Challenges Experienced by Paid Peer Providers in Mental Health Recovery: A Qualitative Study

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Community Mental Health Journal ISSN 0010-3853 Community Ment Health JDOI 10.1007/s10597-012-9541-y

Challenges Experienced by Paid PeerProviders in Mental Health Recovery: AQualitative Study

Galia S.Moran, Zlatka Russinova,Vasudha Gidugu & Cheryl Gagne

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ORIGINAL PAPER

Challenges Experienced by Paid Peer Providers in Mental HealthRecovery: A Qualitative Study

Galia S. Moran Zlatka Russinova

Vasudha Gidugu Cheryl Gagne

Received: 5 October 2011 / Accepted: 18 September 2012

Springer Science+Business Media New York 2012

Abstract Peer providers are increasingly employed in

mental health services. We explored challenges experi-

enced by 31 peer providers in diverse settings and roles

using in-depth interviews, as part of a larger study focusing

on their recovery (Moran et al. in Qual Health Res, 2012).

A grounded theory approach revealed three challenge

domains: work environment, occupational path, and per-

sonal mental health. Challenges in the work environment

differed between conventional mental health settings and

consumer-run agencies. Occupational domain challenges

included lack of clear job descriptions, lack of skills for

using ones life story and lived experience, lack of helping

skills, and negative aspects of carrying a peer provider

label. Personal mental health challenges included overwork

and symptom recurrence. Implications for all domains are

discussed, with focus on training and skill development.

Keywords Consumer providers Mental illnesses Jobdevelopment Workforce integration

Introduction

Peer services involve the employment of individuals with

psychiatric lived-experiences who provide services to

others challenged with similar conditions (reviewed in

Davidson et al. 1999). Peer providers are increasingly

employed by U.S. mental health agencies and peer ser-

vices. They are gaining popularity as viable mental health

services for individuals with serious mental illnesses (e.g.

New Freedom Commission 2003; Campbell and Leaver

2003). Recognition of their value is reflected by efforts in

the last decade to involve and develop peer services

(Chinman et al. 2006; Gates and Akabas 2007; Katz and

Salzer 2006). Such efforts are consistent with recovery-

oriented system transformation processes which encourage

involvement of consumers in all aspects of the mental

health system (Farkas et al. 2005).

Peer providers work in a wide range of roles, services

and settings. For example, they are members of multidis-

ciplinary mental health teams within programmatic asser-

tive community treatment, facilitate recovery-oriented

groups in psychiatric wards, or work as peer educators and

advocates in consumer-run services (e.g. Campbell and

Leaver 2003; Craig et al. 2004; Cleary et al. 2006;

Davidson et al. 2006; Hebert et al. 2008; Salzer and Shear

2002).

In all of these roles, a unifying feature is that peers use

knowledge or wisdom gained through their lived experi-

ence. This includes their personal experience of having a

psychiatric disability, its consequences, and experience

with mental health systems or services. Thus peer providers

engage recipients of service on a deep and authentic level.

This type of connecting is uncommon among professionals

without (or that do not choose to disclose) a psychiatric

condition. Peers can also voice consumer issues through

telling of personal story and experience (Mead et al. 2001;

Salzer 1997).

Research in the last two decades has accumulated

showing that peer providers have beneficial impact on recip-

ients of their services (e.g. Campbell 2004; Clay 2005; Cook

et al. 2012; Davidson et al. 1999, 2006; Felton et al. 1995;

G. S. Moran (&)Department of Community Mental Health, University of Haifa,

Haifa, Israel

e-mail: [email protected]

Z. Russinova V. Gidugu C. GagneCenter for Psychiatric Rehabilitation, Boston University,

Boston, MA, USA

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Community Ment Health J

DOI 10.1007/s10597-012-9541-y

Author's personal copy

McCorkle et al. 2009; Min et al. 2007; Rivera et al. 2007;

Salzer 1997; Solomon 2004). Less is known about the

personal experiences of those employed in peer roles. Such

knowledge could illuminate ways to support peer providers

and peer provision as an emerging occupational modality.

Benefits of Being a Peer Provider

An initial body of evidence points to multiple benefits

accrued from working as a peer provider. Qualitative

reports identified gaining transferable skills, increased self-

knowledge, positive experiences and forging connections

with other peer providers (Mowbray et al. 1998); engaging

in self-discovery, building support systems, learning posi-

tive ways to fill time, building job skills and moving

toward a career (Salzer and Shear 2002); and recently,

recovery and growth outcomes were identified across five

wellness domains including foundational (health & mental

health), emotional, social, occupational and spiritual

(Moran et al. 2012).

Quantitative studies further demonstrate benefits such as

reduced hospitalizations (Sherman and Porter 1991),

increases in sense of hope, self-esteem and recovery

(Ratzlaff et al. 2006), empowerment and generativity

(Moran et al. in press). Benefits emerge even at early stages

through involvement in peer training programs (e.g.

Hutchinson et al. 2006; Salzer et al. 2009).

Negative Aspects and Challenges of Being a Peer

Provider

Multiple challenges facing peer providers have been

described, including role confusion, conflicts with recipi-

ents of services, lack of appreciation of peers roles by

others (e.g. Dixon et al. 1997; Mowbray et al. 1998). Dual

relationships, role conflict and confidentiality, related to

working where one receives (or received) services, were

also challenges identified a decade ago (Carlson et al.

2001).

As peer services expanded and roles became more

diverse, new challenges arose. These related to needs

around support, education, training, and supervision as well

as more job opportunities and payment (Campbell and

Leaver 2003; Cleary et al. 2006; Davidson et al. 2006;

Hebert et al. 2008; Salzer et al. 2009). In parallel specific

dilemmas about working as a paid-peer emerged, such as

managing both a reciprocal role (of a peer supporter) and a

one-directional professional role (like other mental

health practitioners). Questions regarding job description

issues appeared, such aswhat should/should not be

included as part of peer services? (e.g. case management,

group facilitation in hospitals, etc.) (Davidson et al. 2006).

In general a call to develop manuals and models that can

support professional development has been voiced

(Campbell and Leaver 2003).

