To Help Others , We Must Care for Ourselves : The Importance of Self-Care for Peer Support Workers in Substance Use Recovery

Peer support workers, using their shared lived experience, have been recognized in the medical and behavioral health fields as having positive contributions to the well-being and recovery of individuals who are in early stages of recovery or illness management. Many benefits and challenges have been associated with placing peers in a role that emphasizes being an “expert by experience.” Much of the existing literature has focused on outcomes for the recipient of service with less being known about how the peer worker experiences this role. This qualitative study explored the experience of peer support workers and their perception of the intersection between the peer role and their personal recovery. Semi-structured interviews were conducted with 10 peer support workers who are currently employed in this role. Thematic analysis was utilized to identify themes in the data. All of the themes center around the intensity of the role and the need to account for this to avoid burnout and provide peer workers with support. The peer support workers interviewed explained that there is a need to be present in their personal lives, to establish and maintain effective boundaries, and to ensure ongoing attention to their personal recovery. Self-care was identified as being a preventative measure against burnout and other challenges in the role of peer support worker as well as assisting in the management of crossover into one’s personal life.


Introduction
Peer support has been visible in the medical and behavioral health arenas for many years. The value of the shared narrative has facilitated the recognition of the value of peer workers in behavioral health and has taken many forms including mutual aid, peer-based support groups, peer run housing programs, peer clubhouses and paid peer support worker roles. Peer support workers, through having managed their own substance use and recovery journeys, provide practical knowledge that assists in the real-world management of substance use [1]. Peer works serve as a role model and instill confidence that persistence and treatment compliance can provide the desired results [1,2]. Often individuals in the early stages of recovery lack a strong sober support network and need to make changes to their environments to maintain sobriety. Support from peers allows these individuals to begin to establish support networks that can strengthen their recovery and assist with many of the stressors and triggers for relapse [3]. Concerns have been raised in the research that peer workers are tasked with being both a provider and a receiver of services and that this can add stress to the recovery process of the peer worker. This shift in roles has been correlated to experiences of role confusion and discrimination when one of the defining qualifications for employment is self-identification of personal recovery status [4,5]. The perpetuation of stigma through the label of expert by experience may set the stage for inequity of status [6] as well as a lack of credibility in the role of peer worker [7]. Peer support workers have reported a lack of equality between themselves and their non-peer colleagues [8], concerns related to being accepted by coworkers [9], as well as feelings of stigma and discrimination from non-peers and leadership [10]. This negative view of the peer role by non-peer staff may be directly related to the lack of role clarity and the lack of information regarding the differences between peer and non-peer roles.
Peer support workers have been reported to be at greater risk than other mental health professionals for the personalization of the client's successes and failures. This has been attributed to the use of shared experience to influence the outcomes of individuals in recovery [11,12]. There is concern that the role of peer worker will increase the pressure to maintain personal sobriety [12], which can create added stressors for the peer support worker [11]. Concerns related to the potential for being triggered or relapse of the peer support worker have been raised due to the immersion in work that is directly related to their own personal experiences and illness [5,11]. It is also unclear as to how a peer support worker will experience having to resume personal treatment should relapse occur [13]. A shared lived experience is the catalyst for building rapport and positions peers to not only connect but to find commonalities that may be greater than what exists in their day-to-day relationships with family and friends. However, this is only the beginning of the skills that are essential in making this role successful for both the peer worker and the individuals that they are seeking to help, it must be combined with the ability to utilize this expertise effectively to guide others. This includes the ability to engage in self-care, set and maintain boundaries, depersonalize the outcomes of others, and to have awareness regarding the impact of the role on their personal recovery and well-being [14].
While there is no one agreed upon definition of self-care, it has been conceptualized as a way to promote and maintain health through engagement in practices that increase or ensure health and managing illness [15]. Further, many definitions emphasize the role of self-care in preventing burnout, facilitating stress relief, and decreasing the potential for illness [16,17]. Self-care has been linked to promoting well-being in the workplace, facilitating work/life balance, and decreasing the potential for emotional exhaustion [16]. However, recently there has been concern about the identification of self-care as a solution for workplace stressors and burnout prevention as it places the burden on the employee and ignores the workplace issues that can contribute to distress [16,18]. The present study seeks to fill the gap in the research regarding how peer support workers experience this role and the intersection with their own personal recovery [19,20]. This includes challenges to the role and strategies that they utilize to manage these challenges.

