Peer workers and the evidence base

The evidence base for the impact of mental health service initiatives employing Peer Workers is growing and originates mostly from North America, Australia and New Zealand. Reducing admission to inpatient psychiatric care is the most reported outcome, and has been evaluated through observational [2], comparison group [3] and cross sectional [4] study designs. A before-and-after study [5] and a cross sectional survey [6], both from the US, found significant improvement in individual empowerment associated with receiving peer based support. Hope and strength of social networks have also been indicated as important outcomes for service users (consumers) in receipt of support from Peer Workers [7, 8].

A recent literature review [9] details a relative wealth of qualitative research based on lived experience that attests to the benefits of Peer Worker initiatives in mental health services, for Peer Workers themselves and the service users they support. Benefits include enhanced personal sense of empowerment, developing better social support and furthering personal recovery [7, 10]. Some of this qualitative literature has also begun to identify organisational challenges to introducing Peer Workers into mental health service teams, including establishing appropriate boundaries [11], power imbalances within teams [12], stress experienced by Peer Workers [13] and the importance of role distinctiveness [11]. It has been suggested that the introduction of Peer Workers represents a unique set of challenges to existing mental health workforce practices, necessitating further research that pays closer attention to the specifics of service context [14] and acknowledges a learning curve in the development of role, the needs of the worker and the workplace environment [15]. An established organisational research literature provides insight into the development and adoption of new work roles, highlighting issues of role distinctiveness, team consensus around role and institutional support as key to the adoption process [16, 17]. We use this literature to provide a relevant conceptual underpinning to our analysis.

Peer workers and UK mental health and social care policy

In UK health and social care policy the introduction of Peer Workers into the mental health workforce is perceived to offer an opportunity to address capability and skill mix in mental health teams [18] and organisational productivity [19]. Peer support has been identified as a key facilitator across a range of UK health and social care policy agendas, including mental health recovery [20], self-care [21] and personalised health and social care [22]. An implementation programme to support the UK mental health strategy [23] has been established in England with a specific remit to develop and demonstrate new Peer Worker roles [24].

Who becomes a peer worker, how and why?

This theme emerged from a large body of data around employment issues and the perceived benefits of working as a Peer Worker. In all our cases Peer Workers were recruited directly from the service they would be working in through an informal or semi-formal process; staff working in the service approached service users who they thought might be appropriate and asked them if they were interested in taking on the role. In the South of England case past experience of using the service was widely seen as an asset to taking on the Peer Worker role:

It's actually very similar to being part of the group because it is still about sharing experiences and giving examples. It's just that rather than being asked for those examples … it is more a case of ‘this is how it is, this is an example, how does that, does that gel with you?’ (South Peer Worker)

In all cases Peer Workers’ motivations for taking on the role were largely around using their own, often difficult experiences of mental illness to help others with similar experiences:

If the young people want to talk to me my ears are there, my shoulder is there and everything they say is confidential and I would try to help them the best I can as well as what I’ve had done to me really, helped been supported. (North Peer Worker)

I have empathy with people and I felt I can give. (London Peer Worker)

In contrast, managers in all sites spoke about the benefits to the individual Peer Worker of the role as a developmental opportunity, and particularly as a route to further employment. In each case the potential benefit to Peer Workers was an important rationale for employing service users in Peer Worker roles:

It’s good for the support, people want to become support workers, it gives them experience of working with people, it gives them group facilitation skills, personal development skills, self confidence, self esteem and probably, so it's very good for them. (North manager)

This data is suggestive of a tension between the motivation of recruiting managers, at least in part pre-selecting potential Peer Workers on the basis of their likelihood to benefit personally, and the motivation of service users to work as Peer Workers on the basis of sharing their personal experiences with other service users. This tension is explored further in the data analysis that follows.

