Challenges Experienced by Paid Peer

Providers in Mental Health Recovery: A

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

Community Mental Health Journal

ISSN 0010-3853
Community Ment Health J
DOI 10.1007/s10597-012-9541-y

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Community Ment Health J
DOI 10.1007/s10597-012-9541-y

ORIGINAL PAPER

Challenges Experienced by Paid Peer Providers in Mental Health

Recovery: 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 experienced 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 personal 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
Job
development
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
G. S. Moran (&)
Department of Community Mental Health, University of Haifa,
Haifa, Israel
e-mail: galia.moran@gmail.com
Z. Russinova
V. Gidugu
C. Gagne
Center for Psychiatric Rehabilitation, Boston University,
Boston, MA, USA

employed by U.S. mental health agencies and peer services. 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 recoveryoriented 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 multidisciplinary mental health teams within programmatic assertive 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 experience. 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 recipients of their services (e.g. Campbell 2004; Clay 2005; Cook
et al. 2012; Davidson et al. 1999, 2006; Felton et al. 1995;

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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 selfknowledge, positive experiences and forging connections
with other peer providers (Mowbray et al. 1998); engaging
in self-discovery, building support systems, learning positive 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 recipients 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).

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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 management 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 reported by individuals working in diverse workplaces, programs 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 illuminate 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 challenge 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 extensive 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.

Table 1 Demographic and occupational characteristics of study

participants (N = 31)
Variables

n (%)

Mean SD

Sample
Age

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 participate 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 northeastern American city; twenty-six (84 %) worked in conventional 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 program level initiatives (e.g. curriculum development, training, 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 providers (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 interview 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 following 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

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

Marital status
Single/divorced
Married/significant other

11 (37)
23 (74)
8 (26)

Psychiatric diagnosis
Schizophrenia spectrum disorder
Affective disorders

6 (19)
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
Consumer-run
Participants working as trainers/directors

26 (84)
5 (16)
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

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

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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 additional 6 subcategories themes as presented below. This
analytic process was conducted as part of a larger qualitative investigation of peer-providers experiences identifying 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. Second, 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 participant 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 historical 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 discussions 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

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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 organization; 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 conditions. 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 writing. 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) relationship 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 derogatory 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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Table 2 Domains, categories and subcategories of challenges
Domain

Category

n, %a

Work environment
(n = 24, 77 %)

Work conditions

13, 42

Sub-categories
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

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

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 people
arent as honestthey are not as forthright with their true
opinions. 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 interactions 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] to
get 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 get
jobs, 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!

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Problems in Relationships with Supervisors A few complained 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 colleagues 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 have
been times] when Ive been very vulnerable, and people
havent been able to take it. She attributed this to characteristics of peer relations: So When you meet with
somebody 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 we
have to accommodate peoples mood disorders and traumas. 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 experiencing discrepancies between work place requirements,
knowledge, skills and competencies gained in peer trainings. One individual working on a PACT team said: the
trainingwas geared toward being a certified peer specialist there was small portion to assimilate what we

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learned back into the workplace, but not nearly as comprehensive 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 challenge. 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 responsibilities and duties.
Unclear Job Description
Lack of clarity about ones role and requirements by both
employers and peer providers resulted in multiple challenges. Some were assigned tasks and duties not related to
their job role, such as transportation of clients and disbursement of medication. Some working on multidisciplinary 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 personal 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 I
dont have a degree, Ive gained a lot of experience.
Managing Peer Helping Relationships
Challenges emerged in regards to establishing and managing effective peer helping relationships. These included a
peer aspect challengeusing ones personal experiences
with consumers, and a helping aspect challengeestablishing 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 recipients 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 life
or 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 recipients 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-extend
yourself?. A peer trainer explained: This happens with
therapists too, but as a peer, youre much more vulnerableits really tough to figure out where the boundaries
should 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 illness 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 am
tempted to tell people. A seasoned peer-provider corroborated: its very easy to just flip it back to being about
yourself I think that we are too self-absorbed
sometimes.
Difficulties in Establishing a Helping Relationship Being
compassionate to suffering without reacting was challenging: 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 knowing
when 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 be
motivated 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 consumers 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 situation, taking action and using additional professional support 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 entire
mental 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 experience, 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 more
emphasis 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 thats
when 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 highlight 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 multilayered 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), problems 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 challenges 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 helping relationships. And overall, it provides a broader
conceptual framework based on diverse challenges experienced from multiple work settings (other studies mostly
focused on single programs or work settings). We next
discuss the three challenge domains and provide suggestions for improving peer provider training, job development and future research.

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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 providers 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 instability in relationships. These characteristics counterbalance
peers abilities to carry out and accomplish peer-organization tasks and goals. The aspect of peer-run work environment 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 characterized 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 description, difficulties in managing relationships and undervaluing of ones lived experience. This is further reflected in

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Community Ment Health J

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, interpersonal/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 practice 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 effectiveness 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 example, NAMIs In Our Own Voice program involves presenting 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, producing peer provider guidelines based on actual experiences 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 effectively help consumers.
Dealing with Peer Label and Identity
Peer identity carried specific challenges to some participants. These included a risk of being pigeon holed into
specific roles, negatively connoting ones mental illness,
and feeling pressure to identify with the consumer movement, 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-determined 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

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Community Ment Health J

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 presenting 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 foundation and support for novice peer providers in their
occupational path.

sharing recovery stories) and acquiring basic helping skills.

In tandem, it is advised to address peer identity and selfdefinition issues early in training. Finally, personal mental
health domain represents the challenge of practicing selfcare and importance of being informed about job accommodations 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.

Personal Mental Health Domain

Participants reported stress, burnout and (rarely) psychiatric symptoms in, and as a result of their work. Paradoxically, 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 vulnerability 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 challenges. 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 providers 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

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