More recent studies on peer training and employment

showed promise in employability and success of paid peer

providers, and at the same time they highlight continuing

job development challenges and structural barriers. For

example, while Salzer et al. (2009) identified positive

subjective and objective outcomes following a certified

peer specialist training, they identified the need for job

placements and supervision for trained peer providers.

Similarily, Chinman et al. (2010), highlighted a challenge

of peer workforce implementation in clinical case man-

agement teams, proposing to address it by soliciting input

from provider teams and peer specialists.

Thus, while peer services are evolving and carry their

unique merits for recipients of services and more generally

for system changetheir successful implementation is the

field of mental health requires meeting challenges and

further occupational solidification (Campbell and Leaver

2003; Salzer et al. 2009; Chinman et al. 2010). Previous

studies were mostly conducted on a single program or

setting, and usually did not include peer-run organizations.

To address this, this study examines the challenges repor-

ted by individuals working in diverse workplaces, pro-

grams and peer roles, including consumer-run programs.

This provides an opportunity to compare peer providers

experiences in different settings, as well as identify

underlying common experiences. The aim of the study is to

develop a broader conceptual framework that will illumi-

nate challenges experienced by peer workers and serve as a

guide to support peer providers occupational paths.

Methods

This article presents findings from a larger exploratory

mixed-methods study that was conducted to examine the

personal recovery and growth outcomes of 31 employed

peer providers. The study design included 2 interviews

(a recovery interview and a life story interview) and self

report questionnaires. The current study focuses on chal-

lenge outcomes from the first interview. The study was

conducted in two waves: The first wave (February 2009

June 2009) was conducted with 10 participants who

worked as peer providers for at least 2 years and 20 h per

week. The second wave (August 2009December 2009)

broadened criteria to include participants with less exten-

sive work experiences. This was done as part of the larger

study, which assessed if and how various occupational

indicators may be related to recovery outcomes (Moran

et al. in press). The University Institutional Review Board

approved both studies. All study participants agreed to


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participate and filled informed consent forms before data

collection began.

Sample

For the purposes of the study, peer providers were defined

as individuals with a lived experience of mental illnesses

who are employed in providing services to others with

psychiatric conditions. Recruitment was conducted through

advertisements disseminated via electronic communication

in various agencies that hire peer providers and by word of

mouth. The ads invited employed peer providers to par-

ticipate in a study investigating, recovery and growth

experiences related to their work. Inclusion criteria were as

follows: (1) paid peer providers, and (2) a diagnosis of a

serious mental illness of either schizophrenia spectrum

disorders or affective disorders (e.g. depression; bipolar

disorders). The sample included peer providers who

worked in different mental health agencies in a big north-

eastern American city; twenty-six (84 %) worked in con-

ventional human services (e.g. PACT, residential services,

young adults program, etc.) and five (16 %) worked in

peer-run agencies where majority of staff were persons in

recovery. The majority (n = 25, 81 %) worked 20 h a

week or more. Participants engaged in a variety of roles

including personal supports (one-on-one relationships),

group facilitation (e.g. leading recovery groups) and pro-

gram level initiatives (e.g. curriculum development, train-

ing, advocacy). Twelve (39 %) had leading roles as

directors or trainers. Many had been in contact with peer

support or self-help groups prior to working as peer pro-

viders (n = 23, 74 %). More than half (n = 18, 58 %)

were certified through formal peer training. Almost two

thirds had a BA degree or higher (n = 19, 63 %) (See

Table 1).

Data Collection and Analysis

Data were collected based on semi-structured interviews

conducted by the first author. A semi-structured interview

guide was developed for the purpose of the larger study

question which focused on recovery and growth processes

experienced by working as a peer provider, yet the inter-

view also included a section on challenges. The interview

guide was developed by the first and second author based

on a review of recovery literature, and was refined fol-

lowing comments from a senior leading peer provider who

did not participate in the study. Open ended questions were

used to evoke descriptions of personal experiences

reflecting subjects perceptions and feelings. Interviews

began with a general question How did becoming a peer

provider impact your recovery? followed by probing

questions to encourage further elaborations. Open ended

questions about challenges were included more toward the

end of the interview including: What might be some of

the downsides resulting from working as a peer provider?,

what is a low moment related to your work as a peer

provider? and further probing; Please describe why this

particular aspect is a downside for you?. Interviews were

recorded using a mini digital recorder and transcribed

verbatim. Data were analyzed using QSR NVivo 1.3

computer software.

The first 3 authors independently read and coded the first

3 interviews with the purpose to develop an initial list of

codes. Based on that list, the first and third authors coded

remaining interviews, while meeting occasionally with the

second author to reconcile discrepancies and arrive at

consensus. Coding was conducted using open coding,

comparing similarities and differences in the texts which

involved reiterative, inductive, and reductive process that

Table 1 Demographic and occupational characteristics of studyparticipants (N = 31)

Variables n (%) Mean SD

Age 44 11.8

Gender (female) 17 (55)

Race (Caucasian) 30 (97)

Education

Graduate degree 6 (20)

B.A. degree 13 (43

Some college or less 11 (37)

Marital status

Single/divorced 23 (74)

Married/significant other 8 (26)

Psychiatric diagnosis

Schizophrenia spectrum disorder 6 (19)

Affective disorders 25 (81)

Previous job

Helping occupations (e.g. counselor,

childcare)

16 (52)

Non-helping occupations (e.g. vendor,

waiter, clerk)

15 (48)

Past participation in self-help/peer support 23 (74)

Formal peer provider training 19 (61)

Type of agency for current employment

Conventional 26 (84)

Consumer-run 5 (16)

Participants working as trainers/directors 12 (39)

Hours per week in current job

More than 20 h 19 (63)

Working 20 h 6 (19)

Working less than 20 h 6 (19)

Length of employment 4.33 4.75


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organized the data (Walker and Myrick 2006). As analyses

proceeded, new themes that did not fit existing codes

resulted in forming new codes, re-conceptualization of

previous codes, merging codes, and/or elimination of

codes, eventually forming sub-codes, codes and categories.

Initially a list of 26 challenge themes under 9 categories

emerged. In further analyses they were collapsed and

reorganized into 3 domains, with 9 categories, and addi-

tional 6 subcategories themes as presented below. This

analytic process was conducted as part of a larger quali-

tative investigation of peer-providers experiences identi-

fying other themes such as benefits and motivations (see

Moran et al. 2012).

