“Getting the Staff to Understand It:” Leadership Perspectives on Peer Specialists before and after the Implementation of a Peer-delivered Healthy Lifestyle Intervention

Abstract

Over the past two decades, there has been increased recognition of the effectiveness of peer delivered services, with prior research highlighting the benefits for both recipients of peer services and peer providers. Despite this, peer specialists report challenges to their work such as experiencing stigma associated with their role and difficulty integrating into a non-peer dominated workforce. The study sought to explore the perceptions of agency leadership from three supportive housing agencies regarding peer specialists and peer-delivered services within their organization before and after a peer-led intervention to promote healthy lifestyles for people with SMI. Semi-structured qualitative interviews were conducted with agency leadership and analyzed using a content analysis approach. Findings from this study contribute to the literature on the peer specialist workforce by identifying factors (e.g., agency’s prior experience employing peer specialists) and potential strategies (e.g., exposure to peer services) impact the level of workplace integration of peer specialists.

Introduction

Over the past 20 years, peer delivered services have become an integral component of recovery-oriented mental health services (Shalaby & Agyapong, 2020). Peer specialists, individuals who are trained to use their lived experience of recovery from mental health or substance use conditions to help others with similar challenges, are employed across the United States in various mental health service settings. Medicaid now recognizes peer delivered services as reimbursable in over 40 states (Wolf, 2018). Further, research has also demonstrated that peer delivered mental health services are as effective, if not more effective, than treatment as usual (Cook et al., 2012; Davidson et al., 2006), particularly in supporting individuals diagnosed with a serious mental illness (SMI) (e.g., schizophrenia) (Bellamy et al., 2017). Similarly, peer specialists report several benefits of their employment for themselves including an increased sense of self-efficacy, self-esteem, confidence, and a feeling of personal growth from helping others with similar challenges (Colson & Francis, 2009; Miyamoto & Sono, 2012). Despite the known benefits of peer delivered services for both service recipients and peer providers, peer specialists have identified several challenges to their work, primarily stemming from the workplace environment. As the peer workforce continues to grow and receive more attention, research has begun to explore the challenges to peers’ work and identify how to remediate barriers that inhibit successful integration and ultimately peers’ satisfaction in their roles (Gates et al., 2010).

Workplace integration, or the degree to which peer specialists perceive themselves as valuable and integral to their organization, is a common metric used to assess peers’ workplace satisfaction. Peers’ integration is influenced by non-peer staff’s perception of the peer role, with prior literature emphasizing the importance of peer staff feeling respected and appreciated by their non-peer staff colleagues (Kuhn et al., 2015; Smedberg, 2015). Integration is also reinforced by agency leadership who can provide training, develop and implement policies and practices that reduce stigma and misconceptions of the peer specialist role among non-peer staff (Kuhn et al., 2015; Smedberg, 2015). This also helps to reduce peers’ own role confusion and increase unity between peer and non-peer staff (Kuhn et al., 2015; Smedberg, 2015). Workplace integration is achieved when employees can work cohesively together and are positively engaged with one another, increasing job satisfaction for both peer and non-peer staff (Kuhn et al., 2015; Smedberg, 2015). However, studies have found that workplace integration of peers has been hindered, at times, due to misconceptions regarding the peer role, with some non-peer staff questioning peers’ contributions to agency services (i.e., if and how peers’ services are distinct from services provided by non-peer staff) (Kuhn et al., 2015; Smedberg, 2015).

Despite the fact that non-peer staff attitudes toward peer specialists significantly influence peers’ perceptions of their work environment, few studies have examined how to improve non-peer staff attitudes towards peers (Gate & Akabas, 2009; Moran et al., 2012; Kuhn et al., 2015; Smedburg, 2015). Studying agency leadership’s experiences with and understanding of peer specialists and peer delivered services can help identify factors that influence the level of integration of peers within organizations (e.g., acceptability). Further, there is a dearth of longitudinal qualitative research examining non-peer staff experiences working with peer specialists over time. Identifying changes or shifts in agency perceptions over time can provide insight on potential strategies to increase and facilitate peers’ workplace integration. The objectives of this qualitative study were to: (1) explore how agency leadership from three supportive housing agencies described their perceptions of the peer specialist role and peer delivered services within their organization before and after the implementation of a peer-led healthy lifestyle intervention for people with SMI over three years and (2) identify potential strategies to increase workplace integration for peer specialists.