Methods
This qualitative study employed semi-structured interviews to explore peer support worker's experience in this role and their perspectives on the intersection of the peer role with their personal recovery. This study was approved by the Institutional Review Board at Walden University.

Participants
Participants were 10 peer support workers (7 males, 3 females) from Massachusetts working as paid peer support workers. All participants were screened for inclusion criteria and were only chosen if they identified as having stable personal recovery for a period of 12 months or more, working as a paid peer support worker for at least 6 months and were 21 years of age or older. Length of time in the role of peer support worker varied from 10 months to 20 years with an average of 6 years of employment.

Procedure
Recruitment for the study began with an email distribution of a brief study description to agencies in Massachusetts that employ peer support workers. Posts were also made on social medial sites such as LinkedIn and Facebook and interested parties were asked to contact me for more information. In addition, snowball/referral sampling, asking study participants to share information about the study with other peer workers who may want to participate, was used to ensure that saturation was reached.
Once potential participants contacted me, I explained the criteria of the study, the commitment that was being asked of them, and eligible participants were asked to opt in to participate. Informed consent was obtained, participants were reminded that they could withhold any information that they were not comfortable sharing, and their right to withdraw from the study at any point in the process. Data was collected using semi-structured interviews conducted by the author. Development of the interview guide was informed by the key concepts in the literature, open ended questions were used to capture participant descriptions and perspectives of their personal experiences in the role of peer support worker [21], the meaning they attribute to this role, the benefits, and challenges that they have ex-perienced, and the intersection with their personal recovery journey. Interview questions included general questions about the experience such as "What is it like to provide support to others who are in re-covery?" as well as questions related to their personal recovery such as "How do you define recovery for yourself?"and "How does being a peer support worker show up in your own recovery?" Probes were also utilized to encourage further elaboration and peers were given the opportunity to share anything about their experience that they believed was important for me to know. All interviews were audio recorded, password protected and stored on my password protected laptop. Field notes were also taken to ensure a full picture of the data and were stored with the interview recordings. Participant names were substituted with numerical coding (P1-10). Participants were given a $20.00 Amazon gift card as a thank you for their willingness to participate in the study.

Data analysis
All of the interviews were transcribed verbatim by the author and a 6-phase thematic analysis, as recommended by Clarke and Braun [22] was used to analyze the transcripts. The first phase, familiarizing with the data occurred by reading each participant's transcript while listening to the audio recording to increase familiarity with participant interviews [23]. The second phase included taking the data from each transcript and generating initial codes. I began by inductively hand coding all of the transcripts line by line and then uploading them into NVivo 12 for further analysis and another round of manual coding. Both sets of codes were compared for consistency and repeated patterns were identified. Initial codes were then combined into related clusters along with their corresponding data [24] and candidate themes were developed. These themes were then examined in relation to the entire data set and refined to ensure that they accurately represented common themes from the transcripts. Following this, themes were named and defined to ensure that the essence of the theme was captured and quotes that illustrate the elements and central concepts of the themes were selected.

Results
From the transcripts five themes surrounding the importance of self-care were identified and included 1 not for the weak of heart 2 vigilance in personal recovery 3) the outcome is not my responsibility 4) self-awareness, and 5) informal nature makes boundaries fluid. All of the themes center around the intensity of the role and the need to account for this to avoid burnout and provide peer workers with support. The peer support workers interviewed explained that there is a need to be present in their personal lives, to establish and maintain effective boundaries, and to ensure ongoing attention to their personal recovery. Self-care was identified as being a preventative measure against burnout and other challenges in the role of peer support worker as well as assisting in the management of crossover into one's personal life.

