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Archives of Clinical Psychiatry (São Paulo)

Print version ISSN 0101-6083

Rev. psiquiatr. clín. vol.41 no.2 São Paulo Mar./Apr. 2014 

Review Articles

Peer support for people with mental illness

Suporte interpares na doença mental

Filipa Alexandra Lourenço Campos 1   2 

Ana Rita Pinto de Sousa 1   2 

Vânia Patrícia da Costa Rodrigues 2  

António José Pereira da Silva Marques 1   2 

Artemisa Agostinha Monteiro da Rocha Dores 1   2 

Cristina Maria Leite Queirós 1   2 

1Laboratório de Reabilitação Psicossocial da Faculdade de Psicologia e de Ciências da Educação da Universidade do Porto

2Escola Superior de Tecnologia da Saúde do Porto, Instituto Politécnico do Porto (FPCEUP/ESTSPIPP), Porto, Portugal.

2 ESTSPIPP, Porto, Portugal.



Peer support is a mutual aid system based on the belief that someone who faced/overcome adversity can provide support, encouragement and guidance to those who experience similar situations.


To conduct a systematic review that describes this concept and characterizes peer supporters, its practice and efficacy.


Research on ISI Web of Science, EBSCO Psychology and Behavioral Sciences Collection and Medline databases (from 2001 to December 2013) was conducted using as keywords “mental illness”, “mental health”, “psychiatric disability”, “mental health services”, combined with “peer support”, “mutual support”, “self-help groups”, “consumers as providers”, “peer-run services”, “peer-run programs” and “social support”.


We found 1,566 articles and the application of both the exclusion (studies with children, teenagers and elderly people; disease in comorbidity; peer support associated to physical illnesses or family members/caregivers) and the inclusion criteria (full text scientific papers, peer support or similar groups directed for schizophrenia, depression, bipolar or psychotic disorders) lead to 165 documents, where 22 were excluded due to repetition and 31 to incomplete text. We analyzed 112 documents, identifying as main peer support categories: characterization, peer supporter, practices and efficacy.


Despite an increasing interest about this topic, there is no consensus, suggesting realizing more studies.

Key words: Peer support; mental disorders; personal recovery; systematic revision



O suporte interpares é um sistema de ajuda mútua baseado na crença de que alguém que enfrentou/superou adversidades pode oferecer apoio, encorajamento e orientação a outros que enfrentam situações similares.


Realizar uma revisão sistemática que caracterize o suporte interpares como prática, analise a sua eficácia e caracterize os pares prestadores de suporte interpares.


Pesquisa nas bases de dados ISI Web of Science, EBSCO Psychology and Behavioral Sciences Collection e Medline (2001 a dezembro de 2013), utilizando as palavras-chave “mental illness”, “mental health”, “psychiatric disability”, “mental health services”, combinadas com “peer support”, “mutual support”, “self-help groups”, “consumers as providers”, “peer-run services”, “peer-run programs” e “social support”.


Encontraram-se 1.566 artigos e foram aplicados os critérios de exclusão (artigos com crianças, adolescentes e idosos; doença mental em comorbidade; suporte interpares em doenças físicas ou familiares/cuidadores) e de inclusão (revistas científicas com texto integral disponível; suporte interpares ou grupos similares dirigidos a esquizofrenia, depressão, transtorno bipolar e outras perturbações psicóticas), resultando em 165 documentos. Excluíram-se 22 por repetição e 31 por texto incompleto, resultando em 112, os quais se identificaram como principais categorias do suporte interpares: caracterização, prestador de suporte, práticas e eficácia.


Existe interesse crescente pelo tema, embora alguns domínios não sejam consensuais, sugerindo necessidade de mais estudos.

Palavras-Chave: Suporte interpares; transtornos mentais; recuperação pessoal; revisão sistemática


Peer support is a system of mutual aid that is based on principles of respect, shared responsibility and empathic understanding of the other’s situation. This understanding stems from a common experience of emotional and psychological suffering1 - 3, based on the belief that someone who has faced and overcome some sort of adversity can offer support, encouragement, hope and guidance to others who face similar situations2. Peer supporters have an empathetic understanding and can draw on shared experience when working with peers4.