Methods

Study Overview

This qualitative study is part of a larger Hybrid Type 1 Trial examining the effectiveness and implementation of a peer-led healthy lifestyle program for individuals who are overweight or obese and living in supportive housing (Cabassa, 2015). The intervention, Peer Group Lifestyle Balance program (PGLB), was implemented at three different supportive housing agencies, two of which used a treatment first approach, and one used a housing first approach. Prior to the implementation of PGLB, all three sites had experience with peer delivered services and had previously employed peer staff. At Site 1, peer specialists were largely employed on modified Assertive Community Treatment (ACT) teams. Site 2 employed peers as residential counselors in addition to in their peer alumni program. Site 3 had peer specialists working on ACT teams, in their outpatient mental health program (Personalized Recovery Oriented Services; PROS), and a few peer specialists were working in their residential sites. However, none of the sites had experience with peers delivering a manualized intervention. Throughout the trial, the supportive housing agencies hired PGLB peer specialists as part- or full-time employees. The PGLB peer specialists provided on-site services at the supportive housing agency or in participant residences. All study procedures were approved by the Institutional Review Boards of Columbia University and the Philadelphia Department of Public Health. No known conflicts of interest were reported by any of the authors.

Peer Group Lifestyle Balance

The Peer Group Lifestyle Balance program, PGLB, is a 12-month intervention aimed at increasing physical activity and modifying dietary practices for individuals who are overweight or obese. PGLB was adapted from the Group Lifestyle Balance Program (which itself was derived from the Diabetes Prevention Program) (O’Hara et al., 2017)(Kramer et al., 2009). PGLB was adapted to be delivered in supportive housing agencies to individuals diagnosed with a serious mental illness (SMI) and facilitated by a certified peer specialist. Other adaptations included offering in-between session check-ins, make-up sessions for participants who had missed sessions, and flexible session formats (e.g., group or individual sessions) (O’Hara et al., 2017). At Sites 1 and 2, the PGLB peer specialists operated under the auspices their agency’s respective healthcare clinics, while at Site 3, PGLB peer specialists operated as part of the outpatient mental health PROS program. The research team and agency staff supervised peer specialists, each employed by one of the supportive housing agencies (O’Hara et al., 2017). Supervisors had backgrounds in social work, psychology, or medicine, and almost all had previously worked alongside peer specialists in some capacity, though not all as supervisors. Peer specialists participated in joint research and agency supervision meetings, as well as separate supervision/support with each respective supervisor.

Sample

The research team selected leadership to participate in interviews as they had the most working knowledge of health services and level of integration of peer specialists at their respective agencies. Participants were identified using a purposive sampling method whereby agency directors were first interviewed by study team members and then asked to nominate other leadership staff who oversaw health programming.

Phase 1 interviews explored participants’ views towards peer delivered services and PGLB as well as current agency practices for providing physical health services. Following the completion of the PGLB intervention, Phase 2 interviews were conducted to understand if and how the context of health services changed over the course of the study while also exploring mechanisms for sustainability of the PGLB intervention.

Data Collection

Semi-structured qualitative interviews were conducted in-person or via telephone by two members of the research team prior to and following the implementation of PGLB at each of the study sites. In phase 1, interviews were conducted between February and October 2015 to understand agencies’ approaches to physical health, inclusion of peer-delivered services, and perceptions of the PGLB intervention prior to its implementation. For the purposes of this study, we examined interview content that focused on leadership perspectives towards working with peer specialists and views of peer delivered services. Examples of peer-related interview questions asked during phase 1 included: What type of roles or services do peer specialists provide at [study site]? How are staff members prepared to work with peer specialists? Phase 2 interviews were conducted from August to December of 2018 and sought to learn about changes in healthcare services since phase 1 and leadership’s experience with the PGLB intervention. Interview questions asked during phase 2 included: What aspects of PGLB have been sustained (e.g., peer delivered manualized intervention)? How did issues related to [site’s] organizational capacity affect your ability to sustain PGLB? Interviews lasted approximately sixty minutes, were audiotaped, and transcribed verbatim by a professional transcription service.