Theme 1: Not for the weak of heart
Several of the peer support workers described the intensity of working with individuals in early recovery as one of the challenging parts of the role and purported that it requires ongoing self-care to handle effectively. When asked what one of the hardest parts of the role is, P10 explained that it is "dealing with the different personalities, early in recovery." P1 shared that it is the desperation and true understanding of the depths of another's pain that can be heavy to carry.
• It's hard. People are desperate and, they're in so much pain. Even though nobody wants to destroy their lives right…but they're in so much pain and they can't stop it…I know the feeling and I hate seeing people suffering like that. Yea it sucks…I've been suicidal because of my drug and alcohol use, and I've been suicidal because of not having recovery. So, I can identify with being desperate and, and just seeing people in those situations. I know where they're at pain wise. I know how the pain is.
P10 described the work as "not for the weak of heart" recognizing that there are many challenges that can present when using personal experiences to work with individuals in early recovery. P3 shared that seeing the struggles of individuals in trying to get sober and being powerless to change their outcomes as hard to deal with.
• And then it simply comes back to that people fail. That's a bad choice of words but people have aggression, people make bad choices. And it's so hard to be powerless over that, you know, it's just so hard. So, I think that's one of the hard parts too. And to be honest it's just relentless and daunting and draining It's just really, really hard to be on the front lines of addiction. It takes so much out of you. And I think it's really hard to coaching for any length of time because if you are doing it well then you are emotionally invested in the people that you are connecting and it's just really hard.
P9 shared the pain of those who have lost someone is heavy • Going into a room with a guy wailing. I'll never forget the scream of people that lose their child. The scream is like, you never forget it. And consoling them when they may be beating themself up In addition to the desperation, intensity, and pain, P9 shared that dealing with the disparities in the system and the lack of access for many individuals becomes hard to watch • When I've got somebodies daughter at 0 Dark Thirty on a Friday night and I've got a father crying, please help my daughter. And she doesn't have insurance. I would have to give this poor kid a two-hundred-dollar cab voucher to take them to CHL in Worcester because that was the only place in the state that had a bed that accepts her insurance. That's heartbreaking In addition, P9 attributes the high rates of recidivism as correlated to the short-term nature of substance abuse treatment which he terms "spin-dry" as creating feelings of frustration and hopelessness. P8 echoed this sentiment and expressed that it hard to see the challenges that her clients have to face every day and not get discouraged.
Whether that's the child welfare system, the department of transitional assistance, • housing….I think that's been the hardest part of my job, I can do the best work that I can but if they're engulfed in these systems that aren't working it can sometimes feel like is my work even worth it P3 shared that concern that peer support workers need to recognize how much this role drain them and ensure that they find ways to take care of themselves.
It sucks you dry, it's going to empty your cup, you're around unhealthy people and you're listening to and absorbing all of this toxic stuff all day. And so you might be talking recovery to people all day, but you're not filling your cup with that, you're emptying your cup. So we have to work harder to keep our recovery than maybe people who aren't in such toxic environments all the time.
P7 shared that self-care helps to prevent burnout making continuation in this role possible in the face of the challenges and intensity: "We focus on self-care, you know, and you're gonna be no good to anybody if you're burnt out, of course I don't want that on my conscious." P9 also shared the importance of self-care "Take little mental breaks for yourself. Pray before during and after, um yea, take care of yourself so that you have something to bring to the table." Other peer support workers identified strategies such as remembering the positive times that they shared with their participants as a strategy to handle difficult outcomes and manage stress.
• I try to remember a lot of times there's some sort of humor, or some sort of laughing, there's some sort of bond that's created.
And I try to think of that stuff and just think to myself that we shared these good laughs, those good times that this person may not have had if, you know, if anything I was able to give them a good laugh, period. (P7) P9 shared that "celebrating the little victories helps the "roller coaster ride" more bearable.

