Alliance Alert: Ron Manderscheid has long been one of our field’s and movements’ most influential leaders and advocates. Throughout the years, his strong support for peer support has been unwavering. Please read his very powerful piece below and follow the link to learn more about Larry Fricks.
The Evolution and Critical Role of Peer Support
Ron Manderscheid, PhD Adjunct Professor University of Southern California Johns Hopkins University
October 16, 2025
(Author’s Note: On this 2025 Global Peer Support Celebration Day, October 16, 2025, I am delighted to present this commentary on peer support in honor of Dr. Larry Fricks of Georgia, who died earlier this year (1950-2025). Larry was instrumental in bringing peer support to the national behavioral health agenda, and in fostering its growth over the past quarter century. He was a highly-respected voice in the national behavioral health field, and also a wonderful friend and colleague.)
Peer support—the intentional use of lived experience to help others pursue recovery—has evolved from informal, grassroots mutual aid into a recognized, evidence-informed component of behavioral healthcare. Its story tracks broader shifts in mental health and addiction policy: deinstitutionalization, the rise of rights and recovery movements, parity and Medicaid reforms, and, more recently, a push toward community-based crisis care and digital services. This commentary traces that arc, highlights core practices and evidence, and outlines the opportunities and tensions that will shape the next chapter.
The roots of peer support are older than modern psychiatry. Mutual-aid traditions appear in early friendly societies, settlement houses, and faith communities. In addiction, Alcoholics Anonymous (founded 1935) crystallized the power of peer-to-peer identification and sponsorship, showing that credibility born of lived experience can open doors that professional advice often cannot. In mental health, mid-20th-century consumer and survivor networks—galvanized by civil-rights struggles, exposés of institutional conditions, and the promise of new community mental health programs—created drop-in centers, newsletters, and advocacy groups led by people who had used services themselves. These early efforts established two principles that still define the field: peers are not “junior clinicians,” and recovery is not merely symptom reduction but the rebuilding of identity, purpose, and social connection.
Deinstitutionalization during the 1960s–80s both widened need and created space for peers. As long-stay state psychiatric hospitals discharged tens of thousands, communities struggled to offer housing, work, and belonging. Peer-run clubhouses (e.g., Fountain House) and self-help centers offered precisely those social determinants—routine, roles, and relationships—that clinical services seldom provided. Their ethos emphasized reciprocity (“nothing about us without us”), voluntary participation, and strengths-based work: people are more than diagnoses; they have assets worth mobilizing.
The 1990s and early 2000s marked a conceptual turning point: the recovery movement reframed mental illness and addiction as conditions from which people can and do recover. Federal reports and state plans began to codify “recovery-oriented systems of care,” and peer support moved from the margins toward policy. States launched peer training programs; Medicaid authorities in several jurisdictions approved peer services as reimbursable; and a recognizable workforce—Certified Peer Specialists (CPS) and Recovery Coaches—emerged with role definitions, ethical codes, and supervision standards. The shift from volunteerism to paid roles was not just symbolic; it meant peer insight could be integrated across settings—outpatient clinics, inpatient units, emergency departments, criminal-legal diversion, housing programs, and schools.
What distinguishes peer support from traditional helping roles is not only who provides the support but how it is delivered. Core competencies include purposeful self-disclosure; mutuality rather than hierarchy; harm reduction; trauma-informed practice; cultural humility; and a relentless focus on self-determination. Tools have grown more systematic—wellness recovery action plans (WRAP), shared decision-making aids, hope-instilling goal setting, community navigation, and bridging to natural supports—but the engine remains identification: “someone like me has walked this path.”
Evidence has steadily accumulated. Randomized and quasi-experimental studies associate peer support with increased engagement, reduced inpatient use, improved self-efficacy and hope, and higher satisfaction. In substance use, peer recovery coaching is linked to better retention in medication for opioid use disorder, lower return-to-use, and improved continuity after detox. In mental health, embedding peers in assertive community treatment, supported housing, and primary care shows gains in activation and quality of life. While effect sizes vary and measurement is challenging, the trendline is positive, especially when peers are integrated as equal members of teams, with clear roles, good supervision, and career ladders.