Data Analysis

Qualitative data were analyzed using a thematic analysis approach (Boyatzis, 1998). Two research team members independently reviewed each of the study transcripts and met to develop a preliminary codebook. Two research team members then applied the preliminary codebook to four transcripts. The codebook was then finalized, and transcripts were coded line by line in ATLAS.ti. We then used an interpretive/emergent analytical approach to conduct the qualitative analysis (Saldaña, 2003). To begin this process, all ATLAS.ti reports derived from codes most relevant to peer specialists and agency health context (i.e., Usual Care Services, Peer Specialist, Integration) were exported from ATLAS.ti. Three researchers subsequently reviewed each of the relevant reports from phase 1 to understand the agency health context and leadership’s perspectives on peer specialists (e.g., peer specialist role and services) for each site. This same method was then applied to analyze phase reports from phase 2. We used multiple strategies to facilitate our analysis, including creating narrative case summaries of each study site (incorporating both descriptions of the agency (e.g., physical environment, programming offered) and interviewer memos from leadership interviews) and developing a matrix by site to illustrate changes across phase 1 and phase 2. We then identified themes that encapsulated changes over time emerging from the data. Themes were presented to the broader study team for feedback. The analyst team then re-reviewed transcripts to identify subthemes and met to discuss findings. Several strategies were used to enhance rigor and trustworthiness of study findings: maintaining an audit trail, using multiple coders and peer debriefing (Creswell, 2009).

Results

Participant Characteristics

Participants included 12 agency leaders from the three sites (equal participation from leadership across the three sites) at phase 1 and phase 2. Additionally, at both phases, the study sample consisted of three directors, one from each agency, and nine managers. Ten of the 12 leadership staff from phase 1 were re-interviewed at phase 2; two new managers were also interviewed at phase 2 from sites 1 and 3 due to changes in agency leadership personnel. Across the 14 participants, the majority were non-Hispanic white (93%) and female (79%). Most participants were social workers (43%) working an average of 3.7 years for their respective agency and over 15 years with people with SMI.

The following section presents agency leaderships’ views towards peer specialists and peer delivered services before and after the implementation of PGLB at each agency site.

From Valued to Essential

Phase 1

At phase one, agency leaderships’ attitudes towards peer specialists across sites reflected their overall desire to support the peer specialist role. Agency leadership highlighted the value of peer-delivered services in general and the importance of peers’ shared lived experience of recovery from mental health or substance use in their interactions with clients. As one program manager noted,

“The [shared] experience is a huge component. Having someone who has gone through recovery or has had to meet some of the challenges with getting care or go through the housing steps successfully. It’s a role model. It’s someone that the clients can relate to and talk to and it’s just like anything in life you get told to do something by someone who has never been involved in that situation and you’re kind of thrown off by it.” (Site 3, Project Manager)

Unlike non-peer providers, peers were described as having the capability to build rapport with clients who were more ambivalent to accessing services by instilling hope in the possibility of change and utilizing a more pragmatic approach to recovery. Leadership highlighted peers’ ability to normalize client experiences and create trusting relationships with clients. One director highlighted the differences in the peers’ approach to working with a new client,

“And when you work in within a therapeutic model, the credibility that peers have to talk about their experience, the way that other people listen to them, there is - it will sound trite - but there is an element of keeping it real…When a peer says something it has a resonance that it just won’t have coming from my mouth.” (Site 3, Director)

Similarly, leadership described relying on the peer’s own experience to provide insight into client behaviors (e.g., substance use, signs of addiction relapse) that a provider may not otherwise understand or be aware. However, with respect to physical health, the peer role was limited to care coordination. Peers were often described as helping to facilitate conversations between clients and providers or inform providers of client related health issues, rather than provide any formal health care services or support.