Theme 2: Vigilance in personal recovery
A common concern expressed by participants was the need to be vigilant with one's own self-care and recovery for the role of peer support worker to be sustainable on a long-term basis. They shared that being a peer worker to an individual in early recovery is an intense role that can lead to burnout without the right supports and attention to self-care. The participants illustrated the importance of continued engagement in personal recovery activities (P1, P3, P4, P5, P6, P7, P8). Participants also explained that even though there is a benefit to the peer support worker by helping others, working as a peer support worker should not be viewed as self-care.
• I have to remember that recovery coaching is not my self-care, it's not my own personal recovery…because a lot of times people get tripped up that way. You think that you are helping people daily but you're also getting stressed out. It's both of those things. (P5) All of the peer support workers in the present study agreed that a critical part of self-care is continuing to emphasize their own personal recovery in their lives and to not allow their work to become a re-placement for personal recovery activities. "I have to be diligent with my own recovery, like if I'm gonna work with people, I have to take care of myself right" (P1)? The role of helper and of expert by expe-rience was identified by peer support workers as having the potential to create complacency in their personal recovery with all of the peer workers mentioning the need to figure out what will help them to provide self-care and recovery support. "I have to treat my disease, which is going to meetings, doing writing, knowing when to reach out and all that. You know, speak with my sponsor, got to therapy, and stuff that I do for my recovery" (P4).
Yet they also recognized that the challenging nature of this role makes it hard to stay vigilant.
• I work four tens and then I have three days off and it usually takes me three days just to decompress and let it go. To just sit in an Alanon meeting and not be, suffocated, is really hard. It's really hard to keep your own recovery up front. (P9) Many of the peer support workers understood the importance of having a community that they could rely on to support them. P6 iden-tified that colleagues play a key role in helping the role be Citation: Williams C (2021) To Help Others, We Must Care for Ourselves: The Importance of Self-Care for Peer Support Workers in Substance Use Recovery. J Addict Addictv Disord 8: 071. sustainable "Being honest with myself and keeping close to my colleagues that all do the same things so that we can kind of check on each other." P3 shared the power of her recovery network in helping her restore her energy and maintain balance. "I have a huge group of women…they're all these amazing, incredible, powerful women filled with grace and love. I just need to go hang out with them and like my faith in humanity and everything is restored." All of the peer support workers interviewed shared the importance of self-care and the need to recognize what it is that helps them to find balance and "fill up my cup" (P3, P5). They shared that this is a crucial aspect of continuing to be effective in the helping relationship. They also stressed the importance of self-care in the form of self-boundaries, self-awareness, and continuing to work their own recovery programs.

Theme 3: The outcome is not my responsibility
Several peer support workers identified that it is important for a peer support worker to recognize that the outcome is not their responsibility, and it is not within their control. P3 stated "the individual outcomes aren't my responsibility, so I don't get attached to them, it's not about me." P4 expands upon this by sharing the importance of recognizing and allowing individuals to be in the stage of change that they present in "and that's very difficult, unless you understand that it's not my job to take care of their recovery, I can meet them where they are, but they have to do the work." P1 echoed this sentiment "So I think the greatest thing that I get out of this is just trying to plant some seeds now, so that maybe later on they're going to be ready for what's out there for them." P3 and P5 also explained that it can be useful to recognize what your goals are for your role as a peer worker. "I say to even change somebody's quality of life for one second" (P5). "I'm just here. I've been placed here to be of service for whatever duration of time and I just try to believe that I've had an impact on someone…If I have given them a glimpse of hope" (P3).
This was identified as particularly challenging when paired with the systematic limitations that they work in.
• Well, it's just getting a little stressful right now and it's like if you came in there homeless, you're going to end up leaving and still be homeless. The only difference is you won't be addicted to drugs and alcohol. But if you're going back to being homeless, the chances of you picking up, again, are real big. (P10) In addition, recognizing the limits of their capacity to change others and the potential for client relapse or overdose death was identified as an area that needs attention and self-care strategies. "It's really hard when you're working with somebody, and you know they're using when they leave the coffee shop you're at, and you know they are going to go out and potentially die" (P8). P2 explained that while there is a sense of purpose in helping others "I help some, some people die" it does not buffer the effects of a loss. Both P2 and P4 understood that losing someone to opioid overdose is part of the process but that does not negate the painful nature of the experience. "I've had a hard time with it…it is painful for me and um, this is why we have to take good care of ourselves" (P4).