This practice is not based on psychiatric or disease models or on diagnosis criteria that emphasize the person’s symptoms and problems, but on models that value people’s positive aspects of and their ability to function effectively in different contexts3. However, even though peer support is accepted and recognised in the treatment of many conditions (e.g. addictions, cancer...), the stigma and stereotypes associated with mental illness have led people who are at an advanced stage in their recovery process to refrain from offering their contribution to the mental health system2. Despite these barriers, peer support, which allows someone with an experience of mental illness to give and/or receive support from their peers, has been used and is becoming more and more a reality in the mental health system of several countries2 , 5 - 8.

The literature2 suggests that there are three broad categories of peer-delivered intervention: naturally occurring mutual support, participation in peer-run programmes and the use of mental health service users as providers of services and support. Mutual support is a process in which people get together voluntarily to help each other in dealing with common issues and share concerns. This is the most basic form of peer support and is provided by individuals on a one-to-one basis and in an informal setting9. In peer-run groups, activities are carried out in substitution or in addition to peer support2, and administration and support in these services is controlled and organised by patients, and stands as an alternative to the activities provided by traditional mental health services9. Both in mutual support or peer-run groups, relationships between peers must be reciprocal in nature. Although some peers may be seen as having more skills or experience than others, all participants are expected to benefit from this relationship. Lastly, with respect to peers as service providers, these are usually people with a history of mental illness who have experienced significant improvement in their psychiatric condition and, so, offer their services and/or support to others with severe mental disorders who are not yet at an advanced stage in their recovery process2. This type of peer support is considered a formal therapeutic intervention, characterised by an asymmetrical relationship, in which at least one of the parties provides a service/support and the other is the beneficiary of that service/support2. In this type of service, people with experience of mental illness are trained and hired to provide support for other people who resort to the traditional health services. This is the definition most commonly used in mental health literature9.

The effectiveness of peer support has been researched through formal interventions within health services embedded within the community10. Studies show the existence of multiple positive outcomes for people with mental illness6 , 10 and so, it plays an important role in the recovery of all stakeholders involved in this process10 , 11. The positive effects can be grouped into three categories, depending on those who benefit from them: patients, service providers and the mental health system10. These programmes also provide a sense of connection, belonging and community, often lacking in individuals who only benefit from the services of the traditional mental health system12.

Despite these positive effects, peer support in mental illness is still a new and unexplored subject, which generates controversy and ambiguity. This study aims to conduct a systematic review of the scientific literature in this area and presenting a model that allows the description and systematisation of the factors that characterise peer support and their effectiveness over the last twelve years.


Between 2001 and December 2013, a systematic review of the literature was performed on the scientific papers indexed in the ISI Web of Science, EBSCO Psychology and Behavioural Sciences Collection and Medline with Full Text databases. The following keywords and Boolean language search equation were used: “mental illness” or “mental health” or “psychiatric disability” and “peer support” or “mutual support” or “self-help groups” or “consumer as providers” or “peer-run services” or “peer-run programs”. In Medline the following Medical Subject Headings (MeSH) were used: “mental disorders” or “mental health” or “mental health services” and “self-help groups” or “social support” or “peer support”. The terms were searched as “topics” in ISI, and in “all the fields” in EBSCO. The terms selected from this research stem from the knowledge of the literature in the field. No language restriction was applied.

Articles with children, adolescents and elderly people, studies of mental illness in comorbidity with other clinical situations and peer support applied to physical disorders and/or to family members/caregivers were excluded. The studies included were those that met the following criteria: publication in scientific journals, full text available and peer support or similar groups focusing on mental illness (schizophrenia, depression, bipolar disorder and other psychotic disorders).

Titles and abstracts were reviewed by two of the authors to exclude irrelevant or ineligible papers. Each reviewer then analysed the full text of the remaining articles to decide on their eligibility. A third reviewer resolved discrepancies during a consensus discussion. A final group of eighty-two documents was obtained and analysed using NVivo 9.

