Among the many Aesop’s fables, is the story of the Two Pots. The fable goes something like this:
Two pots had been left on the bank of a river, one of brass, and one of earthenware. When the tide rose they both floated off down the stream. Now the earthenware pot tried its best to keep aloof from the brass one, which cried out: “For nothing, friend, I will not strike you.”
“But I may come in contact with you,” said the other, “if I come too close; and whether I hit you, or you hit me, I shall suffer for it.”
And the moral of this story is: ‘equal partnership is best, and especially that the poor or powerless should avoid the company of the powerful’.
Is this a moral to consider for the emerging story of peer support in mainstream mental health services?
Research on peer support in mental health has already been a feature of quite a few Mental Elf blogs, with one blog featuring a comparative case study, and asking the very pertinent question: ‘Is the NHS ready for peer support in mental health?’ The answer was more or less, ‘Umm…not yet sure about effectiveness, but peer support is complex, significantly challenging and could require complete culture change in the NHS’. Many of those who’ve worked as peer workers in mental health are likely to agree with the last sentiment especially.
A recent Dutch literature review gives further insight into how peer workers can fit into traditional mental health services and work alongside mental health practitioner colleagues.
By reviewing the relevant qualitative and quantitative research, the authors aimed to answer the following question:
What are peer workers’ perceptions and experiences to the implementation of peer worker roles in mental health services?
They wanted to explore how their perspectives related to the nature of the peer support innovation; their professional colleagues; the service users; and the social, organisational, economic and political context.
Electronic databases including PubMed, CINHAL, Web of Science, Cochrane Library and PsycARTICLES were searched for studies published between 1998 and 2015. In addition, reference lists of reviews and included studies were hand-searched.
The search initially yielded 2,802 articles, of which 18 were finally included after the screening and selection processes. The 18 included studies all used qualitative research methods.
Studies were included if they were in English or Dutch, were about peer workers aged over 18 and focused on peer workers experiences and perceptions of their role. Study methodology was assessed using CASP tools. Data was extracted and thematic analysis used to synthesise the results of the studies.
The analysis and synthesis of the literature yielded the following themes relating to the barriers experienced by peer workers in a variety of settings, and at a number of levels:
Nature of the innovation
- Lack of role clarity: ambiguous and unclear descriptions of tasks and duties; frustration and confusion about fulfilling their role; time needed to adapt to role.
- Pressure to gain acceptance: role lacks credibility; not accepted as stakeholders; need to continuously justify position because of negative attitudes or misunderstanding.
- Residual and recurring health issues: work-related stressors and social and emotional limitations challenge performance; maintaining wellbeing can be difficult when using own experience.
- Misunderstanding and negative attitudes: lack of understanding about the value of lived experience; staff attitudes and experiences of direct and indirect stigma.
- Impeded by professional routines: task orientated care; different beliefs about what constitutes good care and support; informal support being misunderstood.
- Lack of interest and uncooperativeness: peer support is questioned by service users.
- Challenging personal and interpersonal boundaries: familiarity with service users from using services; friendship boundaries; ambiguity about boundaries because of need to create connection.
- Adverse effects of self-disclosure: experience of distress when using personal experiences; appropriate disclosure; unrealistic expectations of role modelling.
- Struggles with team integration and collaboration: isolation and lacking sense of belonging; collaboration impeded by unclear role; power struggles with other staff; team use of clinical language.
- Conflicted sense of identity: peer support worker identity construction; switch from position of service user to service provider; discomfort with being identified as a professional; limited autonomy.
- Lack of recovery-oriented culture: crisis oriented cultures without service user involvement; importance of recovery orientation.
- Inadequate provision of training: feelings of inadequacy and uncertainty; specific on-going training about managing emotions, self-disclosure, peer relationships and workplace orientation without over-professionalisation.
- Inadequate supervision: emphasis on task performance rather than emotional concerns, boundary issues and personal development.