“So, peer case aid, I think would be the closest to that in terms of if we have high need people around needing to get to appointments, being able to help them articulate with the doctors at the appointments, coaching, teaching, coaching, that kind of thing. Hopefully, not totally acting for the resident…The peer would know immediately to bring in another team member so that they’re doing it together. If the peer is in the medication room at [a residence], say, and the person just took their blood sugar and it’s reading above where it should be, then it’s the team model. Then they’re bringing in somebody from the team.” (Site 2, Program Manager)

“A lot of times they pick them up and bring them in to see [the on-site physician]. They will let the nurses know if they have - if they’re with someone and they are having a problem or they mention that they have a health issue, they’ll usually let the team nurse know.” (Site 3, Program Manager)

Phase 2

While all leaders in phase one acknowledged the value of peers’ lived experience, many expressed in phase 2 that their positive experience with the PGLB intervention and the peers who delivered it shifted their perceptions of peers and the value of their services. One leader described their experience from phase 1 to phase 2,

“I think at the very beginning I was not sure how this will work. I don’t know how our staff will perceive it. I wasn’t clear on the peer’s background. You know, it was just all the—whenever I get a chance to think negatively and critically about liability I do. But I think the right peer with the right program is better than any professional.” (Site 3, Program Manager)

In interviews following the implementation of PGLB, leadership highlighted that peer specialists are “a tremendous asset to the agency.” They expressed enthusiasm about having had the opportunity to expand peers’ involvement in health supports, noting that “the design of the program has been really well-received by both staff and clients.” This translated to peers beginning to offer additional activities and other health-related services at their respective agencies. “[The site 1, peer] is doing more walking with participants, more like structured walking activities. The cooking class she did — she’s done I think twice so far.” (Site 1, Program Manager)

They also identified PGLB’s peer-led approach as critical to the effective delivery of the intervention – “I love the fact that it’s peer-led. That is key…” – and to the high levels of engagement and satisfaction:

“So still it’s a program about health and wellness; and we’re talking about diet and we’re talking about exercise. Now, those are subjects that coming from a doctor, or a nurse are irritating... Like, when my doctor tells me I think you should lose some weight; why don’t you do X; I get pissed off. When a peer tells me, oh, I think maybe we should do blah blah blah because it would be good for us — I’m much more apt to try it.” (Site 1, Director)

“I think it was the important component. I think that the peer relationship is something that you know, all the pieces we were trying to sell to people coming into the program, coming from a peer, the sell’s a lot easier. The sale’s a lot easier.” (Site 1, Director)

They noted that it was not only essential for PGLB to be peer-led but emphasized the importance of the peer specialists “having ownership over it” – being invested, taking initiative in tailoring the material, and being accountable.

“It’s like, you’re a peer coordinator. You’re not just like a peer drop-in volunteer support you know? You are doing these duties because you’re the only one that can; and you’re accountable for the pieces of it.” (Site 2, Program Manager)

From Voicing Concerns to Emphasizing Capabilities

Phase 1

Although leadership valued the peer role during the initial interviews in phase 1, they also expressed concerns about peers’ capabilities. Concerns included doubt in a peer’s ability to navigate and set appropriate boundaries with clients (i.e., fear that peers could blur boundaries between themselves and clients):

“Well, I think some of our challenges - and it hasn’t happened in a while - but it had happened a while ago, is sometimes the boundary issues on knowing there is a difference between being a friend and being a peer. And I think being careful about that sometimes getting too, more on the side of it being a relationship.” (Site 2, Director)

Another site director emphasized this point when talking about areas of focus for supervision of peers:

“I think helping peers maintain boundaries - appropriate boundaries, helping them to manage their self-disclosure in a way that makes it effective for them. And for the clients that they’re serving and not just to make it a self-disclosure for the sake of self-disclosure that has no purpose and direction.” (Site 3, Director) Further, leadership expressed fears that peers did not have the requisite skills to enter the field. As one director explained, “There is always challenges. The workforce, even though they’ve been through this training, they’ve had a lifetime of struggles and their six weeks of training doesn’t make up for a lifetime of struggles.” (Site 1, Director). Leadership acknowledged pre-existing doubts related to the peer’s ability to effectively engage in basic soft skills (e.g., communicating with their supervisor) associated with their role.

