Journal of Mental Health
ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20
Authentic peer support work: challenges and opportunities for an evolving occupation Karen L. Rebeiro Gruhl, Sara LaCarte & Shana Calixte To cite this article: Karen L. Rebeiro Gruhl, Sara LaCarte & Shana Calixte (2016) Authentic peer support work: challenges and opportunities for an evolving occupation, Journal of Mental Health, 25:1, 78-86, DOI: 10.3109/09638237.2015.1057322 To link to this article: http://dx.doi.org/10.3109/09638237.2015.1057322
Published online: 23 Sep 2015.
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Date: 18 February 2016, At: 04:51
http://tandfonline.com/ijmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2016; 25(1): 78–86 ! 2015 Shadowfax Publishing and Taylor & Francis Group, LLC. DOI: 10.3109/09638237.2015.1057322
RESEARCH AND EVALUATION
Authentic peer support work: challenges and opportunities for an evolving occupation Karen L. Rebeiro Gruhl1, Sara LaCarte1, and Shana Calixte2 Centre for Rural and Northern Health Research, Laurentian University, Sudbury, Ontario, Canada and 2Northern Initiative for Social Action, Sudbury, Ontario, Canada
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Abstract
Keywords
Background: The peer support worker (PSW) belongs to the fastest growing occupation in the mental health sector, yet it is often under-valued and poorly understood. Despite an emerging evidence base, and strong support from mental health service users, the PSW remains on the periphery of mainstream services in northeastern Ontario. Aims: To examine the role of the PSW, along with the challenges and benefits, and to understand why the PSW is not more integrated within mainstream services. Methods: A sequential, exploratory, mixed-methods design was used to collect data on 52 survey and 33 focus group participants. Qualitative data were analyzed thematically. Results: Peer support work was described by participants as being authentic when PSWs can draw upon lived experience, engage in mutually beneficial discussions, and be a role model. Authentic peer support was noted to be important to the recovery of mental health service users; yet, participants revealed that many positions continue to reflect more generic duties. Challenges to further integration include acceptance, training and credentialing, self-care, and voluntarism. Conclusions: Future development and mainstream integration of peer support work must reconcile current tensions between standardization and loss of authenticity. Training in communicating the lived experience, setting boundaries and self-care are important steps forward.
Consumer survivor, lived experience, mutual aid, peer providers, role clarification
Introduction Peer support workers (PSWs) are the fastest growing occupational group in the mental health workforce (Doughty & Tse, 2011). According to Solomon (2004), peer support services are ‘‘provided by individuals who identify themselves as having a mental illness and are receiving or have received mental health services for their psychiatric illness, and deliver services for the primary purpose of helping others with a mental illness’’(p. 393). While peer services largely evolved as an alternative to the formal mental health system (Deegan, 2006); more recently, these services are partnering and collaborating with mainstream services (Forchuk et al., 2005). Yet, it remains unclear operationally what constitutes the support provided by peers. Defining the nature and meaning of peer support for mental health consumers is a challenging task, primarily because one of the defining features of peer support is the flexibility to suit people’s needs and interests. This diversity has its drawbacks – namely, with
Correspondence: Karen L. Rebeiro Gruhl, PhD, O.T. Reg (ON), Health Sciences North: Community Mental Health and Addictions Program, 127 Cedar Street, 6th Floor, Sudbury, Ontario P3E 1B1, Canada. E-mail: [email protected]
History Received 6 September 2014 Revised 3 April 2015 Accepted 21 April 2015 Published online 18 September 2015
respect to understanding who the PSW is, what they do, and the value-add they provide for mental health services. Multiple reports have identified peer services as a best practice, yet policy direction for integrated services has been limited (O’Hagan et al., 2009). Kemp & Henderson (2012) conducted a qualitative study exploring the challenges faced by PSWs. The most salient issues identified by the study participants were (1) a lack of clarity in the roles for peers and employers, (2) excessive workload expectations, (3) a lack of supervision, and (4) concerns involving self-disclosure. To address these challenges, it was recommended that standardizing the peer role within mental health services and expanding education of providers and service users would ensure the appropriate utilization of peer resources (Faulkner & Kalathil, 2012; Kemp & Henderson, 2012). The existing literature suggests that peer services positively impact service users in the domains of social support, community integration, personal empowerment, quality of life, symptom distress, utilization of hospitals (Lawn et al., 2008; Lyons et al., 1996), and employment/education (Doughty & Tse, 2011; O’Hagan etal., 2009). Moreover, although less well examined, peer services are thought to effect change on system-level activities, including community planning, public education, advocacy, and action research.
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Janzen et al. (2006), for example, identified peer services to be most helpful in providing (1) a safe, positive, welcoming environment; (2) a social arena to meet and talk with peers; (3) an alternative worldview allowing members to participate and contribute; and(4) community integration. These studies, conducted in an urban setting, provide less guidance as to the transferability of these findings to northern, small town and rural contexts. Our own research on one peer-run program in northeastern Ontario demonstrated several positive outcomes for service users (Legault & Rebeiro, 2001; Rebeiro et al., 2001; Wright & Rebeiro, 2003); however, these studies have not specifically placed a lens on the PSW or the services they provide. The aim of the current study was to expand what is known about the PSW in northeastern Ontario, and to better understand why peer support is not more fully integrated within mainstream services.
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Methods The research employed an exploratory, sequential, mixedmethods design (Figure 1). The research was conducted across three, inter-related phases; each informing the next, as well as, addressing regional knowledge user and decision maker questions, and ensuring that knowledge users were involved in responding to the findings as well as to co-constructing potential solutions. In phase 1, we attempted to answer the question, who is the PSW in northeastern Ontario and what do they do? The questionnaire construction was both experiential and literature-driven, using the PSW general job description developed by Jacobson et al. (2012) to structure questions on job duties
and responsibilities, with additional questions on the level of satisfaction with duties performed. The questionnaire was distributed by e-mail to a database of 300 consumers, consumer survivor initiatives (CSI), and mental health partners in northeastern Ontario, and to others by snowball recruitment. It is estimated that there are 65 paid PSWs in the region; the nature of the volunteer PSW is a challenge to calculating the exact population size. In phase 2, four focus groups were conducted to explore the survey findings in greater depth. Participants were PSWs providing services in consumer survivor programs, Native Friendship Centers (for individuals of aboriginal origin), or mainstream mental health organizations. Initially, the research team was not soliciting recipients of peer support; however, if a recipient wished to be a part of the focus group, they were welcome to participate and their insight into the role and value of the PSW was included in data analyses. Focus group discussions were centered on how the participants defined the role of peer support work and how PSWs are being integrated into mainstream mental health services. Focus groups were audio-taped and transcribed verbatim. A second survey questionnaire was developed for the purposes of member-checking due to the large geography of the study. An executive summary of the findings was developed and distributed using the original mailing list, and requested to be forwarded to other PSWs. Participants were asked whether they agreed with the major themes, and space was provided to comment on the accuracy of the findings. All participants were provided a letter of information outlining the risks and benefits of participation as well as details about how their personal information would be
Research Question: Who is the PSW in northeastern Ontario and what do they do?