Once approached about becoming a Peer Worker, service users weighed up the pros and cons of taking on the role. Some London service users were put off from taking on a Peer Worker role because the issues they would have to deal with were too close to their own experiences. It should be noted that the group in London often supported service users experiencing severe crises:

With this it felt more sensitive, it felt more close to the bone. (London service user)

It might not suit me, like I’m trying to get away from mental health stuff … I’m doing quite well at the moment. (London Service User)

In London a manager and Peer Workers also queried whether prior experience of using the service was sufficient criteria to work as a Peer Worker:

It was designed to be self-selective so that people could come along and you know it’s a very difficult thing, what you think you can do and what you can actually can manage, they can be two very different things … people think ‘actually I really can’t do this work, I am really not willing to go this far.’ (London manager)

We put ourselves forward and then it’s processed by the management, and because we’ve been in the groups, you meet the criteria. (London Peer Worker)

A range of interviewees reflected on the importance of being ready to take on a Peer Worker role:

There was a time when I wasn’t ready … I’m more flexible, I’ve learned to be more flexible. (South Peer Worker)

No. That would be something way, way in the future. You can do that but you have to be ready. (London service user)

In London Peer Workers and a manager reported drop out during training or early into the post among Peer Workers who found the role more demanding than they had anticipated:

Some members started and they found out it was too difficult for whatever reason, so we lost a few you know, initially (London Peer Worker)

We started off with a group of nine … At the end of that training we had five people and then two months later the number dropped and we were down to four people and then those people were the ones who said “listen, I find it really difficult, I am finding it difficult to manage this working in the groups” and so then they progressed. (London manager)

This data is indicative of possible limitations in informal or semi-formal recruitment approaches. Where the rationale for working as a Peer Worker might be different for recruiting manager and potential Peer Worker, individuals might be selected who are not best placed either to benefit personally or to deliver benefits to the service. In addition, in a service that is clinically demanding – such as the personality disorders project in London – the role might be particularly challenging if clinical issues are close to the Peer Worker’s own experience.

Building new teams

A further body of data, focused on the Peer Worker/ non-peer staff relationship, alludes in detail to processes of building new teams that incorporate both peer and non-peer staff roles. Staff and managers spoke positively about their new relationship with former service users and felt there was equality in the relationship:

I’m working alongside those individuals as my colleagues so I’m not … working with them in any other capacity other than on an equal footing … it’s not any different. (South staff)

Difficulties implicit in the changing relationship were acknowledged:

You have to be on your best behaviour, because if you get upset, if I get upset I’m worried that people are going to think, ‘ooh, she’s having a service user moment’. There’s lot of pressures to kind of gain acceptance. (London Peer Worker)

… suddenly they’re a colleague and you get to hear about things that you weren’t privy to before and that feels odd and needs time to sort of settle in, to manage. (London manager)

For Peer Workers these difficulties in renegotiating relationships seemed to impact directly on their experiences of joining existing teams. Peer Workers did not share the view that they were equals in the new team:

I wouldn’t say that I feel completely like I’m a member of the team … I guess I’d still feel somewhat inferior in, I don’t know, how I’m seen by the team or by members. (London Peer Worker)

Some staff identified resistance in the existing workforce to the introduction of Peer Workers into the team:

At first some of the staff were quite negative you know. ‘Oh we can’t do that, what if he becomes ill?’ … but now they’re used to him and see that he's a very good worker and that he works really well and everybody's very fond of him. We all get on very well so it’s worked out. (North staff)

It was recognised that the source of this resistance might lie in the training and background of existing staff; a sense that their roles and responsibilities might be threatened by a new Peer Worker role:

You always have a very small minority, as well, that get quite defensive about their roles, and their responsibilities and their occupation, and, well ‘are you saying that we’re not doing it right?’ (South staff)

The flexible terms and conditions of employment offered to Peer Workers were often appreciated, enabling Peer Workers to work when they felt well and reducing experiences of pressure resulting from the role. However some Peer Workers felt that those terms and conditions devalued the role and contributed to a sense of hierarchy:

I think there’s aspects of the role that are really frustrating, such as being on bank staff is really hard sometimes … having a group cancelled just feels crap sometimes … because I’m a co-facilitator, if my co-worker is on leave and the group is cancelled, I don’t work, which means I have less money. (London Peer Worker)

