Peer Support Groups for People With Bipolar Disorders in New Zealand: A Pilot Study on Critical Success Factors

Correspondence:
Private Bag 92019, School of Population Health,
Faculty of Medical and Health Sciences, University of Auckland, New Zealand.
64- 9- 3737599 (Office) 64- 9- 3035932 (FAX)
s.tse@auckland.ac.nz

Acknowledgements:The authors would like to express our gratitude to group facilitators
who participated in this survey and the New Zealand Bipolar Network for their support of this study.

Abstract
Individuals with bipolar disorder may be at risk of not maintaining positive social networks that are essential for health and wellbeing. Peer support is an intentional form of social support that may help individuals to develop new perspectives on one’s illness and access information, including specific training. The aim of this pilot study was to describe the running of peer support groups for people with bipolar disorder in New Zealand and from the group facilitators’ point of view, to examine the critical factors that determine their success. Data were collected via a descriptive survey of known bipolar support groups within New Zealand. Three key elements of successful peer support group emerged from the study: Firstly, a close partnership between group facilitator and core group members; secondly, defining the roles for mental health professionals in peer support groups; and finally establishing the credibility of the group within the community.

Key words: recovery, social support, self-help

Introduction
Bipolar disorder (BD) is a disruptive major mental disorder. It affects approximately one in 100 adults at some stage in their lives in New Zealand and has a lifetime prevalence in the general population of between 0.3 and 1.5 percent across the world (Silverstone & Romans, 1995, Weissman, et al., 1996). BD has a relapsing and remitting course, in which some individuals have full recovery between manic, depressed or mixed episodes of illness. Nevertheless, research data to date generally points to the relentless nature of BD (Staner, et al., 1997; Winokur, et al., 1994), for example, eight out of 10 patients who reached full recovery from their first episode went on to develop a new episode within the next 10 years. Some clinicians and researchers have suggested that relapse of illness may be related to the scars of the episode themselves, the absence or inadequacy of treatment, the presence of an organic syndrome, ongoing use of alcohol or unprescribed drugs and/ or the absence of social support (Goodwin & Jamison, 1990). More recently it has been suggested that the dominant aspect amongst people who had one episode, and then no further hospitalizations, was the person’s acceptance of responsibility for their own wellness (Copeland, 1998).

In an analysis of Global Burden of Disease, BD features in the top ten most disabling conditions in the world (Murray & Lopez 1996). BD is regarded as a psychiatric disorder is characterised by low prevalence and high life span disease burden. The economic burden of BD alone in the United States in 1990 was estimated to be US$15.5 billion in diminished or lost productivity in work performance (Hitley, Brady & Hales, 1999). In a recent Australian study, it has also been found that mood disorder, which affects 100,000 Australians, costs the health system A$300 million each year, with indirect costs of A$1.3 billion (Pezzullo, 2003). In modern workplaces, the leading source of workers’ disability is depression (Stewart, Ricci, Chee, Morganstein, & Lipton, 2003). A common thread that cuts through the optimal management of BD is the need to minimize the intensity and duration of the individual episodes and if possible, prevent the occurrence of future episodes (Romans & Silverstone, 1994).

Social support has been associated with good health, well-being and functional performance of individuals with BD (Edmonds, et al., 1998; Goldberg, Harrow, & Grossman, 1995; Keck, et al., 1998; Michalak, Wilkinson, Hood, Dowrick, & Wilkinson, 2003; McPherson, Dore, Loan, & Romans, 1992). Social support generally refers to help that is provided by one’s family or friends that facilitates the individual’s ability to cope with stressful life events. It has an element of intimacy, and an opportunity for reciprocal and socially motivated behaviors (Berkman, 1995). However the question of whether and in what form social support may be available is of particular importance for individuals with BD because the social networks are at greater risk due to a variety of reasons such as the stigma associated with mental illness, the lack of effective social skills, the presence of socially undesirable behaviors when the person is manic or depressed, and/or other social sequelae wrought by the illness (e.g., loss of life roles, financial hardship, unemployment).

People with BD sometimes find support, acceptance and comfort in discussing their experiences with other individuals who have experience of similar illness in peer support or mutual-help groups. Davidson and colleagues (1999) defined peer or mutual support as a process by which people come together to help each other address common problems or shared concerns. It is a system of giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful. It is about understanding another’s situation empathically through the shared experience of emotional and psychological pain. Mead, Hilton and Curtis (2001) added that when people find affiliation with others they feel are “like” them, they feel a connection. This connection, or affiliation, is a deep, holistic understanding based on mutual experience where people are able to “be” with each other without the constraints of traditional (expert/patient) relationships. One of the main differences between peer support and naturally occurring social support may be the intentional way in which it occurs, that is, there is usually a specific setting involved where new information, perspectives, training, skills and a supportive social climate are fostered. Some types of peer or mutual support are offered in the context of particular world-views and ideologies that are aimed at assisting people to make sense of their experiences.

