The Challenges of Inter-role Conflicts for Peer Support Workers

Although peer support workers (PSWs) have gradually become a regular part of mental health services worldwide, they still face many problems in their work. Among the greatest challenges for PSWs are discrimination and prejudice, difficulties managing the transition from patient to PSW, lack of credibility of peer worker roles among other staff and some service users, health care professionals’ negative attitudes toward PSWs, tension between PSWs and service users, struggles with identity, cultural impediments, poor organizational structures, inadequate definition of peer support in mental health policies, and unclear definition of PSWs’ roles within organizations (1, 2).

In this study, we focused on the last challenge, unclear definition of PSW roles, which relates to many of the previous issues. PSWs consider their roles as educating clinicians, representing service users, aiding in systematic shifts in services, and being leaders (3). Role description and definition are important because uncertainties exist about the exact roles of PSWs within different service areas.

PSW roles cannot be viewed as static, predefined categories, because role evolution and transition from one role to another are dynamic processes, which can lead to conflicts among them. The aim of this study was to explore the characteristics of the PSW role and identify possible conflicts associated with these roles as they are experienced and perceived by PSWs.

Empirical Study of PSW Roles and Inter-Role Conflicts

Between November 2020 and January 2021, we conducted semistructured interviews with 15 PSWs (ages 31–56 years) working at various locations in the Czech Republic. Eight were women, and six worked in psychiatric hospitals and nine in community mental health services (most of them were working part-time as a PSW). They had been employed as PSWs between 4 months and 7 years. Interview transcripts were analyzed with standard qualitative methods in Atlas.ti software. Results were established and finalized through consensus among study investigators, participants, and stakeholders. The ethical committee of the Third Faculty of Medicine, Charles University, approved the study procedures. All participants provided written informed consent.

On the basis of our empirical research, experience, and literature review, we identified four roles that were usually experienced by PSWs in our sample: friend, professional service provider, staff member, and expert-by-experience. The roles of friend and professional were based on the PSW-client relationship, whereas the roles of staff member and expert-by-experience referred to the teamwork and relationships between PSWs and colleagues. The multiplicity of PSWs’ roles was related to their unclear definition, as noted by one study participant: “I’m something in between a friend, a social worker, and a therapist” (participant age 39 years). In the following, we present the results of an analysis of our data and a discussion of the existing literature.

The Friend: Being Natural

The friend role was based on the sharing of experience of mental illness between the PSW and the client. According to study participants, their relationship with clients was equal, close, and based on trust and partnership. The role of friend also involved authenticity, listening, and an understanding, nonjudgmental approach. It could be seen as service-user support leading to mutual enrichment and inspiration. The PSWs acted as role models to clients. PSWs were often requested by service users to become their friends; for example, service users wanted to meet after working hours or exchange phone numbers.

In a study with service users who had received substantial individual peer support, participants valued having someone to rely on, a friend or someone to socialize with; they viewed peer support as especially valuable because of the opportunity for a nontreatment-based, normalizing relationship (4). The aspect of the role as a friend of service users makes PSWs’ role unique in a mental health team, and as such this role is irreplaceable. The overformalization of the PSW role could inhibit the forming of peer-based relationships, suggesting a need to protect PSWs’ unique position and not overtly identify them as staff (5). Most of the aspects we identified as connected to this role distinguished the PSW from other nonpeer staff roles. At the same time, this role demands that PSWs can balance and maintain the boundaries within their work, which we discuss below.

The Professional: Keeping an Eye on Boundaries

The professional role was based on the PSWs’ acquired competencies as a professional consultant or therapist within the rules of the specific organization and work position. The role transition from friend in the early career stage to a more advanced professional role was challenging and resulted in inter-role conflict for some PSWs. This conflict related to the insufficient distance from, or setting of boundaries in the work with, service users, which affected the personal life of the PSW, contributing to stress, exhaustion, and even burnout.

Levels of burnout among PSWs are similar to those of other mental health staff; specifically, burnout may manifest as emotional exhaustion, depersonalization, and lack of a sense of personal accomplishment (6). Moreover, organizations may fail to address the challenges PSWs face in maintaining professionalism and setting boundaries with service users (1).

Most of the PSWs in our sample recognized and reflected on the challenge of maintaining professional boundaries in their work and proposed some solutions, such as switching off the cell phone after work, not providing a private phone number, adhering to working hours, and successfully balancing personal life and hobbies with work. In accordance with literature reports (1, 2), the findings suggest that receiving psychotherapy and supervision would be helpful for PSWs; however, these forms of support were unavailable to most of them.