Policy and payment reforms helped mainstream this progress. Parity laws and Medicaid managed care created incentives to reduce avoidable hospitalizations, giving systems a reason to invest in engagement and transitions—areas where peers excel. Many states established Medicaid billing for peer services, youth and family peer roles, and recovery community organizations (RCOs). The Affordable Care Act’s focus on care coordination, health homes, and community-based services elevated peer roles in emergency department “warm handoffs,” reentry from jail or prison, and chronic-disease self-management. Recent crisis-system reforms—including 988, mobile crisis teams, crisis stabilization units, and peer respites—explicitly call for peers at every link of the chain: answering lines, joining field responses, welcoming people at walk-in centers, and supporting post-crisis follow-up.
Practice models likewise diversified. In addition to traditional peer support in clinics and RCOs, we now see:
- Peer respites: short-stay, homelike alternatives to emergency departments, fully peer-operated, emphasizing autonomy and connection rather than containment.
- Digital peer support: moderated online communities, text-based coaching, and app-enabled groups that extend reach, especially for youth and rural residents.
- Youth and family peer roles: specialists who share the experience of parenting a child with behavioral health needs or navigating services as a young person.
- Forensic peers: mentors supporting diversion, reentry, and problem-solving courts, addressing stigma and practical hurdles like ID restoration and housing.
- Housing and employment: peers embedded in permanent supportive housing and Individual Placement and Support (IPS) teams, aligning clinical recovery with “ordinary life” outcomes—home, work, school, relationships.
Alongside growth have come real tensions. First, role clarity: peers can be diluted when systems treat them as case aides or “mini-clinicians.” Preserving the unique peer value—mutuality, hope, and shared power—requires distinct supervision, scopes of practice, and opportunities for advancement that do not depend on abandoning lived-experience identity. Second, fidelity and outcomes: because healing relationships resist reduction to checklists, measurement must balance structure (training, supervision, caseload norms) with meaning (hope, dignity, belonging). Co-produced metrics—developed with peer leadership—are essential. Third, workforce sustainability: burnout and moral distress rise when peers are underpaid, isolated, or asked to police rather than partner. Living wages, anti-stigma culture change, and trauma-responsive workplaces matter as much as curricula. Fourth, equity: peer support’s promise is strongest when it reflects the communities served—by language, culture, disability identity, gender diversity, and immigration experience—and when it addresses structural barriers (transportation, discrimination, housing markets) alongside symptoms. Finally, medicalization and co-optation: integration into mainstream systems brings resources but can erode independence. A healthy ecosystem includes peer-run organizations with real governance power, not only peer roles embedded in clinical agencies.
Despite these challenges, the future is bright—and practical. Three directions stand out. First, deeper integration with community settings: libraries, schools, barbershops, faith congregations, and workplaces can host peer programs that meet people where they live, learn, and earn. Second, crisis-to-well-being pathways: peers should anchor post-crisis care transition, including rapid follow-up, benefits navigation, medication linkage, and social connection over 30–90 days—often the difference between stabilization and relapse. Third, data that serves people: participatory evaluation, qualitative narratives, and patient-reported outcome measures can humanize dashboards and guide improvement.
At its best, peer support rebalances behavioral healthcare. It complements professional expertise with the wisdom of lived experience, reframes people as agents rather than objects of care, and expands the unit of intervention from the individual to the community. The work began as mutual aid among people who refused to be defined by diagnosis. It matured into a profession that helps systems reach those who mistrust them, stay with people when motivation wavers, and translate clinical recommendations into daily life. Its next evolution will be judged by whether it keeps faith with its roots—mutuality, dignity, and choice—while embracing the scale and partnerships needed to reach everyone who can benefit. In a field rightly focused on evidence, peer support reminds us that relationship is a pathway to recovery and, for many, a reason to believe it is possible.
Thank you, Dr. Larry Fricks, for helping us to understand the critical role of peer support. © 2025 R.W. Manderscheid