 12 total across all programs, pointing to the value of this kind of support to recipients. That these included a substantial portion of voicemails attests also to the communication of availability as a important part of support, not merely an attempt to schedule it.
Research & Policy Implications
Future research should acknowledge the fundamental value of presence in peer support services and extend focus beyond instrumental or emotional support features and quantifiable outcomes. Nuanced approaches to research that seek to understand how peer support may covey presence and the benefits of presence is warranted. As detailed in the Practice Implications that follow, policymakers, should recognize that communicating presence may require flexibility at the level of the support provided as well as the levels of protocols, standards, and financial policies that govern their funding.
Presence, or “being there”, is central to the provision of peer support and, as such, should not be overlooked in the design and implementation of peer support programs. Knowledge about disease and its prevention and management, assistance with access to care, or skills for caring for oneself are frequent and enduring themes of peer support programs. Program managers and peer supporters should recognize, however, that their first objective may be simply to be someone who is interested in and has time to spend with those they would help. Even if not needed to convey helpful knowledge and assistance in prevention or disease management, simply “being there” for people may convey substantial benefit.
Program developers and managers should generally prioritize ‘being there’ as a peer supporter’s first priority. Indeed, focusing peer supporters too much on technical knowledge, disease information, or referral resources may distract from the fundamental value of their presence. The workflow processes of peer supporters should reflect this, by prioritizing active listening and allowing time to build rapport with clients before addressing more in-depth information gathering and problem-solving. Additionally, intentional follow-up for the sole purpose of checking in with clients and communicating concern about them and their well-being should be emphasized. Documentation systems that facilitate records of conversations with clients – while avoiding distractions of requiring too much or unnecessary detail – allow for personalized messages that emphasize presence and the connection between supporter and client, even when peer supporters carry high caseloads of clients. Reflecting all of this, training should emphasize that listening and “being there” for clients can be profoundly impactful and are integral parts of peer support initiatives.
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Conflicts of Interest
General Graham is the Senior Director and Ms. Castellano is the Peer Support Director of the Rutgers University Behavioral Health Care National Call Center from which these observations were drawn. Ms. Dreyer Valovcin is the program coordinator for the Mom2Mom and Worker2Worker programs of the Center that are among those from which observations were drawn. No other authors have any pertinent conflicts of interest.
All patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the data presented.
This work was supported by the The Healthcare Foundation of New Jersey through a grant to Rutgers University Behavioral Health Care. This project was also supported from the University of North Carolina –Michigan Peer Support Core of the Michigan Center for Diabetes Translational Research (P30 DK092926, William Herman, PI) and by a grant from The Merck Foundation to Edwin Fisher as principal investigator.
Thanks to Muchieh Maggy Coufal, Ulrike Ehlert, Peter Goth, Yuexing Liu, John Piette, Yiqing Qian, Joel Rodríguez-Saldaña, Frank Snoek, Chanuantong Tanasugarn, Silvana P. Barros and Wessel van Lith for assistance in the translations of vernacular expressions regarding “being there.”
Table 1. Ways in which Rutgers Health University Behavioral Health Care Peer Support Conveys Presence
Table 2. Quotations from Clients and Peer Supporters illustrating key features of presence - Part 1
Table 2. Quotations from Clients and Peer Supporters illustrating key features of presence - Part 2
Figure 1. Mean Number of Contracts per Client, Disaggregated by Voicemail and Telephone Calls
Edwin B. Fisher, Patrick Y. Tang, Megan Evans, Nivedita Bhushan, Mark A. Graham, Dawn Dreyer Valovcin, & Cherie Castellano
Edwin B. Fisher, is Professor in the Department of Health Behavior in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. Prior to moving to UNC in 2005, he was Professor in Medicine, Pediatrics and Psychology and Director of the Division of Health Behavior Research at Washington University in St. Louis. A clinical psychologist, he has served since 2008 as Global Director of Peers for Progress that promotes evidence, resources, and advocacy for peer support in health, health care, mental health and prevention around the world.
Patrick Y. Tang, is a program manager at Peers for Progress, in the Department of Health Behavior, Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. In this position, he has a track record of successfully developing, implementing, and evaluating peer support programs in clinical and community settings. His research interests are focused on mental health and chronic disease management, but he enjoys working outside of those areas when providing consultation and technical assistance to collaborating organizations.
Megan Evans, is a doctoral candidate in the Department of Health Behavior in the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. She holds a Bachelor of Science in Psychology and a Master of Science in Community and Behavioral Health, both obtained from the University of Iowa. Her research centers around social factors and mental health, in particular the role of social and peer support in promoting and maintaining mental health and wellbeing.
Nivedita Bhushan, is a Postdoctoral Fellow at the Institute for Global Health and Infectious Diseases at the University of North Carolina, Chapel Hill. Dr. Bhushan’s research examines how social relationships, including peer support and related interventions, impact sexual, reproductive, and mental health outcomes especially among adolescent girls and young women, particularly in settings with a high burden of HIV.
Mark A. Graham, is a retired Major General in the US Army and the Executive Director of the National Call Center of Rutgers University Behavioral Health Care. The Center includes the national Vets4Warriors peer support program, the New Jersey suicide crisis line, and the programs that are the focus of this paper, Cop2Cop, Vet2Vet, Worker2Worker (for child protection workers), Care2Caregiver (caregivers of those with dementia), and Mom2Mom (mothers of children with special needs).
Dawn Dreyer Valovcin, is a Program Coordinator at Rutgers University Behavioral HealthCare working with many programs including Mom2Mom, Worker2Worker and Cop2Cop for the last 10 years. In her role as Program Coordinator, Ms. Valovcin is responsible for Rutgers National Call Center for Peer Support training, grant writing, staff supervision and coordinating with state agencies.
Cherie Castellano, is a national expert in the field of peer support after twenty years of experience as the creator of the “Reciprocal Peer Support Model” recognized as a national best practice by the American Psychiatric Association (2018) and Department of Defense Center of Excellence (2011.) As the Director of the Rutgers National Center for Peer Support, she directs over 200 staff in 14 peer programs with over ten million dollars of funding annually.
Keywords: Peer support, mutual support, being there, and sense of presence