The data analysis was performed by two independent investigators and validated by a third one (rater). The content analysis process, using the NVivo 9 consisted of a deductive analysis (with previous categories) whose categories and subcategories derived from the knowledge of literature in the field and translated the topics expressed in the reviewed literature. The developed model was applied to the coding of the material. The two researchers coded the material based on the hierarchy tree with the identified (sub)categories and both analysed the entire material. Record units considered were ideas (units of imprecise dimension but that allow the comprehension of the context, giving greater meaning to the record unit). The counting unit was the criteria of every time the unit (topic) appears. The coding was performed independently, thus seeking to test the robustness and the internal validity of the tool previously built. Peer agreement was calculated using Cohen’s kappa (0.95), as it is considered a more robust measure than simple percentage. Cohen’s kappa is a measure for assessing the reliability of categories, i.e., checking the percentage in which two researchers agree on a given number of items/categories. It is one of the most widely used measures of inter-rater agreement13.


In total, 1,566 articles were identified and after the application of the inclusion and exclusion criteria, 165 papers remained, of which 22 were excluded due to repetition and 31 due to not including the full text. The remaining 112 documents were analysed in their entirety (Figure 1), and it was found that, despite some fluctuations, the number of publications that meet the criteria for this review has increased over the last years (Figure 2).

Figure 1 Flow chart showing effects of inclusionary and exclusionary criteria on final sample selection. 

Figure 2 Number of publications in the previous twelve-year period. 

Nuclear primary and secondary order categories related to peer support should be highlighted: Characterisation (Definition, Types, Objectives and Target Population); Peer Supporter (Characteristics, Selection Process, Training and Supervision); Practices (Models, Local, Contact Phase and Programmes); and Efficacy (Empirical and Theoretical Studies). The several categories were broken down into the dimensions that emerged most frequently in the literature, in some cases, reaching seventh level variables (Table 1 to Table 4).

Table 1 Results to category characterization 

Characterization Results Authors
Definition Peer support definitions can be conceptualised into three main groups: Mead et al .1 (2001)
  – a system for giving and receiving help based on the principles of respect, shared responsibility and mutual aid Davidson et al .2 (2006)
  – emotional and instrumental support, mutually offered or provided to people with similar experiences of mental illness, with the goal of producing the desired personal or social changes Grant et al .14 (2012)
  – a system based on the belief that people who have faced and overcome adversity can offer useful support, encouragement and hope to others who are in similar situations Kemp and Henderson15 (2012)
  Kern et al .16 (2013)
  Loumpa17 (2012)
  Moran et al.18 (2013)
  Moran et al.19 (2012)
Moran et al.20 (2012)
Repper and Watson21 (2012)
  Solomon22 (2004)
Swarbrick23 (2013)
  Stastney24 (2012)
  Scott and Doughty25 (2012)
    Weingarten26 (2012)

Types In literature there are different types of peer support: Davidson et al.2 (2006)
  – mutual help group Moran et al.18 (2013)
  – on-line and phone support groups Moran et al.19 (2012)
  – peer-provided services Solomon22 (2004)
  – operationalization of peer-provided services/programmes Scott and Doughy25 (2012)
  – peer partnerships Coniglio et al.27 (2012)
  – employability of peer supporters in health services DeAndrea and Anthony28 (2013)
    Mancini et al.29 (2013)
    Rabenschlag et al.30 (2012)
    Walker and Bryant31 (2013)
Objetives The objectives are mainly centred around the concepts of personal recovery, empowerment and advocacy, seeking to improve social functioning in daily life activities, self-esteem and self-efficacy Brown et al.32 (2008)
    Chinman et al.33 (2006)
    Corrigan et al.34 (2013)
    Fukui et al.35 (2010)
    Henderson and Kemp36 (2013)
    Hodges and Segal37 (2002)
    Ostrow and Adams38 (2012)

Target group The studies analyse the severity, stage and type of mental illness to which peer support is most suited: Corrigan et al.34 (2013)
  – it is used in people with serious mental illness Burns-Lynch and Salzer39 (2001)
  – it is used in first-episode psychosis, acute crisis or chronic and persistent psychosis Chinman et al.40 (2002)
  – people with mood disorders, psychotic disorders (schizophrenia) and anxiety disorders Chinman et al. 41 (2001)
    Finn et al.42 (2009)
    Lucock et al.43 (2007)
    Pistrang et al. 44 (2008)
    Shahar et al.45 (2006)
    Yip et al.46 (2004)