“It’s just sort of like things like ‘Call if you are going to be late.’ Things like that. Things that you would typically assume people would know about when you start work again. So, it was sort of that soft skill stuff, we had to work with her on.” (Site 2, Project Manager)

Another project manager shared similar concerns:

“they might not have some of the polish that other staff members may have. Or they might have some of them – might have less of the social skills. Like, the expectations of what they need for the role is different. And so, you might have to do a little bit more training on interpersonal stuff. And I’ve had to that here with [Certified Peer Specialists] if there’s little conflicts that go on and I need to step in at times. (Site 1, Project Manager)

Leadership also described uncertainty about peers’ education, knowledge of health behaviors, and capacity to deliver a manualized health intervention within their agency.

“And there are varying degrees of [peers’] writing ability and data tracking and all of that sort of stuff. Some of that is like we probably need to end up doing more training, but do we need to do…some really basic English 101 type stuff bringing in that person…? But, where the rest of our staff usually with like meeting a minimum of a bachelor’s degree, you’re usually expecting that there’s going to be a higher level of producing there.” (Site 1, Project Manager)

Phase 2

Leadership described that their experience with PGLB led not only to positive perceptions of peer-delivered services, but also a greater understanding of peers’ capabilities and unique strengths:

“The fact that the peers were very well trained in an ongoing way and kind of advanced their skills over time with all the coaching that they had. I could definitely see them learning more and more ways to engage people and ways to engage with the agency.” (Site 1, Program Manager)

There was consensus across leadership that PGLB helped to establish peer specialists as credible leaders of manualized interventions, helping to dispel misconceptions about peers’ capabilities. One program manager highlighted the uniqueness of having the PGLB peer specialist successfully deliver a manualized intervention within their agency.

“For me, that fact that it’s peer delivered and that I was able to demonstrate to [non-peer] staff that peers can be trained to [teach] manualized [interventions]. If you were to talk to them before, the peers I currently have, they can’t do curricula. That’s a supervision and training issue. The peer aspect of it was huge for me. There is lots of manualized stuff, but it’s not always peer led, and I think it’s less effective.” (Site 3, Program Manager)

In further contrast to the concerns regarding boundaries in phase 1, leadership considered the peers’ ability to support each participant individually and across a broad range of challenges as a significant asset at phase 2.

“The support that [the peer specialist] has provided to participants has been really helpful. I know she has people who will reach out to her all the time… [She provides support around] really any barriers that would come from maintaining a healthy lifestyle. Like life stressors. She’ll talk to anyone about other things that are going on in their lives.” (Site 1, Program Manager)

In a similar trend, leadership at Phase 2 also moved away from expressing concerns about the capacity of peers to deliver a health program and the fit of the program with existing services to embracing the peer led health model.

“I did not hear one negative thing. And I know in the beginning I was very critical because I couldn’t see how this would fit into our essential programs. I couldn’t see like, how we would engage the clients. But from the outside looking in, it was seamless. Any one of my — I wouldn’t call them fears, but concerns; none of them even came close to coming true. It’s amazing.” (Site 3, Program Manager)

As noted above, leadership credited several aspects of the project’s structure, such as training and supervision, and collaborative approach in facilitating peer specialists’ ability to learn and apply skills and take ownership of PGLB.

“The intensive training [for the peer specialists]…trying to get it standardized, but also, like getting their ownership of the material...doing that one on one [support and supervision] with [the peer specialist], but also helping him connect to a larger group of [peers at the other sites]…incorporating him into [a] research presentation…as like a co-led thing between the researchers and the peers was really beautiful.” (Site 2, Program Manager)

Finally, while more broadly recognizing peers’ skills and abilities in phase 2, leadership also expressed a desire to continue to gain a deeper understanding of how peer-delivered services “work” in efforts to further articulate their value – “what is it about the peer…that makes it good…”

From Misunderstanding the Peer Role to Integrating and Expanding Peer Services

Phase One

Although there was consensus across leadership that peers had an “unquantifiable” value, leadership also expressed uncertainty about how non-peer staff would react to working with someone who identifies as a peer. As one director mentioned, “I do think there are folks that are uncomfortable working with peers” (Site 2, Director). This discomfort was primarily attributed to the stigma of having a mental health or substance use diagnosis. As another leader mentioned, “I think the other difficulty is not an issue with peers, but it is an issue with training our staff on how to interact with peer staff. And how not to make peer staff second class employees” (Site 3, Director). Another leader from the same agency shared a similar sentiment:

