Employment trajectories of recently certified peer support specialists: a longitudinal qualitative analysis

Abstract

Background:

Recent work has highlighted the challenges and benefits that Certified Peer Specialists (CPS) experience in the workforce. While their work can lead to personal fulfillment and financial independence for CPSs, and improved mental health and substance use recovery outcomes for their clients, little is known about CPS employment trajectories or the circumstances that impact their early career workforce involvement over time.

Methods:

This study used within- and across-case analyses of longitudinal data from qualitative interviews with 13 CPS that participated in a multistate, 3-year observational prospective cohort study of CPS graduates to explore employment changes and circumstances that led to these transitions. Qualitative results were organized according to whether cases were ‘employed as a CPS at follow-up’ (N = 5) or ‘not employed as CPS at follow-up’ (N = 8).

Results:

Participants ‘employed as a CPS’ at follow-up held various positions following certification, they shared a sense of optimism about their future work. At the second interview, most remained in the same positions they held at baseline and described personal fulfillment and a supportive work environment as reasons for remaining. Participants who were ‘not employed as a CPS’ at follow up were also not employed as a CPS at their baseline interview but aspired to pursue future CPS work. At their second interview, many remained unemployed due to poor health and disability, or described past traumatic experiences, stress, and burnout related to being a CPS as reasons for leaving the CPS work force. All participants were challenged to find work as a CPS at various moments in their trajectories.

Conclusion:

Results indicate that securing employment as a CPS was challenging for participants. Findings are discussed with implications for supporting CPS job seeking, wellbeing, and workforce retention.

Introduction

Peer specialists are individuals with lived experience of a diagnosed mental health or substance use disorder who have completed training and are often certified to deliver peer support services under state standards (National Association of Peer Specialists, 2021). Certified peer specialist (CPS) roles typically include advocacy and resource sharing, outreach and engagement, and emotional, instrumental, and social support to those who use substance or mental health recovery services,¹ though their services are often delivered as an adjunct to care from licensed professionals.² Peer specialists also lead recovery groups and mentor individuals on setting and achieving recovery goals. Imparting knowledge related to self-determination and wellness management is also germane to peer support and is accomplished by sharing lessons from peer specialists’ personal experiences with mental health and substance use recovery.³

A thriving CPS workforce benefits society in several ways. CPSs’ services support clinical (e.g. decreased substance use and psychiatric symptoms⁴) and functional improvements among those in recovery, while facilitating personal growth among CPSs by challenging self-stigma and contributing to financial independence.² Peer-based services also increase availability of mental health and substance use services in locations experiencing mental health professional shortages.⁵ Despite the benefits of a robust CPS workforce, CPSs are known to experience challenges when searching for employment and when working. These challenges include a lack of available positions, experiences of isolation once employed,⁶ and burnout.⁷ Other challenges include stigma from other professionals, a need for skills to solve workplace challenges, and for navigating professional relationships.⁸

With the goal of understanding the employment trajectories and perspectives of early career CPSs, the present study’s team conducted a longitudinal survey which followed a cohort of N = 681 recently certified CPSs across multiple US regions over a three-year period known as “CPS Career Outcomes Study.” Survey results indicated that CPS paths to employment are circuitous, with 24% of the study sample opting out of the peer support workforce.⁹ While this survey identified barriers to CPS employment, such as burnout¹⁰ and challenges finding peer support work,⁶ whether and how the trajectories of CPSs changed early in their careers was unclear.

The present qualitative study draws on analyses of longitudinal data collected from in-depth interviews over two timepoints with N = 13 early career CPSs that participated in the CPS Career Outcomes Study. We aim to explore employment changes that over the course of the first several months post-certification and the circumstances that led to these transitions. We also explore differences and commonalities across participants who remained in the CPS workforce in the months after their baseline interview, relative to those who did not. Findings from this study can inform best practices for supporting CPS workers in their employment transitions during the early career period following certification and beyond. Understanding CPS trajectories (which can impact future workforce participation and longevity) can also identify supports needed to promote retention of CPSs in the field and, ultimately, strengthen their contributions to recovery-oriented service systems.

Methods

Sampling

States were selected to participate in the parent study based on having large cohorts of peer specialists certified in 2019, and either had a public database of CPSs, and/or were willing to share their master list of CPSs or obtain consent from CPSs to reveal their identifying information to the study team. The sample included CPS graduates who completed their certification in one of four states representing the West Coast, Southwest, Southeast, and Northeast US regions.