There has been increased popularity in the use of peer support groups for people with mental health problems such as bipolar disorder, schizophrenia, alcohol and substance abuse disorders (Corrigan, et al., 2002; Felix-Ortiz, Salazar, Gonzalez, Sorensen, & Plock, 2000; Kingree & Thompson, 2000; Powell, Yeaton, Hill, & Silk, 2001). Several studies examined the attitudes, behaviors and experiences of mental health professionals toward psychiatric peer support groups (e.g., Chinman, Kloos, O’Connell & Davidson, 2003; Powell, Silk, & Albeck, 2000). For instance, Powell and his colleagues (2000) found that whether or not psychiatrists made referrals to peer support groups depended upon several factors, the presence of such groups in the same facility as the psychiatrists’ clinics, the psychiatrists’ receipt of information about peer support groups and his or her beliefs about its benefits and limitations.   A number of other variables may dictate who gets involved in peer support. Some individuals with BD may avoid face-to-face support groups or fear discrimination if employers, workmates or friends learn about their difficulties. Some of these have turned to cyberspace in the form of Internet support groups (ISGs) (Lamberg, 2003). Researchers have found that, both face-to-face and online support groups offer emotional support (it is often considered by group members as the chief benefit), encouragement and information (Hoston, Cooper, & Ford, 2002; Klemm, Reppert, & Visich, 1998; Powell, et al., 2001; Rappaport, 1993). Corrigan and his associates’ (2002) work was the first that the authors are aware of to examine the recovery processes that might account for the positive outcomes occurred in peer support groups for people who have serious mental illness. Yet despite the vast literature on social support and mental illness, there is paucity of research on critical factors influencing the outcomes of peer support groups for people with BD.

There were two aims of the present study. The first was to describe the running of peer support groups for people with BD in New Zealand. How many groups existed in New Zealand and how were they distributed over the country? What were the common types of activities? What was the background of the group facilitators? The second objective was to examine, from the group facilitators’ perspective, what were the critical factors determining the success of peer support groups for people recovering from BD?

Method
Procedures and participants
This study was implemented as part of the evaluation framework for the New Zealand Bipolar Network which is a voluntary, charitable organization governed by consumers with mood disorders (primarily bipolar disorder) in New Zealand. The network is funded by membership, donations and community funding agencies (but not the central government). The present descriptive survey used a naturalistic design and the sampling frame was all the nineteen support groups (in some regions there are multiple groups) within New Zealand. This included groups identifying themselves as depression support groups, where these groups were also members of the New Zealand Bipolar Network. To be eligible for inclusion groups could be professionally facilitated, peer-run support groups or groups that adopted a combination approach but they needed to incorporate some aspect of social support, broadly defined. Of these support groups, five were excluded due to there being no group in existence or the former group being in recess. A further member group was identified as not specifically a BD support group and was not asked to return the survey form. Groups offering support primarily to relatives or family members were also excluded. A total of 13 surveys were mailed to the key contact person or group facilitator in each region, further copies of the survey were also emailed as an attachment to online members of the newsletter mailing list to maximize the chances that any unknown groups might also respond. Two reminders were circulated by email to group facilitators in order to improve the response rate. From the 13 groups surveyed, ten groups (77%) responded.

Measures/Instruments
Key questions for the present survey were formulated based on a forum held in 2003 at the National New Zealand Bipolar Conference. That particular forum was about an update on peer support groups in each region which gave useful clues on what should be covered in the questionnaire. The first author took notes of the session and discussed the drafted questionnaire with the research team. The finalized questionnaire included following areas:
•   General description of the bipolar peer support group in each region (e.g., background of group facilitators, frequency of meeting, time of meeting);
•   Types of activities organized in the meetings;
•   A reflective question on how the group facilitators rated the overall functioning of the group(s). “1” denotes “close to not functioning at all, and “10” indicates “achieving the group set objectives”;
•   An open-ended question pertained to what were the critical factors to successful peer support group.

