In the analysis, three principal categories with related subcategories were identified. Additionally, an overarching theme running throughout the categories was distinguished and will be discussed below. The findings suggest that managers find themselves in a quite undefined field, where they attempt to develop their perspective on peer support and justify decisions regarding their inclusion in their organization, without clear boundaries or structures for doing this. We describe this theme as Navigating liminal spaces when implementing peer support in mental health systems. Liminality denotes transitional or transformative states, where usual practices and structures have been suspended but where new ones have not yet been established (32), and has been applied in recent literature to explore and describe the complexities involved in transformational change in roles and cultures within mental health systems (33).
The theme, the main categories and subcategories are presented in table 3. Along with the descriptions of the categories below, citations are given where references are to the managers in regions A, B and C, (as listed in table 1), and are identified as follows: (A1-7), (B8-12) and (C13-18).
Table 3. Theme, main categories and categories
Navigating liminal spaces when implementing PSW in mental health systems
Incentives and conditions
Implementation and organization
Experiences of peer support
Previous experience and commitment
Opportunities for full scale support
User movement collaboration
Preparation phase at the start
The working role of the PSW
The PSW in the client work
The PSW in the working team
Thoughts on the future
Incentives and conditions
This main category includes the managers' descriptions of factors that had contributed to, or otherwise affected the decision to commit to implementing peer support in their services.
Previous Experience and Commitment
Amongst the managers, the initial enthusiasm for peer support implementation ranged from being a bit hesitant to being an engaged champion. Those who were hesitant had little prior knowledge of peer support and typically had no other incentive to join the project other than that of saying yes to something “exciting and interesting to test” (C14).
On the other end of the continuum, several managers expressed a serious dedication to the implementation of peer support. These managers typically had theoretical as well as experiential knowledge of recovery-based practice and user involvement. Some of them had been pioneers in peer support implementation in Sweden and had also often been the initiators and champions for joining the current project.
In describing what had contributed to the decision to take on a PSW, they frequently expressed a commitment to strengthen user participation in the services. Some noted how this drive had been spurred, during the last decade, by the increased emphasis in directives and policy on user participation. The activities of NSPH and a national governmental initiative focusing on psychiatry were noted as important elements in supporting this shift in the caregiving culture. Some managers described the current project as providing an opportunity for taking the next step, and when offered the opportunity to employ a PSW it was “natural to say yes” (A5).
Opportunities for Full-Scale Support
It was generally appreciated that the “all-inclusive concept” (A5) implied no financial and little administrative burden on the services. Some managers had experience of peer support within time-limited projects where uncertainties regarding the position had led to problems. The fact that the current project involved an ‘implementation package’ including staff education, supervision and facilitation, contributed to their enthusiasm to be involved. Other managers described how witnessing other services successfully implementing peer support had stimulated their willingness to try, some having waited for such an opportunity.
Many described the full external funding as a major incentive for joining the project, where they had the opportunity to try out something they really wanted despite limited financial budgets:
The budget allotments that we have to follow aren´t always in line with our real needs. So, I considered this a golden opportunity (A7).
The most committed expressed regret that the only opportunity they had for taking on a PSW was within the framework of a time-limited project rather than a proper, internally determined and financed implementation.
User Movement Collaboration
The category user movement collaboration describes comments on various forms of networking with user organizations locally as well as nationally that had affected the conditions for implementation.
Among the managers, there was a wide variety of opinions as to what extent a collaborative culture had been established with user organizations, and regarding the quality of the implementation support from NSPH. Many noted how regions who had established working collaborations with the user movement could contribute to wider progress through networking. This development was described as “spreading like ripples on water” (B12).
Regarding user organization involvement in the implementation process NSPH was clearly the user organization who had the primary role, although one region (C) had developed its own local structure for supporting user influence. One manager noted how the focus on user involvement in general had been instigated by national initiatives and directives from the central authorities, and how NSPH now had moved forward with this mission in a commendable way:
Then it is not least NSPH who has taken the baton and raised the issues nationally, and when it comes to PSW they have developed training packages, structure and organization of implementation and received a very positive and well-earned response. By this, PSW had had a real boost in recent years (B11).
The collaboration with NSPH before entering the project was commonly described as supportive and well structured. Not least, managers reported how the presence of NSPH in meetings had provided an important forum for ventilating both doubts and opportunities that engaging a PSW might entail. However, one of the managers noted a lack of support from local user organizations. The service was located in a rural area and they described the national umbrella organization as having overshadowed a focus on involving local user organizations.
Implementation and Organization
In this main category, various factors are described that were viewed as significant for the implementation and organization of peer support in the service.
Preparation Phase at the Start
This category describes issues that affected staff readiness for taking on a PSW. It concerns the managers’ descriptions and views of staff training, of staff attitudes and concerns, and of their own actions in the introduction of a PSW in the team.
The managers often underscored the importance of anchoring new interventions in the team, of the team having the opportunities to ventilate questions, concerns and opinions in open discussions. It was noted how introducing a new profession constituted a challenge for the team, something which needed to be handled with sensitivity.
