Mental Health Peer-Led Cafés—A Complementary Approach to Traditional Crisis Care: A Protocol for a Systematic Scoping Review

Abstract

Introduction: Psychiatric services are gradually becoming more recovery-orientated. With such orientation came the peer movement, a process which began during the civil rights movement of the 1960s and 1970s and has grown exponentially since. In June 2020, the Irish Department of Health released ‘Sharing the Vision’, a policy which envisioned the implementation of crisis cafés as part of mental health service provision. In addition to this, recovery and peer support movements allowed for the timely establishment of peer-led services, thus raising the question: can such crisis cafés as posited in current Irish mental health policy be peer-run? Methods and Analysis: A systematic scoping review is proposed within this paper, the aim of which is to investigate the effectiveness of peer-led cafés on an individual’s recovery journey along with its impact on mental health, safety, and coercion-based outcomes within mental health crisis care. To ensure a transparent and empirically sound approach to the search and reporting of this systematic scoping review, the PRISMA guidelines will be adhered to in this review. Additionally, Arksey and O’Malley’s original framework will be employed to support the adherence to the relevant methodological processes when reporting on this kind of review. Arksey and O’Malley’s original framework presents scoping reviews through a five-step process, which includes stating search terms and searching databases (CINAHL, psycINFO, psycARTICLES, and PubMed) and repositories (Google, Cochrane Online Library, and ETHos), for papers to be included, based on a pre-determined inclusion/exclusion criteria. Discussion: This protocol is the first, to the authors’ knowledge, that reports the qualitative, quantitative, and mixed method evidence into peer-run cafés for mental health crisis management. The use of the PRISMA guidelines and Arksey and O’Malley’s methodological framework enhances the methodological rigour, transparency, reproducibility, and accuracy of this review. The review is limited, as it does not report on study quality or risk of bias. This will not occur in order to maintain its adherence to Arksey and O’Malley’s original framework. The preprint protocol was added to the OSF Registries and is freely available. It will be updated once the paper is published.

1. Introduction

In recent years, mental health services have been the subject of much philosophical debate, particularly in relation to the service structure, policy, and culture [1,2,3]. Adding to this debate is the considerable growth and influence in recent times that was brought about by the flourishing of the personal recovery movement [4]. According to William Anthony [5], recovery, in this context, refers to living a life full of hope and meaning regardless of the constraints/limitations that are imposed on the person by their mental health challenges. This new interpretation of recovery paved the way for the vital restructuring of mental health policy which began to develop in the early 2000s to support the development of this ideal. Within the Irish mental health service provision, ‘A Vision for Change’ [6] became the gold-standard policy document in supporting the service’s quest towards recovery orientation. Although not all commitments made in ‘A Vision for Change’ came to fruition, it, along with similar policies like ‘A National Service Framework for Mental Health’ [7] in the United Kingdom, was the catalyst behind the closure of traditional asylums, the creation of community mental health teams, the recognition of personal recovery, and the establishment of the peer support movement within traditionally, biomedically orientated mental health services [8]. The commencement of such peer roles within mental health service provision was a monumental step in the realisation of recovery as a value within services. It demonstrated that, within mental health care, there is more than just one knowledge set that is of value. Here, experiential knowledge—the knowledge obtained through living with a mental health challenge and subsequent recovery—is now beginning to be realised as a useful and powerful knowledge set in the provision of mental health services. However, much more study is needed in order to foster it and protect the essence of lived experience when working in services that can be described as traditional and biomedically orientated [9].

