The article addresses the critical role of peer support programs in the delivery of behavioral health services. Peer support is instrumental in fostering mental health and overall wellness. Its efficacy is widely recognized in the broader population, including minority groups and communities.

Peer support programs also offer distinct benefits for the health of Native American communities. When specifically tailored to these communities' needs, they address individuals' unique cultural, historical, and social challenges during their recovery journey.

However, the persistent supervision gap in the peer support workforce poses a significant challenge to implementing these programs. This gap not only hampers the effectiveness of the programs but also limits their potential benefits. The paper conducts a comprehensive exploration of the causes and consequences of this supervision gap, underscoring the urgent need to address it and its implications for the mental health of Native American communities. The urgency of addressing this supervision gap is paramount, as it directly impacts the mental health and wellness of Native American communities.

Also, it identifies and advocates for best practices in supervising peer support workers, explicitly focusing on Native American individuals and communities. In this vein, it raises awareness for more culturally sensitive, effective, and impactful peer support programs for Native American communities. The main objective is to improve Native communities' mental health and wellness by harnessing the power of peer support and ensuring its effective implementation through adequate supervision.

Keywords: native American peer support, native American recovery, peer support supervision, native American peer support supervision

MB, Mitochondrial diseases; mtDNA, mitochondrial DNA; MRI, magnetic resonance imaging; GTCS, generalized tonic-clonic seizure; HSV, herpes simplex virus; ENMG, electroneuromyography

Peer support programs have gained widespread recognition for their effectiveness in mental health and wellness promotion. These initiatives, rooted in the potential of individuals who have experienced emotional challenges, provide compassionate support, encouragement, and guidance and offer hope for others facing similar issues. These individual characteristics can be cumulatively defined as “lived experience.”^1–3 They have shown great potential to improve mental health and overall well-being for Native Americans,^4,5 adding tangible hope to the field of mental health services. However, a crucial problem lies in the need for more adequate supervision within the peer support workforce, a significant obstacle to the successful implementation of these programs. This paper thoroughly investigates the root causes and implications of this supervision gap, shedding light on its critical role in developing successful peer support programs tailored to the specific needs of Native American communities.

Numerous studies and reports have acknowledged that peer support programs have significantly promoted mental health and wellness. They are uniquely positioned to address the Native communities’ distinct cultural, historical, and social nuances, offering tailored support that resonates with the lived experiences of Native American individuals.^4,5

However, a critical challenge that hinders the successful implementation of these programs is a problematic supervision gap within the peer support workforce. This problem can be a significant obstacle to the effectiveness and impact of these programs. So far, there is limited research on peer specialists' need for adequate supervision. However, some studies suggest that inadequate supervision can lead to:

1. Reduced job satisfaction and burnout among peer specialists⁶
2. Decreased quality of care and services provided⁷
3. Increased risk of boundary violations and ethical concerns⁸
4. Lower client satisfaction and outcomes⁹

This paper explores the root causes and far-reaching implications of this supervision gap. Each tribe and community within the Native American population has specific needs and challenges. This paper underscores the importance of understanding and addressing these nuances in designing and delivering peer support programs for Native American communities.

Theoretical foundations of peer support

Peer specialists play a crucial role in the mental health field. They are individuals who have overcome obstacles in life and are trained to provide services to others with similar life challenges. Peer specialists promote recovery, foster resilience, and build on patients' strengths to support community integration and help them lead more fulfilling lives. These are the substantial aspects of the recovery model.^10,11

In their efforts, they enhance hope and social networking through role modeling and supplement existing treatment with education and empowerment. In contrast to other mental health professionals, peer specialists routinely disclose aspects of their illness and share their paths to recovery. They offer practical advice about managing symptoms, navigating complex service systems, addressing the shortage of personal resources, and dealing with discrimination.^11,12

Research has shown that while peer support and clinical practice typically perform fairly equally on traditional outcome measures like rehospitalization and relapse, peer support scores better in areas related to the recovery process. In particular, peer support offers more significant levels of self‐efficacy, empowerment, and engagement.^10,12,13

This aspect could come from the social connectedness experienced from interacting with peers, as reflected in anecdotal reports and the vast literature on the subject. The mutual exchange of strategies to cope with the everyday challenges of living with a mental illness is also an essential aspect of the peer-to-peer relationship.^4,5,10,11,12