There is a hierarchy in terms of payment and position. (South Peer Worker)

In the London site Peer Workers could feel disempowered by the working arrangements:

You end up feeling powerless a lot of the time because of how things are set up. (London Peer Worker)

The step-up, step-down was supposed to be empowering to people, so they could stand down when they didn’t feel able to work. But on a couple of occasions it’s been sort of used to tell us not to come in, so that’s sort of really difficult. (London Peer Worker)

Again in the London case – where work was more clinically based – there seemed to be a mismatch in expectations. Peer Workers’ lack of specific clinical training and knowledge meant they found it difficult to participate fully in team meetings or to take on the role in group work they had hoped to. This experience was also acknowledged by a non-peer member of the team:

If I’m in that meeting and I say something that isn’t, sort of psychodynamic, it might be a kind of practical idea, then … it’s never like criticized, but I just feel that, it’s not the way things are done. (London Peer Worker)

The initial idea of Lead Service Users taking the groups was so they, members would be even more empowered, really, and run their own groups, but that didn’t kind of happen … when the service started up, it was organized around a clinical model, a kind of clinical direction, being led by a doctor, and the team meetings had a sort of psychodynamic basis, so I think there were certain norms established that would have made it difficult to become what it intended to be. (London staff)

Being a peer worker: an experience of conflicted identity

Not quite being able to feel part of the staff team also seemed to be reflected in a conflicted sense of identify reported by many Peer Workers. There was consensus among both managers and Peer Workers that the Peer Worker role did offer an alternative, positive identity that was focused on something other than mental ill health:

It’s very powerful how it lifts people out of that sick role, to say, ‘let us give them a job, here’s some responsibility, I believe in you, you can do this’… (South manager)

It’s almost made me feel normal in inverted commas, it’s been a big thing, a great positive and I really look forward to going every time. (North Peer Worker)

However, both Peer Workers and their non-peer colleagues acknowledged that the Peer Worker identity was complex, noting that the role enacted neither a wholly service user-, nor wholly staff identity:

It’s quite a hard place to have that middle ground and being not quite professional, not a service user. (London Peer Worker)

Particularly when you’ve got a service user running the group with you as well, they’re in this sort of ‘no-man’s-land’. They’re not quite staff, they are staff, but they’re not quite the same, because you can’t share certain information with the service users that you might with other staff. (South staff)

The transition at the London site between informal and formal roles provided an opportunity to explore how the challenges of a conflicted identity can be exacerbated by the structuring of the role:

This idea of Lead Service Users as somebody who could … be a member of the group one day and the next day working in the group, created enormous conflict for them … (London manager)

We were meant to be users and stepping up and then stepping down in our groups … other members found doing the same role that they felt intimidated by the members knowing what was wrong with them and they’d seen them in vulnerable situations. (London Peer Worker)

Challenging boundaries

Peer Workers, managers and non-peer staff all made specific reference to the importance of boundaries both within the team, and between Peer Workers and service users. In all cases there was a perception that the introduction of Peer Workers into existing teams had challenged the boundaries those teams had been used to working within:

We were being with a client and [the Peer Worker] would just burst in and sit down and start listening to what was going on which was very confidential and everyone was getting very upset and angry with him. (North staff)

I think the relationships have to change because, although I don’t see the role of the facilitator as the same as a traditional health care professional, there are still boundaries, and the boundaries are there for people to sort of come up against and give limits. (London Peer Worker)

The need to establish and maintain boundaries seemed in large part to stem from awareness within teams of the mental health needs of new Peer Workers, and that they retained a duty to support Peer Workers with their mental health:

When we first employed our member of staff, he wasn't really complying with his medication. We didn't realise at the time and [he] was becoming quite ill and quite psychotic at times … but we kind of missed the early signs and we all felt terrible because we should have known, working in mental health, about what was happening to him … (North staff)

… the sort of support and supervision they need is actually different to other members of the team, and the flexibility, or working with somebody who may have their own health crises for one reason or another, needing more support. (London manager)