Rigor

The quality and credibility of the study was enhanced by

using triangulation of sources and analysts across data

collection and analyses. The logic of triangulation is based

on the premise that the method reveals different aspects of

empirical reality, and multiple methods of data collection

and analysis provide more grist for the research mill (Patton

1990). First, the interview guide was developed based on

multiple resources, described in the previous section. Sec-

ond, participants were invited for an additional interview

which focused on their life story (including their life before

the mental illness erupted and before they became peer

providers). This allowed the first author to gain a deeper

understanding and context of becoming a peer provider in

the perspective of their life history. For example, one par-

ticipant was a successful peer provider in terms of rising

quickly in the professional peer provider career ladder.

However, the significance of his success was emphasized,

when given the context of his past struggles with severe

mental disorder and multiple hospitalizations. This histori-

cal context was revealed only in the second interview. Thus,

the life story interviews enabled the researcher to gain

perspective and appreciation of the personal experiences

and challenges described in the first interview.

Third, analyses involved triangulation by having at least

two researchers independently analyze the interviews and

then compare their findings, followed by subsequent dis-

cussions with the second author in order to either reach

consensus or eliminate non-reconcilable themes. This

strategy provides an important check on potential selective

perception and blind interpretive bias (Patton 1990).

Fourth, an additional analyst, a research assistant with a

lived experience of psychiatric condition, helped refine the

analysis by highlighting relevant themes and nuances that

might otherwise have been overlooked through subsequent

meetings with the first author (see also Moran et al. 2012).

Involving representatives of the population/phenomenon

examined in the analytic process of qualitative studies is

encouraged. Such input provides an insiders perspective,

can be illuminative, and offer opportunities for deeper

insight of the text (Patton 1990).

Results

A variety of challenge themes emerged which were ordered

into conceptual domains: (a) work environment domain,

related to challenges emerging according to type of orga-

nization; mostly specific to conventional mental health

agencies, and some specific to consumer run settings,

(b) occupational path domain, related to training, and the

practice of peer work and (c) peer providers mental health

state. The domains, their categories and subcategories are

detailed next (see Table 2).

Work Environment Domain

Work Conditions

Participants complained about taxing and poor work con-

ditions. Work overload resulted in stress and burnout,

especially for those holding multiple responsibilities such

as providing mental health services along with community

organizing, research projects, advocacy and/or grant writ-

ing. One participant said: work becomes the entire thing,

and thats not healthy, another mentioned working sixty,

seventy, eighty hours a week. A senior peer provider

working in a peer-run organization said that at times shed

crash and burn. Another said: I barely had time to do

the work Im really good at, which is working one-on-one

with people and leading [recovery] groups. Others noted

lack of workspace to meet consumers, lack of a desk and

computer for documentation and paperwork, and low pay.

Working in Conventional Mental Health Settings

Multiple challenges were found specific to working in

mental health organizations. Four themes were identified:

(a) direct and indirect expressions of prejudice; (b) rela-

tionship problems with co-workers; (c) lack of recovery

environment; and (d) being the only peer provider in the

agency.

Direct and Indirect Expressions of Prejudice Participants

complained that supervisors and co-workers used deroga-

tory language when venting about clients: I dont know

why they do it, but they tend to make fun of clients outside

of the appointment and that was hard to be around. A

participant working on a program of assertive community

treatment (PACT) team said: sometimes Id be angry with

my co-workers, the way they sometimes treat clients, it


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does affect me. They dont always say nice things. I mean

theyre venting and stuff, but when it goes on and on and

on I just have to walk away [and I feel like telling them]

thats why theyre here, and give them a break and if you

dont want to do it, youre not in the right field. I dont say

that but I think it in my head. You know, if youre not

going to have a little bit of patience or speak respectfully to

somebody, why are you here?!

Participants also reported feeling that negative behavior

was directed at them on part of workers/supervisors as a

result of their diagnosis: the minute you disclose peoplearent as honestthey are not as forthright with their trueopinions. So theres a difference there, I definitely see it.

Another said: if I say something, it may be negated as no

thats tangential or just the work interactions, you know, you

may feel brushed aside. Others said they felt devalued,

overprotected or experienced less authentic interac-

tions with coworkers once their diagnosis was revealed.

Lack of Recovery Orientation Study participants were

dismayed by non-recovery oriented attitudes and practices

evident in their work places. A participant working on a

PACT team said: I realized that we werent operating

from a true recovery model, we were using a maintenance

model, negative modeling, preventing people from making

mistakes, not allowing them to take risks [as opposed] toget them to look at their own beliefs and values, not just the

absence of symptoms - its the creation of meaning and

valued roles and living in communities and situations of

our choice and when the teams leaders doing this stuff,where do you go?. Others mentioned their agencies did

not use individualized treatment plans, and did not involve

consumers in their own rehabilitation processes.

Supervisors sometimes lacked sufficient understanding

of the value of lived experiences for service recipients:

I had a boss tell me; you know, just dont share so much

of yourself. Just listenjust focus on helping people getjobs, just dont share anything about yourself and try to get

them jobs. Another complained: I am assistant director

of recovery services, I am not the director, and my director

doesnt know anything about recovery. Not only does he

not know anything, but he doesnt even believe in it!

Table 2 Domains, categories and subcategories of challenges

Domain Category n, %a Sub-categories

Work environment

(n = 24, 77 %)

Work conditions 13, 42 Lack of infrastructure/accommodations

Low payment

Working in conventional

mental settings

16, 52 Direct and indirect expressions of prejudice

Lack of recovery orientation

Problems in relationships with supervisors

Being the only peer provider in the agency

Working in peer-run agencies 4, 13 Unstable relationships

Loose work structure and roles

Occupational path

(n = 19, 59 %)

Insufficient training 10, 32 Insufficient knowledge, skills, competencies

Lack of congruence between training and job requirement

Uneven training/qualification

Unclear job description 13, 42 Assigned tasks unrelated to peer work (administer medication)

Lived experience not valued by supervisors or staff

Managing peer helping relationships 18, 58 Difficulties in establishing a peer-relationship

(disclosing/sharing, setting boundaries)

Difficulties in establishing a helping relationship

(keeping a helping approach, dealing with

consumers stuck or in crises)

Having a peer provider identity 4, 13 Peer label experienced as confining

Peer label limits other opportunities

Personal mental health

(n = 13, 42 %)

Feeling distressed/overworked 9, 29 Taking worries home

Hearing about extreme negative experiences

Hearing negative experiences similar to mine

Recurrence of symptoms 4, 13 Disorientation, hallucinations

Depression

a Percentages in domains and categories may exceed those in domains because participants noted more than one category under a domain


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Problems in Relationships with Supervisors A few com-

plained about not getting enough autonomy from bosses,

feeling intruded, and having disagreements and arguments.