The theoretical underpinnings of peer support are deeply rooted in public health, psychology, and sociology. The primary theoretical basis for peer support is the health-enhancing effects of social support. This concept is multifaceted, encompassing emotional support, informational guidance, role modeling, and mentoring regarding the personal meaning of recovery. In this frame, one of the defining characteristics of peer support is the emphasis placed on lived experience and experiential knowledge.¹⁴ This unique perspective, often overlooked in conventional care approaches, constitutes the essence of peer support. ^4,5,10-12

Interactions with peers who possess lived experience are believed to instill hope and bolster motivation in individuals contemplating or embarking on their journey toward change. Peer support is a fundamental pillar in providing mental health and addiction services. It has garnered significant recognition for its potential to facilitate recovery.^10,11

Role of peer support workers in mental health services: challenges and opportunities

Integrating a peer support workforce offering unique support based on “lived experience” is a transformative asset for mental health services. Peer Specialists, individuals who have successfully navigated their mental health challenges, play a crucial role in empowering others on their recovery journey. Despite the evident benefits, challenges persist in developing work environments conducive to peer support workers’ success.^10,11

One significant hurdle lies in the shortage of supervisors who fully comprehend the distinct role of peers and can provide adequate supervision. Unfortunately, supervisors often struggle to grasp the nuances of peer workers’ functions and responsibilities. Proper supervision ensures quality care and professional growth among peer support workers. It requires a delicate balance between understanding their unique roles, drawing from their “lived experience,” and providing guidance that fosters their development.^6,15,16

The peer support workforce is rapidly expanding, with over 30,000 peer supporters currently employed across the United States. These dedicated individuals serve in diverse settings, including inpatient psychiatric units, emergency departments, peer-run organizations, and telehealth services. Their impact extends beyond reducing hospitalizations and costs. They assist individuals in taking ownership of their well-being, improving overall health outcomes, and enhancing quality of life.^1–3

Also, certification programs for peer specialists are now widespread, standardizing training and scope of practice. They allow experienced peers to demonstrate their expertise and position them for leadership roles within the field.¹⁷ As peer support continues to be integrated into all areas of healthcare, recognizing the value of peer workers and providing adequate supervision remain critical priorities.

Causes of the supervision gap of peer specialists

Critical issues related to supervision issues include the presence of supervisors lacking “lived experience” (the unique, person-centered knowledge, insight, and expertise), the expertise in overseeing peer support services, and a lack of clarity regarding the peer role. Additionally, both implicit and explicit stigma toward workers with lived experience of mental illness, including the neglected intergenerational trauma histories among mental health providers, constitute added barriers to fostering successful working relationships and supervision. Adequate supervision enhances their skills, confidence, well-being, and quality of care. Moreover, it positively affects the overall experience of the work environment.^6,15,16

To overcome these gaps, organizational or systems-level interventions should strengthen the training for the peer support workforce and their supervisors' skills. By leveraging the expertise of experienced peers, programs can enhance the quality of peer supervision and promote the well-being of specialists and their peers. Therefore, this approach includes understanding the unique nature of peer support work and the meaning of "lived experience."

Causes of the supervision gap for peer specialists

Peer specialists are critical in mental health services, offering unique insights and support based on their lived experience. However, adequate supervision of peer specialists remains a challenge due to several key factors:^{6–9,12,15,16,18}

1. Many supervisors lack familiarity with the peer support worker role and approaches. As a result, they may struggle to provide high-quality supervision to peer specialists.

1. Implicit and explicit stigma toward workers with lived experience of mental illness can lead to peer specialists being minimized, stigmatized, marginalized, undermined, exploited, and even retraumatized.
2. Supervisors must recognize and address these challenges to create a supportive environment for peer specialists.

1. Mental health providers often have trauma histories, which can influence their ability to supervise effectively.
2. Acknowledging and addressing intergenerational trauma histories among mental health providers is crucial for fostering successful working relationships and supervision.

1. Organizations must align with recovery-oriented values to support the effective supervision of peer specialists.
2. Adequate supervision enhances peer specialists’ skills, confidence, well-being, and quality of care, ultimately benefiting the work environment.

Therefore, addressing the supervision gap requires a concerted effort to educate supervisors, reduce stigma, recognize trauma histories, and promote recovery-oriented values within organizations.

