Therapeutic Approaches

Working with Peer Support Workers

Research has shown many benefits of using peer support workers, but their effectiveness is blunted if the organisation through which they work does not understand or value their role.

By Mental Health Academy 2023-11-08 06:23:26

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Research has shown many benefits of using peer support workers, but their effectiveness is blunted if the organisation through which they work does not understand or value their role.

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Introduction

Peer support roles have proliferated in recent decades, with peer support workers constituting an increasingly central element in the treatment plan of many mental health service consumers. In previous articles (Peer Support: Definitions, History and Benefits for Mental Health and Peer Support: Roles, Clients and Settings), we have detailed what peer support work is, what roles there are in Australia for peer support workers, the benefits of using such personnel, and what forms or models there are for service delivery. Peer support workers do not work in a vacuum. Generally, they are attached to the hospital or public health system through which they work; in Australia, that entity is frequently the primary health network (PHN) in the area. Hence, the PHN plays a large role in how effectively peer support personnel are utilised. But, do PHNs value this lived experience role? Do PHN health professionals even understand it? What do PHNs need to do to ensure the success of peer support programs? What are the challenges for peer support workers (PSWs) and medical/health professionals working alongside each other? This article answers those questions, and notes how to gain certification as a peer support worker in Australia.

The role of the primary health networks (PHNs): The “have-to-do” tasks

The National Mental Health Commission’s review of mental health programs and services in 2014 (the so-called “Fifth Plan”) recommended that a mental health peer support workforce be developed to work together with consumers, families, support people, and multi-disciplinary teams to provide proactive, person-centred support; the review recognised that strengthening the mental health peer workforce is an important element of the wider mental health workforce and multi-disciplinary environment (Australian Government, Department of Health, 2019). To achieve that, PHNs realised that they had both short-term and longer-term goals to meet.

Short-term deliverables

In the short term, PHNs needed to develop an understanding of peer work policies and programs, employment conditions (including wages), and models of practice and standards relevant to their respective state/territory government agencies and mental health organisations. The PHNs needed to provide input to the development of the peer workforce and equitable employment of peer workers in their area (Australian Government, Department of Health, 2019).

Longer-term deliverables

Over time, PHNs knew that they needed to:

  1. Support models of practice incorporating peer workers as specialised members of multi-disciplinary teams providing person-centred, recovery-oriented, trauma-informed stepped care in mental health and suicide prevention services.
  2. Ensure the PSWs received appropriate training, peer supervision, and career development
  3. Promote the development of standards of practice and a code of ethics for peer work in partnership with relevant community mental health organisations, government agencies, and local consumer and carer networks
  4. Support the development, promotion, and equitable distribution of appropriate supports for peer workers with lived experience of disability and co-occurring mental health issues, or who come from vulnerable groups (e.g., lesbian/gay, bisexual, or transgender communities; Aboriginal or Torres Strait islander communities; or CALD (culturally and linguistically diverse) communities (Australian Government, Department of Health, 2019).

The “should-do” tasks: Creating a welcoming, workable environment

If you have been following our other articles in this series or if you have your own experience of peer support work in the context of a large health system, you will already know that a key to making it all work is integration of PSWs into the wider workplace. As we noted previously, peer support work has been evolving for over half a century, and has come to stand for a recovery orientation. Yet, even when health care and hospital systems say that they are recovery-oriented, they often contain many elements of a treatment focus. Thus, the employment and integration of peer providers into such treatment-based teams has naturally led to a shift in care team structures, as organisations strive to incorporate lived experience staff into a professional role. In the transition, there is friction. To assuage this, organisations particularly need to pay attention to engaging stakeholders and training colleagues.