Peer support within an Irish context is not a new concept [10]. It can be observed both in the inpatient and community setting where service users of every background support one another in recovery. One only needs to go to the smoking area of an inpatient setting to see how service users offer support and encouragement to face their issues, overcome them, and move on with their lives. From an international perspective, the exact timeline regarding the establishment of peer support is somewhat contested, with some suggesting that it started as far back as the 18th century [11,12]. In terms of the peer support work that services today experience, this is believed to have commenced around the time of the civil rights movement in America, where it was evident in the space of substance misuse. Peer support has expanded into other areas since but is still noted within the addiction field today, where groups like SMART Recovery, Narcotics Anonymous, and Alcoholic Anonymous still utilise the concept to support abstinence from illicit substances. Within the mental health service space, peer support is utilised through two main mechanisms: peer support at a collective/group level, powered by the concept of co-production, and peer support at an individual, therapeutic, one-on-one basis. Peer support on a one-to-one individual basis has been evident in many jurisdictions for a number of years, particularly the United States, the United Kingdom, and Australia, to mention just a few. However, within an Irish context, the idea was first posited by Naughton and colleagues [13] in 2015, and, from February 2017 onwards, have become implemented in statutory mental health services [14]. In 2021, the sustainability of this was achieved through the award of a continuous funding stream for the role. This, according to the Health Service Executive [15], was estimated to benefit approximately 130 service users in 2022, with this number due to increase in the next few years. Additionally, in 2022, Peer Support Workers have attained their own grade code within the Health Service Executive—the first to be issued in more than 20 years. This new grade code means that Peer Support Workers and their new senior grade, Peer Support Team leaders, are now recognised by traditional mental health services as a discipline in their own right.

Peer support can also be received collectively through the use of peer-led services. Internationally, there are many examples of good practice in terms of peer-led services, including Clubhouse [16,17] and the Veteran Administration (VA) [18,19], to name just a few. Within an Irish context, peer-led services such as Involvement Centres and Gateway have developed in recent years. A recent evaluation of two such services, Gateway and Aras Follain, identified that utilising such services correlated with a notable increase in social activity whilst learning valuable coping skills from those in a similar life situation [20]. Evidence like this led the Department of Health to call for a formal evaluation of all peer-led services in Ireland within their recently released policy document, ‘Sharing the Vision’, under Recommendation 74 [21], the purpose of which is to help support the development of new peer-led services in Ireland through learning what can be gained from already established peer services [22]. More details regarding the proposed evaluation and the plan for its recommendations are also documented within ‘Sharing the Vision’’s new implementation plan which was released in late 2022 [22].

In tandem with these positive developments was the development of crisis cafés like ‘Safe Haven’ in the United Kingdom. Crisis cafés are an out-of-hours walk-in service for individuals experiencing emotional distress [23]. The service is run by community crisis assessment teams whose responsibility it is to assess the mental state of the individual and provide a fast track to relevant services as required. It is seen as a complementary service to reduce the pressure on an already overstretched emergency department. The word complementary is used here to describe services that operate in a supportive nature to the traditional, statutory mental health services. However, it has also been established that emergency departments are unsuitable environments for those in a mental health crisis or with an altered mental state as these services are often ill-equipped to deal with such presentations [24,25]. In an Irish context, a feasibility study was commissioned by the Kilkenny Mental Health Services in order to identify if such a service would be viable in an Irish service context. Within the report, there was strong evidence to suggest that any attempt to create a crisis café needs to be based strongly within the peer space, allowing for it to be peer-led with little medical input from other, traditional professionals [26]. This is an approach that is developing, particularly in the United States where peer respite centres are being developed to support those in distress through the power of peer support [27]. In Ireland, there is now a peer-led café, known as Galway Community Café, which operates as an out-of-hours service for those in crisis. The idea, like many of the peer spaces mentioned previously, is that peer support is used to support a person through their crisis situation. Much of this work occurs through the sharing of similar experiences and the use of presence as a mechanism of nonverbal support. The peer-led café is situated on the grounds of an actual café business, Mr. Waffles, which supports the peer connectors employed in such peer-led cafés to create the informality required for peer support to truly occur [28].

Although such services have the potential to offer a wide range of benefits, for example, the implementation of trauma-informed care and a strengths-based ethos to a predominantly paternalistic, biomedical system [29], they can also have a number of challenges that can impede the operation of such services. Firstly, in terms of means, peer-led café services are not available in every area [30]. This could be as a result of the risk-adverse, biomedical orientation of the service in question—particularly as it relates to issues of governance and the prevention of critical incidents. Additionally, such services could cause a discontinuation of support by the service user’s multi-disciplinary care team, which can result in an over-reliance on peer interventions beyond crisis care [30] Such crisis interventions can also lead to the possibility of peers dealing with more complex cases that would be better addressed by a multi-disciplinary response [30]. Other challenges to the operation of such peer services are practical issues such as their location and access to appropriate transportation to get to the café in question [31]. Finally, as such cafés are physical locations, and not online entities, other challenges relating to anonymity and confidentiality may impede the work of such services due to poor attendance and/or reluctance to self-disclose lived experience as a result of these issues [32].