Best practices for effective supervision of peer specialists

The technical aspects of supervising peer support workers will not be referenced here in detail as they are thoroughly covered by several sources, which we list in the article references. However, we can focus on some of its salient aspects. Competent supervision can emphasize a clear definition of peer support, which thoroughly highlights responsibilities and boundaries. In addition, it recognizes and builds on the strengths of peer support workers, encouraging them to leverage their “lived experiences” and unique perspectives to support others. Additionally, it fosters an environment that prioritizes accountability while empowering and motivating peer workers.^{6–9,12,15,16,18}

Therefore, mental health clinics and hospitals must dedicate adequate financial, human, and time resources to ensure peer support workers receive consistent and valuable supervision. Even under administrative budget constraints, maintaining the quality and frequency of supervision sessions should be a top priority. Likewise, all staff members would gain from understanding the significance of supervision and its beneficial effects on peer support workers' performance, job satisfaction, and overall program. Of course, providing high-quality supervision requires a necessary set of skills. As stated by reliable sources, such training could provide supervisors with an understanding of the variety of peer roles and the core competencies of peer workers.^{6–9,12,15,16,18}

As frequently acknowledged, a significant contributing factor to the supervision gap is the lack of experience and working knowledge of peer practice, accentuated by insufficient training for supervisors and the lack of their "lived experience," as already stated. While many supervisors may have mental health or social work expertise, they may not have the "lived experience" and knowledge in the recovery field, which is essential to a recovery-based supervisory role.^{1–3,17,19,20} Personal "Lived experience" is invaluable for peer specialists' supervision. It seems reasonable to state that it should be included as one of the criteria for their selection.

Furthermore, In their roles, supervisors will emphasize the difference between the traditional clinical and recovery-based approaches, which aim at developing strategies and plans to improve individuals' quality of life. ^{6–9,12,15,16,18} In addition, peer support workers may face complex challenges, including navigating boundaries, managing self-disclosure, adhering to a code of ethics and the employers' code of conduct, and dealing with histories of poverty, trauma, and discrimination.^{1–3,17,19–21} These issues require the assistance of a steady and competent supervisor.

However, the decision to have the peer workforce supervised by “competent mental health professionals,” as defined by each state, has led to complexities in implementing peer support. While recognizing the need for reliable supervision, it defaulted to clinical supervision models, perpetuating a watering down of genuine peer support given its oversight by non-peer supervisors.^13,22

Donald Hume, one of the most experienced peer specialists in New Mexico, stated, “Many Peer Specialists who have tenure in their field have begun to recognize that the changes proposed by managed care organizations and state-funded facilities could mean that they may slowly evolve to offer services according to models based on regulatory and administrative paradigms rather than lived experience. There is an inherent danger of losing the foundations that built the Peer Support field. As we take comfort in complex documentation, long billing code taxonomies, and the writing of treatment plans for every service, we are also letting go of the hands-on model that started with one person in recovery giving back to another.”²²

Because of these likely changes, the very nature of the recovery process could be altered and reduced to a hybrid of clinical and recovery principles controlled by traditionally trained clinicians operating under the managed care model. One of the direst consequences is that individuals who want to follow a recovery-based plan and not necessarily get involved with a traditional clinical paradigm will be potentially deprived of a substantial source of support. Also, given that there may be no alternative resources to Medicaid for the provision of Peer support, recovery-oriented agencies utilizing Peer Support Specialists will have two options: accepting the new trends and rules or trying to operate without Medicaid funds, which will put their survival at stake. Moreover, this shift in peer roles and functions could be particularly harmful to frontier states like New Mexico, which experience consistent problems with access to mental health services.

Understandably, these changes can lead to psychological burnout without adequate support and supervision. Therefore, as Donald Hume clearly states, the training for peer support should also cover issues relating to perceived threats to their traditional roles.^13,22 Therefore, organizations must address these key areas to support the work of peer providers more consistently.

Culturally relevant models for supervising professionals working with Native American individuals

Besides the general rules illustrated in the previous sections, providing appropriate supervision for peer specialists working with Native American individuals requires knowledge of specific aspects of Indigenous cultures as they apply to mental distress and well-being. Therefore, proper supervision of peer specialists working with Native American individuals is even more challenging as it requires solid knowledge of Indigenous cultures and healing practices.^23–32 The following section illustrates the work of Dr. Eduardo Duran, a Native American mental health professional renowned for his expertise in addressing emotional and psychological distress within Indigenous populations and communities.^33,34 The authors feel that his approach can benefit the training of peers and peer supervisors. 