Web-based survey 51 participants
Research Question: What are the challenges to further mainstream integration of the PSW in northeastern Ontario?
Focus Group 1 CT=7 participants
Focus Group 2 NL=8 participants
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Focus Group 3 NB=10 participants
Focus Group 4 SM=5 participants
Individual Interview SM=1 participant
Member Checking Questionnaire: Participant confirmation of findings
Figure 1. Data collection process.
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managed. All participants were assigned a coded identifier to provide anonymity, given the small communities within which data were collected. Ethics approval was granted by the Health Sciences North Ethics Committee.
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Data analysis Survey data were analyzed to answer the questions who is the PSW and what do they do, and to provide a descriptive profile of the PSW in northeastern Ontario, with a particular lens on urban, small town, and rural settings. Focus group and interview transcripts were initially read by all authors and reflected upon as to the overall meaning. Data analysis was an iterative and open-ended process; inductively generating categories from the raw data (Boyatzis, 1998; Creswell, 2007) (Figure 2). Emerging patterns were merged into themes that described and organized the data, as well as provided an interpretation of the data (Boyatzis, 1998). The themes help to make explicit PSW and the challenges they face with integration within mainstream mental health services in northeastern Ontario.
Results Survey results The survey results are based on the responses from 51 PSWs. Who is the peer support worker in northeastern Ontario? The PSW in northeastern Ontario is a mature workforce with 67% being over 40 years of age. The peer support workforce is mostly female (65%) and Caucasian (85%). Sixty percent of the participants completed University or College, and another
27% had some University or College education. Sixty percent of our sample had received training as a PSW (ranging from 1 week to 1 month duration). In comparison to the general population of the northeastern Ontario, wherein only 42.83% have completed high school, the PSWs in our study are a highly educated workforce. Where is the peer support worker located? The study draws from a predominantly urban-based workforce, located in proximity to the larger centers (Figure 3). Seven percent of the survey participants identified living a rural, small town of less than 10 000 residents. Most paid positions were located in CSIs, with a few PSW positions within First Nations and housing organizations. PSWs working within mainstream mental health services were mostly on assertive community treatment (ACT) teams. What does the peer support worker do? Participants identified spending the majority of their time in the following top five activities: communicating and working collaboratively, completing documentation, attending team meetings, sending and receiving e-mail/telephone calls and participating in training. Most of these activities would be categorized as indirect work activities. In contrast, participants identified deriving the most satisfaction from the following direct work activities: sharing and discussing common experiences with clients, participating in training, communicating and working collaboratively with others, initiating, establishing and maintaining relationships with clients, and helping clients to set goals and work towards them (Table 1).
Survey Data + Data from 4 focus groups and one interview Documents
Inductive coding of all data sources
Iterative process of identification of patterns, interpretation, and theme development
Lived Experience: Therapeutic use of self
Reciprocity: mutuality of peer support
Role modeling: Society’s mirror
Acceptance and valuing
Training and credentialing
Voluntarism
Self-care
Challenges to authentic peer support and to mainstream integration
AUTHENTIC PEER SUPPORT
Figure 2. Data analysis process.
Rural and small town
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Figure 3. Location of survey and focus group participants.
Table 1. Rank-ordered comparison of activities frequently performed and activities most satisfying.
Activity/duty/responsibility (direct/indirect)a Communicate and work collaboratively with team members Attend team meetings Complete require documentation Send and receive e-mails/telephone calls Participate in any training required Initiate, establish and maintain relationships withclients Share & discuss common experiences with clients Work collaboratively with clients, co-workers and community Help clients to create meaningful lives Connect clients to resources All other responsesb Education and awareness building efforts Help clients set goals and work developing skills Help to build a collective sense of community for client Meet with supervisor to discuss performance Work directly with clients to address problems and answer questions a
Frequently performed activity
Most satisfying activity
1 2 2 3 4 5 6 7 8 9 10 410 410 410 410 410
2 4 47 47 2 3 1 47 47 47 7 4 4 5 6 6
Direct activities involved face-to-face contact with a peer. Indirect activities do not involve face-to-face contact. Other responses include: advocate on behalf of clients, help clients to navigate the health and social services systems, meet clients both in the hospital and in the community, coach and mentor clients, plan, organize, develop, lead and facilitate group activities, observe and educate regarding medication, and participate in any training required for the position.
b
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What is the level of integration of peer support worker within mainstream services? An interesting finding was that 78% of the survey participants identified their work to be integrated within mainstream services, often, very often, or all the time – a finding that did not align with what we have observed in everyday practices. To help understand this discrepancy, the question was brought forward to the focus groups for further exploration.
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Focus groups Thirty-three individuals participated in the focus groups, including 25 PSWs and 8 recipients of peer support. Seventeen PSWs have received training for their work; however, the training was inconsistent across the participant groups, especially in smaller town communities. Fourteen of the 25 PSWs are paid for their work, and 11 function as voluntary PSWs. Participants are coded based upon the community they lived in and by their registration number (e.g. CT-01 would be the first registrant in the Cochrane Timiskaming district) in order to maintain anonymity in these smaller communities.
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model’’ (NB10). One focus group participant explained the importance of lived experience to peer support work: I just felt like due to my own lived experience and where I’ve been in my journey that I felt like you can’t learn what we’ve lived in a textbook. As a mental health worker, that’s great. But unless you’ve walked in those shoes, there’s nothing that you’re going to be able to add that someone without college can add. It’s just priceless and that’s my take. (SM03) Reciprocity Authentic peer support was described as mutually beneficial. Participants spoke to the personal benefits of doing peer work, in particular, as a means to also help them to keep well: I get a lot out of helping others and it helps benefit myself. (NL05) Other participants spoke of how the act of sharing or therapeutic use of self, furthers their own healing process as well as mirroring to others that recovery is possible:
Authentic peer support Authentic peer support is a conceptual term used to capture what participants identified to be the essence of their work, and the value-add of PSW to mainstream mental health services. Authentic peer support did not necessarily reflect what participants were doing in their everyday work, as evidenced by the survey findings. Instead, authentic peer support was described to be flexible and idiosyncratic; that is, driven by the recipient of peer support, rather than drawing upon a particular list of duties or activities. Survey and focus group participants attributed the following to the authenticity of peer support work: drawing upon lived experience and the therapeutic use of self; reciprocity and the mutuality of PS work; and, the value of role modeling. Authentic peer support work was advanced by the participants to be a gap in the mental health system, and the rationale for mainstream integration: I think that one of the most important things that has trained me for my job description is the lived experience. I have a degree in education; I have a degree in psychology. I have all kinds of diplomas in education background and I have been an educator for most of my life, but having the lived experience of severe mental illness has given me a lot of insight, and patience, and tolerance and compassion . . . the lived experience is the most important thing that I bring to the table. (NB09)
Drawing upon lived experience Participants described the philosophy of peer support work to be drawn directly from lived experience and with an insider’s perspective of what is helpful, and what is not so helpful. Participants identified how authentic peer support work is about ‘‘supporting people in their recovery, and not defining it for them, and about sharing my story and my experience as a point of validation and also as an example or role
So I guess what drives me, I feel like my peer support work is mutually beneficial . . . like I feel like being able to share my life with people to where it’s like, yeah I get that. (NB07) For me sharing my story, I feel validated and yet it comes back the other way, too because they’re standing there going, holy crap, I’m not alone. (NB04) Society’s mirror The next category helping to unpack authentic peer support work concerns how the PSW provides a mirror reflection to mental health users that recovery is possible. In the context of peer support, participants recognized the value of one who has been there to providing hope to others: And because I had gone through it and I was sitting in front of her she had said to me that it was nice to know that somebody is out there that has gone through it and has come out at the other end. (NL01) Another PSW emphasized the power implicit in the act of sharing to another’s recovery: I really wanted that peer aspect of it, right, that normalcy that you can get through it . . . for the women that are feeling like they’re never going to get out of it, that they’re hopeless, I want to be able to project and show them that two years ago, I was in my bed unable to get out of the house . . . (SM04) Challenges to the mainstream integration of the peer support worker Despite the abovementioned stated benefits derived from access to authentic peer support, there were also notable
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challenges to their further integration within mainstream mental health and addictions services in northeastern Ontario. These challenges were categorized as acceptance and valuing, training and credentialing, voluntarism, self-care, and rural and small town contexts.