Rationale for Systematic Scoping Review Protocol

As such, this systematic scoping review protocol and subsequent systematic scoping review itself have been created to support the examination of peer-led cafés for those presenting with a mental health crisis/emotional distress in Ireland. This review is timely for three reasons. Firstly, as noted earlier, one such café has recently been created in an Irish context which is purely peer-led. Secondly, other services across the country are looking to adopt a similar model in their given service, and, thirdly, Irish services have shown their commitment to such crisis supports, out of hours, by recently publishing a model of care for the establishment of crisis resolution services—with peer input being recognised as an essential component of such new developments [33]. Due to this and the above-mentioned paucity of this discussion documented outside of the United States, this review will be useful for establishing a more collective understanding of whether such an approach can work and, in particular, be governed. Finally, the review is also necessary as mental health policy is now also examining the possible implementation of a crisis café model in Ireland [21]. ‘Sharing the Vision’ states that:

“Out of hours crisis cafés should be piloted and should be operated based on identified good practice.”

([21] p. 99)

As such, the systematic scoping review proposed here will be in line with the latest policy and evidence in this area of study. Therefore, the review aims to examine the evidence base on peer-led cafés in the provision of mental health service crisis care To support the achievement of this aim, a number of objectives have been created:

• To examine the breadth of the literature relating to peer-led cafés within mental health service provision;
• To identify the types of peer-led services used for those experiencing a mental health crisis/emotional distress;
• To explore the advantages and challenges of peer-led cafés within mental health service provision;
• To explore the possible governance structures associated with such peer-led cafés internationally;
• To identify whether such peer-led cafés have an impact on the mental health of those who utilise them;
• To describe what is known regarding the implementation of such peer-led cafés within mental health service provision;
• To identify recommendations that can be used to support the further development of peer-led cafés in an Irish context.

2. Methods and Analysis

To achieve the above aim and objectives, a systematic scoping review is proposed. In order to comply with relevant methodological standards, the relevant Preferred Reporting Items for Systematic Reviews and Meta-Analysis [PRISMA] standardised reporting guidelines for scoping reviews will be used [34]. Additionally, this systematic scoping review will be methodologically supported by Arksey and O’Malley’s original framework [35]. The framework consists of five steps: (1) identifying the question in which the search will be based, (2) identifying relevant studies, (3) the selection of studies, (4) the charting of data, and, finally, (5) the collation, summarisation, and reporting of the results [24]. Finally, the systematic scoping review protocol was entered into the Open Science Framework (OSF) Registries on 7 May 2021. Protocol Registration Number: https://doi.org/10.17605/OSF.IO/JVK7D. It is available for free from the OSF registries website. This registration will be updated once the present systematic scoping review protocol is published. Arksey and O’Malley’s original methodological process for presenting scoping reviews will now be presented below.

2.1. Stage One: Identifying the Research Question

As the proposed work is to be a systematic scoping review, the question for investigation needs to be broad [34], as it is through this broad scope that reviewers can investigate the breadth of the literature on the chosen subject area without dealing with issues of study quality and risk of bias. Additionally, there are a number of mechanisms that can be used to create a suitable research question. These include techniques like SPIDER and PICO [36,37]. However, for this systematic scoping review, the principles of PICO [36] (

Table 1. PICO research question formation.

Population	Service users, and family members/carers
Intervention	Peer-led/Peer-run cafés
Comparison	Emergency departments
Outcome	Decreased mental distress, and decreased use of coercive treatment and hospitalisations

) were chosen to create the following research question for investigation: “How effective are peer-led cafés on the recovery journey of service users in crisis?”.

2.2. Stage Two: Identifying Relevant Studies

In order to gather the data required for this proposed systematic scoping review, a search strategy needs to be developed. The first part of this is to identify the databases and repositories used for the search. For this search, two types of literature (peer-reviewed and grey) will be explored. The search will use the following databases: CINAHL, psycINFO, psycARTICLES, and PubMed. These databases were chosen as they are more associated with the storage of health research than other databases. Secondly, repositories and other sources (Google; Cochrane Online Library, and ETHos) will also be searched. Once again, these repositories were chosen because of their association with health research. In addition, the references of included papers will be searched for additional resources that could be used in the review. This last activity will support the fourth step of Arksey and O’Malley’s original framework.