Individuals with a state-verified certification completion date between January 2019 and early 2020 and were age 18 or older were eligible to participate in the parent study and in the qualitative study. Individuals who could not read or speak English or were unable to provide consent were not eligible. While the parent study’s target population included individuals in their first year following certification, 38% (n=261) of the parent study’s respondents were certified before 2019, but were recorded as having a 2019 or 2020 certification date in state records. These individuals were either “legacied” into their state’s new certification program or had been recertified during that time; both situations resulted in a “new” certification date. These respondents were retained in the study and reported their original certification date.

To collect a range of employment experiences among qualitative participants, we used a maximum variation sampling approach,¹¹drawing from the pool of individuals that completed the parent study’s baseline survey (N = 602). Of these participants, N = 372 were recently certified, while N = 230 received their initial certification prior to 2019. We then identified individuals who were working full-time, part-time, or unemployed, which resulted in six groups. From the ‘recently certified’ group, we randomly selected 12 participants from the ‘full-time,’ 10 from the ‘part-time,’ and 11 from the ‘unemployed’ sub-groups. From those with a certification date prior to 2019, we randomly selected eight participants working ‘full-time’ and five from both the ‘part-time’ and ‘unemployed’ groups. The 51 potential participants were then invited to participate in an interview during Summer 2020. Higher proportions of unemployed persons and Black persons completed a first qualitative interview; whereas higher proportions of full-time workers and Native American individuals declined to participate.⁶ Twenty five individuals completed a first qualitative interview. Recruitment for follow-up interviews occurred during the spring and summer of 2022. Each participant was invited to participate in a second interview that focused on their employment experiences and professional transitions that occurred since the first interview. Thirteen participants participated in a follow-up interview. While many who opted out of a second interview did not explain why, some reported not having time. Compared to those who completed a second interview, a larger proportion of those who chose not to were white and were employed as a CPS at follow up.

Data Collection

For both baseline and follow up interviews, the research team included individuals with lived recovery experience; one individual who had worked previously as a peer advocate; and other experts in peer support services, and PhD trained experts in mental health services research. These individuals collaboratively developed the interview guides that focused on CPS experiences with finding and maintaining employment, their current work, goals for the future, and reflections on the utility of the CPS training in this process. The same team developed the follow-up interview guide, which also included probing questions about transitions that had occurred since their first interview, such as “Are you currently working? Have you changed jobs since our last interview?” and “tell me more about what led to your job change.” Participants were also asked to describe the circumstances that led to employment transitions (or non-transitions), the positive and challenging aspects of their jobs, and future goals. Both guides were developed based on the team’s expert knowledge on CPS certification and CPS employment transitions. Follow up interviews occurred 12–22 months after their baseline interview. All interviews lasted for up to 60 minutes and were audio-recorded and professionally transcribed. This study was approved by the Institutional Review Board of Temple University.

Data analysis

Data for each participant consisted of one baseline and one follow up transcript and notes from each interview, which included an interview summary along with note-taker impressions. Notes were taken by BA-trained members of the study team who were knowledgeable about peer support and study goals.

Our analysis followed a longitudinal qualitative case study approach,¹² which emphasizes building rapport (which is needed to engage participants in two interviews) and preserving and analyzing the contextual elements of participant experience (e.g. whether employed as CPS or unemployed), which can be lost when using thematic approaches like grounded theory.¹³ This approach also facilitated comparison of experiences across participants who remained in the CPS workforce after their baseline interview relative to those who did not, and changes over time.

Our analysis occurred in three main stages. For both baseline and follow up interviews, the study team first followed a procedure of coding consensus, co-occurrence, and comparison.¹⁴ After collecting the baseline data, all co-authors independently open-coded three randomly selected transcripts, and then developed a code book.^{15 16} Once consensus on code use was achieved, the baseline transcripts were coded independently by either ES or MP using Dedoose.¹⁷ The same code book was used to code the second interviews, though new codes were added capture emergent topics such as ‘job change.’ Two trained research assistants assisted in the coding of the second interviews. ES supervised the overall coding process. The second stage took advantage of the longitudinal data and used coded data and notes to develop case summaries for each participant, which focused on employment transitions. Summaries were compiled into a case summary matrix.¹² During this stage, the team identified individuals that were employed and unemployed as CPSs at follow-up, using information from transcripts, and created separate case-study matrices for each group. The third stage involved multiple case study analysis within-and-across cases.¹⁸ During this stage, ES wrote memos on emerging patterns, similarities, and differences of those employed and not employed in CPS positions at follow up.