Dr. Duran created a thorough and detailed framework for overseeing mental health professionals working with Native American individuals. Duran's method prioritizes five essential strategies that are especially pertinent to the mental well-being of Native Americans: cultural humility, strengths-based practice, decolonizing practices, and trauma-informed care in the context of specific community traditional cultural beliefs and practices.

Cultural humility is a critical component of Duran's framework. Supervisors must cultivate a deep understanding and respect for the traditions, experiences, and traditional practices of Native American communities. Cultural humility in peer worker supervision involves fostering an open and teachable attitude and a lifelong process of self-exploration, self-critique, and willingness to learn from others. It also requires acknowledging and reflecting on one's cultural identity, biases, and stereotypes while embracing a relationship with another person to honor their beliefs, customs, and values. It means acknowledging differences and accepting individuals for who they are. Supervisors should work collaboratively with the supervisee to develop culturally appropriate interventions responsive to the unique needs of Native American clients. This approach requires a willingness to fix power imbalances and to create partnerships with individuals and groups who advocate for others.

The strengths-based approach is integral to Eduardo Duran's comprehensive framework. In supervising peer workers, this approach involves recognizing and leveraging their unique skills and experiences. Supervisors set achievable goals aligned with these strengths, provide constructive feedback, and foster an empowering and inclusive environment. Celebrating successes, offering relevant resources, and building trust-based relationships enhance peer workers' confidence, motivation, and professional growth, leading to a more effective and positive workplace. This method allows supervisors to help peer workers identify and nurture the inherent strengths and resilience within the Native American community, rooted in a rich cultural history of wisdom, resilience, and strength. By embracing this approach, individuals can actively participate in their healing process, fostering hope and optimism and taking ownership of their mental health journey for a recovery that is more sustainable and empowering.

Furthermore, integrating decolonization practices is crucial for advancing mental health and wellness within Native American communities.³⁴ Duran's framework emphasizes the role of supervisors in supporting supervisees in recognizing and confronting colonial influences on mental health while honoring Indigenous knowledge and perspectives based on Native American customs and heritage. This approach involves identifying and dismantling colonial biases and power structures while acknowledging the enduring effects of colonization and intergenerational and historical trauma on Native American communities, highlighting the necessity of decolonizing mental health practices. Supervisors should educate themselves on the histories, cultures, and impacts of colonization, fostering an inclusive decision-making process where peer workers' voices are valued. This approach promotes the autonomy and leadership of peer workers, leveraging their cultural strengths. Creating a supportive environment that respects diverse identities, offering culturally relevant mentorship, and engaging with the community of peer workers are crucial to developing cultural sensitivity. As emphasized in Duran's strengths-based approach, reflective practice and ongoing training on decolonization and cultural humility help address systemic inequities, ensuring a more equitable and empowering workplace.

Trauma-informed care is another critical aspect of Duran's framework. Supervisors should recognize the likelihood of Native American individuals having a history of trauma and acknowledge the impact of historical trauma and other forms of trauma on their lives. This supervisory approach creates a safe, empowered, and healing culture. It leverages the power relationship to support both supervisors and supervisees through the development of trauma-informed interventions sensitive to the unique needs of Native American clients. Trauma-informed care requires a deep understanding of the cultural and historical context of trauma in Native American communities. It involves sharing power with supervisees to prevent and work through traumatic stress, promoting a supportive and inclusive environment that supports healing, recovery, and resilience.

Social determinants of health

Social determinants of health are the conditions in which people are born, grow, live, work, and age, which can influence their health outcomes. They include poverty, unemployment, housing insecurity, lack of access to healthcare, and discrimination.^35–37

The major social determinants of health, like poverty and unemployment, are particularly pivotal to the mental health outcomes of Native Americans.^38–41 They present multiple facets, like housing insecurity and inadequate access to health care. Discrimination and racism further compound these challenges, leading to heightened levels of stress and anxiety for Native Americans experiencing mental health crises.^39,42,43