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As for peer support, there’s only two of us here who have taken that two week peer support training–two of us in this room. (TM05)
Voluntarism Acceptance and valuing
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Participants identified being accepted and valued by others in the mainstream mental health system to be a primary challenge to the PSW, acknowledging that acceptance within the mental health system was inconsistent at best: It’s a good start, but it doesn’t have support. It’s very difficult. When you say integrated, we’re trying, we’re trying to bring to the hospital let’s bring peer support into the hospital. We’re trying, but wow it’s a battle. And that battling sense is wrong. I really feel we should be able to be critical of the system. And that’s what is getting attention. (NB10) Participants also discussed the value of training and credentialing to fuller acceptance within mainstream mental health systems. While some participants feared a trend to over-qualifying of the PSW, or to being masked under different titles and jobs; others identified providing generic mental health duties within which unique PSW activities and values were less visible to outsiders as a challenge to mainstream acceptance. One participant explained: I have a position that is labelled partial peer support worker . . . is that my job? Nope, it’s part of it when there’s time. (SM05)
Training and credentialing Participants perceived that the mainstream mental health system was more accepting of a diploma or of the training routinely provided to other mental health workers as the preferred way of ‘‘knowing’’, rather than lived experience. These insights helped to explain the push for generic training and to do generic ‘‘activities’’ over authentic peer support work: But when I went for my training, I felt like pretty much everything in my peer support training, like lined-up with what I learned being like a counselor and the only thing that was really different was using my own lived experience as strength instead of a problem. (NB07) In rural and small town communities, training was often inconsistent or missing, and may explain the stated lack of acceptance and valuing of the PSW in these settings: I haven’t taken any training. I’m not even aware that it’s been offered up where I am. . . . I do not have a policy degree as a social worker or anything. I’m coming from the centre where I was formerly a volunteer and that was it. So it’s lived experience plus I’ve been sent for crisis intervention, conflict resolution . . . those kinds of things. (NB04)
Voluntarism was raised as a way to provide PSW in communities that did not have paid positions, as well as a meaningful occupation for many of the participants. Voluntarism was also perceived to reflect a lack of acceptance and valuing of PSWs and serve as a barrier to mainstream integration: I did that on my own time, she’s [manager] not interested in that. And to me, that is being a peer support worker. But it had no validity to anyone except me and the person. (NB04) I have been a volunteer in mental health for the past 10 years. I’ve been volunteering, helping my peers for all kinds of things. I work 7 days a week, close to. (TM01) For some of the participants, voluntarism was identified as a challenge to the credibility of this evolving workforce. Yet, others in the member check raised concern with the loss of voluntary PSW opportunities due to standardized training. Self-care Self-care was the final challenge raised by participants; underscoring ambiguous personal boundaries as a pressing challenge to the PSW: In regards to boundaries, I actually have really rigid boundaries. As far as self-disclosure goes, I’m OK with that and I do that because that’s the whole idea that part of peer support . . . I work 60 hours a week and I raise a kid, so there has to be a point for my own personal self-care where I do turn off because if I don’t I’m likely to end up in a really bad situation. (NB10) PSWs identified the importance of establishing clear, personal boundaries with recipients of PSW to their ongoing recovery and ability to help others: For me it’s within those hours and my own wellness. I live with my moods going up and down. I have to really take care of myself. And I have a really firm line for me- how I’m going to support someone. (SM04) PSWs also raised the challenges of establishing and maintaining personal boundaries in places where there is a limited understanding of peer support work, where there are only sole practice PSWs, or in situations in which the scope of duties have not been provided by a peer supervisor or mentor. In this study, PSWs in urban areas who had a well-defined peer network of support were more likely to establish personal boundaries and be supported in using them. SM05, a new PSW, raised concern regarding the ambiguity of boundaries in their work,
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Yeah, I played with how much do I share? How much do I,like I want there to be a boundary set between I’m still here for you, it’s not about me . . . but I wasn’t there as a stomping ground for my issues . . . (SM05) Burnout. Burnout, a consequence of limited self-care, was a
further challenge to this evolving occupation and to their future development and integration into mainstream services. In particular, participants identified a disconnect between their training and the draining nature of their work: One person trying to do all this is crazy. (NB08) I think it’s very important to put those services in place to help peer support workers not burn out. (NB10) It can be really, really tiring and draining to just be on for hours and hours. (NB05) The final challenge to the mainstream integration of the PSW concerns place. In rural and small town communities, PSWs were identified to be less known, visible, accepted, valued, and accessible to service users in mainstream services. Boundaries were also acknowledged to be blurred in smaller communities, elevating the risk for burnout, and limiting opportunities for self-care:
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Rural and small town.