The Staff Member: Coming Up With Something That They Haven’t Thought of

The role of staff member referred to the position of PSWs within the multidisciplinary team and involved cooperation with colleagues. PSWs especially appreciated the helpfulness, openness, patience, friendship, absence of prejudice, acknowledgment, and sensitive feedback from nonpeer colleagues. As one participant said, “Over time, I’ve realized that when I am saying my opinion, they’re really listening to it. It’s like I’m coming up with something that they haven’t thought of” (participant age 46).

The most challenging aspect was the feeling of not being at the same level as other members of the team. PSWs reported some unequal work conditions: lacking a workplace of their own, not being invited to team meetings, and not receiving information about the very clients with whom they are supposed to be working. Such scenarios occurred more often in psychiatric hospitals than in community services. One participant noted, “Sometimes it seems to me that I would need from my colleagues more awareness of the fact that I’m the person who has a mental illness. So I would expect a more moderate approach from them, more space to communicate, and less time pressure during the counseling work” (participant age 35).

In a qualitative study, Debyser et al. (7) sought to understand how mental health peer workers experienced their transition from patient to worker and how this transition affected their view of themselves and their immediate work environment. The authors found that novice peer workers experience peer work as an opportunity to liberate themselves from mental suffering and to realize an acceptable form of personal self-maintenance. Experiencing inequality, a lack of clarity about their duties and responsibilities, or a lack of openness discourages peer workers in the self-development process (7). It may be helpful to train the whole team, especially in inpatient settings and places of employment that are in organizations different from those where the PSW was originally residing as a patient. Supervision practices can be implemented to bolster role clarity, supervisor responsiveness and flexibility, peer value and input, and peer professional development (8).

The Expert-By-Experience: Being a Bridge Between Colleagues and Clients

The role of an expert-by-experience involved the influence of the PSW’s illness on their work and position within the team. Lived experience with mental illness could have two conflicting implications for the PSW role. On the one hand, lived experience is an important source of experience, an enrichment of the work with clients that can complement the views of other colleagues. As one participant said, “I think that I am a kind of bridge between my colleagues and the clients” (participant age 36). On the other hand, it could cause both self-stigma and stigmatization by colleagues. The role conflict between staff member and expert-by-experience stems from the unequal position of the PSW within the team, as related by another participant: “In the psychiatric hospital, I feel partially stigmatized. I am seen as a former patient and often feel that I am not being told everything” (participant age 51).

Gates and Akabas (9) describe this role conflict and confusion on two levels: for the individual PSWs being both recipients and providers of services and for coworkers in terms of PSWs’ changing relationships with service users. Many people, including mental health professionals (MHPs), are likely to have internalized at least some negative stereotypes about individuals with serious mental illness. A study on the experiences of associative stigma among MHPs reported that such stigma is related to more depersonalization and emotional exhaustion and to less job satisfaction. In addition, in units where professionals report more associative stigma, service users experience more self-stigma and less satisfaction with the quality of services. Moreover, MHPs working in psychiatric hospitals reported more associative stigma than MHPs working in community or rehabilitation centers (10). Peer workers also experience indirect and direct stigmatization. Indirect stigma refers to PSWs’ witnessing disrespectful language and behavior toward service users; direct stigma is associated with professionals’ patronizing attitudes toward peer workers’ diagnoses and history as service users (2).

Conclusions

To successfully integrate PSWs into mental health teams, the complexity of their roles and possible conflicts among these roles must be taken into account. The role as friend of service users is unique to PSWs in mental health teams but is often in conflict with the role of professional, a conflict that causes problems in maintaining boundaries with service users. Similarly, the role of expert-by-experience brings a unique perspective to mental health teams, but this role can clash with the requirements of the staff member role. To prevent these conflicts, high-quality training and supervision should routinely be offered to mental health teams and PSWs. Unfortunately, supervision is not provided to all PSWs, increasing the risk for problems such as burnout. Certain supportive conditions should be provided to PSWs such as equal working conditions for both PSWs and other MHPs, including the provision of an adequate workplace and equal involvement in the team and information sharing, such as invitations to team meetings. The definition of the PSW position in the health care system is not well anchored in law; therefore, systems and organizations should create appropriate definitions and rules. We note that stigmatizing attitudes by staff members, especially in inpatient settings, are detrimental to the well-being of PSWs.