Theme 4: Self-Awareness
Peer support workers benefit from engagement in ongoing self-reflection and awareness building to be able to recognize the impact of helping on their own well-being. Having self-awareness decreases the risks posed by the acuity level of the individuals that the peer support worker is engaged with on a daily basis. There's always there that challenge of being around, you know, people that are all doing the same things that you used to do (P6).
P6 shared that it is important to have an awareness of your own potential to be triggered. You have to be very aware that, you know, I mean, if you're somebody that's given to you know having triggers or any form of PTSD, you need to make yourself, be honest with yourself and keep yourself very self-aware because you're working with people and some of them are still sick individuals. P3 expressed the need for self-awareness about when you need self-care. One of the challenges is like I need to be well and sometimes I don't know how well I am or how not well…I can only give away what I have. I can't give away something I don't have. P3 also shared that it is important to recognize when the role is too much, or burnout is occurring, and to not feel that you must stay in the role out of obligation or duty, but to grant yourself permission to walk away. "I think it's really ok to walk away, you pay a price personally when you burnout meaning that you don't have to be saints and saviors for all eternity to earn our spot."

Theme 5: The informal role makes boundaries fluid
The ability to have boundaries or separation between work and home and be present in one's own life was a construct that was identified by the peer support workers interviewed. P6, P7, P8, and P9 described the role as having the potential to becoming all-consuming and shared the need to instill self-boundaries to prevent it from taking away from their personal lives. "If you don't shut it down, it could become a 24/7 thing. We have to say who a wait a minute. Turn off the phone, be present in your own life, walk the dog, talk to your girlfriend" (P9). P6 shared that this can be particularly challenging for peer workers who are just entering the field.
• It's hard early on because we're always busy, crises happen for recoverees all hours of the day and night. Um you learn to keep your phones to a regular hour. You learn to check your own behaviors and keep an eye on yourself. I mean, you used to be early on, you were almost never off. Seems like you're on the clock all the time and that just does not work. It just does not work, you're either going to burnout or you're going to start making judgment mistakes.
The informal nature of the role of peer worker creates a dynamic where boundaries are fluid and while there are some concrete boundaries that exist the majority of the boundaries are created by the peer support worker "kind of case by case" (P7). "You have to remember that no is a complete sentence. You can get taken advantage of by people" (P5). P1 shared the discomfort that he encountered at times when placed in situations that he was unsure of and that went against the formal training he had received in other roles in his life. Now if I had them in my car, like that was probably the first time I've ever done something like that. I remember having to go pick somebody up to take them to a meeting and I was like I can't do this. It's just so awkward. I don't feel safe… it makes me sick to my stomach.
Many of the participants work and participate in recovery activities such as self-help groups in the communities in which they are also providing services creating the potential for even more crossover into their personal lives by encountering individuals that they are currently working with or have worked with in the past.
• I can't be too specific about the stuff that I share, like I will tell someone I'm married, I'll tell someone I have kids. I won't tell them where I live. I'll tell someone I got to meetings in Worcester, you know, maybe I'll tell them where I'm going because that doesn't matter, anybody can see me at a meeting. (P1) P8 shared how strict boundaries in the community in which she lives helps to protect her ultimately.
• I have to protect myself or else I'm never going to be able to help anybody else. So, for example, if I see someone out in the community, I'm not going to ignore them if they come up and say hi. But if they try to start talking to me about something work related I just let them know that I'm not in the office right now, they have my number, they can give me a call in the morn-ing.
P8 explained the importance of this for her in her role of peer worker.
• If I become too invested outside of work hours, I think it lends itself to burnout and overextending myself and not only am I in recovery, but I also have three children. I have a family. So I have to keep some of myself secret in order to give to my children and my family who depend on me.
P5 also shared that self-care and boundaries allows him to continue to be present for his family and to find balance rather than allowing the intensity of the work to take all his energy.