In a couple of instances conflicts led to being fired.

Being the Only Peer Provider in the Agency Being the

sole peer provider in conventional mental health settings

was hard: it can be tough, you feel shunned at some

places, and sometimes things your professional col-

leagues say trigger from your own recovery processes. In

addition, participants missed not feeling connected to

other peers. Being a sole peer provider was also noted as

challenging for those interested in promoting system

change: its hard to be a trail blazer when you are the only

peer provider on staff.

Working in Peer-Run Agencies

Consumer-run agencies carried their own relational and

structural challenges. Relationships among peers were

described as sometimes vulnerable to ruptures and hard to

predict. A participant explained: We can be oversensitive.

We can be triggered. We can have an episode[there havebeen times] when Ive been very vulnerable, and people

havent been able to take it. She attributed this to char-

acteristics of peer relations: So When you meet withsomebody who shares your life experiences to a degree

where you have that powerful connection its almost like

a drug. Like, God, youve been there, youve felt this,

wow! But simultaneously you realize, oh, this persons just

as hurt as I am. How is that going to manifest itself and

where is it going to come out?.

These relational characteristics were further attributed to

difficulties in carrying out tasks appropriately: And even

in this organization we have a tough time because wehave to accommodate peoples mood disorders and trau-

mas. In addition, consumer-run organizations sometimes

had a loose work structure and ill-defined roles: its

challenging because we have less hierarchy than most

organizations. Which can be a plus, but it can also be

confusing, because youre not sure whos the boss and who

you turn to.

Peer Provider Occupational Path Domain

Insufficient Training

Transitioning from training to a job resulted in experienc-

ing discrepancies between work place requirements,

knowledge, skills and competencies gained in peer train-

ings. One individual working on a PACT team said: the

trainingwas geared toward being a certified peer spe-cialist there was small portion to assimilate what we

learned back into the workplace, but not nearly as com-

prehensive enough to deal with what I had to deal with. In

general, need for more knowledge about mental illnesses,

recovery processes and the mental health system was

expressed, as well as want of acquiring more skills to

support consumers recovery and specific rehabilitation

goals.

Lack of uniformity of peer trainings was another chal-

lenge. Participants complained that lack of professional

standards make being a peer provider a bad name and that

working shoulder to shoulder with fellow peers who hadnt

had equivalent training, resulted in some having to do

more of the work, and being assigned additional respon-

sibilities and duties.

Unclear Job Description

Lack of clarity about ones role and requirements by both

employers and peer providers resulted in multiple chal-

lenges. Some were assigned tasks and duties not related to

their job role, such as transportation of clients and dis-

bursement of medication. Some working on multidisci-

plinary teams felt uncertain regarding: who does what?

and how to collaborate? with co-workers. For example a

participant wasnt sure how much to share from her per-

sonal experience regarding a specific educational track

with a consumer because it might overlap with the job

developers specialty. Others felt their position was

unvalued by employers and co-workers and used for mere

tokenism: I wonder sometimes if those people [DMH

personnel] realize kind of what I do; I feel like peers

arent taken seriously as other workers even though Idont have a degree, Ive gained a lot of experience.

Managing Peer Helping Relationships

Challenges emerged in regards to establishing and man-

aging effective peer helping relationships. These included a

peer aspect challengeusing ones personal experiences

with consumers, and a helping aspect challengeestab-

lishing a constructive helping relationship.

Difficulties in Establishing a Peer Relationship Different

challenge themes specific to the peer role emerged. First,

disclosing ones past was not always well received by recip-

ients of services. A participant said he received the following

response: What?! You are crazy and you think you can help

me? Another mentioned a consumer laughed at him and

asked to be seen by someone who can really help her.

Second, participants struggled with questions about

how?, when?, and what to disclose?. Issues of concern

involved how to share without sharing too much? and


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how to keep to the principle of I am here to tell you what

my life was like but not to tell you how to run your lifeor to compare mine to yours. A peer trainer described

ongoing peer relationships as involving delicate situations

that have to be negotiated where the challenge is about

being able to share your recovery story in a way that is not

going to hurt them, scare them, set standards too high, or

make them think there is no hope at all.

Third, setting boundaries posed a challenge. Participants

felt prone to over-invest or exceed their limits with recip-

ients of service: I sit down with them for three hours if I

have to each of them. And that really compromises your

own health needsyou know, is it good to over-extendyourself?. A peer trainer explained: This happens with

therapists too, but as a peer, youre much more vulnera-

bleits really tough to figure out where the boundariesshould be. Thus participants experienced ongoing tension

in keeping a balance between their desire to help and their

need to take care of themselves.

Finally, balancing self-focus and other-focus in the

interpersonal exchange was a challenge. A tendency to

focus on oneself at the expense of recipients needs was

noted. A beginning peer provider dealing with mental ill-

ness and alcoholism described: sometime I see people

who have a substance use history, and its hard not to keep

my AA out of it, to want to say; so much of my recovery

was from being involved in AA, and its like, its free, go

every day and be surrounded by positive its like I amtempted to tell people. A seasoned peer-provider cor-

roborated: its very easy to just flip it back to being about

yourself I think that we are too self-absorbedsometimes.

Difficulties in Establishing a Helping Relationship Being

compassionate to suffering without reacting was chal-

lenging: its hard to sit with suffering or The hard part

about being a peer provider is knowing how someone is

suffering, and allowing them to suffer and knowingwhen is enough. In addition, participants were challenged

sometimes in keeping a non-judgmental approach: I try

not to judge them, but you know some days its hard or;

if they havent picked up some tools and begun to bemotivated and work forward, its easy to wallow, I have

trouble with self-pity.