Because it’s a small town . . . I do outreach in the community, it’s like, oh yeah, you’re with [org] do you think you could come and talk to us about it? I’m not shy at all about that; however, I have had to draw the line with some members. I have seen them at my door and if I’m not feeling up to it, I just won’t answer my door. (NB03) According to the participants, few knew about peer support in their communities and therefore had little to no knowledge of the benefits of PSW or why they might need them: Because nobody wants to admit they come to [CSI] it’s confidential . . . it’s a hush-hush kind of thing. It’s a secret society kind of thing . . . But, I mean because it’s not known in society, and you can’t even look at it on the Internet . . . there’s nothing about [CSI] . . . Unless you know about it, but nobody knows about it . . . it’s very secretive. (TM05)
Discussion The findings of this study mirror the existing national and international literature on peer support in many respects. There is strong support of the importance of lived experience, mutuality, and role modeling to the benefits of the PSW (Berry et al., 2011; Cabral et al., 2013; Davidson et al., 2006; Doughty & Tse, 2011; Jacobson et al., 2012; Lien & Meissen, 2012; Mead, 2003; Mead & MacNeil, 2006; O’Hagan et al., 2009; Solomon, 2004); as well as for the role of the PSW in enhancing the mental health system’s capacity to address service user recovery needs (Chinman et al., 2001; Davidson et al., 1999; Doughty & Tse, 2011; Grant et al., 2010; Herbert et al., 2008; Janzen et al., 2006; Repper & Carter, 2011; Rivera et al., 2007). Despite this support, these benefits are
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not necessarily reflected in the current roles and responsibilities of PSWs in northeastern Ontario. Instead, participants suggested that other factors, such as, non-peer supervisor perceptions, may influence existing job descriptions more than what participants described to be authentic peer support. Non-peer development of job duties and responsibilities may help to explain why the activities in which PSWs in northeastern Ontario spend the most time, do not easily align with activities described to be authentic peer support. Participants identified spending more time in indirect mental health duties – rather than the direct, one-on-one peer support in which they draw heavily upon their lived experience. It may also help to explain the lower levels of satisfaction expressed by study participants with their current jobs. Faulkner & Kalathil (2012) explained that support was most helpful if both peers have other things in common such as cultural background, religion, age, gender and personal values. Additionally, relationships were more supportive if both people were willing to provide and receive support and had gained some distance from their own situation, so that they were able to help each other think through solutions, rather than simply give advice based on their own experiences. For these reasons, Faulkner & Kalathil strongly advocated for training, supervision and support for peer workers employed in health services. Repper (2013) commented on the importance of reciprocity or the mutual aid of peer support to recovery, noting how both PSW and service users are supported in their own recovery journeys. Repper & Carter (2010) also identified that employment as a PSW provides individual benefits, including self-esteem, confidence and personal recovery. O’Hagan(2011) noted how the values of mutuality and experiential knowledge are unique to peer support, and highlight differences in boundaries exercised by PSWs and traditional professionals. O’Hagan described the work of the PSW to be situated somewhere between a friend and a traditional professional relationship. However, our findings highlight the difficulty of this positioning within PS work – especially in the absence of more formal training or support networks. Similar to our study, researchers recommend that peer support services would benefit from further standardization with respect to training and education (Faulkner et al. 2013). Training opportunities can develop the capacity, potential and leadership of individuals giving and receiving peer support (Repper & Carter, 2010). This is challenged by findings that the peer workforce in mainstream settings is poorly understood, underpaid, discriminated against and expected to work according to traditional values and ethics (Daniel et al. 2010). Daniels et al. (2010) questioned whether mainstream integration of peer support services may in fact pose the greatest risk to peer services yet; specifically, that mainstream services will colonise peer support work and create a workforce and services in its own image. In our study, participants did raise concern about losing the value of peer support through a process of over-professionalising the peer workforce, and in particular, of non-peer supervisors determining peer support roles and responsibilities. The research literature was less explicit regarding the challenges facing the PSW residing in rural and small town
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communities. In this study, it was observed that as the PSW migrates away from the urban center, there was an increased likelihood of burnout, role blurring, unclear personal boundaries, fewer support networks, and an increased likelihood of volunteer than paid peer work. Minore & Boone (2002) previously identified the potential benefits for peers to collaborate in mental health and addictions care in rural and small town northern places; yet, this study highlighted that more work is needed to achieve the level of mutual respect necessary for effective collaboration. To address this essential work, we offer several recommendations to further the understanding of authentic peer support, the development of this workforce, and their integration within mainstream services.
Recommendations
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larger urban centers more challenging; nonetheless, our findings are consistent with the literature.
Conclusions Most PSWs in this study experienced difficulty in describing what they did, and why the mental health system needed peer support, other than by describing the activities they performed in their jobs. This did little to make explicit their unique contribution to mainstream mental health services, or why they should be hired if they are engaging in generic mental health tasks. In many ways, authentic peer support is particularly important to the mental health system in that it drills down to essential human needs for compassion, empathy, listening, validation, and hope. Future training should embrace authenticity and any standardization of peer support work should be based in it.
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Education The need for an investment in annual training and in the further development of this workforce was raised. The findings of this study highlight inconsistent training, which is especially problematic in rural and small towns. The establishment of a minimum standard of training for PSWs is recommended, notably, reflecting the skills and perspectives of authentic peer support work. Furthermore, the findings point to the need to create a network of supports to ensure that the peer support workforce is able to survive and thrive in the mainstream system, and importantly, collectively advocate for its authenticity. Mainstream integration The further integration of the PSW within mainstream mental health services is contentious, with some viewing integration as a way to better recognition and job opportunities; and others fearing the costs of assimilation. Participants in this study identified that it is in the authenticity of peer support work that brings value to the current mental health system. In this study, we learned that limited integration was a result of inconsistent training and role functions – each contributing to vague understandings of what PSWs bring to mental health systems. While participants clearly articulated the benefits to authentic peer support, they also acknowledged that this was not often possible within current positions. Future research Future research will track PSW employment as well as level of integration within mainstream mental health services over time. We are interested to observe the influence of more formal credentialing and the implementation of national standards for PSWs in Canada on their employment and integration trajectories, and importantly, on the stability of authenticity. And finally, we remain interested in understanding urban/rural differences, especially regarding hiring practices, training and the effects of a peer network of support on solo, rural, and small town PSWs. Limitations This study was conducted in small cities and rural towns in Northeastern Ontario and make generalizing the results to
Acknowledgements The authors would like to acknowledge all of the participants of this study for their time, their wisdom and their intimate sharing with the research team.
Declaration of interest The authors declare no conflicts of interest.
