More than 3.4 million rural¹ veterans are enrolled in the VA health care system [1]. Men and women from geographically rural and highly rural areas make up a disproportionate share of service members, comprising about one third (32 %) of the enrolled veterans who served in the recent conflicts in Afghanistan and Iraq, referred to here as Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) veterans. Many of these soldiers are returning to their rural communities [1], and there is a shortage of mental health professionals practicing in rural areas. Hence, rural veterans face significant disparities in accessing care, especially highly specialized services [2].

Rural veterans with depression and anxiety disorders are significantly less likely to receive psychotherapy services, and when they do receive them, the amount provided is limited, relative to rural veterans’ urban counterparts [3]. While telehealth and other technological interventions are successful strategies to address some of these issues [4], geographical inequities in the availability and distribution of mental health professionals are unlikely to change in the near future [5].

Effectively treating veterans with posttraumatic stress disorder (PTSD) in a timely manner remains a pressing public health concern. Up to 13 % of OEF/OIF/OND veterans have combat-related PTSD [6, 7]. Despite the availability of evidence-based treatments, which ameliorate core PTSD symptoms and prevent further negative consequences such as substance use disorders (SUDs) and suicide [8, 9], help-seeking veterans often do not follow up with the recommended course of psychological [10] or pharmacological [11] therapies. This may be due, in part, to problems at the interface between the veteran and the health care system. Recent research suggests that veterans with PTSD are less likely to perceive their health care experience as being positive [12] and that negative perceptions of mental health care (e.g., lack of trust in mental health professionals) predicts low service utilization [13].

Further, research has found that veterans’ concerns about treatments are larger barriers than stigma, emotional readiness, or logistical issues [14]. These concerns include being misunderstood by clinicians or belief that medications will not relieve their symptoms [14]. For veterans who live in rural communities, studies suggest that the rural culture itself may foster a perceived need for greater self-reliance, independence, and conformity to social norms (whether positive or negative toward mental health treatments) and thereby delay identification of mental health problems and discourage the use of formal mental health services [15, 16]. Finally, OEF/OIF/OND veterans are less likely to present in mental health outpatient treatment than veterans from previous eras [5] and may be prone to prematurely dropping out of PTSD treatment altogether [10, 11]. In light of these challenges, there is a pressing need for innovative interventions that focus on enhancing the reach of PTSD treatment, that is, making treatments more accessible and easier to engage in and adhere to [17].

Involving peer support in the care of rural veterans is an innovative solution [18, 19]. Peer support providers have personal experience with mental illness and have attained significant improvements in their own condition. Peer support programs offer formal services and support to a peer considered to be not as far along in his or her own recovery process. Consistent with this definition, and integral to the peer support process, is that the peer support providers reveal their experiences with mental illness and specifically focus on the skills, strengths, supports, and resources they used in their recovery. Peer support is considered a form of health care, with peer support providers acting as members of the mental health care team [19, 20]. While the use of peer support to provide services to individuals living with serious mental illness, such as bipolar disorder and schizophrenia, has been well investigated, the use of such an intervention for individuals with PTSD is a relatively new concept [21, 22]. We have previously postulated that the principal mechanisms of action of such a peer support intervention are (1) the promotion of social bonds, (2) the promotion of recovery, and (3) the promotion of knowledge about the health care system [23].

With regard to care delivered in rural regions, peers can potentially play a key role in augmenting the PTSD and substance use disorders (SUD) care offered by overburdened mental health professionals. We are not suggesting that peers replace the evidence-based psychotherapies and pharmacotherapies for PTSD and SUDs offered by qualified mental health professionals but, rather, that they provide innovative supplemental services that aim to engage those with PTSD and SUDs in treatment long enough that they might experience benefit from professionally delivered treatment. Also, because these peers come from the same rural community as the patients they are serving, this shared background may be helpful in combating some of the stigma associated with the decision to seek mental health services.

Mr. Guy Holmes, a Peer Support Program employee since March 2012, is a Vietnam veteran from Sonora, CA, who works 20 hours/week providing peer support services at the VA Sonora clinic. Mr. Erik Ontiveros, a Peer Support Program employee since April 2013, is an Iraq war veteran who provides peer support services at the VA clinics in Stockton and Modesto, CA, 20 hours/week. Kaela Joseph and Hannah Holt have provided administrative and research assistance for the program. William Boddie is a licensed clinical social worker responsible for providing clinical supervision for the certified peer specialists. Dr. Shaili Jain and Dr. Steven Lindley are both psychiatrists and provide administrative leadership and direction for the program. In addition to these partners, the program has the following consultants: Craig Rosen, a health services researcher and deputy director of the National Center for PTSD; Darryl Silva, senior mental health administrator for the Stockton, Modesto, and Sonora Community Based Outpatient Clinics and national director of VA Peer Support Services, located in the VA central office.

A private donation from the Michael Alan Rosen Foundation solely funds the certified peer specialist and program support assistant positions. The funding is primarily used to support the salaries, benefits, and associated costs of the peer specialist and the part-time program support assistant. Additional associated costs include peer specialist training and financial support for outreach efforts and mileage. Along with the Michael Alan Rosen Foundation, Stanford and the VA contribute resources towards the program’s support, such as the time of Dr. Lindley and Dr. Jain for project leadership and the computers, servers, telephones, administrative support, office supplies, and workspaces already in place at VA clinics.

In early 2012, we developed the Peer Support Program as a clinical demonstration project at the Sonora Community Based Outpatient Clinic of the VA Palo Alto Healthcare System. During the initial stages we relied on the existing support and infrastructure provided by the national VA Peer Support Services to guide many decisions for implementing the procedures and policies related to this project. Program leadership and direction came from the Menlo Park campus of this health care system, which is located 130 miles from Sonora. The Sonora clinic serves more than 3500 veterans in the Sierra Nevada Foothills, a rural region of Northern California, and its services include mental health, general medicine, social work, substance abuse, and wellness. The majority of veterans seeking services at the clinic are male (93 %) and Caucasian (75 %), and their average age is 61 years. The most common primary diagnosis at the Sonora clinic is PTSD (49 %), and 19 % of veterans have a secondary diagnosis of SUD. Prior to implementing the program, the clinic employed a mental health team that included two full-time general mental health social workers and one OEF/OIF case manager. All psychiatry appointments are conducted through telemental health, unless the veteran opts to commute to another VA clinic for psychiatric care. In light of the success of this demonstration project, in April 2013 the program was expanded to the Stockton and Modesto Community Based Outpatient Clinics, both in underserved regions of Northern California that serve patients who reside in rural areas.

“The rural clinics are busy,” offers William Boddie, the clinical social worker and supervisor for the certified peer specialists. “It feels like we are putting out fires constantly.” The biggest challenges he encounters in his daily work for the Peer Support Program are managing referrals to overbooked mental health professionals and engaging veterans in treatment. He continues, “The peer specialists are in a unique position to help with both of these challenges.” Boddie helps the peer specialists communicate with other mental health providers and integrates their peer support services with the rest of the veterans’ care, thus supporting and augmenting existing mental health services. Boddie says, “I couldn’t do my job without the peer specialists. The role of Erik and Guy [certified peer specialists] is crucial in connecting to veterans who have experienced very painful circumstances. I can relate to my patients as a clinician, but the peer can relate on their level. No matter how much training I have as a licensed clinical social worker, I will never be able to share their experience.”