Working with consumers who were not making progress

further challenged participants. One said: When people

get stuck and they dont have much going on in their life,

especially people who have been in the system for a long

time, it is hard not to feel discouraged, not just for them,

but with them. Others said When someone is not getting

better, and even getting worse it can be really draining

and one felt a little helpless sometimes peoples illnesses

are very powerful or their stuckness is very stuck.

Finally, participants felt ill equipped in handling con-

sumers who were in crisis, i.e., self-injurious behavior,

actively psychotic and/or agitated and angry. Such

instances called for proactive ways to deal with the situa-

tion, taking action and using additional professional sup-

port for consultation.

Having a Peer Provider Identity

A few participants felt uncomfortable about carrying a

peer label for different reasons. One said I do feel

sometimes like I just get into this negative frame of mind

where I feel like, well, I want to work on my life more

than just mental illness, and: sometimes I feel like

being labeled a peer is a little degrading, I feel almost like

thats lessened because of this peer role. A peer provider

early in their career felt ideological pressure to identify

with the consumer movement: Im not sure I agree with

all of it Im not sure I want to represent the entiremental health community.

Senior peer providers noted working as mental health

advocates in public roles such as presenting in conferences

or sitting in mental health committees has pigeon-holed

them into a peer persona, sometimes experienced as

confining. A participant with 15 years of peer work expe-

rience, said: mental health is a big part of my identity, you

know? Ive been on radio and newspapers and things.

I dont know what kind of job I could get outside the

mental health field now.

Another participant said he is known as the poster boy

for mental health and that I wish there was moreemphasis on moving beyond the labels, maybe going

beyond a peer worker, to just a person. He decided to

move to another state in order to start a new occupational

path.

Personal Mental Health Domain

Feeling Distressed/Over Worked

Participants experienced emotional toll and work overload

sometimes. These included taking worries about clients

home and becoming distressed as a result of hearing

consumers extreme negative experiences (e.g. restraint

and seclusion, overdosing). In addition, hearing stories

similar to their own could be stressful: I worked very

intensely with someone who lost his mother and that had

been the precipitating factor in my first hospitalization. So

it was very rewarding but I felt like I was on a tight line

there. Cause I was able, having experienced it myself to

be able to share it, but I was really raw for about a month

after that.


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Experiencing Recurrence of Illness symptoms

A few participants experienced their own depression

re-emerge following communications with consumers who

were severely depressed. Participants needed additional

support from their supervisors, friends or therapists:

sometimes when I work with him it takes me back to

when I was really depressed and would be hospitalized a

lot and just didnt have any hope for my future and couldnt

climb out of that hole. I start getting that feeling thatswhen I have to pick up the phone and call people and get

some support. One participant reported experiencing

disorientation and hallucinations as a result of a heavy

workload.

Discussion

Challenges of employed peer providers were explored as

part of a larger study about the personal impact of working

as a peer provider. Multiple challenges were identified

across three domains: work environment, occupational

path, and personal mental health. These challenges high-

light current obstacles experienced by peer providers in

diverse roles, work settings and with different levels of

work experience. The results of this study suggest a mul-

tilayered perspective relating to challenges of peer work as

an emerging modality in the field of mental health.

Our study confirms outcomes reported elsewhere, as well

as adds new knowledge about peer provider challenges. It

confirms previous findings about lack of a clear job

description (Carlson et al. 2001; Chinman et al. 2006, 2010;

Cleary et al. 2006; Dixon et al. 1997; Mancini and Lawson

2009; Mowbray et al. 1998; Salzer and Shear 2002), prob-

lems in work structure, low pay, lack of uniformity in

trainings, lack of sufficient supervision (e.g. Chinman et al.

2010; Hebert et al. 2008; Mowbray et al. 1998; Sabin and

Daniels 2003; Salzer et al. 2009), and emphasizes chal-

lenges in establishing and managing relationships with

recipients of peer services (e.g. Carlson et al. 2001; Dixon

et al. 1997; Hebert et al. 2008; Mowbray et al. 1998).

Our study goes beyond previous reports in several ways.

First, it addresses new challenges that arise specifically in

peer-run environments (previous studies were mostly on

conventional environments). Second, it illuminates

nuanced challenges in establishing an effective peer help-

ing relationships. And overall, it provides a broader

conceptual framework based on diverse challenges expe-

rienced from multiple work settings (other studies mostly

focused on single programs or work settings). We next

discuss the three challenge domains and provide sugges-

tions for improving peer provider training, job develop-

ment and future research.

Challenges in Conventional Organizations are Distinct

from Challenges in Peer-Run Organizations

The current study reveals how challenges depend on

organizational context. We begin with non-peer run agencies,

and then consider peer run ones. Working in a non-peer

agency of multidisciplinary professionals poses challenges

such as direct and indirect expressions of prejudice, lack of

recovery environment, and being the only peer provider in

the agency. These outcomes reinforce the need to address

challenges from an organizational perspective (e.g.

Campbell and Leaver 2003; Salzer et al. 2009; Chinman

et al. 2010).

Specifically, preparing, training and educating non-peer

staff should be an integral part of incorporating peer pro-

viders in conventional mental health settings. Our study

further emphasizes the importance of having more than one

peer provider in an agency, and the need to value peer work

on a par with other professional contributions on the team.

In general, leadership training efforts should focus on

fostering a recovery-oriented culture, and a flexible and

accommodating workplace (Moran et al. 2012).

In addition peer providers should receive supplemental

preparation and supervision specific to the job context

above and beyond generic peer training programs. For

example, one study participant who was recruited to a

PACT team, reported he lacked the specific knowledge and

skills required for this position, which was not part of the

peer training curricula.

Interestingly, new challenges emerged in peer-led

organizations. Some peer providers reported challenges

related to loose and ill-defined role definitions and insta-

bility in relationships. These characteristics counterbalance

peers abilities to carry out and accomplish peer-organi-

zation tasks and goals. The aspect of peer-run work envi-

ronment has not been previously researched and warrants

further investigation. We suggest investigating examples of

successful peer-led organizations in order to learn how to

promote resiliency of such organizational structures. We

further note that peer-run organizations are often charac-

terized by limited resources and training which may

account for some of these challenges (Legere 2010).