Engaging stakeholders

One Australian study found that organisational leadership and commitment was the principal factor determining whether the peer support program would be successful (Franke et al, 2010). Some specific strategies which can engage stakeholders include:

  • Providing training for non-peer support staff about peer support’s history, values, and evidence base
  • Ensuring executive support from the beginning, and having several senior staff members as “champions” of the peer support work
  • Creating mechanisms within the organisation for professional staff to discuss (safely, without judgment) any concerns which arise about the peer program
  • Circulating news of updates and any milestones reached in the peer programs
  • Ensuring that there are feedback structures for all staff (Bell, Panther, & Pollock, 2014)

Training colleagues

Here we mean training of the professional, non-peer support colleagues of PSWs. The health and medical professionals need to know the core principles and functions of the work. But it is also important to address:

  • Relevant disability and discrimination legislation, including how to provide reasonable adjustments for PSWs who may be stable but still wrestling with mental health issues
  • Use of person-first language, and a respectful attitude towards all co-workers
  • Strategies for resolving conflict in the workplace, including how to talk openly about issues of power and hierarchy
  • Hope-inspiring peer work success stories (Davidson, Bellamy, Guy and Miller, 2012)

Creating the paradigm/cultural shift in the organisation that will optimise PSWs’ contribution is a big job. Understandably, things don’t always go to plan. Let’s look at the challenges when peer support and non-peer support staff come together as colleagues.

Challenges for peer support staff and health professionals working together

While numerous investigations (detailed in our previous articles) have examined the benefits of peer support work to consumers of mental health services, their carers, and the broader health system, far fewer studies have looked into the experiences of the peer support workers themselves, or of the professional (non-peer support staff) with whom they must collaborate to give the service consumer the best experience possible.

Peer support workers find their work deeply meaningful . . .

A 2022 Swedish study which interviewed peer support workers to gauge their experience found that most viewed their work as “deeply meaningful” and that they often “sensed appreciation” from the professional staff. In 2018, an American study surveying “peer support specialists” about their professional activities, job satisfaction, and financial wellbeing found that more than 75% were satisfied with their workplace supportiveness. Similarly, a Canadian interview study published in 2021 exploring the role of PSWs in the care of people who use drugs during and after hospitalisation found a common theme of the peer support workers being viewed as a “bridge” between the patients who used the drugs and the hospital’s professional staff. The PSWs in this study were seen – and saw themselves – as people who could rebuild trust between those two parties: people who were able to advocate for the patients, helping them navigate transitions and generate peer-facilitated care planning (Wall et al, 2022; Lapidos et al, 2018; Lennox et al, 2021). These reports are all positive; however, the “but . . .” lingers in the air.

. . . but there are issues. Role clarity is one

Most studies about peer support work, whether from the perspective of the PSW or that of the professional staff, have included some version of “What is this job about?” Recruiting hospitals, or their agents, have sometimes known that they needed to bring in some PSWs, but not known exactly what their work would entail; the jobs have evolved over time. In the American study referred to above, fewer than half of the respondents (126 of 299) agreed that non-peer staff are trained about their role, a complaint echoed in an Australian literature review investigating how to establish an effective peer workforce (Bell et al, 2014; Lapidos et al, 2018).

In the Australian review, it emerged that there is often not a clear distinction between peer support roles and consumer leadership and advocacy roles, and peer workers have often been required to do advocacy/consumer consultant work and vice versa. The review pointed out that the two streams of work require different skill sets, and should be treated as separate disciplines (Watson, 2013, in Bell et al, 2014). Role clarity at least means squashing any expectation that the PSW is a “mini-clinician”.

We can understand the role confusion given that, in peer support work, former patients may now be counted as “staff”. As one PSW in the Swedish study (above) lamented, it wasn’t clear where to use the toilets. The PSWs were clearly not “patients”, but on the other hand, the “staff” toilets were locked and inaccessible! Similarly in that study, some respondents noted that, in their roles as mediators between professional staff and patients, there sometimes arose issues of loyalty; if a staff member and a patient were having a disagreement about some aspect of their treatment, whose side should the PSW be on? Usually, the PSW would have experienced some form of the same issue when they were a patient, and might be very understanding of the patient’s perspective, yet now they were hired to be “staff”.

The Swedish study also threw up an overall theme of “authenticity and balance” which, in part, had to do with closeness to and distancing from their clients, the patients (Wall et al, 2022). Typically, PSWs in early stages of their training have been known to wonder how much of their similar experience it was appropriate to share with a client, and how much would be “too much information”. The main qualification of the lived experience worker is that they have gone through something similar, yet issues of role clarity cloud how much of that experience is helpful to share.

