The incorporation of peer support in the treatment process for individuals experiencing mental health challenges has been increasing over recent decades (Campbell, 2005). Adults with mental health conditions have pursued roles as facilitators in recovery-based work (Mead, Hilton & Curtis, 2001), and attained roles as peer support providers in diverse settings (Chinman et al., 2008; Gopalan, Lee, Harris, Acri, & Munson, 2017). More recently, youth have also filled critical roles as peer support providers, as young people with mental health challenges may relate better to another young person with lived mental health experience.
A further development in peer work is the recent inclusion of Youth Peer Advocates (YPAs) in High Fidelity Wraparound (HFW; Walker, Baird, & Welch, 2018). HFW is an intensive care coordination model for children with complex mental health challenges. The New York State System of Care (NYS SOC) initiative, a pilot study of HFW implementation, encourages YPA involvement in the HFW process. Here, YPAs tend to work one-on-one with youth HFW participants and collaborate with members of the care team, including caregivers, care managers, and family peer advocates.
Including YPAs in the HFW process would appear to offer several advantages over HFW as usual. However, research on the impact of youth peers, particularly in HFW, is currently quite limited. This article describes some of the positive enhancements YPAs can bring to the HFW process, and some potential challenges of involving YPAs in HFW, both theoretically and in preliminary findings from our ongoing evaluation of the NYS SOC initiative. While the research described here is qualitative and exploratory, the findings may provide directions for future efforts to integrate youth peers in HFW.
Potential Impacts of YPAs in HFW
HFW uses a team-based process in which a care manager works with youth and, when applicable, their caregivers, as well as other providers and supporters, to address needs through strategies that capitalize on families’ skills, interests, and abilities. Establishing trust early in the process can lead to better family, and particularly youth, engagement, allowing for fuller implementation of HFW and maximizing its intended outcomes. Research on adult peer-to-peer services has demonstrated that peer support can foster the trust and rapport needed for effective service delivery and connections with service systems (Chinman et al., 2008; Hardiman, 2004; Sells, Davidson, Jewell, Falzer, & Rowe, 2006); programs involving youth and young adult advocates have suggested similar benefits (Lombrowski, Griffin-Van Dorn & Castillo, 2008; Silva, Petrilla, Matteson, Mannion & Huggins, 2019). In HFW, YPAs’ common mental health histories and similar ages afford youth participants a confidant during the critical rapport-building phase, promoting trust and reducing isolation. Further, YPAs remain confidants throughout the wraparound process and can help youth advocate for themselves (Lombrowski, et al., 2008; Silva, et al., 2019). For example, YPAs may guide youth in determining their goals, provide coaching and preparation before team meetings, or help youth articulate their needs in meetings.
Additionally, participation may benefit the YPAs themselves. YPAs may experience a sense of purpose and meaning through their efforts, and develop valuable work experience and skills (Walker, Baird, & Welch, 2018). HFW involvement thus provides another opportunity for YPAs to pursue their own recovery: while not a primary goal of HFW, increased wellness for YPAs is both a positive outcome and could allow them to be more effective within HFW.
But peer support services are not without challenges. Adult peers have reported a lack of role clarity and job expectations, as well as feelings of isolation from professional team members (Chinman et al., 2008; Kemp & Henderson, 2012). Hierarchical social structures may also result in less emphasis on peer input versus the opinions of professional team members. These barriers make it difficult for peers to collaborate effectively with other team members, and have the potential to be magnified among YPAs, who are particularly vulnerable to being under-valued or dismissed by providers who prioritize professional views (e.g., Delman & Klodnick, 2017; Walker et al., 2018). In particular, when YPAs’ views about the best course of action conflict with the perspectives of caregivers and other team members, they may be ignored, limiting the ability of YPAs to effectively work with care teams and advocate for the youth participant. Additionally, these negative experiences may hinder the YPA’s own recovery.