As a result the response from teams to boundary issues was often protective in nature, putting measures in place that would reduce the exposure of the Peer Worker to situations where professional and social contact might overlap:

There has just been written a service user policy for when they’re in that no-man’s-land, because I know they’ve been giving out their phone numbers and meeting, and it’s been quite difficult. (South staff)

Any referrals we get from this particular area we don't pass on to this member of staff … because he has friends amongst the service users in this particular area … he goes out socially with them and so that would have made relationships a bit difficult really. You know if someone was going through problems they might not have felt they could talk to him. (North staff)

Supervision and training for Peer Workers was described as further reinforcing boundaries:

We offer supervision to people and again a lot of these issues can be addressed and you know we have to put in boundaries about confidentiality. (North staff)

You may be asked by a member ‘where do you live?’ or ‘have you taken this medication then?’ … role playing deals with these boundary issues, what to do if you’re asked a question like that, role playing different ways in which to respond and deal with this. (London Peer Worker)

This culture of ‘being boundaried’ seemed to have been absorbed by Peer Workers in the London case, who raised the issue of being boundaried in their work with service users:

I do have to remind myself of the new role. I might be asked by a member ‘where do you live?’, or ‘have you taken this medication then?’ I have to be boundaried for them and for me. (London Peer Worker)

… having to have boundaries with service users is like, different. Especially when … someone shows sort of sexual interest in you, or too much attention, or pats you on the back or touches you in some way, and you think ‘well they can’t really do that’ … it’s difficult to try and sort of tell people that because it kind of distances me more from being a service user, which is good I guess, in doing the job … it’s about safety, your own as well as the group member’s safety. (London Peer Worker)

For some Peer Workers this sense of distance and boundaried conduct was associated with professionalism:

There is a degree obviously to which you have to be professional … how you conduct yourself … professional conduct is something that is covered in the training … I do feel like a professional when I’m up there. (South Peer Worker)

This man who was a patient … said something to me before quite sexist about a certain part of my body … and I had to bite my lip … I don’t know if that’s like a normal thing that people who work here think, they develop a thick skin. (London Peer Worker)

This data raises a question about the extent to which a protective approach to boundary setting within the team might, in creating this ‘safe distance’ between the Peer Worker and service user, inhibit the Peer Worker in giving of their personal experiences of mental health issues in supporting service users. As noted above, this was often Peer Workers’ motivation for taking on the role and we explore below the extent to which this ‘giving of personal experience’ was seen as a component of the emerging practice of Peer Workers.

Is a body of peer practice emerging?

Our study collected a large body of data on the perceived benefits to the service and the staff team of the introduction of the Peer Worker role. Both Peer Workers and non-peer staff said that they thought that having someone on the team who had experienced the service at first hand helped to engage service users and to role model progress:

It was very useful to be able to have service users who have actually used it and are really able to sell it to you. (South staff)

I’ve been there, done that and bought the t-shirt so I want to put my experience through to them and how to lead them into that right direction instead of going downhill like I did. (North Peer Worker)

It gives us role models for other people that you know people can do it and can move on and progress. (North manager)

Non-peer staff, managers and service users all thought Peer Workers brought insight to the team that would otherwise be lacking:

We sometimes feel as if, ‘are we imposing things on people and being too patronising with the decisions we've made and the groups we're operating?’ … but having a service user on the staff brings us down to earth a bit and kind of opens our eyes a bit more because when you're working you have wonderful ideas of what's good for people, but that might not be the reality of it and we can check it out with our [peer] member of staff. ‘What do you think? Do you, as a service user as well, do you find that a bit patronising or a bit too much or what do you think?’ (North staff)

She was obviously a lot more like tuned in about the structure of the groups and the way that it should go. (London service user)

Managers also identified that Peer Workers brought additional skills and resources to the team:

It makes service users feel comfortable, it makes us approachable, makes it relaxed, makes it safe … You're drawing from a larger resource pool of skills as well because your staff, if it's service users as well so it's unlimited really. (North manager)

