Table 1 Coding framework for role of peer support workers’ experiences for substance use disorders in Egypt

Theme 1: Role clarity

1.1 Building therapeutic relationships with service users and instillation of hope

“Addiction therapists (he is referring to PSWs) can make patients believe that there is always hope for recovery by telling them how they gave up on addiction and their personal recovery stories. Particularly when the patient is first admitted to the treatment center, he is in denial of his addiction problem or he thinks that his addiction cannot be treated, so therapist will represent hope for him” (≠ PSW 05)

“At first, the addiction therapist (he is referring to PSW) should be a role model and a recovered addict before being a therapist, this fact connects the therapist directly to the patient and opens the door for therapist- patient relationship to exist. The patient first enters the treatment facility with his own judgements and trust issues, the idea of him putting his trust on an ex addict requires first seeing a model that can give him hope, and be his first step towards recovery, and before conducting any therapeutic technique, this should be the first thing to be considered from addiction therapists” (≠ PSW 16)

“The therapist (he is refereeing to PSW) tries to be closer to the patient, especially when the patient knows that he is with someone who was in the same situation but recovered and stopped addiction, this gives the patient hope” (≠ PSW 17)

“I use my personal experience as a kind of hope, when I like to convey hope; how I was able to recover and change, and where I am now” (≠ PSW 04)

“I don't say all the time I have a lived experience, I let the patient see that we share commonalities” (≠ PSW 07)

“You bring out the motivation from inside the patient, do not tell him what to do, I let him say his problems, and I ask him what he needs, he says I need to stop the addiction, he is the one who decides” (≠ PSW03)

“I do not control the patient, I am not a police officer, and I always say that I am dealing with souls and human beings who need you to provide them with motivation and positive feelings” (≠ PSW13)

“Motivational interviewing is important as a beginning step with the patient when he comes first to the treatment facility, the patient comes with denial and lack of motivation to change. Here it comes the role of the addiction therapist to motivate the patient to be engaged in treatment” (≠ PSW10)

“Addition therapist (he is referring to PSWs) must have professional ethics, so that he can be responsible for the patient and gain this trust” (≠ PSW14)

“The therapist (he is referring to PSW) should practice therapeutic limits in dealing with the patient, for example accepting gifts from patients is prohibited” (≠ PSW09)

“In trainings, we study professional ethics academically, what is really important is to practice it in our professional career” (≠ PSW07)

1.2: Working with multidisciplinary teams

“Every successful addiction institution has addiction therapist (he is referring to PSW) and like everyone in the team, he has an important role in this process. unlike doctors, the addiction therapist is always available for the patient 24 h and has been through the same issue, so the team needs the doctor, nurse and the addiction therapist” (≠ PSW05)

“We discuss different points of view regarding the treatment plan, but it is for the patient benefit. For example, yesterday there was a patient, we were concerned about giving him a holiday from the treatment facility, because the patient’s condition, he is not stable and has some problems, so we were consulting if he could take a break, because of the possibility that he might relapse. These are not difficulties, but they are judgments and points of view until we reach what is in the best of the patients at the end, and to do what is right. I advise him in the first place to be a part of the team, and not to consider himself as the patient’s healer alone” (≠ PSW01)

“We have an integrated team; addiction therapist, addiction volunteer, doctor, and psychologist. We emphasize the psychological aspects behind SUDs, we perform psychological tests using psychometric questionnaires. We should understand the psychological reasons behind SUDs” (≠ PSW06.)

“The decision is supposed to be collective because individual decisions are harmful, so when we all have an agreement on a specific point of view and my team members think this is not good for the current situation I don’t challenge and I do what we all agree on (≠ PSW02)

“When I started my professional training, I learned that the therapeutic team consists of three pillars, an addiction therapist (he is referring to PSW), a psychiatrist, and a psychologist. I listen to the opinion of the doctor and the opinion of the specialist, we all discuss the case. There are places in Cairo that work in the family and marriage issues, few places that work in this way” (≠ PSW03)

“If there is disagreement in the professional point of view, we vote. The treatment team includes a consultant, a doctor, a specialist, and a therapist, four or five people. When we disagree we vote” (≠ PSW12)

1.3: Professional training, peer-supervision, and self-care activities

“The addiction therapist (he is referring to PSWs) has his own recovery story but he must support it with professional training experience. The lived experience without professional training is not enough” (≠ PSW17)

“I talk and share with supervisors, peer-meetings, it helps me a lot and help in re-charging my batteries” (≠ PSW11)

“I personally like Narcotic Anonymous as a preparation program for being a professional addiction therapist and a rehabilitation and treatment program too” (≠ PSW08)

“I attend peer group meetings regularly and talk about my problems and conflicts so I can be qualified to offer counseling and support to service users, because the therapist must keep working on resolving his problems that had not been solved during his recovery journey (≠ PSW01)

“Since SUDs is a chronic disease and it continues with me for the rest of my life, I should keep managing it and work on my recovery because I can possibly relapse at any time. I share and participate in peer supervision meetings, I must also participate on personal aspects related to myself; I make mistakes, I have pressure on me and sometimes I have difficulty in managing my feelings, so I must always participate” (≠ PSW05)