Preliminary Findings on the Impact of YPAs in HFW Implementation
As part of our evaluation, we collected interview and survey data from individuals in many roles in HFW, including YPAs, youth participants and caregivers, family peer advocates, and care management agency administrators.
HFW Enhancements from YPAs: Across roles, participants spoke about how YPAs’ common mental health experiences and similar ages were key drivers in building trust and engaging youth participants in the HFW process. As one caregiver stated, “I adore [FPA] and [YPA] – they’re amazing. They ‘get it,’ they ‘get us.’… [They’re] all about helping and they listen to both sides – no judgment. I feel I can open up to them about anything.” YPAs further described how common experiences helped encourage trust in the HFW process. One YPA felt that “being able to say I’ve come through it gets more buy-in than I went to school and I know all about it.” Some suggested that YPA’s similar age helped transcend generation-based cultural barriers. One YPA shared, “I’m like them. I have Instagram, snapchat, et cetera. Older people might not have that knowledge or relationship with youth. I’m like an older sibling, easier to relate.” As an YPA noted, “you can’t educate [sic] that empathy.”
Further, YPAs were able to keep youth’s perspective centered. As one YPA noted, her focus is on “…reminding the family about youth; talking to and empowering the youth… Youth know for the first time that these meetings are about the youth. Other systems don’t do that.” A family peer advocate observed, “[Youth] could share experience with YPAs. Share hope. [Youth]’s face would light up. [Youth] felt heard. [Youth] could share their voice without fear of being disciplined – [YPA] facilitated that.” As such, YPAs were able to coach youth so they could share their opinions, and then reinforce those positions to ensure that the youth’s perspective honored in the HFW process.
These relationships promoted engagement with the HFW process and youth progress. One youth participant related, “I have a good bond with the YPA. That helps. If the YPA didn’t join the program, I don’t know if I’d be doing as well as I am.” Similarly, a care manager offered, “Sometimes the strongest relationship in the unit is between the YPA and the youth and we rely on that to drive the case forward.” Taken together, these findings suggest YPAs facilitate youth participation and movement through the HFW process.
Challenges in YPA Involvement: One frequently noted challenge was the perception of built-in role-based hierarchies that kept YPAs from being perceived as equal contributors. Some YPAs felt their work was unappreciated and that other HFW participants tended to discount them, taking care managers and clinicians more seriously. YPAs reported that some HFW participants tended to discount them and their input, taking care managers and clinicians more seriously. Care managers also weighed in on role hierarchies, stating that they felt the need to oversee YPAs to ensure they fulfilled tasks.
Interviewees noted that YPAs may struggle with working with youth with complex mental health challenges due to a lack of specialized training. A family peer advocate remembered that an YPA felt, “working with difficult cases can be very intimidating.” Another YPA shared, “There should be more credentialing in place. More than a high school degree – [it’s] not appropriate to send [YPAs] out to work with these families. Crisis calls, CPS, probation, hospitalizations, you have to know how to do that. That concerns me.” These findings suggest that YPAs need additional training and support specific to working in HFW, such as guidance on their role in responding to such crisis situations or how to support youth when they may be involved with other service systems (e.g., child welfare or juvenile justice).
Youth Peer Advocates have the potential to enhance High Fidelity Wraparound by facilitating family trust in the process, elevating youth perspectives, and fostering youth engagement through their lived experiences and relationships with youth. However, YPAs may need enhanced training to meet complex family needs, and avoid being relegated “to the sidelines” within the care team. As such, future HFW instantiations looking to include YPAs should consider the supports needed to maximize their potential value in the HFW process.
The Center for Human Services Research at the University at Albany evaluates the New York State System of Care initiative. The Center has over 25 years of experience conducting evaluation research. See more at https://www.albany.edu/chsr/.
Darren Cosgrove, LMSW is a Doctoral Candidate at the University at Albany School of Social Welfare. Thomas M. LaPorte, PhD, is a Research Scientist at the Center for Human Services Research at the University at Albany. Margaret Gullick, PhD is a Senior Research Scientist at the Center for Human Services Research at the University at Albany.