Table 2 Results to category peer supporter 

Peer supporter Results Authors
Characteristics Information regarding the stage of the disease, the contractual relationship and the role of individuals in organisations is structured as follows: Davidson et al.2 (2006)
  – Peer supporters must suffer from the same pathology as the target population, but they must be at an advanced stage of the recovery process Grant et al.14 (2012)
  – In the case of mutual help or self-help groups, peer providers work on a volunteer basis, without any compensation – In the remaining types of peer support, peer supporters employees, earning a monetary remuneration Repper and Watson21 (2012)
  – There are also some organisations where volunteer work and employment of people with experience of mental illness coexist Solomon22 (2004)
  – The service rendering scheme is generally organised in part-time shifts Walker and Bryant31 (2013)
  – The role of peer supporters is to promote group activities, provide support in daily life activities, at work and in the community with their peers. They also assist their peers in making informed decisions and developing new strategies for dealing with symptoms Brown et al.32 (2008)
    Chinman et al.33 (2006)
    Chinman et al.41 (2001)
    Chinman et al.47 (2008)
    Hodges and Hardiman48 (2006)
    Lawn et al.49 (2008)
    Moll et al.50 (2009)
    Nestor and Galletly51 (2008)

Selection process Few references were found regarding the methods and procedures to adopt or the most valued characteristics, and it is not clear who should be responsible for the selection process References found value the following selection criteria for this role: Franke et al.9 (2010)
  – personal experience with the pathology Repper and Watson21 (2012)
  – readiness to professional development Lawn et al.49 (2008)
  – good social and communication skills Moll et al.50 (2009)
  – motivation to take on this role Ahmed et al.52 (2013)
    Barber et al.53 (2008)
    Dennis54 (2003)
    Gillard et al.55 (2013)
    Simoni and Franks56 (2011)

Training Training must be administered by health professionals and by more experienced peer supporters, although it is not clear who should be in charge. There is no consensual information on the methods, type and duration of the training, and we found only one article that mentions a 40-hour training programme. In general, relevance is given to topics such as: Franke et al. 9 (2010)
  – dealing with/sharing one’s experience with mental illness Bouchard et al.10 (2010)
  – communication and group leadership skills Grant et al.14 (2012)
  – the educational process regarding mental illness Kern et al.16 (2013)
  – personal recovery, suicide prevention Repper and Watson21 (2012)
  – definition of the role of the peer supporter Weigarten26 (2012)
    Rabenschlag et al.30 (2012)
    Ostrow and Adams38 (2012)
    Chinman et al. 41 (2001)
    Chinman et al.47 (2008)
    Lawn et al.49 (2008)
    Nestor and Galletly51 (2008)
    Gillard et al.55 (2013)
    Cook et al.57 (2010)
    Fukkink58 (2011)
    Pickett et al.59 (2010)
    Rabenschlag et al.60 (2012)
    Robinson et al.61 (2010)
    Swarbrick et al.62 (2009)

Supervision Supervision provides information on: Mead et al. 1 (2001)
  – Methods vary according to the organisations where the activities are developed, which are not specified Franke et al.9 (2010)
  – The majority of studies indicate a weekly periodicity Moran et al.19 (2012)
  – The person in charge varies, and it may be a health care professional or a more experienced peer supporter Repper and Watson21 (2012)
  – Overall this is considered an important procedure for the good performance of peer supporters Chinman et al.33 (2006)
    Lawn et al.49 (2008)
    Gillard et al.55 (2013)
    Nestor and Galletly51 (2008)
    Barber et al.53 (2008)
    Chinman et al.63 (2010)

Table 3 Results to category practices 

Practices Results Authors
Models The models most advocated are the following:        Kern et al.16 (2013)
  – Social support Solomon22 (2004)
  – Experimental knowledge Swarbrick23 (2013)
  – “Helper-therapy” principle Scott and Doughy25 (2012)
  – Social learning theory Brown et al.32 (2008)
  – Social comparison theory Finn et al.42 (2009)
  – Empowerment theory Lucock et al.43 (2007)
  – Cognitive-behavioural therapy Dennis54 (2003)
  – Socio-ecological model Rabenschlag et al.60 (2012)
    MacDonald-Wilson et al.64 (2013)

Local Peer support can take place in several contexts:  Shahar et al.45 (2006)
  – In outpatient and inpatient hospital treatments Dennis54 (2003)  (2011)
  – In the community: at home, at school, in prisons and in primary care centres Landers and Zhou65
    Robinson et al.61 (2010)
    Delaney66 (2010)
    Janzen et al.67 (2007)