Analyses
Data from the 13 returned questionnaire were analysed using a general inductive approach to identify key themes relevant to the research objectives. This analytic strategy is similar to grounded theory and leads to a theoretical framework developed inductively from data and emerged themes (Strauss & Corbin, 1990, 1998; Thomas, 2003; 2000). The first and second author reviewed the data individually and then the whole research team examined the overall results. Studying the written data repeatedly enabled the development of themes and sub-themes and their linkages. Analyses were performed primarily by cross-case analyses of each returned responses and the constant comparative method (Huberman & Miles, 1998). Focus for the present data analyses included: general description on peer support groups, respondents’ opinion on critical factors to successful peer support groups. Special attention was given to possible meanings of each emerging theme and sub-theme. All these findings were then synthesized into a framework to explain the keys to successful peer support groups for individuals recovering from bipolar illness.

Results
Bipolar peer support groups in New Zealand
Four of the ten respondents came from New Zealand metropolitan cities (Auckland, Wellington, Christchurch, Hamilton and Dunedin). Only one out of the ten groups was led by mental health professionals whereas the rest were facilitated by people with experiences of BD or co-led by both professionals and service users. The average meeting attendance was ten people. The average self-reported rating by facilitators on the overall functioning of the peer support groups was about “7” out of a ten-point scale, where a high score indicated optimal functioning. Other key findings are summarized in Table1.

Table 1. Survey on Bipolar peer help Groups in New Zealand

Respondent¹	Facilitation style	Frequency of meeting	Meeting time		Average number of people attending	Impression on overall functioning: 1- very poor; 10- very well
1, NMC	Combined- led by peer and professionals	Weekly	Evening, (i.e., after 7pm)		8	9
2, NMC	Peer facilitation	Fortnightly	Evening		12	7
3, MC	Combined	Weekly	Combined		5	Did not complete
4, NMC	Peer facilitation	Weekly	Both- evening & day time meetings	15		10
5, NMC	Peer facilitation	Monthly	Evening	6		4
6, MC	Professional facilitated	Monthly	Day time	14		10
7, NMC	Peer facilitation	Did not complete these items²				0
8, NMC	Peer facilitation	Weekly	Day time	7		7
9, MC	Peer facilitation	Monthly	Evening	10		5
10, MC	Combined	Did not complete	Both	Did not complete		10

¹ NMC Non Metropolitan City, MC Metropolitan City
² This respondent provided useful descriptive data so her responses were not discarded in this survey.

The topics for education, sharing of personal experiences and opinions were grouped as follows:
•   Medication (values, benefits, side effects)
•   Early warning signs (what they are when noticeable? when to act? what to do and where to seek help?)
•   Nutrition for the mind (use of food and supplements that affect mood)
•   Cognitive-behavioral therapy
•   Spiritual well-being
•   Life style issues (e.g., energy level, sleep pattern, diet, opportunity for making life-style changes)
•   Managing family (spouse/ partners, children) and friend relationships
•   Alternative treatments (what have people heard? where to get information?)
•   Dealing with discrimination and stigmatization (how to deal with? what to say?)
•   Diagnosis and its replications
•   Housing
•   Employment
•   Talks from other non-government organizations about the services they provided
•   Talks by health professionals, social welfare agencies and income support services
•   Privacy law
•   Educational video on people’s recovery journey
•   Update on changes in mental health services or system
•   Report on national organizations and conferences

During the peer support group sessions, a range of activities was also used to promote mental health. They are: yoga and meditation, physical exercise, training in time and stress management, sharing of jokes, recovery and depression awareness course.

“Informal tea/ coffee and biscuits time” was the most commonly used activity to promote social interaction and emotional support among group members. Some groups had set time for each attendee to discuss how things have been in between the meeting time with special emphasis on how they were coping instead of why they are not. Shared dinners, meals and festival gathering were also very popular social activities. Occasionally friends, partners and family members were invited to come along and they brought a different social dimension to the peer support groups.

Critical factors contributing to the success of bipolar peer support groups from group facilitators’ perspective
There were three major factors or themes emerged from the results. Factor one was related to the qualities of group facilitators and how they worked with their core members in the group. Factor two captured key issues arising from the group that members and facilitators alike have to deal with in order to run the group successfully. Peer support groups do not exist in a vacuum. Respondents identified additional issues external to the group in factor three, which would potentially determine the outcome of peer support groups.

Factor one: Group leaders and group members

Factor two: Coping with internal challenges arising within the group
The most important challenge identified by facilitators has been to ensure confidentiality and trust is maintained among group members. One respondent mentioned that having clear rules about safety in the group, knowing how to manage differences in opinions was a useful way to reinforce that. Coping with different level of wellness among group members or people at different stages along the recovery continuum of bipolar affective disorder was mentioned as another important challenge.