Results

Our sample consisted of 13 individuals who completed both baseline and follow-up interviews, which resulted in 26 transcripts and 26 sets of interview notes. The average age of participants at baseline was 44.5 years (range = 21–66 years), with the majority identifying as female (62%, N = 8). Most participants described their race as Black (54%, N = 7) or White (38%, N = 5), with 15% (N = 2) identifying as Latinx. Most of the sample (77%, N = 10) were certified in 2019, while three participants who were “legacied” into their state’s new certification process in 2019 were certified in 2012, 2014, and 2015. See table 1.

Table 1:

Sample Characteristics

Variable	Frequency (percent)
Region
Southeast	4 (31%)
West Coast	1( 8%)
Northeast	5 (38%)
Southwest	3 (23%)
Gender
Female	8 (62%)
Male	5 (38%)
Non-binary	0 (0%)
Original certification year
2019–2020	10 (77%)
2014–2015	2
2012	1
Race
White	5 (38%)
Black	7 (54%)
Other	1 (8%)
Hispanic
Yes	2 (15%)
No	11 (85%)
CPS Job at baseline
Yes	3 (23%)
No	10 (77%)
CPS Job at follow up
Yes	5 (38%)
No	8 (62%)
Age at baseline
Age range	21–66
Age Median	44

Given the study team’s interest in early-career employment transitions, and in the experiences of participants who remained in or left the CPS workforce in the months after their baseline interview, study results are organized according to whether they were working as a CPS at the time of their second interview. At the second interview, N = 5 respondents were employed in CPS positions, while N = 8 respondents were not. Below we separately explore respondent experiences according to these groups. Figure 1 summarizes our qualitative results, while figure 2 illustrates participant employment status at baseline and follow up.

Figure 1:

Qualitative Results

Figure 2:

Employment at baseline and follow up

I. Respondents employed as CPS at follow-up interview

IA. Optimism at Baseline

During their baseline interviews, four individuals from this group were working in positions that required CPS certification, while one worked in a non-CPS mental health position. These individuals all described challenges they experienced in obtaining CPS employment. One individual, who worked as a full-time peer specialist in a recovery center where they had been a program participant, first had to apply for “every opening every year for three years in my county” before being hired. Another individual first started as a volunteer, noting that securing a paid CPS position was competitive, having secured their position only after their predecessor died.

At baseline, those employed as CPSs reported having positive work experiences. One described themselves as “passionate,” explaining, “I love my job and love my people.,” Respondents also reported feeling “intimidated” and noted some professional insecurities. For example, one individual in a behavioral health leadership position remarked: “It’s a huge responsibility and I don’t want to mess it up,” while another, who at first held a position as a county liaison for locating detox facilities and long-term treatment options, held insecurities surrounding being ‘on par’ with other clinical team members.

At baseline, these respondents also expressed optimism about their careers and described their plans to work permanently in the peer support field. One individual, who worked in a state-level leadership position, aspired to hold a federal position or to represent the lived experience community in research. Another respondent had the goal of becoming a Licensed Clinical Social Worker and equine therapist, while continuing to practice as a CPS. While many expressed optimism, one individual (who was not employed as a CPS at baseline) articulated that there is a lack of respect surrounding the CPS role, and that CPS are not taken seriously despite having much to offer.

IB. Positive Employment Experiences at Follow-up

In their follow-up interviews, each of these respondents (and one other who was not employed as a CPS at baseline) were working in CPS positions focused on employment and housing support, and case management in mental health and substance use service environments, while one participant continued working in their state-level position. Three respondents remained employed in the positions they held at baseline, though two received promotions and one changed employers. Overall, they maintained a positive outlook on their work, noting that their employment contributed meaningfully to the community and to their personal growth. One respondent, who was working for their same employer as baseline, commented: “I’m very happy with the decisions I’ve made...”. This individual described their use of self-disclosing their own substance use recovery to help clients: “I’m in direct contact with clients who are actively suffering from substance use and abuse. One of my methods of ice-breaking is to let it be known to my clients from the beginning, I’ve had (SU) issues. I do it in a humorous way...”

At follow up, a participant who began a CPS position between their first and second interviews focused on helping clients find employment. They remarked:

I’m really enjoying it. I think it’s good for me and it’s good for the people that I work with. Right now, when it comes to the clients, I’m still developing rapport with them.

Other respondents noted that peer support professionals were valued at their jobs, with one commenting: “At our agency, peers are looked highly upon.”

Still, these respondents also described workplace challenges. Some were challenged by their workloads, particularly the administrative burden, with one reporting:

Some of the downsides is being the only peer and having so much responsibility... or being the only person in my county...There’s so many different clients and not enough space to put them all, so I’m having to really add more and more to my schedule...