In general, this domain highlights the relevance of

studying peer providers with attention to different work

contexts.

Occupational Path Challenges: Peer Competencies,

Helping Skills, Peer Identity

Occupational challenges in conventional mental health

settings include: insufficient training, unclear job descrip-

tion, difficulties in managing relationships and undervalu-

ing of ones lived experience. This is further reflected in


123


our study participants reports regarding lack of uniformity

of peer trainings, knowledge, competencies and skills.

There seems to be a gap in translating the essence of peer

work, in particular, that of sharing of personal wisdom and

being a role model (Mead et al. 2001; Salzer 1997), into

training and practice.

We suggest addressing these challenges by developing

training in three focus areas-peer competencies, interper-

sonal/helping skills, and peer label/identity, as detailed

next:

Peer Competencies: Self-Disclosure and Bringing

a Personal Perspective

Questions regarding how to use ones story?, to what

degree?, and in what context?, involve the core prac-

tice of peer work and set the stage for the unique potential

inherent in peer relationships (e.g., Davidson et al. 2006;

Mead et al. 2001; Salzer 1997). Yet, our study participants

demonstrate how using personal biography in service of

helping others is easier said than done. Peer providers can

become emotionally involved, find it hard to set boundaries

and balance disclosure. In this respect, the peer role

involves emotional labor beyond that in other mental health

practices (Mancini and Lawson 2009). We suggest training

on intentional disclosure employing a recovery story focus

(rather than an illness story focus) can enhance effective-

ness and reduce personal stress when sharing parts of ones

autobiographies with recipients of services.

We can learn about disclosure and personal story also

from other realms in mental health worldwide. For exam-

ple, NAMIs In Our Own Voice program involves pre-

senting personal knowledge in front of diverse audiences to

reduce stigma. (IOOV; NAMI retrieved from http://www.

nami.org/template.cfm?section=In_Our_Own_Voice). In

Israel, a similar program named Du-Siach (meaning

dialogue), trains individuals with a lived experience to

publicly tell their stories and elicit conversations as a stigma

reduction initiative (Du-Siach, retrieved from http://www.

enosh.org.il/Index.asp?ArticleID=7034&CategoryID=654&

Page=1). Furthermore, vocational/employment resources

are available worldwide and can be used to support decision

making processes regarding disclosing (when? and how?

How much? etc.). Possible resources are Boston University,

Center for Psychiatric Rehabilitation, retrieved from http://

www.bu.edu/drrk/research-syntheses/psychiatric-disabilities/

job-accommodations/, in USA and http://www.socialfirms.

org.au/files/downloads/SoFA_DES_handbook_disclosure.

pdf in Australia.

In general, these approaches involve the following

principles: developing ones life narrative from a genuine

personal recovery perspective, weighing advantages and

disadvantages of disclosure, role play training, and

supervised practice in real life situations. Eventually, pro-

ducing peer provider guidelines based on actual experi-

ences with consumers could constitute part of a future peer

training kit.

Helping Skills: Establishing the Foundation

of Rehabilitation Relationships

Our study participants were challenged by not feeling

proficient in helping skills demanded in their work. Thus,

training in basic helping skills akin to other mental health

vocations such as social work and psychology is warranted.

Specifically, we suggest acquiring knowledge on basic

psychiatric rehabilitation approach and skills (Gagne et al.

2007; Anthony et al. 2002), learning how to establish a

working alliance with consumers (Horvath and Symonds

1991), and incorporating use of motivational interviewing

skills (Miller and Rollnick 2002). These are all relatively

accessible learning modalities which are in line with the

recovery paradigm and a humanistic psychology approach.

Learning how to bond, agree on goals and tasks, geared to

achieving valued roles, pursuing a goal, utilizing resources,

skills and supports can all support peer provider to effec-

tively help consumers.

Dealing with Peer Label and Identity

Peer identity carried specific challenges to some partici-

pants. These included a risk of being pigeon holed into

specific roles, negatively connoting ones mental illness,

and feeling pressure to identify with the consumer move-

ment, despite not agreeing with all of its agendas.

From the perspective of the recovery paradigm, this

raises questions about the transition from a person in

recovery to being simply a person. Engaging in peer work

in this regard may make it more difficult to leave the illness

identity part behind in advanced stages of recovery. At the

same time, for those in earlier stages of recovery, engaging

in peer work or being thrust into an explicit and public role

as part of the peer job may interfere with the pace of their

personal recovery processes, which is thought to require

integration of illness into a larger, multifaceted sense of

identity (e.g. Onken et al. 2007; Ridgway 2001; Williams

and Collins 1999).

A useful perspective on challenges related to peer

identity can be gained from self-determination theory

(Ryan and Deci 2000). This theory posits that self-deter-

mined behavior is undermined if a person does not feel

autonomythe feeling of being an origin and not a pawn,

of acting out of free choice. When external expectations

exert strong forces, autonomy is reduced. Thus, feeling

forced into the consumer movement, or being pigeonholed


123


as a peer poster boy, may be confining and ultimately

lead to burn out and lack of intrinsic motivation.

To practically address these challenges, we suggest to

specifically focus on the potential personal implications of

carrying a peer label already in peer trainings. For example,

group discussions with experienced peer providers can

increase awareness about upsides and downsides of pre-

senting as a peer, and how it may affect ones sense of self

and recovery process. These discussions can elaborate on

complexities, developing insights that will provide foun-

dation and support for novice peer providers in their

occupational path.


Participants reported stress, burnout and (rarely) psychiat-

ric symptoms in, and as a result of their work. Paradoxi-

cally, the personal and meaningful nature of this kind of

work (Moran et al. 2012), can at the same time risk peer

providers own health. This inherent vocational vulnera-

bility should be addressed in early stages of training by

discussing the potential risks of engaging in a personal

occupation (Mancini and Lawson 2009), coupled with

ways and opportunities to address mental health chal-

lenges. For example, training on self-help interventions

(e.g. WRAP; Copeland 2002) to address mental health

symptoms and informing about rights and possible supports

for peer providers in times of distress and crisis on the job.