2.3. Stage Three: Study Selection

Next, the search strings needed for input into these databases and repositories need to be identified and stated. To support this, similar reviews of the literature were examined to identify suitable search terms. As a result, the search will consist of the following search terms that will be adhered to for all databases and repositories:

[“peer-run centre” OR “crisis cafe” OR “peer centre” OR “peer support” OR “alternative mental health crisis care” OR “peer initiatives” OR “peer interventions” OR “peer provided services” OR “consumer run organisation” OR “consumer provided services” OR “peer respite” OR “service user led services”]

AND

[“impact” OR “effectiveness” OR “benefit” OR “advantages” OR “usefulness” OR “effective” OR “effect” OR “influence” OR “evaluation”]

AND

[“mental health” OR “crisis” OR “mental ill health” OR “mental illness” OR “mental health crisis” OR “psychiatric crisis” OR “mental disorder” OR “psychiatry” OR “psychiatric health” OR “mental health challenge” OR “mentally ill”]

AND

[“service user” OR “client” OR “customer” OR “consumer” OR “family member” OR “carer” OR “patient” OR “brother” OR “sister” OR “parent” OR “child” OR “user of services”].

These search terms were also used to identify other terms through a synonym search of the keywords identified through both the use of the PICO framework and the review of similar reviews published in the literature as noted above. No time limits will be added in order to capture as much of the relevant literature as possible into peer-led cafés within mental health service provision. However, literature published on or after 31 October 2023 will not be included in this proposed review as the review process will begin on this date.

In order to shortlist the papers retrieved from the databases and repositories, three rounds of screening will occur. For the first round of screening (title of papers only), breaking down the question for investigation into its PICO components (Table 1) is sufficient. Consequently, as the process of screening develops, further criteria will be needed to support the inclusion of studies that relate to the question for investigation. Such criteria are referred to as the inclusion/exclusion criteria, which are documented in

Table 2. The inclusion/exclusion criteria for this systematic scoping review.

Inclusion	Exclusion
Peer-reviewed articles, reports, and dissertations	Any kind of literature review, discussion/editorial/periodical papers, case reports, and perspective papers
Quantitative, qualitative, and mixed method studies
English language	Papers that are not written in the English language
Mental health	Addictions, physical health, and intellectual disabilities
General adult mental health	Child/Adolescent mental health, older adult, rehab and recovery mental health, mental health, and ID services
Any peer-led café
Focussing on service-user-based experiences and outcomes	Examining service provider or family member perspectives of peer-led cafés
Focusses on structure, governance, and mechanism of action of peer-led cafés

below.

Round two of screening involves applying the above inclusion/exclusion criteria to the abstracts of papers gathered. Between the second and third rounds of screening, a reference screening of the included articles will occur. This is carried out to satisfy the systematic aspect of this review. The final round of screening involves the complete implementation of the inclusion/exclusion criteria to the full text. Any papers that remain after the three rounds of screening are automatically included in this proposed systematic scoping review. The systematic scoping review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR), as evident through a checklist [34]. Additionally, to further support transparency, a PRISMA flow diagram (Figure 1) will visually interpret the selection of the study’s process. Please note that the PRISMA flow chart is currently empty and is included for demonstration purposes. The PRISMA flow diagram will be filled when the protocol is activated to produce a work.

The search for relevant papers will commence on 31 October 2023. It will conclude by 20 December 2023 when the final number of studies included will be narrowed down.

2.4. Stage Four: The Charting of the Data

The proposed systematic scoping review aims to document the breadth of evidence on peer-led cafés. To do this, key aspects of each paper will be described using a table format. This information will be electronically captured using a specially prepared Excel spreadsheet. This stage is expected to last for the entire month of January 2024. On the final manuscript, the collected data will be presented using a table. Such data include:

• Authors, year of publication, country where the study was conducted, or the affiliation of the first author;
• Journal;
• Target audience;
• Format of the paper—dissertation, empirical, or report;
• Aim of the study;
• Study design;
• Methodological orientation—if known;
• Theoretical framework—if known;
• Method of data collection;
• Sampling;
• Type of peer-led centre;
• Advantages of peer-led centres;
• Challenges to peer-led centres;
• Mechanism of implementation of peer-led centre;
• Governance structure;
• Impact on mental health;
• Strengths and limitations of the study;
• Study recommendations.