Contact Phase This is a relatively unexplored topic, although the authors who have studied it argue that the first contact should occur early in the onset of the illness and still in inpatient treatment or immediately after discharge   Chinman et al.41 (2001)
    Lawn et al.49 (2008)
    Nestor and Galletly51 (2008)
    Robinson et al.61 (2010)

Programmes No consensus was found regarding the activities that should comprise each programme With regard to the number of participants, the maximum number was established at around 15 per programme In terms of duration there was a trend for weekly periodicity and no maximum overall duration Davidson et al.2 (2006)
    Fuku et al.35 (2010)
    Burns-Lynch and Salzer39 (2001)
    Finn et al.42 (2009)
    Lawn et al.49 (2008)
    Nestor and Galletly51 (2008)
    Barber et al.53 (2008) 
    Cook et al.57 (2010)
    Corrigan et al.68 (2002)

Table 4 Results to category efficacy 

Efficacy Results Authors
Users services   Reduction in hospitalisations and psychiatric symptoms; increased quality of life and self-esteem; increased social networking; reintegration into the community; improved coping strategies; management of the illness; improved functioning in daily activities; increased sense of empowerment; increased recovery potential; increased hope for recovery Repper and Carter3 (2011)
Moran et al.18 (2013)
Moran et al.19 (2012)
Moran et al.20 (2012)

Repper and Watson21 (2012)
Peer supporter Greater personal growth; increased self-confidence; improved self-esteem; greater empowerment; improved sense of self-efficacy; improved quality of life; benefits for the personal recovery process; reduced hospitalisations; financial remuneration; opportunities for the development of vocational skills  Solomon22 (2004)
Coniglio et al. 27 (2012)
Rabenschlag et al.30 (2012)

Walker and Bryant31 (2013)
Mental health system Lower costs for the mental health system; Improvement of the efficacy of mental health services; Increase of the satisfaction with mental health services Chinman et al .33 (2006)
    Corrigan et al.34 (2013)
    Henderson and Kemp36 (2013)
    Chinman et al.41 (2001)
    Lawn et al.49 (2008)
    Moll et al.50 (2009)
    Ahmed et al.52 (2013)
    Gillard et al.55 (2013)
    Cook et al.57 (2010)
    Rabenschlag et al.60 (2012)
    Corrigan et al.68 (2002)
    Biegel et al.69 (2013)
    Jonikas et al.70 (2010)
    Van Gestel-Timmermans et al.71 (2012)


Despite the variations, the growing number of publications that meet the criteria of this review reveals the current interest in peer support and its relevance as a research area. The literature review resulted in a better conceptual outlining of this practice and its contribution for the personal recovery of people with experience of mental illness, as well as in a more detailed knowledge of the main limitations associated with the studies and knowledge on the subject. Taking as a starting point the four major categories that emerged (characterisation, peer supporter, practices and effectiveness), with respect to characterisation, it was found that peer support interventions are used in a wide variety of mental illness pathologies, although it is still unusual to see those pathologies portrayed in specific studies.

As to the practices, the theory behind them is the area most explored in literature, and there is some consensus, in particular, as regards their definition and types. However, the models upon which this practice is based are mentioned only in a minority of those same studies22 , 32 , 42 , 43 , 54. Similarly to what is observed in models, there is also a greater need for consensus regarding the goals of peer support, which, although becoming more and more associated with concepts like recovery and empowerment, are not yet fully defined. On the other hand, in relation to peer support programmes, it appears that, although it is advocated that they may be applicable in a variety of locations, the issues which they address, as well as the frequency and duration with which they take place, tend to vary from one organisation to another. The way these programmes are evaluated is also a gap in the knowledge concerning this topic.

With regard to the provider or peer providing the support, a consensus was found regarding the characteristics required, although its role within the organisations is still not completely defined, a fact that is pointed out in some studies as a barrier to the implementation of peer support47. The same was observed with respect to all procedures underlying the inclusion of peer supporters in organisations (process of selection, training and supervision), and information on such procedures is almost non-existent.