Conclusions

Peer services in mental health are expanding and are an

integral part of recovery oriented system change. Thus

gaining a broad understanding of current challenges to

peers is warranted. This study revealed three challenge

domains: the work environment, occupational path, and

ones personal mental healtheach carrying specific

challenges currently experienced by employed peer pro-

viders in diverse roles and settings. Work environment

represents challenges experienced in different types of

mental health organization: conventional services often

lacked recovery orientation, and could involve experiences

of stigma and prejudice. While these were not apparent in

peer-run services, they offered their own challenges in the

realm of relationship stability and work role definition.

Further investigating challenges in the contexts of work

environment are suggested, especially examining sources

of resilience in successful peer-run organizations. Next,

occupational path domain represents a myriad of skills and

competency challenges. Suggestions include improving

peer competencies (skills of self-disclosure and effectively

sharing recovery stories) and acquiring basic helping skills.

In tandem, it is advised to address peer identity and self-

definition issues early in training. Finally, personal mental

health domain represents the challenge of practicing self-

care and importance of being informed about job accom-

modations and rights as an integral part of peer work, in

face of possible risks for excessive emotional labor and in

rare occasions, recurrence of symptoms.

Overall, study findings can guide further peer training

and job development to support the evolution of peer

providers as an occupational modality in the field of mental

health.

References

Anthony, W. A., Cohen, M. R., Farkas, M., & Gagne, C. (2002).

Psychiatric rehabilitation. Boston, MA: Center for PsychiatricRehabilitation.

Boston University Center for Psychiatric Rehabilitation. Retrieved

from http://www.bu.edu/drrk/research-syntheses/psychiatric-dis

abilities/job-accommodations/.

Campbell, J. (2004). Consumer-operated services program (COSP)multisite research initiative overview and preliminary findings.Retrieved from http://www.power2u.org/downloads/COSPVA

REPORT.pdf.

Campbell, J., & Leaver, J. (2003). Emerging new practices in organizedpeer support: Report from NTACs national experts meeting,March 1718, 2003. Retrieved from http://www.consumerstar.org/pubs/Emerging%20New%20Practices%20in%20Oraganized%

20Peer%20Support.pdf.

Carlson, L. S., Rapp, C. A., & McDiarmid, D. (2001). Hiring

consumer-providers: Barriers and alternative solutions. Commu-nity Mental Health Journal, 37(3), 199213.

Chinman, M., Shoai, R., & Cohen, A. (2010). Using organizational

change strategies to guide peer support technician implementa-

tion in the veterans administration. Psychiatric RehabilitationJournal, 33(4), 269277.

Chinman, M., Young, A. S., Hassell, J., & Davidson, L. (2006).

Toward the implementation of mental health consumer provider

services. Journal of Behavioral Health Services & Research,33(2), 176195.

Clay, S. (2005). On our own together: Peer programs for people withmental illness. Nashville, TN: Vanderbilt University Press.

Cleary, M., Freeman, A., & Walter, G. (2006). Carer participation in

mental health service delivery. International Journal of MentalHealth Nursing, 15(3), 189194.

Cook, J. A., Copeland, M. E., Floyd, C. B., Jonikas, J. A., Hamilton,

M. M., Razzano, L., et al. (2012). A randomized controlled trial

of effects of wellness recovery action planning on depression,

anxiety, and recovery. Psychiatric Services, 63(6), 541547.Copeland, M. E. (2002). Wellness recovery action plan. West

Dummerston, VT: Peach Press.

Craig, T., Doehrty, I., Jamieson-Craig, R., Boocock, A., & Attafua, G.

(2004). The consumer-employee as a member of a Mental Health

Assertive Outreach Team. I. Clinical and social outcomes.

Journal of Mental Health, 13(1), 5969.Davidson, L., Chinman, M., Kloos, B., Weingarten, R., Stayner, D., &

Tebes, J. (1999). Peer support among individuals with severe

mental illness: A review of the evidence. Clinical Psychology:Science and Practice, 6(2), 165187.


123


Davidson, L., Chinman, M., Sells, D., & Rowe, M. (2006). Peer

support among adults with serious mental illness: A report from

the field. Schizophrenia Bulletin, 32(3), 443450.Dixon, L., Hackman, A., & Lehman, A. (1997). Consumers as staff in

assertive community treatment programs. Administration andPolicy in Mental Health, 25(2), 199208.

Enosh, The Israeli Association for Mental Health. Du-Siach.Retrieved from http://www.enosh.org.il/Index.asp?ArticleID=

7034&CategoryID=654&Page=1.

Farkas, M., Gagne, C., Anthony, W., & Chamberlin, J. (2005).

Implementing recovery oriented evidence based programs:

Identifying the critical dimensions. Community Mental HealthJournal, 41(2), 141158.

Felton, C. J., Stastny, P., Shern, D. L., Blanch, A., Donahue, S.,

Knight, E., et al. (1995). Consumers as peer specialists on

intensive case management teams: Impact on client outcomes.

Psychiatric Services, 46(10), 10371044.Gagne, C. A., White, W., & Anthony, W. A. (2007). Recovery: a

common vision for the fields of mental health and addictions.

Psychiatric Rehabilitation Journal, 31(1), 3237.Gates, L., & Akabas, S. (2007). Developing strategies to integrate

peer-providers into the staff of mental health agencies. Admin-istration and Policy in Mental Health and Mental HealthServices Research, 34(3), 293306.

Hebert, M., Rosenheck, R., Drebing, C., Young, A. S., & Armstrong,

M. (2008). Integrating peer support initiatives in a large

healthcare organization. Psychological Services, 5(3), 216227.Horvath, A. O., & Symonds, B. D. (1991). Relation between working

alliance and outcome in psychotherapy: A meta-analysis.

Journal of Counseling Psychology, 38(2), 139149.Hutchinson, D. S., Anthony, W. A., Ashcraft, L., Johnson, E., Dunn,

E., Lyass, A., et al. (2006). The personal and vocational impact

of training and employing people with psychiatric disabilities as

providers. Psychiatric Rehabilitation Journal, 29(3), 205214.Katz, J., & Salzer, M. S. (2006). Certified peer specialist training

program descriptions. Retrieved from www.upennrrtc.org/var/tool/file/33-Certified%20Peer%20Specialist%20Training%20-%

20PDF.pdf.

Legere, L. (2010), June 28, Personal communication.