Another was challenged by a lack of training, though they acknowledged the benefit of being forced to figure things out on their own:

I’m still trying to find my way...like, even as far as the paperwork, doing the progress reports how they want it done, what to include...I’m like, “Well, I can’t write clinical...”

Another participant, who held a leadership position, experienced workplace micro aggressions:

When I came on it was only me... I would say that they didn’t do a lot of things right...My office was originally on a different floor than the rest of the Behavioral Health Services in a closet kind of thing. It was an office, but it took a long time to get a badge to open something. [Things] I would consider micro-aggressions.

Still, in the end, all respondents who were working as CPSs at their follow up interview planned to stay in their positions long-term, with this goal best summarized as: “I’m not planning to leave anytime soon.” While some respondents were considering the logistics of how to retire in their current positions, others were strategizing to pursue master’s degrees focused on substance use and social work while remaining in their jobs. All reported that they enjoyed working in the service of others as a CPS.

II. Respondents not employed as a CPS at Follow-up interview

II A. Not Employed as a CPS at Baseline

The individuals that were not employed as a CPS at follow up were also not employed as a CPS at baseline. These participants described challenges finding CPS employment due to lack of available positions and challenges with their health. Two participants worked in peer support positions prior to their baseline interviews, though one described burnout as a reason for leaving, noting that: “I was experiencing burnout with the staff that I was working with. Also, I ended up going on disability because I just I didn’t do well there.”

Many respondents articulated plans either to change jobs or to become employed, and many wanted to find a CPS position in the future. As one participant commented: “My goal right now is to get a CPS role...” They continued:

I would love to work full-time. I want to work with adults in a hospital environment; I know that I want to work with adults.

Other respondents planned to pursue clinical degrees. One individual hoped that additional training would improve their employment prospects and remarked: “I’m taking some online classes ...to get my associate’s in psychology and social work so that I can potentially go on to advanced degrees for those things and work more with the therapy side.” While many individuals aspired to change jobs, two had the goal of remaining in their community service support positions long term.

II B. Many Barriers to Working as CPS at Follow-up

At the time of their follow-up interviews, four participants in this category were employed in non-CPS jobs, three of whom remained in the same or similar position, while four others remained unemployed. One employed individual, whose CPS certification had lapsed, received a promotion and commented:

I’m not [CPS] certified. I still use my training, and I work for social services, so I use a lot of my peer work...But I’m not certified peer support specialist anymore.

Some individuals who were unemployed at baseline remained unemployed for reasons related to health and disability. Participants also discussed barriers to finding and maintaining peer support employment and one described their state’s requirement that CPS workers have a counseling license as an additional barrier. At least one participant described the CPS job marked in substance use recovery as follows: I’ll speak for mental health peer supports, not the substance ones. Because somehow, it’s different. People are way more willing to take on... the peer supports that are doing the substance use. It’s easier for them... it looks like they are getting a lot more jobs.

Others shared the sentiment that the value of CPSs is misunderstood. As one remarked: “It’s not like everyone is on board with the peer support specialist because they don’t know what we do...” Another individual, who wanted to provide peer support through independent practice, felt that there were no role models for doing so, and that the chance of malpractice litigation was too high. Concerns related to liability also applied to peer support in general: So often the job description is like, ‘You’re going to have to drive.’ And then you think about things like...what about the person’s liability?

Two respondents described how traumatic experiences that occurred while working as a CPS between their interviews have deterred them from pursuing future CPS work. One reported being very disturbed by a client crisis they were not trained to handle:

I’m going to be honest with you. I think I was just so distraught and turned off with what had happened that I just wanted to be done with peer support all together.

Though they planned to resume employment as a CPS after a brief break, they realized work as a CPS was not for them:

I don’t want a CPS role because of the pay... and one of the things that became obvious to me through that experience is that I have a lot of potential and I have a lot to offer. It felt like to be in that role, I had to dumb myself down and make myself small.

Another participant reported a brief period of employment as a CPS between interviews, but does not plan to take a CPS role again:

I was so stressed out from the job and I was so beat down and I was so exhausted that it ended up leading me to hospitalization, and so I chose not to go back to the job and I’m going to be moving forward from here. I’m not sure what I’m going to be doing next but I know it won’t be taking a CPS role. In the end, some respondents continued working towards the completion of clinical training, though one left their associate’s in Psychology program after their baseline interview to work in the restaurant industry. Many still wanted to return to CPS work to help people in recovery, and believed their certification would eventually be helpful in this regard. Still, others planned to leave the human service sector permanently due to burnout.

