Effects of Online and Recovery-oriented Peer Support Groups Facilitated by Peer Support Workers in Times of COVID-19

The "signatures" of MHPIs is a term formulated by the American National Institute of Mental
Health to designate the broad range of genetic, biological, psychological, and social factors
that may "sign" a specific mental disorder, depending on an individual's sex, history,
lifestyle habits, and so on. In 2010, the Research Centre of the Montreal Mental Health
University Institute (MMHUI), in Canada, implemented the "Signature Bank" project for the
collection of biological and psychosocial dimensional signatures from all psychiatric
emergency patients of the MMHUI (catchment area of about 600,000 inhabitants). More than
4,000 patients are treated annually at the MMHUI, while an additional 2,000 patients per year
are treated by means of outpatient or ambulatory services. Our activities provide us with one
of the largest populations of patients with MHPIs in Canada. By collaborating with the MMHUI
Research Centre, MMHUI-hospital managers have contributed to the implementation of this
large-scale project that aims at measuring the (epi)genetic, biological, psychological, and
social signatures of people living with MHPIs who receive the MMHUI's clinical services.
Typically, these measures are obtained at four different points in the clinical visit of
patients at the MMHUI: (T1) when patients are admitted to the psychiatric emergency services,
(T2) when they are discharged from the hospital, (T3) when they are admitted to an outpatient
clinic, and (T4) 12 months after T3. This study now goes even further in understanding not
only the signature of MHPIs, but also the dimensions of personal-civic recovery and as
reported by our patients who will additionally complete the Recovery Assessment Scale (7),
the Citizenship Measure (8) and the COVID19 Stress Scales (9) components.

Several instruments have been developed by clinicians and academics to assess clinical
recovery. Based on their life narratives and to assess personal-civic recovery, measurement
tools have also been developed through community-based participatory research and validated
by persons living with MHPIs; for instance the Recovery Assessment Scale and the Citizenship
Measure questionnaires. As users of mental health services typically tend to prefer
interventions to help them recover, reintegrate with society, and achieve their personal
goals, this pre-post research feasibility trial design is undertaken to evaluate the outcomes
on personal-civic recovery (primary outcome) and on clinical recovery (secondary outcome).
Among the Signature Bank participants diagnosed with (a) psychotic disorders, or (b) anxiety
and mood disorders, and who have further accepted to be invited to participate in this study,
an half will only receive the corresponding control intervention, and the other half will
also receive our experimental Peer Support Workers' online group intervention based on peer
support (random allocation control/experimental intervention ratio = 2:1). The abovementioned
additional measures of personal-civic recovery and the COVID19 Stress Scales will be
repeated, along with the measures of clinical recovery, which are routinely collected among
all Signature Bank participants.

The aim is to collect data for a future Randomized Controlled Trial design by clarifying a
certain number of remaining uncertainties and by determining an effect size that would be
specifically attributable to transitional online peer support groups as facilitated by
trained PSWs. Analyses will thus also consider scientific reasons, processes, resources, and
management in preparation for a more definitive trial. Indicators of feasibility will include
recruitment rates practices, participants and facilitators, as well as feasibility and
retention rates in study protocol.

When a person shows up at the Emergency Department of MMHUI for the first time, he or she is
systematically approached by a Research Nurse after a first medical authorization is granted
for that person to be approached (sometimes this authorization is not granted for medical or
security reasons). The Research Nurse then explains what objectives of the Signature Bank
project are and invites the person to participate. Those who accept sign the Information and
Consent Form (T1), fill out a series of questionnaires, including for sociodemographic
information, consent to the taking of biological samples, and they are also asked if they
accept to be contacted for other research purposes (like our own study). Then, as with any
other MMHUI patients, they are evaluated by the Evaluation and Liaison Module during their
hospital stay when they are hospitalized. A diagnostic is established or confirmed by
psychiatrists on the ward, and coded according to the World Health Organisation International
Classification of Disease (ICD-10). According to these diagnoses, after discharge (T2) they
are referred to a specialized outpatient clinic (T3). Whether for psychotic disorders or for
anxiety and mood disorders, pharmacotherapy or psychotherapy, or a combination of both, are
then offered in accordance with guidelines of the Royal College of Physicians and Surgeons of
Canada.

PSWs will learn with participants via a series of co-learning workshops that they will
organize and facilitate as focus group panels in a manner to simulate a typical peer support
group. The difference of our experimental and transitional online peer support groups to real
community-based peer support groups is that (A) they will have to be facilitated by trained
PSWs and (B) they will have a personal-civic recovery focus. They will also (C) have a fixed,
predetermined duration (a series of 10 weekly 90-minute online workshops), and this is why
they are said to be transitional. Indeed, as defined by the World Health Organization: "Peer
support groups bring together people who have similar concerns so they can explore solutions
to overcome shared challenges and feel supported by others who have had similar experiences
and who may better understand each other's situation. Peer support groups may be considered
by group members as alternatives to, or complementary to, traditional mental health services.
They are run by members for members so the priorities are directly based on their needs and
preferences. Peer support groups should ideally be independent from mental health and social
services, although some services may facilitate and encourage the creation of peer support
groups" (10).

The objective is to prevent the deterioration of the participants' recovery potential due to
the COVID-19 pandemic and its aftermath. It is also about stimulating this potential by
encouraging them to share their worries and their coping strategies in relation to the
current situation. More generally, they will be asked to project themselves beyond this
situation and to discuss future challenges of social inclusion and civic participation, for
example by attending already existing community-based peer support groups, in the medium or
long terms, and of which they will have heard of during the intervention. This is why this
intervention is said to be transitional. Their own goals during the pandemic may be different
from those post-pandemic and the effects of the response may also be different. However, the
whole online intervention is intentionally designed to be readily adaptable to other
(pandemic) situations.

To generate a collective narrative, the output of each workshop will be a brief written
account of the group discussion, to which the next workshop will open up, and so on. To
trigger discussion, PSWs will use animation cards and techniques inspired and adapted from
materials initially designed to help healthcare teams develop the psychosocial skills of
patients in Therapeutic Patient Education. Each workshop will be filmed via a secured video
communication system for subsequent qualitative observational and content analyses. In
accordance with our model of patient engagement, PSWs will each time start by disclosing
being themselves persons in recovery, and feed with content drawn from their lived experience
while asking participants to share their own lived experience and coping strategies. This is
in line with experiential learning (11). After each workshop, the PSWs will meet for a
30-minute debriefing session, asking themselves what they have just learned, personally and
professionally (also recorded). This is a process of recovery mentorship as an expression of
psychological empowerment, as embodied in and practiced by the PSWs as mentors, and as an
egalitarian relation that helps facilitate the empowerment of the mentees (12).