Another key factor to successful peer support group was related to the group’s ability to strike a balance in group size, and a right mix of gender and people with different personalities and energy level. “Getting the right mix of people for each group and keeping groups small” (group facilitator 10). It also needs to have a balance of structured (i.e., had set topic, format and process) versus free, open discussion. Respondent 4 added, “Variety is a spice and having a variety of activities, speakers, and group members makes for no two nights being the same”.

Along a similar vein of findings, some respondents mentioned how it was important to manage the balance in terms of the group being facilitated by mental health professionals (that usually do not have experience of mental illness) or peers who have experience of bipolar illness. If professionals led the group, people attending peer support group would start looking to paid mental health practitioners for opinions and support rather than peers. Tension did start to happen as the peer support group went in a different direction to a recovery model. One respondent reflected on the value of adopting the recovery model in peer support group such as the principles of promoting personal responsibility, individual and collective self-determination, instilling hope.

“I think that support groups have the most to offer if they run on a peer support model and that health professionals have an important role to play in building the capacity of group members to take the group over for themselves. Having said this, from personal experience it can be very hard to extricate yourself once people have come to rely on you” (group facilitator 3).

Some respondents showed reluctance in accepting input from professionals who did not have appropriate interpersonal and communication skills. One example is:
“The group had difficulty with a mental health professional talking down to attendees with a condescending attitude. The need for good listening and conversational skills, an unconditional positive regard for others in the group and good congruency became very apparent in both group and individual support” (group facilitator 2).

On a practical note, having good up-to-date library resources and solving group members’ transport problem were important issues in enabling people to attend and stay involved in a peer support group.

Factor three: Coping with external challenges
The greatest external challenge for a bipolar peer support group is to create credibility among the people the group seeks to give support to, and importantly with the government mental health services and other non-government mental health service providers such as family doctors through whom referrals come. Group facilitator 4 elaborated, “It is important for the group to have a good front people who can represent the group well in the community and as people first make contact through the telephone people who have a good phone manner and knowledge of the group”. Ongoing success of the peer support group in each region depends on the group’s ability in obtaining funding to cover the ongoing costs for venue hire, staff costs and information provision and other specific activities like educational workshops, festival gatherings, and small research projects. “We have good leadership among the group members however funding has become a limiting factor in the effectiveness and versatility of the group” (group facilitator 4). Recently, there has been a challenge from funders about the value of having a peer support group specifically for people with BD as opposed to a group supporting the full spectrum of mental illness.

Discussion
While the mental health recovery movement appears to have gained significant momentum in countries like the United States and the United Kingdom, its impact on mental health sector is gradually becoming more visible in New Zealand. The recovery approach was developed and endorsed in New Zealand by the Mental Health Commission as a new and fresh approach to working with people suffering from mental health problems (Mental Health Commission, 1998). The New Zealand Mental Health Commission (1999, p. 1) defines recovery as “the ability to live well in the presence or absence of one’s mental illness (or whatever people choose to name the experience)” and emphasizes the importance of acknowledging one’s cultural background, in particular the Maori culture (the indigenous people in New Zealand). “Recovery orientation is compatible with Maori mental health models, in that a balance is sought between the body, person, whanau (extended family), and the environment and ecologies within which they exist” (Lapsley, Nikora, & Black 2002, p. 2).

If people with bipolar illness are going to get well and stay well, ongoing education about the principles of recovery and elf-management skills specific to bipolar disorders is important. Individuals should be encouraged to obtain as much information as possible, through books, educational videos, health professionals and talking with other people recovering from BD. Results from the present study highlight three aspects support group facilitators see as paramount.

Firstly, this study found that in addition to personal qualities and effective skills of a group leader, it is important to create a close partnership between group facilitator and core group members to ensure successful running of peer support groups. This study challenges the conventional view that the group facilitators or leaders in clinical settings hold the key to successful group experiences. The group leader is seen as having the primary responsibility to manage behaviors and reduce anxiety inherent in bringing together a group of strangers who enter the group because they are in need (Dies, 1983; Yalom, 1985). In this study, according to group facilitators, a successful group experience requires strong commitment of certain members to the caring community created in the peer support group. These core group members need to work closely with the group facilitator regardless of whether the facilitator is coming from a service user’s background or not. This finding is consistent with recent work on recovery processes in mutual-help groups. In a study on a structured educational program and a caring community found that “(to) decentralize from self and participate in community” was one of the key recovery processes inherent in peer support group (Corrigan et al., 2002, p. 291). In turn, participation in a sharing and caring community helps lighten the group facilitators’ workload thereby contributing to the long-term survival and successful outcomes of the peer support group.