“I don’t want my staff treating that person differently. They’re doing the same job or more...the peer specialist will have a huge responsibility, more so than the residential counselors. But I don’t want this to have a stigma attached to it where the residential counselor says, ‘Oh that’s a peer, that’s a client. Why is that person doing that job? Or push him away.” (Site 3, Program Manager)

“You’re going out to a bar after work. A bunch of people are going out after work. And you know what I’m saying? There are complications socially that then affect I think some of the relationships in the workplace not in any formal way and people get along okay. But you can just see some of those dynamics happening. And I think that gets complicated. And I don’t know what to say to that.” (Site 2, Director)

Leadership, overall, expressed reluctance to further incorporate individuals with a mental health diagnosis into their agency’s workforce emphasizing the importance of finding the “right fit”. This belief was reinforced by leadership’s perception that peers may not perform well with full-time work. As one program manager explained, “at part-time [the peer specialists] were doing amazing, amazing, amazing work. Then [the peer specialists] really fall apart at full-time. I’ve seen that happen.” (Site 1, Program Manager). Leadership often attributed this concern to the possibility that the peers’ own well-being may suffer if they worked with clients diagnosed with an SMI.

“This is a really stressful line of work…even as a provider, but I think as a peer especially…obviously you’ve built up some resiliency skills if you are in recovery and you are able to maintain that, that’s a beautiful thing. But I worry about when they are face to face with other people who are in a different space in their lives and are really struggling or they are kind of secondary traumatization, you know, I worry about that in our peers in making sure that they can kind of maintain a healthy outlook while they are working with folks that have been traumatized…I just don’t want to put people in at-risk situations.” (Site 2, Program Manager)

Leadership across sites reflected concerns about peers’ ability to fully integrate into the mental health workforce, emphasizing that peers may not have the capacity to fulfill their roles, nor would they be able to integrate with other non-peer staff members. These concerns made leadership feel uncertain about further incorporating peer services into their respective agencies.

Phase 2

At Phase 2, leadership described changes in their overall treatment approach, with agencies moving away from a medical model to a community-based model to better serve their clients, “I think through the changes in the industry; going from like a medical model to like a community model to now like a peer-led model” (Site 2, Program Manager). These changes led leadership to think about ways to further embed and support peers in each of their respective agencies. As one director stated, “At this agency, we are focused on involving peers to the greatest extent possible. As we’ve seen anecdotally, what a tremendous impact that can have on not only clients but also other staff that are working with peers” (Site 3, Program Manager). They also described the need to think critically about the workplace environment and how peers experienced their role and the agency. Another director highlighted their broader goals for the peer workforce at Site 1, “to really meet all [peer specialists] with their goals and help give them the support they need to achieve them; have them heard by the leadership of the agency. Have their ideas heard and incorporated in a more formal way” (Site 1, Program Manager).

Leadership across the sites also noted how the agency’s organizational context shifted from trying to reduce stigma around peer delivered services to trying to integrate peers into the fabric of the agency. Leadership highlighted several ideas of how to increase peers’ presence at their agencies including increasing non-peer staff buy in, supporting the development of more peer workers, and expanding peer services.

While overall acceptance of the peer role within agencies improved from phase 1 to 2, there remained considerable variation in peers’ overall level of workplace integration. Reasons for varying levels of peer integration often stemmed from lingering misconceptions of peer specialist capabilities, their role, and contributions within the agency from non-peer staff more broadly. This was due to a lack of collaboration that occurred between peers and non-peer staff. This was primarily attributed to overall staff buy in for peer delivered services. In the words of one program manager, “I mean it’s not, not valued but I think there’s room for growth and education” (Site 2, Program Manager). When prompted to provide potential suggestions to increase overall staff buy in, the program manager noted, “I don’t know. I would need a better understanding of how peers are used in the agency now, and how they are valued and how much they are integrated into teams. It’s very unclear” (Site 2, Program Manager). Multiple site leaders also expressed the need to formally address and provide training to dispel misconceptions about peer specialists and peer delivered services.