Mancini, M. A., & Lawson, H. A. (2009). Facilitating positive

emotional labor in peer-providers of mental health services.

Administration in Social Work, 33(1), 322.McCorkle, B. H., Dunn, E. C., Wan, Y. M., & Gagne, C. (2009).

Compeer friends: a qualitative study of a volunteer friendship

program for people with serious mental illness. InternationalJournal of Social Psychiatry, 55(4), 291305.

Mead, S., Hilton, D., & Curtis, L. (2001). Peer support: A theoretical

perspective. Psychiatric Rehabilitation Journal, 25(2), 134141.Miller, W. R., & Rollnick, S. (2002). Motivational interviewing:

Preparing people to change (2nd ed.). New York: Guilford Press.Min, S.-Y., Whitecraft, J., Rothbard, A. B., & Salzer, M. S. (2007).

Peer support for persons with co-occurring disorders and

community tenure: A survival analysis. Psychiatric Rehabilita-tion Journal, 30(3), 207213.

Moran, G., Russinova, Z., Gidugu, V., Yim, J. Y., & Sprague, C. (2012).

Benefits and mechanisms of recovery among peer providers with

psychiatric illnesses. Qualitative Health Research, 22(3), 304319.Moran, G., Russinova, Z., & Stepas., K. (in press). Toward

understanding the impact of occupational characteristics on the

recovery and growth processes of peer-providers. PsychiatricRehabilitation Journal.

Mowbray, C., Moxley, D., & Collins, M. (1998). Consumers as

mental health providers: First-person accounts of benefits and

limitations. The Journal of Behavioral Health Services andResearch, 25(4), 397411.

NAMI. In our own voice. Retrieved from http://www.nami.org/template.cfm?section=In_Our_Own_Voice.

New Freedom Commission on Mental Health. (2003). Achieving thepromise: Transforming mental health care in America. Finalreport (DHHS Pub. No. SMA-03-3831). Rockville, MD.Retrieved from http://www.mentalhealthcommission.gov/reports/

FinalReport/toc.html.

Onken, S. J., Craig, C. M., Ridgway, P., Ralph, R. O., & Cook, J. A.

(2007). An analysis of the definitions and elements of recovery:

A review of the literature. Psychiatric Rehabilitation Journal,31(1), 922. doi:10.2975/31.1.2007.9.22.

Patton, M. Q. (1990). Qualitative evaluation and research methods.Newbury Park: Sage Publications.

Ratzlaff, S., McDiarmid, D., Marty, D., & Rapp, C. (2006). The

Kansas consumer as provider program: Measuring the effects of

a supported education initiative. Psychiatric RehabilitationJournal, 29(3), 174182.

Ridgway, P. (2001). Restorying psychiatric disability: Learning from

first person recovery narratives. Psychiatric RehabilitationJournal, 24(4), 335343.

Rivera, J. J., Sullivan, A. M., & Valenti, S. S. (2007). Adding

consumer-providers to intensive case management: Does it

improve outcome? Psychiatric Services, 58(6), 802809.Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the

facilitation of intrinsic motivation, social development, and well-

being. American Psychologist, 55, 6878.Sabin, J. E., & Daniels, N. (2003). Managed care: Strengthening the

consumer voice in managed care: VII. The Georgia peer specialist

program. Psychiatric Services, 54(4), 497498. doi:10.1176/appi.ps.54.4.497.

Salzer, M. S. (1997). Consumer empowerment in mental health

organizations: Concepts, benefits, and impediments. Adminis-tration and Policy in Mental Health, 24(5), 425434.

Salzer, M. S., Katz, J., Kidwell, B., Federici, M., & Ward-Colasante,

C. (2009). Pennsylvania certified peer specialist initiative:

Training, employment and work satisfaction outcomes. Psychi-atric Rehabilitation Journal, 32(4), 301305.

Salzer, M., & Shear, S. L. (2002). Identifying consumer-provider

benefits in evaluations of consumer-delivered services. Psychi-atric Rehabilitation Journal, 25(3), 281288.

Sherman, P., & Porter, R. (1991). Mental health consumers as case

management aides. Hospital and Community Psychiatry, 42(5),494498.

Social Firms Australia (2010). Roles, rights and responsibilitiesdisclosure of a mental illness in the workplace: A guide foremployment consultants. Social Firms in Australia LTD; LegalService Board. Retrieved from: http://www.socialfirms.org.au/

files/downloads/SoFA_DES_handbook_disclosure.pdf.

Solomon, P. (2004). Peer support/peer provided services underlying

processes, benefits, and critical ingredients. Psychiatric Reha-bilitation Journal, 27(4), 392401.

Walker, D., & Myrick, F. (2006). Grounded theory: An exploration of

process and procedure. Qualitative Health Research, 16(4),547559.

Williams, C. C., & Collins, A. A. (1999). Defining new frameworks

for psychosocial interventions. Psychiatry, 62(1), 6178.


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Challenges Experienced by Paid Peer Providers in Mental Health Recovery: A Qualitative StudyAbstractIntroductionBenefits of Being a Peer ProviderNegative Aspects and Challenges of Being a Peer Provider

MethodsSampleData Collection and AnalysisRigor

ResultsWork Environment DomainWork ConditionsWorking in Conventional Mental Health SettingsDirect and Indirect Expressions of PrejudiceLack of Recovery OrientationProblems in Relationships with SupervisorsBeing the Only Peer Provider in the Agency

Working in Peer-Run Agencies

Peer Provider Occupational Path DomainInsufficient TrainingUnclear Job DescriptionManaging Peer Helping RelationshipsDifficulties in Establishing a Peer RelationshipDifficulties in Establishing a Helping Relationship

Having a Peer Provider Identity

Personal Mental Health DomainFeeling Distressed/Over WorkedExperiencing Recurrence of Illness symptoms

DiscussionChallenges in Conventional Organizations are Distinct from Challenges in Peer-Run OrganizationsOccupational Path Challenges: Peer Competencies, Helping Skills, Peer IdentityPeer Competencies: Self-Disclosure and Bringing a Personal PerspectiveHelping Skills: Establishing the Foundation of Rehabilitation RelationshipsDealing with Peer Label and Identity


ConclusionsReferences

Challenges Experienced by Paid Peer Providers in Mental Health Recovery: A Qualitative Study

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