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Herbert M, Drebing C, Rosenheck R, et al. (2008). Integrating peer support initiatives in a large healthcare organization. Psychol Serv, 5, 216–27. Jacobson N, Trojanowski L, Dewa C. (2012). What do peer support workers do? A job description. BMC Health Serv Res, 12, 205. Janzen R, Nelson G, Trainor J, Ochocka J. (2006). A longitudinal study of mental health consumer/survivor initiatives: Part IV – Benefits beyond the self? A quantitative and qualitative study of system-level activities and impacts. J Commun Psychol, 34, 285–303. Kemp V, Henderson AR. (2012). Challenges faced by mental health peer support workers: peer support from the peer supporter’s point of view. Psychiatr Rehabil J, 35, 337–40. Lawn S, Smith A, Hunter K. (2008). Mental health peer support for hospital avoidance and early discharge: An Australian example of consumer driven and operated service. J Mental Health, 17, 498–508. Legault E, Rebeiro KL. (2001). Occupation-as-means to mental health: A single case study. Am J Occupat Therap, 55, 90–6. Lien AD, Meissen G. (2012). Peer perspectives: Expectations and satisfaction with certified peer specialist services. Int J Psychosoc Rehabil, 17, 5–16. Lyons JS, Cook JA, Ruth AR, et al. (1996). Service delivery using consumer staff in a mobile crisis assessment program. Commun Mental Health J, 32, 33–40. Mead S. (2003). Defining peer support. Available from: parecovery.org/ documents/DefiningPeerSupport_Mead.pdf. Mead S, MacNeil C. (2006). Peer support: What makes it unique? Int J Psychosoc Rehabil, 10, 29–37. Minore B, Boone M. (2002). Realizing potential: Improving interdisciplinary professional/ paraprofessional health care teams in Canada’s
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northern aboriginal communities through education. J Interprof Care, 16, 139–47. O’Hagan M. (2011). Peer support in mental health and addiction: A background paper. Wellington: Kites Trust. O’Hagan M, McKee H, Priest R. (2009). Consumer Survivor Initiatives in Ontario: Building for an equitable future. Report for CSI Builder Project. Toronto, ON: Ontario Federation of Community Mental Health and Addiction Programs. Rebeiro KL, Day DG, Semeniuk B, et al. (2001). NISA: An occupationbased, mental health program. Am J Occupat Therapy, 55, 493–500. Repper J. (2013). Peer support workers: Theory and practice. London: Centre for Mental Health. Available from: centreformentalhealth.org.uk/pdfs/ImROC_peer_support_workers_theory_practice. pdf. Repper J, Carter T. (2010). Using personal experience to support others with similar difficulties: A review of the literature on peer support in mental health services. London: Together/University of Nottingham/ NSUN. Available from: together-uk.org/wp-content/uploads/ downloads/2011/11/usingpersexperience.pdf. Repper J, Carter T. (2011). A review of the literature on peer support in mental health services. J Mental Health, 20, 392–411. Rivera JJ, Sullivan AM, Valenti SS. (2007). Adding consumer-providers to intensive case management: Does it improve outcome? Psychiatr Serv, 58, 802–9. Solomon P. (2004). Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatr Rehabil J, 27, 392–401. Wright C, Rebeiro KL. (2003). Exploration of a single case in a consumer-governed mental health organization. OT Mental Health, 19, 19–32.
ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20
Authentic peer support work: challenges and opportunities for an evolving occupation Karen L. Rebeiro Gruhl, Sara LaCarte & Shana Calixte To cite this article: Karen L. Rebeiro Gruhl, Sara LaCarte & Shana Calixte (2016) Authentic peer support work: challenges and opportunities for an evolving occupation, Journal of Mental Health, 25:1, 78-86, DOI: 10.3109/09638237.2015.1057322 To link to this article: http://dx.doi.org/10.3109/09638237.2015.1057322
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http://tandfonline.com/ijmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, 2016; 25(1): 78–86 ! 2015 Shadowfax Publishing and Taylor & Francis Group, LLC. DOI: 10.3109/09638237.2015.1057322
RESEARCH AND EVALUATION
Authentic peer support work: challenges and opportunities for an evolving occupation Karen L. Rebeiro Gruhl1, Sara LaCarte1, and Shana Calixte2 Centre for Rural and Northern Health Research, Laurentian University, Sudbury, Ontario, Canada and 2Northern Initiative for Social Action, Sudbury, Ontario, Canada
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Abstract
Keywords
Background: The peer support worker (PSW) belongs to the fastest growing occupation in the mental health sector, yet it is often under-valued and poorly understood. Despite an emerging evidence base, and strong support from mental health service users, the PSW remains on the periphery of mainstream services in northeastern Ontario. Aims: To examine the role of the PSW, along with the challenges and benefits, and to understand why the PSW is not more integrated within mainstream services. Methods: A sequential, exploratory, mixed-methods design was used to collect data on 52 survey and 33 focus group participants. Qualitative data were analyzed thematically. Results: Peer support work was described by participants as being authentic when PSWs can draw upon lived experience, engage in mutually beneficial discussions, and be a role model. Authentic peer support was noted to be important to the recovery of mental health service users; yet, participants revealed that many positions continue to reflect more generic duties. Challenges to further integration include acceptance, training and credentialing, self-care, and voluntarism. Conclusions: Future development and mainstream integration of peer support work must reconcile current tensions between standardization and loss of authenticity. Training in communicating the lived experience, setting boundaries and self-care are important steps forward.
Consumer survivor, lived experience, mutual aid, peer providers, role clarification
Introduction Peer support workers (PSWs) are the fastest growing occupational group in the mental health workforce (Doughty & Tse, 2011). According to Solomon (2004), peer support services are ‘‘provided by individuals who identify themselves as having a mental illness and are receiving or have received mental health services for their psychiatric illness, and deliver services for the primary purpose of helping others with a mental illness’’(p. 393). While peer services largely evolved as an alternative to the formal mental health system (Deegan, 2006); more recently, these services are partnering and collaborating with mainstream services (Forchuk et al., 2005). Yet, it remains unclear operationally what constitutes the support provided by peers. Defining the nature and meaning of peer support for mental health consumers is a challenging task, primarily because one of the defining features of peer support is the flexibility to suit people’s needs and interests. This diversity has its drawbacks – namely, with
Correspondence: Karen L. Rebeiro Gruhl, PhD, O.T. Reg (ON), Health Sciences North: Community Mental Health and Addictions Program, 127 Cedar Street, 6th Floor, Sudbury, Ontario P3E 1B1, Canada. E-mail: [email protected]
History Received 6 September 2014 Revised 3 April 2015 Accepted 21 April 2015 Published online 18 September 2015
respect to understanding who the PSW is, what they do, and the value-add they provide for mental health services. Multiple reports have identified peer services as a best practice, yet policy direction for integrated services has been limited (O’Hagan et al., 2009). Kemp & Henderson (2012) conducted a qualitative study exploring the challenges faced by PSWs. The most salient issues identified by the study participants were (1) a lack of clarity in the roles for peers and employers, (2) excessive workload expectations, (3) a lack of supervision, and (4) concerns involving self-disclosure. To address these challenges, it was recommended that standardizing the peer role within mental health services and expanding education of providers and service users would ensure the appropriate utilization of peer resources (Faulkner & Kalathil, 2012; Kemp & Henderson, 2012). The existing literature suggests that peer services positively impact service users in the domains of social support, community integration, personal empowerment, quality of life, symptom distress, utilization of hospitals (Lawn et al., 2008; Lyons et al., 1996), and employment/education (Doughty & Tse, 2011; O’Hagan etal., 2009). Moreover, although less well examined, peer services are thought to effect change on system-level activities, including community planning, public education, advocacy, and action research.
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Janzen et al. (2006), for example, identified peer services to be most helpful in providing (1) a safe, positive, welcoming environment; (2) a social arena to meet and talk with peers; (3) an alternative worldview allowing members to participate and contribute; and(4) community integration. These studies, conducted in an urban setting, provide less guidance as to the transferability of these findings to northern, small town and rural contexts. Our own research on one peer-run program in northeastern Ontario demonstrated several positive outcomes for service users (Legault & Rebeiro, 2001; Rebeiro et al., 2001; Wright & Rebeiro, 2003); however, these studies have not specifically placed a lens on the PSW or the services they provide. The aim of the current study was to expand what is known about the PSW in northeastern Ontario, and to better understand why peer support is not more fully integrated within mainstream services.