- Lack of resources and adverse effects of working conditions: low financial compensation and lack of workplace resources (desk space, access to a computer and records); ambiguity about working under supportive conditions; lack of clear promotion and future work direction.
- Dissatisfaction with rigid organisational structures and task allocation in traditional settings: high workload; overly administrative procedures compromising peer support work values, authenticity and activity.
Economic and political context
- Dissatisfaction with contracting and recruiting: poor or non-existent financial compensation; lack of credibility for role; temporary contracts and income security; inadequate recruitment strategies.
- Lack of recognised certification and funding: impedes acceptance and influence; peer support seen as a temporary project; inadequate support for sustainability.
- Interference of work with social security regulations: contracts may not offer paid holidays; restrictions posed by welfare benefits system.
The authors conclude that a form of co-production between peer workers and practitioner colleagues could start to address some of the cultural and practical barriers:
Mental health professionals and peer workers should enter into an alliance to address barriers in the integration of peer workers to enhance quality of service delivery.
Strengths and limitations
By analysing and synthesising the findings from 18 studies, this research gives a comprehensive picture on what the challenges are for successfully introducing and embedding peer support in mental health services and mainstream practice at all levels from frontline to organisational and beyond.
In terms of applying research into practice, the findings themselves could inform a practical, evidence-based implementation framework for mental health organisations wishing to introduce peer support workers.
The limitations, as noted by the authors, are posed by the included studies themselves. The qualitative research on mental health peer support workers is of varying methodological quality with several studies having very small samples. In eight of the included studies there is ‘a lack of in-depth outline of the analysis process’, and in five there was ‘no adequate discussion of evidence for and against the researcher’s arguments’, both of which raise questions about study rigour.
The included studies also give no clue about how diversity and discrimination might function in relation to peer workers in mainstream mental health settings. Do black peer workers have more negative experiences than white peer workers in relation to colleague attitudes and stigma? Do experiences and perceptions differ by gender? We don’t yet know.
A while ago a Mental Elf blog on a Cochrane review on the effectiveness of peer workers explored what research was suggesting about the effectiveness of peer support in mental health services. The conclusion was that it is no better or worse than support provided by workers with professional training.
However, the findings of the study explored in this blog suggest that the effectiveness of peer support and performance of peer workers could be impeded by many factors, not least those relating to stigma, attitudes, organisational structures, culture and values.
If we cross reference these findings with what we know about other service user driven approaches that have been implemented into unreformed mental health services, such as recovery (Boutillier et al, 2015), we can adopt a critical view of what the evidence is suggesting. When asking if peer support is effective, we should perhaps also ask if it’s able to be effective given mental health service cultures and structures, and consider how we can best measure the effects in ways that are meaningful to those who use services, rather than to the services themselves.
Research like this study is helpful for illuminating what the conditions are like for introducing and mainstreaming something as potentially radical as peer support in traditional mental health services. While it says things about the intervention or activity, it also says important things about the system and culture into which it is being introduced.
Finally, to return to Aesop’s Two Pots and the moral of the story that ‘equal partnership is best, and especially that the poor or powerless should avoid the company of the powerful’. Is this also a good moral for the story this research is telling about peer support? I’ll let you decide…
Vandewalle J, Debaser B, Beeckman D, Vandecasteele T, Van Hecke A, Verhaeghe S. (2016) Peer workers’ perceptions and experiences of barriers to implementation of peer worker roles in mental health services: A literature review. International Journal of Nursing Studies. 2016 Aug;60:234-50. dos: 10.1016/j.ijnurstu.2016.04.018. Epub 2016 May 11. [Abstract]
Le Boutillier C, Chevalier A, Lawrence V, Leamy M, Bird VJ, Macpherson R, Williams J, Slade M. (2015) Staff understanding of recovery-orientated mental health practice: a systematic review and narrative synthesis.
Implementation Science 2015 Jun 10;10:87. doi: 10.1186/s13012-015-0275-4. [Full Text]