“I know there are some people who are very aware of peer services and the importance of them in general. But I don’t think that’s through the whole staff at all levels. Like it is here, you know — you walk onto a team; there’s a peer on the team. You meet the peer. You see how they work; and you know, and you’re immediately learning about what they do.” (Site 2, Program Manager).

Similarly, when another leader was asked about how to create a viable peer workforce, they emphasized, “it’s getting the [non-peer] staff to understand it” (Site 2, Program Manager).

Leadership experiences with PGLB also sparked ideas for how to further expand peer involvement in services and sustain the intervention; for example, by having participants who completed PGLB take on a facilitator role: “[Maybe] having some veterans who went through [PGLB] to talk with others. Having ones who went through it becoming the peers who run it” (Site 2, Director). Additionally, leadership shared ways in which they were making conscious efforts to address challenges related to funding and reimbursement of peer services, “We’re looking to expand those services even further, we recently applied for an infrastructure funding for [a peer program]” (Site 3, Program Manager).

Discussion

This study sought to examine the perceptions of agency leadership towards peer specialists before and after the implementation of a peer-delivered healthy lifestyle intervention, PGLB, in three supportive housing agencies. Interviews with agency leadership elicited their perspectives on the peer specialist role, integration of peers into their organizations, and if/how they plan to incorporate the peer role into their organization following completion of the trial. Our findings revealed changes in the ways peer specialists were viewed among agency leadership over time across each site, with leadership reporting having an improved understanding of the peer role and peers’ capabilities.

Prior research has documented the value of peer delivered services to instill hope (Bochicchio et al., 2019) improve engagement, and to reduce the burden on the health care system (Davidson et al., 2012; Simpson & House, 2002). At the same time, prior studies have also highlighted several challenges to inclusion of peers in the mental health workforce, such as discrimination and prejudice encountered by peer specialists while working with non-peer staff (Jones et al., 2019). This has primarily been attributed to the stigma associated with hiring and working alongside individuals with a disclosed mental health condition (Jones et al., 2019). Historically, people with mental health conditions have been perceived as “unsuitable” for the workforce due to falsely held beliefs that mental health symptoms hinder one’s ability to perform and/or participate in the workplace (Krupa et al., 2009). However, when peers are effectively integrated into workforces, they have reported feeling a “sense of belonging” on their teams and a sense of satisfaction that not only influenced their work performance but also their mental health (Kuhn et al., 2015; Mowbray et al., 2021). Providing opportunities for peer specialists, such as delivering a manualized intervention where they can not only incorporate their own lived experience into the intervention, but be integral to increasing engagement, can help facilitate workplace integration of peers. The findings from this study highlight how attitudes towards the peer specialist role can change when non-peer staff are exposed to peer delivered services and have participated in the supervision of peer staff.

Prior to the implementation of PGLB, all three supportive housing agencies described positive perceptions of the peer specialist role, often emphasizing the practicality of working with individuals with personal experience (e.g., insight to a client’s behavior; ability to connect with clients on a mutual level). However, leadership also expressed common concerns about expanding the peer role and the potential consequences of hiring someone with a mental health diagnosis. Reflecting findings of prior research, leadership concerns regarding peer specialist roles in phase 1 were often attributed to fears that peers may have skills deficits, difficulties maintaining boundaries, and challenges managing their own recovery while working with others who have similar mental health concerns (Chapman et al., 2018; Firmin et al., 2019; Jones et al., 2019; Moran et al., 2013). While all agencies had previously employed peer specialists at their agencies, the peer specialist role within health services was often constrained to assisting clients with transportation or accompanying clients to appointments, limiting leadership’s exposure to the breadth and scope of peer services. Our findings indicate that exposure to and experience with PGLB peer specialists helped to demystify preconceived beliefs of individuals with lived experience working in the mental health field. Specifically, leadership emphasized how working with PGLB peer specialists who were well-trained, able to deliver a manualized intervention, and able to effectively use self-disclosure to help foster motivation and connection with participations shifted their understanding of peer services. Leaders’ experiences with PGLB largely helped to combat assumptions regarding peers’ capabilities and increased their understanding of peer delivered services. By phase 2, leadership expressed viewing peers as not only valuable but essential in their role within the agency. The success of the peers delivering PGLB also motivated leadership to want to expand peer voice and services throughout their agencies.