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Methods The research employed an exploratory, sequential, mixedmethods design (Figure 1). The research was conducted across three, inter-related phases; each informing the next, as well as, addressing regional knowledge user and decision maker questions, and ensuring that knowledge users were involved in responding to the findings as well as to co-constructing potential solutions. In phase 1, we attempted to answer the question, who is the PSW in northeastern Ontario and what do they do? The questionnaire construction was both experiential and literature-driven, using the PSW general job description developed by Jacobson et al. (2012) to structure questions on job duties
and responsibilities, with additional questions on the level of satisfaction with duties performed. The questionnaire was distributed by e-mail to a database of 300 consumers, consumer survivor initiatives (CSI), and mental health partners in northeastern Ontario, and to others by snowball recruitment. It is estimated that there are 65 paid PSWs in the region; the nature of the volunteer PSW is a challenge to calculating the exact population size. In phase 2, four focus groups were conducted to explore the survey findings in greater depth. Participants were PSWs providing services in consumer survivor programs, Native Friendship Centers (for individuals of aboriginal origin), or mainstream mental health organizations. Initially, the research team was not soliciting recipients of peer support; however, if a recipient wished to be a part of the focus group, they were welcome to participate and their insight into the role and value of the PSW was included in data analyses. Focus group discussions were centered on how the participants defined the role of peer support work and how PSWs are being integrated into mainstream mental health services. Focus groups were audio-taped and transcribed verbatim. A second survey questionnaire was developed for the purposes of member-checking due to the large geography of the study. An executive summary of the findings was developed and distributed using the original mailing list, and requested to be forwarded to other PSWs. Participants were asked whether they agreed with the major themes, and space was provided to comment on the accuracy of the findings. All participants were provided a letter of information outlining the risks and benefits of participation as well as details about how their personal information would be
Research Question: Who is the PSW in northeastern Ontario and what do they do?
Web-based survey 51 participants
Research Question: What are the challenges to further mainstream integration of the PSW in northeastern Ontario?
Focus Group 1 CT=7 participants
Focus Group 2 NL=8 participants
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Focus Group 3 NB=10 participants
Focus Group 4 SM=5 participants
Individual Interview SM=1 participant
Member Checking Questionnaire: Participant confirmation of findings
Figure 1. Data collection process.
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managed. All participants were assigned a coded identifier to provide anonymity, given the small communities within which data were collected. Ethics approval was granted by the Health Sciences North Ethics Committee.
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Data analysis Survey data were analyzed to answer the questions who is the PSW and what do they do, and to provide a descriptive profile of the PSW in northeastern Ontario, with a particular lens on urban, small town, and rural settings. Focus group and interview transcripts were initially read by all authors and reflected upon as to the overall meaning. Data analysis was an iterative and open-ended process; inductively generating categories from the raw data (Boyatzis, 1998; Creswell, 2007) (Figure 2). Emerging patterns were merged into themes that described and organized the data, as well as provided an interpretation of the data (Boyatzis, 1998). The themes help to make explicit PSW and the challenges they face with integration within mainstream mental health services in northeastern Ontario.
Results Survey results The survey results are based on the responses from 51 PSWs. Who is the peer support worker in northeastern Ontario? The PSW in northeastern Ontario is a mature workforce with 67% being over 40 years of age. The peer support workforce is mostly female (65%) and Caucasian (85%). Sixty percent of the participants completed University or College, and another
27% had some University or College education. Sixty percent of our sample had received training as a PSW (ranging from 1 week to 1 month duration). In comparison to the general population of the northeastern Ontario, wherein only 42.83% have completed high school, the PSWs in our study are a highly educated workforce. Where is the peer support worker located? The study draws from a predominantly urban-based workforce, located in proximity to the larger centers (Figure 3). Seven percent of the survey participants identified living a rural, small town of less than 10 000 residents. Most paid positions were located in CSIs, with a few PSW positions within First Nations and housing organizations. PSWs working within mainstream mental health services were mostly on assertive community treatment (ACT) teams. What does the peer support worker do? Participants identified spending the majority of their time in the following top five activities: communicating and working collaboratively, completing documentation, attending team meetings, sending and receiving e-mail/telephone calls and participating in training. Most of these activities would be categorized as indirect work activities. In contrast, participants identified deriving the most satisfaction from the following direct work activities: sharing and discussing common experiences with clients, participating in training, communicating and working collaboratively with others, initiating, establishing and maintaining relationships with clients, and helping clients to set goals and work towards them (Table 1).
Survey Data + Data from 4 focus groups and one interview Documents
Inductive coding of all data sources
Iterative process of identification of patterns, interpretation, and theme development
Lived Experience: Therapeutic use of self
Reciprocity: mutuality of peer support
Role modeling: Society’s mirror
Acceptance and valuing
Training and credentialing
Voluntarism
Self-care
Challenges to authentic peer support and to mainstream integration
AUTHENTIC PEER SUPPORT
Figure 2. Data analysis process.
Rural and small town
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Figure 3. Location of survey and focus group participants.
Table 1. Rank-ordered comparison of activities frequently performed and activities most satisfying.
Activity/duty/responsibility (direct/indirect)a Communicate and work collaboratively with team members Attend team meetings Complete require documentation Send and receive e-mails/telephone calls Participate in any training required Initiate, establish and maintain relationships withclients Share & discuss common experiences with clients Work collaboratively with clients, co-workers and community Help clients to create meaningful lives Connect clients to resources All other responsesb Education and awareness building efforts Help clients set goals and work developing skills Help to build a collective sense of community for client Meet with supervisor to discuss performance Work directly with clients to address problems and answer questions a
Frequently performed activity
Most satisfying activity
1 2 2 3 4 5 6 7 8 9 10 410 410 410 410 410
2 4 47 47 2 3 1 47 47 47 7 4 4 5 6 6
Direct activities involved face-to-face contact with a peer. Indirect activities do not involve face-to-face contact. Other responses include: advocate on behalf of clients, help clients to navigate the health and social services systems, meet clients both in the hospital and in the community, coach and mentor clients, plan, organize, develop, lead and facilitate group activities, observe and educate regarding medication, and participate in any training required for the position.
b
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What is the level of integration of peer support worker within mainstream services? An interesting finding was that 78% of the survey participants identified their work to be integrated within mainstream services, often, very often, or all the time – a finding that did not align with what we have observed in everyday practices. To help understand this discrepancy, the question was brought forward to the focus groups for further exploration.
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Focus groups Thirty-three individuals participated in the focus groups, including 25 PSWs and 8 recipients of peer support. Seventeen PSWs have received training for their work; however, the training was inconsistent across the participant groups, especially in smaller town communities. Fourteen of the 25 PSWs are paid for their work, and 11 function as voluntary PSWs. Participants are coded based upon the community they lived in and by their registration number (e.g. CT-01 would be the first registrant in the Cochrane Timiskaming district) in order to maintain anonymity in these smaller communities.