“The mentor is very important indeed, without the mentor we may relapse” (≠ PSW13)

“It is very helpful to believe that there is someone who I can talk to and motivates me to continue, I am willing to always get back to him and discuss issues related to my work and personal recovery with. Supervision is really important” (≠ PSW10)

I take a break and come back to work with a fresh mind, because I may have negative feelings that would affect patients negatively, and perhaps a word or a behaviour that come from me ruin the job with the patient if I am stressed” (≠ PSW04)

“With the intense and hard responsibilities of this job, I always delegate duties, I have a deputy director and when I go for holidays, I completely turn my mind off” (≠ PSW06)

1.4: The therapeutic use of lived experience

“I use my story when the patient stops listening to us as a therapeutic team or when he gets into deep desperation, here it indicates that my consultation is not just coming from a professional place, so it is not necessary to use my experience all the time” (≠ PSW13)

“You know what, for reassurance, sometimes I tell the patient that I have gone through addiction experience, so he can speak comfortably with me. However, there are smart patients who notice if the therapist talks about his experience a lot. The patient will feel that the therapist is only here to talk about himself and what he did in a bragging way. So one should be very careful” (≠ PSW14)

“When we have an evasive or hard patient, we sometimes tell him that as addiction therapists we are like him, we share the same mind, our thinking is similar” (≠ PSW17)

“When the client has negative thoughts and he can’t speak it up, here I can bring my personal experience to help him talk, and no need for many details, also in situations where he feels shameful to talk I encourage him by talking about me being the same. It all meant to make him not to feel alone” (≠ PSW08)

1.5: Knowledge and integration of therapeutic schools

“Besides formal training, addiction therapist should study different therapeutic schools, sometimes we use combination of therapeutic techniques from different schools with the patient” (≠ PSW16)

“Generally, all therapeutic schools have things in common, they differ in the concepts, for example the Cognitive Behavioral Therapy (CBT) focuses on changing thinking, and the Narcotic Anonymous (NA) goes in steps and the patient must attend 90 meetings in 90 days with a supervisor attending with him, some programs have combined NA & CBT as the matrix model. I should first explain to the patient that all programs can work toward his recovery” (≠ PSW05)

“Addiction therapist should be familiar with all therapeutic schools, he should not work in one way, one path may not succeed” (≠ PSW03)

Theme 2: PSWs’ need for organizational and stakeholders’ support

“Formal training to undertake a job as addiction therapist must be set mandatory by the policy makers, addiction therapists should be supported financially to undertake these training. That should be mandated by laws. Additionally, therapists should be evaluated and tested to ensure they are qualified enough to take this job role” (≠ PSW10)

“You know that training courses are expensive, and it is not easily available too, when I was at the Al-Matar hospital, we used to find courses every two or three years, courses about the role of the addiction therapist and the role of the treatment counsellor. We take these courses at our own expense…silence, and you know that we have already lost a lot of money and financial resources during our recovery and treatment journey” (≠ PSW06)

Theme 3: Challenges to the role integrity

“The new types of abused drugs are challenging, because it has different presentation from the known substances. All the new types make the patient go through terrible long psychological withdrawal symptoms, and the patient’s condition is very unstable for a long time, he goes through a period of hope in five minutes, and five minutes feels like failure and frustration. The most difficult time is in the first month, he has many thoughts and his condition is unstable, he starts treatment and then goes in denial, and he wants to leave and does not want to complete the treatment. Stabilizing the case is the most challenging part in the treatment plan. The therapist needs to learn about these new drugs, this must be included in the professional training of addiction therapists.” (≠ PSW01)

“Not everyone who has recovered from SUDs can work as an addiction therapist (he is referring to PSWs) and not anyone who has recovered and given up addiction for six or nine months can call himself an addiction therapist, we also have no support or union” (≠ PSW13)

“Our media only shows the darker side of the addiction treatment facilities, and this is a catastrophic thing” (≠ PSW17)

“Long shifts…. (deep sigh) … the addiction therapist works usually for four consecutive days which is a big burden, in the last day he may reach the limit and gets tired. He is an ex-addict and that must be considered and not forgotten “(≠ PSW09)

“The parents have a very important role in the treatment Plan, however, we face big difficulties arising basically from low family awareness about recovery of SUDs, for example when we talk about a person who started treatment and, the parents begin to see him getting better, he eats and sleeps well, his mother says that she wants him to marry, he is now starting to recover and stand on his feet, he has to take responsibility, their thinking revolves around that they want him to settle down even if he is not ready for that step “(≠ PSW16)

“Some private facilities do not separate between the financial issues with patients’ family and patients’ care. for example, a patient may be suitable to go outside the facility for a break or a holiday but the facility won’t allow this because of the debts family owe to the center, then the patient comes to me wondering why he couldn’t go out” (≠ PSW15)

“Unfortunately, addiction training courses are optional, this is a catastrophic thing. For example, you can study eighteen months in an addiction treatment school and eventually the certificate is not accredited in Egypt, but it is recognized and accredited internationally” (≠ PSW12)