Secondly, some respondents in the present survey indicated their reluctance in accepting help from mental health professionals in facilitating bipolar peer support groups. This comment equates with the findings of Kurtz (1990) that stated over-involvement of the professional, including leadership or facilitation, risks professionalizing the group and reducing the opportunities for members to help one another. Doughty (2002) argued this was not meant to undermine mental health professionals’ expertise and knowledge about the nature, or clinical treatment, of psychiatric symptoms, but simply to acknowledge that experiential wisdom and personal struggle are important facets in helping others to seek their own wellness and recovery. However other studies suggested that professional leadership could have a positive impact (Stewart 1990, Stewart, Banks, Crossman, & Poel, 1995) while others found few or no differences between peer-led and professional-led groups (Shepherd et al., 1999). We tend to agree with Shepherd and associates that the dichotomous view of comparing peer-led versus professional-led support groups was artificial and that professional involvement in mutual aid was a continuum, with most groups having a moderate level of professional involvement. Furthermore one should not ignore the fact that the number of people with a mental illness taking up professional training in mental health sector is on the rise, both in New Zealand and internationally (Hansen, 2003). It was suggested that professionals should be engaged in a dialogue with peer-led support groups about the realities of the potential benefits and conflicts for example, what to do when a peer support group gives a service user a suggestion contrary to the advice of their treating psychiatrists or mental health workers (Chinman et al., 2002).

The third major finding of this study was about establishing credibility of the peer support groups for people with bipolar illness. Indeed without a good reputation in the community, it is very difficult to secure continuous funding for the group. Credibility of a peer support group for specific illness is often associated with helpfulness perceived by group members. It was found in a recent study that members’ perceived helpfulness of a mutual help group was strongly correlated with ratings of referent power (influence based on sense of identification among members, peer leaders and mental health professionals) and expert power (influence based on knowledge and expertise) (Salem, Reischi, Gallacher, & Randall, 2000). Group members reported experiencing high level of referent power with their fellow members and peer leaders. They reported higher levels of expert power for mental health professionals and peer leaders than for fellow members.

Implications for implementation
Chinman et al. (2002) and Powell et al. (2000) drew attention to the encouraging nature of research on the utility of peer support groups for those with serious psychiatric disabilities, including bipolar disorder. Specifically, they highlighted research that related participation in such groups to lower hospitalization rates, fewer days spent in hospital, less substance use, reduced symptomatology, more positive social functioning, enhanced social networks and promoting advocacy. Despite overwhelming anecdotal evidence (e.g., Lish, Dime-Meenan, Whybrow, Prince, & Hirschfield, 1994, Doughty, 2002) that illness-specific peer support groups play an integral role in allowing individuals and families timely access to information, there still are relatively few New Zealand organizations that receive funding for peer support. To date less than one quarter of the peer support groups surveyed in the present study received adequate financial support. Employing people with a mental illness as group facilitators reflects a recognition that professionally credentialed and formally trained health professionals cannot meet all of the needs of people with serious mental illness and that service users themselves bring something distinctive to the service process (Mowbray, Moxley, & Collins, 1998).

In a survey of 1,100 mental health professionals, it was found that participants tended to view professionally led groups more positively than they did peer support groups on a number of dimensions (Salzer, Rappaport, & Segre, 1999). Their analyses suggested that the curative factor associated with professionally led groups was valued over factors associated with peer support groups. Salzer and colleagues (1999) suggested that one of the implications of their study is that professionals may be less willing to provide much needed resources and referrals to peer support groups as long as they are evaluated from a professional services framework. Adoption by funders and policy makers of an alternative framework that values the benefits of both professional and consumer-run initiatives would recognize their unique contribution to mental health services (Salzer & Shear, 2002).

Strengths and limitations of the present study
One of the strengths of this study is it is a pilot study to explore critical factors contributing to successful outcomes of peer support groups. This study also provides a description of a range of activities used in peer support group to promote education, enhance social networking and support among people with BD. However, the study is limited by assessing only one perspective on critical factors to successful peer support groups.

Conclusions
In summary, the present study provides a useful account of the key factors that make up a for successful peer support groups from a facilitator’s perspective. What seems to work best is that the peer support group has clear purposes, a simple group process and a suitable governance structure. It especially highlights the need to manage any tensions that arise and strike a balance in the area of working cooperatively with health professionals. Future studies should seek to incorporate some elements of experimental design. For example even if random allocation to groups was not possible it may be useful to examine psychosocial outcomes for individuals by making comparisons between those participating in a group with factors critical to successful peer support and those assigned to control group without additional qualities. The demographic and cultural background of people attending the bipolar peer support groups was not included in this study. Further studies of factors predicting the success of peer support group should aim for more heterogeneous samples inclusive of indigenous people, ethnic minorities, different age groups and men .

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