Integrating the social determinants of health into the supervisory training enhances the quality of supervision of peer workers. During the training of peer supervisors and peer specialists, emphasis on social, economic, and environmental factors may be pivotal for developing a holistic approach to address the most compelling social determinants of health in Native American communities.^39,42,43 Of course, connecting individuals with housing, transportation, and educational resources in partnership with local organizations and tribal health services will be highlighted as one of the priorities. By embedding these factors into their supervision, supervisors will help peer workers provide comprehensive, culturally sensitive support, improving health outcomes and well-being for Native American individuals. Also, contextualizing the social determinant of health within the frame of historical trauma can be extremely helpful, as it can foster a deeper understanding of the social and historical reasons for the development and occurrence of psychological distress in Native Communities.^39,42

Native American peer programs: a culturally relevant approach to recovery

The collective impact of Native American Peer Programs has been demonstrated through positive outcomes in areas such as well-being, cultural renewal, community support, and recovery within Native American populations. Integrating evidence-based practices with culturally relevant approaches significantly contributes to the well-being of Native American individuals. The following are some of the most prominent Native American peer programs:^44–47

Pathfinder solutions PBC’s native American peer recovery services program: Pathfinder Solutions PBC has designed a program specifically for Native American communities to establish a supportive network where individuals can assist each other in healing and thriving. This program integrates evidence-based practices with culturally sensitive approaches and emphasizes cultural renewal to address intergenerational and historical trauma. Outcome measures indicate increased self-reported well-being and recovery, enhanced social connectedness and community support, reduced substance use and mental health symptoms, and improved cultural identity and pride.

Peer recovery support services (PRSS) in tribal communities: PRSS programs build upon existing recovery movements within Native American communities. These programs address historical and contemporary trauma, emphasizing cultural renewal and healing. Outcome measures include decreased relapse rates and hospitalizations, increased engagement in culturally relevant activities, improved coping skills and resilience, and strengthened social support networks.

Native American student support & success program (ASP): NASSSP prepares incoming Native American students for successful school years. By strengthening K-12 pathways to higher education, this program ensures educational success and develops Native American leaders. Outcome measures include higher high school graduation rates for Native American students, increased enrollment and persistence in higher education, development of leadership skills, and community advocacy. Although not directly linked to specific mental health outcomes, this program was included because of potential indirect benefits for the mental health and well-being of the participants.

Peer-to-peer program for native Americans in recovery: This program equips Native Americans to provide support and community referrals in recovery. Focusing on relapse prevention and recovery support, it targets individuals completing treatment, “re-entry” from incarceration, or seeking recovery. Outcome measures include reduced substance use and criminal justice involvement, increased engagement in recovery-oriented activities, and enhanced social support and peer connections.

In conclusion, improving supervision within peer support programs can improve mental health and wellness in Native American communities. This goal calls for a holistic and synergistic strategy, engaging the concerted efforts of policymakers, community organizations, and peer support personnel. Appropriate supervision is paramount to fortifying peer supporters' efficacy and catalyzing favorable patient health outcomes.^6,9,16

However, peer support initiatives must honor the cultural tapestry and ethos of Native American societies. It is paramount to tailor these programs to align with individual patient needs while upholding cultural reverence.^44,45,32

Specialized training and supervisory skills are essential to empowering peer workers to deliver culturally attuned and supportive care to Native American patients.^6,16,44 Adopting these best practices and customizing peer support frameworks to the distinctive requirements of Native American individuals and communities will substantially bolster health outcomes and improve the well-being of these historically underserved populations.^44,45

Enhancing supervisory practices within peer support programs is a pivotal strategy for advancing mental health and wellness among Native American communities. This objective necessitates a comprehensive and integrative approach, mobilizing the collective endeavors of policymakers, community institutions, and peer support staff. Adequate supervision is crucial in strengthening the competence of peer supporters and triggering positive health outcomes for patients.^6,9,16

Nevertheless, peer support initiatives must respect and reflect the rich cultural heritage and values of Native American communities. These programs must be meticulously designed to meet the unique needs of individual patients while maintaining a deep respect for cultural traditions.^32,44,45

Developing specialized training programs and supervisory skills is vital to equip peer workers to provide culturally sensitive and supportive care to Native American patients.^6,16,44

Implementing these best practices and adapting peer support frameworks to meet the specific needs of Native American individuals and communities can significantly enhance health outcomes and contribute to the overall well-being of these historically marginalized populations.^44,45,50

None.

None.

The authors declare that there is no conflict of interest.

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