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model’’ (NB10). One focus group participant explained the importance of lived experience to peer support work: I just felt like due to my own lived experience and where I’ve been in my journey that I felt like you can’t learn what we’ve lived in a textbook. As a mental health worker, that’s great. But unless you’ve walked in those shoes, there’s nothing that you’re going to be able to add that someone without college can add. It’s just priceless and that’s my take. (SM03) Reciprocity Authentic peer support was described as mutually beneficial. Participants spoke to the personal benefits of doing peer work, in particular, as a means to also help them to keep well: I get a lot out of helping others and it helps benefit myself. (NL05) Other participants spoke of how the act of sharing or therapeutic use of self, furthers their own healing process as well as mirroring to others that recovery is possible:
Authentic peer support Authentic peer support is a conceptual term used to capture what participants identified to be the essence of their work, and the value-add of PSW to mainstream mental health services. Authentic peer support did not necessarily reflect what participants were doing in their everyday work, as evidenced by the survey findings. Instead, authentic peer support was described to be flexible and idiosyncratic; that is, driven by the recipient of peer support, rather than drawing upon a particular list of duties or activities. Survey and focus group participants attributed the following to the authenticity of peer support work: drawing upon lived experience and the therapeutic use of self; reciprocity and the mutuality of PS work; and, the value of role modeling. Authentic peer support work was advanced by the participants to be a gap in the mental health system, and the rationale for mainstream integration: I think that one of the most important things that has trained me for my job description is the lived experience. I have a degree in education; I have a degree in psychology. I have all kinds of diplomas in education background and I have been an educator for most of my life, but having the lived experience of severe mental illness has given me a lot of insight, and patience, and tolerance and compassion . . . the lived experience is the most important thing that I bring to the table. (NB09)
Drawing upon lived experience Participants described the philosophy of peer support work to be drawn directly from lived experience and with an insider’s perspective of what is helpful, and what is not so helpful. Participants identified how authentic peer support work is about ‘‘supporting people in their recovery, and not defining it for them, and about sharing my story and my experience as a point of validation and also as an example or role
So I guess what drives me, I feel like my peer support work is mutually beneficial . . . like I feel like being able to share my life with people to where it’s like, yeah I get that. (NB07) For me sharing my story, I feel validated and yet it comes back the other way, too because they’re standing there going, holy crap, I’m not alone. (NB04) Society’s mirror The next category helping to unpack authentic peer support work concerns how the PSW provides a mirror reflection to mental health users that recovery is possible. In the context of peer support, participants recognized the value of one who has been there to providing hope to others: And because I had gone through it and I was sitting in front of her she had said to me that it was nice to know that somebody is out there that has gone through it and has come out at the other end. (NL01) Another PSW emphasized the power implicit in the act of sharing to another’s recovery: I really wanted that peer aspect of it, right, that normalcy that you can get through it . . . for the women that are feeling like they’re never going to get out of it, that they’re hopeless, I want to be able to project and show them that two years ago, I was in my bed unable to get out of the house . . . (SM04) Challenges to the mainstream integration of the peer support worker Despite the abovementioned stated benefits derived from access to authentic peer support, there were also notable
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challenges to their further integration within mainstream mental health and addictions services in northeastern Ontario. These challenges were categorized as acceptance and valuing, training and credentialing, voluntarism, self-care, and rural and small town contexts.
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As for peer support, there’s only two of us here who have taken that two week peer support training–two of us in this room. (TM05)
Voluntarism Acceptance and valuing
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Participants identified being accepted and valued by others in the mainstream mental health system to be a primary challenge to the PSW, acknowledging that acceptance within the mental health system was inconsistent at best: It’s a good start, but it doesn’t have support. It’s very difficult. When you say integrated, we’re trying, we’re trying to bring to the hospital let’s bring peer support into the hospital. We’re trying, but wow it’s a battle. And that battling sense is wrong. I really feel we should be able to be critical of the system. And that’s what is getting attention. (NB10) Participants also discussed the value of training and credentialing to fuller acceptance within mainstream mental health systems. While some participants feared a trend to over-qualifying of the PSW, or to being masked under different titles and jobs; others identified providing generic mental health duties within which unique PSW activities and values were less visible to outsiders as a challenge to mainstream acceptance. One participant explained: I have a position that is labelled partial peer support worker . . . is that my job? Nope, it’s part of it when there’s time. (SM05)
Training and credentialing Participants perceived that the mainstream mental health system was more accepting of a diploma or of the training routinely provided to other mental health workers as the preferred way of ‘‘knowing’’, rather than lived experience. These insights helped to explain the push for generic training and to do generic ‘‘activities’’ over authentic peer support work: But when I went for my training, I felt like pretty much everything in my peer support training, like lined-up with what I learned being like a counselor and the only thing that was really different was using my own lived experience as strength instead of a problem. (NB07) In rural and small town communities, training was often inconsistent or missing, and may explain the stated lack of acceptance and valuing of the PSW in these settings: I haven’t taken any training. I’m not even aware that it’s been offered up where I am. . . . I do not have a policy degree as a social worker or anything. I’m coming from the centre where I was formerly a volunteer and that was it. So it’s lived experience plus I’ve been sent for crisis intervention, conflict resolution . . . those kinds of things. (NB04)
Voluntarism was raised as a way to provide PSW in communities that did not have paid positions, as well as a meaningful occupation for many of the participants. Voluntarism was also perceived to reflect a lack of acceptance and valuing of PSWs and serve as a barrier to mainstream integration: I did that on my own time, she’s [manager] not interested in that. And to me, that is being a peer support worker. But it had no validity to anyone except me and the person. (NB04) I have been a volunteer in mental health for the past 10 years. I’ve been volunteering, helping my peers for all kinds of things. I work 7 days a week, close to. (TM01) For some of the participants, voluntarism was identified as a challenge to the credibility of this evolving workforce. Yet, others in the member check raised concern with the loss of voluntary PSW opportunities due to standardized training. Self-care Self-care was the final challenge raised by participants; underscoring ambiguous personal boundaries as a pressing challenge to the PSW: In regards to boundaries, I actually have really rigid boundaries. As far as self-disclosure goes, I’m OK with that and I do that because that’s the whole idea that part of peer support . . . I work 60 hours a week and I raise a kid, so there has to be a point for my own personal self-care where I do turn off because if I don’t I’m likely to end up in a really bad situation. (NB10) PSWs identified the importance of establishing clear, personal boundaries with recipients of PSW to their ongoing recovery and ability to help others: For me it’s within those hours and my own wellness. I live with my moods going up and down. I have to really take care of myself. And I have a really firm line for me- how I’m going to support someone. (SM04) PSWs also raised the challenges of establishing and maintaining personal boundaries in places where there is a limited understanding of peer support work, where there are only sole practice PSWs, or in situations in which the scope of duties have not been provided by a peer supervisor or mentor. In this study, PSWs in urban areas who had a well-defined peer network of support were more likely to establish personal boundaries and be supported in using them. SM05, a new PSW, raised concern regarding the ambiguity of boundaries in their work,
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Yeah, I played with how much do I share? How much do I,like I want there to be a boundary set between I’m still here for you, it’s not about me . . . but I wasn’t there as a stomping ground for my issues . . . (SM05) Burnout. Burnout, a consequence of limited self-care, was a
further challenge to this evolving occupation and to their future development and integration into mainstream services. In particular, participants identified a disconnect between their training and the draining nature of their work: One person trying to do all this is crazy. (NB08) I think it’s very important to put those services in place to help peer support workers not burn out. (NB10) It can be really, really tiring and draining to just be on for hours and hours. (NB05) The final challenge to the mainstream integration of the PSW concerns place. In rural and small town communities, PSWs were identified to be less known, visible, accepted, valued, and accessible to service users in mainstream services. Boundaries were also acknowledged to be blurred in smaller communities, elevating the risk for burnout, and limiting opportunities for self-care:
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Rural and small town.