Implications

Our findings demonstrate the importance of developing organizational buy-in and support for peer specialists across agency staff. While not a primary aim of the Hybrid Type 1 Trial, exposure to PGLB peer specialists helped to expand leadership’s views of specialists across all three agencies. At phase 2, leadership described a shift from identifying concerns and challenges regarding peer delivered services to actively working to have the peer role accepted by non-peer staff and working to improve the integration of peer specialists within their agencies. This highlights the importance of increasing non-peer staff knowledge of and exposure to the peer specialist role and the versatility of peer delivered services, as a means to demystify misconceptions of peer specialists. This will also help to reduce potential bias towards peers among non-peer staff and improve understanding of the unique contributions of peer specialists to agency services.

Enhancing peer integration can take multiple forms, including through providing robust supervision for peer specialists and training opportunities for all staff. Our findings suggest that training content may include elaborating on the various roles that peers can occupy and the benefits of working with peer specialists. Such efforts may help increase organizational readiness and capacity to ensure positive workplace integration of peer specialists. The feasibility and maintenance of successful workplace integration of peer specialists is only possible through collaborative efforts from agency leadership and with buy-in from all non-peer staff, emphasizing the need for training to include staff at all levels including frontline staff and agency leadership. Findings from this study are reinforced by several other qualitative and quantitative studies examining peer workforce integration that have highlighted the importance of engaging all staff (peer and non-peer alike) in training on peer delivered services (Gates & Akabas, 2007; Kuhn et al., 2015; Mancini, 2018). Additionally, prior literature has emphasized the importance of dedicating available resources (e.g., money, training, education, physical space, time) for peer specialists to develop and expand their skillset and provide opportunities for upward mobility (Jones, Kosyluk, et al., 2020; Jones, Teague, et al., 2020; Kuhn et al., 2015).

Limitations

The current study focused on a small sample of individuals in leadership roles who participated in an effectiveness trial conducted in three supportive housing agencies in two large, urban cities in the Northeast. Nevertheless, these agencies also offer diverse programming and services (e.g., Assertive Community Teams, Personalized Recovery Oriented Services, Federally Health Qualified Center), increasing the relevance of findings across the mental health services field. The supportive housing agencies also all had prior experience hiring and working with peer specialists, suggesting that these agencies may be more readily able to facilitate and foster workplace integration of peers compared to agencies new to peer services. Despite this limitation, each supportive housing agency varied in how peer specialists were employed, offering some diversity of context. Additionally, the study sample was primarily comprised of white individuals in leadership position, reflecting an imbalance between the race of those in leadership roles and the peer specialists themselves as well as the population served. Therefore, the views and perspectives of leadership may not be reflected of other stakeholders from more diverse backgrounds. Finally, this study relied on the perceptions of leadership to explore how peer specialists were viewed and so, future studies are needed to measure any changes in the level of workplace integration quantitatively.

Conclusions

This qualitative study contributes to the literature on the peer specialist workforce by identifying factors and potential strategies that may impact the level of peer workplace integration. Recommendations to enhance the implementation and integration of peer delivered services in mental health settings include increasing exposure to peer specialists and peer delivered programming, providing training for non-peer staff on the peer role, and providing formal supervision to enhance peers’ capabilities. These findings underscore the importance of the work on identifying mechanisms of peer-led services and highlight the need for further research to implement and test the feasibility and acceptability of these strategies efforts to increase peer workplace integration and the effectiveness of peer delivered services.

Table 1.

Sample Characteristics (n=14)^*

	Mean (SD)	N	%
Age	45.1 (12.2)
Gender
Female		11	79%
Male		3	21%
Race
White		13	93%
Asian/Pacific Islander		1	7%
Ethnicity (Latinx)		1	7%
Professions
Social Worker		6	43%
Medical professionals		3	21%
Administrator		4	29%
Other		1	7%
Average years working in organization	3.71 (4.19)
Average years working with people with SMI	15.6 (9.46)

^*Between Phase 1 and 2, two leaders left their organization and as a result were not reinterviewed. As a result, two different leaders were hired and interviewed at Phase 2. Participant characteristics were collected at each participant’s initial interview.