Discussion

Respondents from this study were challenged to find peer support work in their early careers. Most were not employed as CPSs at the time of either interview, and few transitioned to and remained in CPS positions between interviews (see Figure 2). Despite their challenges with finding peer support employment, respondents who were employed as CPSs at the second interview reported positive work experiences and planned to continue in their positions for the foreseeable future. Conversely, those who were not employed as a CPS at the second interview reported several barriers to employment that related to health, trauma, job-market challenges, and burnout. While CPSs often support clients across a range of mental health and substance use recovery needs, at least one unemployed peer specialist shared the sentiment that specializing specifically in substance use recovery would have been an easier path to employment, and others were planning to pursue additional education and training that focused on substance use recovery. From this analysis, we offer actionable steps to support recently certified CPSs in their transition to and retention in the peer support workforce.

Challenges related to securing employment as a CPS related to lack of available positions, low pay, and respondents’ health. While a robust literature has described the value of peer support specialists in many roles,² few studies have explored mechanisms for placing new CPSs with employers. In this instance, it is possible that the COVID-19 pandemic negatively impacted their employment prospects.¹⁹ Still, future work could develop and evaluate processes for matching employers with aspiring CPSs during the training and certification process itself. Given that study participants Future research might also explore how job seeking and career experiences (and satisfaction) differ between CPSs that specialize in substance use vs mental health.

In other instances, participants’ own recovery and health status undermined their workforce participation. Recent work has acknowledged the mental health needs of peer support specialists,²⁰ and suggests that the delivery of virtual peer support services could increase technological access (and skills) for peer specialists, and provide job flexibility to accommodate their health and recovery needs.¹⁹ This point might have been particularly important within this study’s context, since our baseline interviews coincided with the COVID-19 lockdowns of 2020. Our study also revealed that a small number of respondents in the ‘not working as a CPS at follow-up’ category transitioned briefly into peer support positions between interviews. However, these respondents permanently opted out of CPS work due to traumatic experiences and burnout that occurred while working as a CPS. It is well-documented that peer support specialists need workplace supports once employed.^7,10 Several organizational strategies can facilitate a psychologically safe workplace culture for peer specialists, including strong supervision²⁰ and the development of senior peer roles. Access to supervisors who also have recovery experience can also protect the authenticity of the peer role²¹ and can support their CPS staff members when challenges occur.²²

Despite challenges that undermined workforce participation, individuals classified as ‘working in peer support at follow up’ demonstrated positivity surrounding their trajectories at both interviews, and about their future options. However, most respondents in this category were at some point challenged to become employed as a CPS but persevered in their job search. During their first interviews, they also described their passion for their work and believed that their organizations valued the peer support role. During their follow-up interviews, individuals in this category remained optimistic, and continued to feel valued by their employers. Environments that employ CPSs can convey their support for CPSs by implementing the organizational strategies described above.^20–22

Limitations and Strengths

We acknowledge that the data presented here are limited in that they are a ‘snapshot’ of a CPSs career over the course of 12–22 months, whereas career progression is often gradual. The nature of our sample also precludes us from generalizing to the peer support workforce. Further, the individuals who opted in might not represent the average CPS, and those that participated in the follow up interview might have represented extreme cases, whether positive or negative, and the experiences of individuals that opted out of participating in a follow up interview are unknown. An additional study limitation pertains to the composition of our study sample, which includes 13 of 25 individuals who completed a baseline interview.

Our study also has several notable strengths including prolonged engagement of study participants through collection of longitudinal data, multiple data sources including interview transcripts and notes from two time points, and maintenance of an audit trail following analytical decisions. Our use of ‘maximum variation’ qualitative sampling approach¹¹ invited a diversity of experiences.

Conclusion

Our results indicate that securing employment as a CPS was challenging for participants. Regrettably, personal perseverance and individual circumstances appear to be important considerations for securing these positions, and long-term exit from the field may occur in their absence, particularly during the height of the COVID-19 pandemic. Once employed, strong training and supervision, as well as a workplace culture that values the peer role, are needed to promote workforce retention and career empowerment among CPS professionals. Despite challenges, many individuals who participated in this study were passionate about their work as CPSs. Our findings provide additional evidence that successful peer support employment outcomes are possible in moments when the workplaces give the right supports, and contributions of CPS professionals are recognized. However, guidance at the CPS training and certification stages is also needed to give CPSs and CPS trainees skills for navigating the job market and their own career paths.

Highlights.

• Peer specialists can experience barriers to becoming employed early in their careers.

• Barriers to employment included lack of available positions, low pay, and respondents’ health and recovery.

• Negative work experiences, poor health, and burnout caused some of our study participants to exit the peer support workforce permanently.

• Participants that remained employed as peer specialists for both post-certification interviews were optimistic and passionate about their work