A corollary challenge inherent in the issue of role clarity is that of where the boundaries are. In their unique work, PSWs know that they are not “friends” of their clients, yet they are not medical staff, either. When they are able to communicate that they, for example, can’t just go and “hang out” with the recovering client as a friend because of being in their role, they are able to set boundaries more clearly. The result experienced by the Canadian PSWs (above) when boundaries could not be set was a crushing sense of burnout (Lennox et al, 2021).

Stigma

Are peer support staff just as “valuable” as highly-trained medical professionals? The Swedish study identified both internal and external sources of stigma, consistent with much literature on peer support work, noting that:

“Peer supporters often fought against an already low self-esteem in an atmosphere where their own role and work identity were not experienced as self-evident. Stigmatization was experienced to originate both from within the self and from the surroundings and to be constantly present. . .. They reported feelings of inferiority in relation to the other team members . . . from the start” (Wall et al, 2022).

PSWs in many settings have the sense that they are undervalued, having only part-time “project” or subsidised employment, as opposed to requested fulltime employment. We identified this for Australia earlier, noting how by the 2000s, funding was still only .6 of a fulltime job for newly-minted managerial peer roles (Peerinside, 2019). In the Swedish study, undervaluing manifested in the fact that the PSWs did not have their own work code in the salary system, being coded as a “craftsman” or “hostess”, and the PSWs had the lowest salaries of all. Many PSWs have had long periods of unemployment or precarious employment arising from their time of having mental ill health and/or being a services consumer/patient (Wall et al, 2022).

Job insecurity, lack of career advancement, and financial “frailty”

In the American study (above), 67% of respondents were satisfied with their job security, but that percentage decreased to 41% of respondents who believed that they had opportunities for promotion. The Australian review pointed out that there are two distinct pathways for promotion: either continuing along the peer route (e.g. becoming a consultant or supervisor) or moving to a non-peer segment of the health system. The former choice may be dependent on continued funding and the latter may only be able to happen for PSWs who gain additional qualifications (Lapidos et al, 2018; Bell et al, 2014), thus contributing to a sense of either job insecurity or inability to progress in the work.

The American study reported that the mean hourly wage for PSW work was $14.90, with a resultant “financial fragility rate” of 66%, yielded by the percentage of respondents who either “certainly” or “probably” would not be able to generate $2000 in 30 days if an unexpected need arose (Lapidos et al, 2018). Likewise, the Australian scene for peer support work shows that financial compensation is an area that “needs attention” and that the field is under-supported, with more people needed in the roles. Talent.com (2023) notes that the average peer support worker salary in Australia is around $70,000 per year, with a range between $67,000 and $84,000 (the “average” wage in Australia is around $90,000: McDonald, 2023).

Certification for peer support work

Western societies embracing peer support have evolved a long way to understand how someone who has “been there” can contribute their lived experience to assist in the recovery and enhanced wellbeing of another similarly-afflicted person, but it’s clear that we have some ways to go, both in the recognition and valuing of the work and in the formal integration of peer support roles into the wider system through appropriate remuneration and career paths. Still, there are increasing numbers of people who want to help in this way. If you’re one of them or you know someone who is, the appropriate qualification to become a certified PSW in Australia is:

CHC43515 – Certificate IV in Mental Health Peer Work (this superseded CHC42912, the original training, in August, 2015, and was updated to the current program in December, 2015) (see www.training.gov.au for further updates)

Additionally, experts note that many certificates, diplomas, and degree-bearing programs in multiple mental health fields, such as social work, counselling, and psychology, are helpful adjunct areas of study.

Conclusion

Our three articles covering aspects of peer support have shown it to be a fast-expanding part of the mental health workforce: an integral element of recovery which offers its clients a responsive framework grounded by lived experience. Given its status as relative newcomer to health systems, challenges are yet to be met in integrating it with the wider workforce and ensuring that peer support work is understood, valued, and respected by other health workforce staff.

Key takeaways

  • PHNs still have work to do in creating a work environment which establishes standards, values and integrates peer support work, and offers PSWs the same support as other health workforce staff receive
  • Challenges abound when PSWs and non-peer support staff work alongside one another. These include problems with role clarity and boundaries, the presence of stigma, and issues of job security, career advancement, and financial vulnerability due to low pay.
  • In Australia, a person can get certified to do peer support work through successful completion of the Certificate IV in Mental Health Peer Work.

References

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