To further demonstrate the scale of the literature relating to the question for investigation and to ensure that all relevant studies have been captured from the screening process, a visual figure will be built using the platform, connectedpapers.com. This works by identifying a lead paper through the process of reference screening (discussed above) on all included articles, after which the platform creates a visual graph highlighting all the studies that should be included in such a review. As such, the platform ensures that all relevant papers are included in the proposed systematic scoping review.

2.5. Stage Five: The Collation, Summarisation, and Reporting of the Results

As this proposed systematic scoping review will gather both qualitative and quantitative data, two separate mechanisms of summarising and reporting the results are required. Firstly, for qualitative data, the results of these papers will be presented using Braun and Clarke’s reflexive thematic analysis [38,39,40]. For the quantitative data, a modified narrative approach will be used [41]. However, no data synthesis, quality or risk of bias processes/assessments will occur due to the type of review employed here [35]. Instead, the narrative that will be developed will demonstrate a review of all material gathered without such depth being recorded. The results will refer back to the question for investigation, created in this systematic scoping review protocol. Gaps within the literature will also be captured, documented, and reported as recommendations/requirements for further study into this emerging area. The results of this proposed systematic scoping review will be written up and completed in February 2024 for submission to a peer-reviewed journal in March 2024.

2.6. Ethics and Dissemination

Since the present paper documents a protocol for a systematic scoping review, there is no requirement for ethical approval. The review data will be stored with a registry where they can be accessed free of charge. The data gathered in this proposed systematic scoping review will be disseminated through peer-reviewed publications in high-impact scholarly journals relating to the subject matter.

3. Discussion

This proposed systematic scoping review aimed to explore the scale of evidence on peer-led cafés for those in crisis. To achieve this, the systematic scoping review protocol described here will support the adherence to the methodological criteria suggested by Arksey and O’Malley’s original framework [35]. The present systematic scoping review protocol will also support transparency through the use of the PRISMA-ScR [34] reporting guidelines. The organisation of this proposed systematic scoping review, as outlined above, will hopefully increase the methodological rigour, transparency, and accuracy, whilst also reducing any potential risk of bias that may be associated with the proposed review itself.

Strengths and Limitations

As with any review, this protocol has several strengths and limitations [42]. Firstly, this review is designed to examine the breadth of the literature on a subject matter and not its analytical depth. As a result, it is impossible to comment on the quality of studies that could be included in the proposed systematic scoping review, which can potentially weaken the intended impact of the end review itself. Additionally, it is worth noting that it is impossible to gather every piece of literature ever written on peer-led cafés. Whilst the reviewer has opened the search as wide as possible, evident through no restriction on publication dates, there is still a considerable risk that a minority of papers are not extracted for inclusion in this proposed systematic scoping review. As such, this could be a potential limitation. In this instance, to help alleviate the risk as much as possible, the reviewer will seek the support of a librarian during the searching and narrowing down of studies to ensure that all evidence is extracted and examined for eligibility for inclusion in this review. This proposed systematic scoping review will be carried out by one reviewer which may unintentionally impact the intended effect of the end review. However, the use of a librarian will significantly reduce this limitation. Finally, another potentially important limitation is the lack of patient and public involvement in the design of this review. This could be particularly problematic given the subject matter of the review and, as such, this may weaken the potential impact of the review further. In terms of a strength of this review, this proposed systematic scoping review is the first to examine the evidence base on peer-led cafés and their potential use in mental health crisis management. Although there is a risk that little literature could be extracted from databases on this subject matter, this proposed systematic scoping review will either highlight the immense volume or paucity of the literature into peer-led cafés within mental health service provision.

4. Conclusions

In conclusion, this paper presents a protocol for a systematic scoping review examining peer-led cafés within mental health service provision for crisis management. The systematic scoping review protocol presents a process on how to carry out and report this scoping exercise based on the methodological orientation provided by Arksey and O’Malley [35]’s original framework and guidance from the PRISMA-ScR reporting guidelines [34], both of which support the methodological rigour of the proposed systematic scoping review. The future review will be useful for crisis resolution teams, emergency department staff, peer support workers, their line management, and service managers in determining the placement of peer support within the mental health crisis space. Any changes in this systematic scoping review protocol will be appropriately reported in the final publication, including alterations in dates, search terms, databases, and/or eligibility criteria.