Lastly, from the analysis conducted on the effectiveness of peer support, it was found that several authors argue that, despite the scarce evidence and the need for further studies3 , 72, this practice is generally considered as beneficial for customers, for peers providing the service and for the mental health system altogether40 , 44. It was also possible to observe that efficacy studies are mainly focused on the benefits for customers and that the results they report are similar to those obtained in traditional mental health services and even better when applied concurrently. Furthermore, it was concluded that there are more empirical than theoretical studies addressing this subject, and that the procedures, participants and instruments used in these studies vary, adjusting to the goals set by each author.

It should be noted that previous literature review studies on peer support exist3 , 44, although infrequent or focusing only on specific areas of this subject. In this work, the structural methodology is new in this area and, in addition, it analyses peer support in a comprehensive way, attempting to portray this reality in the factors that characterise the concept, the peer supporters, the practice, and also its effectiveness. There was, thus, an attempt to find answers on the use of peer support as a mental health service for those engaged in research or clinical practice in this area, through more systematised and updated information, aiming at contributing to the implementation of a model that appears to have benefits both for people with mental illness and for the services.


Peer support is a practice that can significantly contribute to the recovery of individuals with personal experience of mental illness, through support provided by other people who have experienced and overcome similar situations, by means of understanding, hope, and the sharing of strategies and guidelines. Apart from the role that the peer supporter can play in their own rehabilitation process and in that of its peers, this intervention will also improve the services provided by mental health organisations and possibly reduce costs for the very mental health system, by reducing the number of institutionalisations. The production of scientific evidence and the creation of more specific lines of research, which demonstrate effectiveness and generate guidelines for the development and implementation of peer support programmes, may facilitate the dissemination of this practice in other countries. The results obtained in this study clearly demonstrate that this is a promising field for further research, which explore the areas of the literature listed above.


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. Moran S, Russinova Z, Gidugu V, Gagne C. Challenges experienced by paid peer providers in mental health recovery: a qualitative study. Community Ment Health J. 2013;49:281-91. [ Links ]

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. Moran G, Russinova Z, Stepas K. Toward understanding the impact of occupational characteristics on the recovery and process of peer providers. Psychiatr Rehabil J. 2012;35(5):376-80. [ Links ]

. Repper J, Watson E. A year of peer support in Nottingham: lessons learned. J Ment Health Training Educ Pract. 2012;7(2):70-8. [ Links ]

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. Swarbrick M. Wellness-oriented peer approaches: a key ingredient for integrated care. Psychiatr Serv. 2013;64(8):723-6. [ Links ]

. Stastney P. Introducing peer support work in Latin American mental health services. Cad Saúde Coletiva. 2012;20(4):473-81. [ Links ]

. Scott A, Doughty C. “Confronted with paperwork”: information and documentation in peer support. J Ment Health. 2012;21(2):154-64. [ Links ]

. Weingarten R. The development of peer support in Netherlands, Brazil, and Israel. Psychiatr Rehabil J. 2012;35(6):476-7. [ Links ]

. Coniglio F, Hancock N, Ellis L. Peer support within clubhouse: a grounded theory study. Community Ment Health J. 2012;48:153-60. [ Links ]

. DeAndrea D, Anthony J. Online peer support for mental health problems in United States: 2004-2010. Psychol Med. 2013;43:2277-88. [ Links ]

. Mancini A, Linhorst M, Menditto A, Colemand J. Statewide implementation of recovery support groups for people with serious mental illness: a multidimensional evaluation. J Behav Health Serv Res. 2013;40(4):391-403. [ Links ]

. Rabenschlag F, Schusterschitz C, Conca A, Knuf A, Needham I, Hoffmann H. Influence of single peer interventions on the recovery attitude of persons with a psychiatric disability. Scand J Caring Sci. 2012;26:755-60. [ Links ]

. Walker G, Bryant W. Peer support in adult mental health services: a metasynthesis of qualitative findings. Psychiatr Rehabil J. 2013;36(1):28-34. [ Links ]

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Received: April 22, 2014; Accepted: May 8, 2014

Address correspondence to: António José Pereira da Silva Marques. Laboratório de Reabilitação Psicossocial da FPCEUP/ESTSPIPP, Faculdade de Psicologia e de Ciências da Educação da Universidade do Porto. Rua Alfredo Allen, s/n – 4200-135 – Porto, Portugal. E-mail:

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