• Part of my recovery is my family and if I've been dealing with
people all day and complex cases it's like when they talk about what level are you at? Is your gas tank empty? Sometimes giving so much of yourself, because of the nature of your peer role, at the end of the day you can come home empty and you may react to your family that way.
All of the peers shared an appreciation for the informal nature of the relationship and the fluidity in boundaries when working with individuals and shared that they felt it made the role successful. However, they recognized the need to set boundaries around their time, their energy, to prevent crossover into their personal lives, and to do so with compassion. "I'm by the book, so hard boundaries, but at the same time, I can bring a little compassion to it" (P10).

Discussion
The results of this study support the recognition that while there are many rewards and benefits to serving in this role for the peer worker, that it is one that can be intense, challenging and lead to burnout if self-care is not made a priority. The peer support workers interviewed explained that to be effective as a peer worker on a long-term basis, there is a need to establish and maintain effective boundaries and to be present in their personal lives while safeguarding against their peer role crossing over too much into their personal lives. The informal nature of the peer role and flexibility in service delivery can increase the emotional impact, making self-care an important component. This is consistent with the literature that self-care and self-awareness are unique attributes of the peer worker role [14].
All of the peer workers interviewed in the present study described some of the biggest challenges as being the acuity of the individuals that they encounter, the participants' readiness to change, the inten-sity of the role and participant death. They cautioned about the need to watch for burnout in oneself and to engage in self-care to prevent burnout. This is consistent with previous studies that suggested the need for safeguards to ensure that harm does not come to the peer worker from serving in such an intense role [25]. Further, it supports previous research that identified that many peer workers do not have previous work experience and highlights the need for support, particularly in the form of supervision, to ensure that job readiness skills are present and that there is a plan for initial and ongoing training of peer workers [26]. The peers in the current study were concerned about the how challenges would be faced by peer workers and recognized the need for ongoing support and training to buffer against the demands of the role. Future quantitative studies could look at the relationship between supervision, perceived social support and burnout in peer support workers. Such research could lead to an understanding of the role that supervision and social support play in peer worker burnout.
Although the findings from this study contribute to the literature regarding how peer support workers experience their role and the intersection with personal recovery, there are some limitations that should be considered. All of the peer support workers are from the state of Massachusetts. Massachusetts is a state that has a formal recovery coach academy and is working on a process by which credentialing can occur for coaches. It is recommended that similar studies be conducted in other locations to understand potential similarities and differences in results where the peer support worker model is not as well supported as well as the impact of training on the experience of the peer worker. While saturation appears to have been reached, further investigation with a larger sample may have revealed additional insights.

Conclusion
This study identifies some areas in which peer support workers can be better supported in their role including supervision by individuals with experience in recovery, ongoing training on how to manage individuals with high acuity, as well as support in effectively handling the relapse of a patient, or potentially more challenging, patient death. The peer support workers interviewed in the current study illustrated the use of coping skills to manage these challenges faced in the role of peer worker, however, all cautioned new workers to ensure that they did not personalize participant outcomes and identified situations in which they saw peer workers be ineffective or experience distress as a result. This study highlights the crucial role of ongoing training and support for individuals whose role it is to use their shared lived experience as the catalyst for promoting change in others. If peer support workers are not provided with adequate training and support, there is a very real possibility of ineffective peer help as well as burnout for the peer worker themselves.