This data is suggestive of an emerging body of practice characterising the Peer Worker role, incorporating a number of key elements: demonstration or role modelling of personal recovery to current service users; bringing insight and knowledge to the staff team (enhancing the team’s skills mix); creating a more engaging, relaxed environment that feels safe and is conducive to talking and listening. However, the ‘giving of personal experience’ that Peer Workers envisaged when they took on the role seemed to remain problematic in the context of the boundaried role that we described above:

‘… it has been quite hard to assert myself sometimes and, you know, try and be a professional.’ (London Peer Worker)

In the London case Peer Workers articulated the personal costs of that giving:

Well as a user and being a staff, the risks are that certain things are brought up to you at times. You know, something that can be very painful. (London Peer Worker)

I guess I’m trying to … look out for my own needs … it just ends up feeling worse if you feel that you’re giving, giving, giving and not really getting things back. (London Peer Worker)

At the same time there was a sense that the support and training that was on offer did not always help Peer Workers deal with these issues:

There’s the clinical supervision, to sort out things like boundaries with members and what happens in groups, and there’s management supervision to sort out stuff like time sheets and hours but that doesn’t, it feels like banging your head against a wall sometimes … (London Peer Worker)

There have been ideas maybe to do you know, like an introduction to group analysis, or something, but nothing kind of, nothing beyond that really. I haven’t sort of undertaken any formal training to be a group facilitator. (London Peer Worker)

Again this data speaks of tensions; between what Peer Workers were expected to do (the practice that was valued), and what ‘in practice’ they actually did. The Peer Workers we interviewed wanted to give of their personal experience in supporting others, recognised the difficulties and costs of doing this and felt that they were not always supported to do so. The managers and non-peer staff recognised and valued a number of assets Peer Workers brought to the team, but this did not seem to include the ‘giving of personal experience’. Indeed there was a sense that to do so crossed boundaries that were carefully established to protect Peer Workers and service users. This apparent conflict between ‘giving of personal experience’ as a Peer Worker and ‘trying to be a professional’ (to maintain the prescribed, boundaried role) seemed to encapsulate the tensions inherent in the Peer Worker role and to constrain the emergence of a distinctive body of Peer Practice that the whole team could agree on.

Strengths and limitations of the secondary analysis approach

Potential weaknesses in secondary analyses of qualitative data have been identified where there is not a good fit between data collected in the primary study and the questions asked of the data in the secondary analysis [47]. Our primary study was designed to elicit data on expectations and experiences of support for self-care provided by mental health services. We noted that many of our interviewees spoke about the role of users of those services employed as staff; the role was identified as a valuable aspect of support for self-care and the data to warrant closer analysis [25]. As such there was a reasonably good fit between primary data set and secondary analysis questions. However that fit was not even across the dataset. There was a relative lack of data from service user participants (compared to Peer Workers, non-peer staff and managers, from most of whom data was collected). A number of service user participants spoke about whether or not they felt ready to take on a Peer Worker role, but our interview schedule did not further elicit their views on their experiences of being supported by Peer Workers. This data would have strengthened our exploration of an emerging, distinctive body of peer practice. Future research in this area should be careful to address specific questions across a full range of relevant stakeholders. In addition, data informing some of our themes came predominantly from the London site, perhaps because that team had been most pro-active in trying to integrate the new role into the team. Again, a primary study around the introduction of Peer Worker roles in mental health services would set out to elicit similar data to investigate team building dynamics in a range of service specific contexts [14].

As strength, the robustness of our analysis was enhanced by the input of two service user researchers. New codes were created that foregrounded issues neglected in the preliminary framework, including staff retention of benevolent power as a constraint on the development of distinctive peer practice, and the experience of a conflicted Peer Worker identity. Issues such as flexibility and hierarchy were flagged as more than employment issues, characterising tension inherent in the Peer Worker experience. These issues helped shape the emergence of our meaningful themes. This cross-checking of the analysis by two researchers who were independent of the primary study, but who as service user researchers worked from a complementary standpoint was a strength of our approach, increasing the rigour of the methodological process and the explanatory power of the analysis.