Because it’s a small town . . . I do outreach in the community, it’s like, oh yeah, you’re with [org] do you think you could come and talk to us about it? I’m not shy at all about that; however, I have had to draw the line with some members. I have seen them at my door and if I’m not feeling up to it, I just won’t answer my door. (NB03) According to the participants, few knew about peer support in their communities and therefore had little to no knowledge of the benefits of PSW or why they might need them: Because nobody wants to admit they come to [CSI] it’s confidential . . . it’s a hush-hush kind of thing. It’s a secret society kind of thing . . . But, I mean because it’s not known in society, and you can’t even look at it on the Internet . . . there’s nothing about [CSI] . . . Unless you know about it, but nobody knows about it . . . it’s very secretive. (TM05)
Discussion The findings of this study mirror the existing national and international literature on peer support in many respects. There is strong support of the importance of lived experience, mutuality, and role modeling to the benefits of the PSW (Berry et al., 2011; Cabral et al., 2013; Davidson et al., 2006; Doughty & Tse, 2011; Jacobson et al., 2012; Lien & Meissen, 2012; Mead, 2003; Mead & MacNeil, 2006; O’Hagan et al., 2009; Solomon, 2004); as well as for the role of the PSW in enhancing the mental health system’s capacity to address service user recovery needs (Chinman et al., 2001; Davidson et al., 1999; Doughty & Tse, 2011; Grant et al., 2010; Herbert et al., 2008; Janzen et al., 2006; Repper & Carter, 2011; Rivera et al., 2007). Despite this support, these benefits are
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not necessarily reflected in the current roles and responsibilities of PSWs in northeastern Ontario. Instead, participants suggested that other factors, such as, non-peer supervisor perceptions, may influence existing job descriptions more than what participants described to be authentic peer support. Non-peer development of job duties and responsibilities may help to explain why the activities in which PSWs in northeastern Ontario spend the most time, do not easily align with activities described to be authentic peer support. Participants identified spending more time in indirect mental health duties – rather than the direct, one-on-one peer support in which they draw heavily upon their lived experience. It may also help to explain the lower levels of satisfaction expressed by study participants with their current jobs. Faulkner & Kalathil (2012) explained that support was most helpful if both peers have other things in common such as cultural background, religion, age, gender and personal values. Additionally, relationships were more supportive if both people were willing to provide and receive support and had gained some distance from their own situation, so that they were able to help each other think through solutions, rather than simply give advice based on their own experiences. For these reasons, Faulkner & Kalathil strongly advocated for training, supervision and support for peer workers employed in health services. Repper (2013) commented on the importance of reciprocity or the mutual aid of peer support to recovery, noting how both PSW and service users are supported in their own recovery journeys. Repper & Carter (2010) also identified that employment as a PSW provides individual benefits, including self-esteem, confidence and personal recovery. O’Hagan(2011) noted how the values of mutuality and experiential knowledge are unique to peer support, and highlight differences in boundaries exercised by PSWs and traditional professionals. O’Hagan described the work of the PSW to be situated somewhere between a friend and a traditional professional relationship. However, our findings highlight the difficulty of this positioning within PS work – especially in the absence of more formal training or support networks. Similar to our study, researchers recommend that peer support services would benefit from further standardization with respect to training and education (Faulkner et al. 2013). Training opportunities can develop the capacity, potential and leadership of individuals giving and receiving peer support (Repper & Carter, 2010). This is challenged by findings that the peer workforce in mainstream settings is poorly understood, underpaid, discriminated against and expected to work according to traditional values and ethics (Daniel et al. 2010). Daniels et al. (2010) questioned whether mainstream integration of peer support services may in fact pose the greatest risk to peer services yet; specifically, that mainstream services will colonise peer support work and create a workforce and services in its own image. In our study, participants did raise concern about losing the value of peer support through a process of over-professionalising the peer workforce, and in particular, of non-peer supervisors determining peer support roles and responsibilities. The research literature was less explicit regarding the challenges facing the PSW residing in rural and small town
Authentic peer support work
DOI: 10.3109/09638237.2015.1057322
communities. In this study, it was observed that as the PSW migrates away from the urban center, there was an increased likelihood of burnout, role blurring, unclear personal boundaries, fewer support networks, and an increased likelihood of volunteer than paid peer work. Minore & Boone (2002) previously identified the potential benefits for peers to collaborate in mental health and addictions care in rural and small town northern places; yet, this study highlighted that more work is needed to achieve the level of mutual respect necessary for effective collaboration. To address this essential work, we offer several recommendations to further the understanding of authentic peer support, the development of this workforce, and their integration within mainstream services.
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larger urban centers more challenging; nonetheless, our findings are consistent with the literature.
Conclusions Most PSWs in this study experienced difficulty in describing what they did, and why the mental health system needed peer support, other than by describing the activities they performed in their jobs. This did little to make explicit their unique contribution to mainstream mental health services, or why they should be hired if they are engaging in generic mental health tasks. In many ways, authentic peer support is particularly important to the mental health system in that it drills down to essential human needs for compassion, empathy, listening, validation, and hope. Future training should embrace authenticity and any standardization of peer support work should be based in it.
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Education The need for an investment in annual training and in the further development of this workforce was raised. The findings of this study highlight inconsistent training, which is especially problematic in rural and small towns. The establishment of a minimum standard of training for PSWs is recommended, notably, reflecting the skills and perspectives of authentic peer support work. Furthermore, the findings point to the need to create a network of supports to ensure that the peer support workforce is able to survive and thrive in the mainstream system, and importantly, collectively advocate for its authenticity. Mainstream integration The further integration of the PSW within mainstream mental health services is contentious, with some viewing integration as a way to better recognition and job opportunities; and others fearing the costs of assimilation. Participants in this study identified that it is in the authenticity of peer support work that brings value to the current mental health system. In this study, we learned that limited integration was a result of inconsistent training and role functions – each contributing to vague understandings of what PSWs bring to mental health systems. While participants clearly articulated the benefits to authentic peer support, they also acknowledged that this was not often possible within current positions. Future research Future research will track PSW employment as well as level of integration within mainstream mental health services over time. We are interested to observe the influence of more formal credentialing and the implementation of national standards for PSWs in Canada on their employment and integration trajectories, and importantly, on the stability of authenticity. And finally, we remain interested in understanding urban/rural differences, especially regarding hiring practices, training and the effects of a peer network of support on solo, rural, and small town PSWs. Limitations This study was conducted in small cities and rural towns in Northeastern Ontario and make generalizing the results to
Acknowledgements The authors would like to acknowledge all of the participants of this study for their time, their wisdom and their intimate sharing with the research team.
Declaration of interest The authors declare no conflicts of interest.
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