Managers described an initial mix of attitudes in the working team, from those who showed great enthusiasm to those who were entirely negative. Amongst those with the most skeptical staff members there was one that even had been worried that a couple of staff would treat the PSW badly. Typically, teams who had previous experiences of peer support or of other models for user involvement were relatively positive to taking on a PSW. According to some, they “had made the journey” (C18), were “one step ahead in the thinking” (C13) and were “further along” (B12) than many other services.
Managers expressed that staff training had been much appreciated and experienced these as having contributed to readiness. However, the degrees to which staff had participated in training varied.
The Working Role of the PSW
The category the working role of the PSW concerns issues of developing and defining the role. It involves managers’ experiences of initial concerns amongst staff relating to role expectations and identity issues. In addition, it concerns the practical, administrative aspects of the role. In view of the SIS scale, these matters might be understood to concern implementation components of organizational fit of the intervention.
Defining the role was viewed as important but also difficult since all involved; staff, managers and the PSW, had to “deal with grey zones” in relation to the traditional clear division between staff and service users.
The managers reported that some of the initial concerns expressed were that the PSW would take over many desirable but informal contacts with the patients or disturb the “free zone” (C16) in the personnel room where they could “breath out and ventilate” (C16). They expressed their own uncertainties about what the PSW would be allowed to “see and hear” (C17), and worried that the PSW, who lacked care training and might be particularly vulnerable and have difficulties setting appropriate boundaries.
Several managers reported staff skepticism regarding having “a staff member that is simultaneously really a service user” (A3). Notably, the prospect of taking on a PSW was described as emotionally charged among staff and something that was commonly thought to require overcoming one’s “prejudices” (B12, C15) and “fears” (B12). Such concerns were often noted to be counteracted by receiving clear descriptions of roles and responsibilities during the training. In some cases, the managers reported that they themselves had decided on work tasks for the PSW while others had allowed the PSW role to unfold or to develop in practice. Some appreciated the excitement of “breaking new ground” (C18) and the necessity to hold back so as to allow for the fresh and different perspectives of the PSW to discover what needed to be added to the routine practice. As one manager observed:
One of the benefits of peer support is to find the gaps that we have not noticed, therefore we have said that we will take it easy (C18).
Perceptions of the organizational belonging of the PSW sometimes reflected an uncertainty and ambiguity. The managers in the region where the PSW were employed within the service generally expressed how this was the natural and optimal arrangement in order for PSW to be “for real” (B12), ensuring that the PSW becomes a valued member of the team. These managers describe how the PSW participated in staff meetings and trainings on the same conditions as other staff, “like one of us” (C15, C17).
Managers expressed the difficulties involved in handling this unfamiliar working role, not knowing whether to give special consideration to the PSWs due to their potential vulnerability or whether to “treat them as anyone else” (C15).
They expressed a variety of expectations regarding the PSW role, including ”a role that is supposed to develop the service” (C6), and the PSW as someone who” helps build alliances” (B9) and “supports communication” between users and staff (B11). The managers describe the PSW as “serving as a link [to the users]” (A2, B9, C15) or “listening with a third ear, on another frequency … and then conveying it to the staff” (A6). When describing expectations for the PSW role as differing from traditional roles, managers described how the PSW should be prone to “see health factors and strengths” (B12), to sit down and talk with clients “without having an agenda” (B2), and how the PSW may instill hope by being “living proof” (B9) that recovery is possible.
A characteristic that was frequently mentioned as desirable in a PSW was that the person should be “far along” (B12, C15) in or even having completed his or her journey of recovery. This is expressed as important in that it ensures that the PSW has a “certain maturity” (A7) and “can tell the difference between what is professional and unprofessional” (A5) and “what is private and personal” (C15). The person needs to be “strong and stable enough” (A7) and “in control of his or her baggage” (12B) not to “take too much room for him-/herself and start things he or she cannot handle” (A7). They even described having come “a long way in their recovery” (C15) as insuring that the PSW is “not there for his or her own sake” (A2, C15) in order to “process experiences and past events” (C15) and that the PSW does not “carry any resentment” (C15).
The specific tasks of the PSW, as described by the managers, involved participating in group activities, “being out on the floor” (B12), being available for spontaneous talks, “for taking that walk and for staying a bit longer in a conversation” (C18) than is possible for ordinary staff to do. Many of the managers suggested that the PSW should not be involved in documentation and treatment, while others, including some of the most experienced ‘local champions’ stated that the PSW should have full access to journals and participate in treatment conferences.
Throughout, implementation was described as more successful when continual support was provided by NSPH n the form of facilitation, guidance and supervision for mangers, staff and for the PSWs. In many cases managers expressed that NSPH had been ”present and accessible” (B11) for support in any issues that arose during the project period while some others had experienced such support as largely lacking.
Managers reported that external supervision was provided for the PSW, most often from NSPH. Generally, they appreciated this form for external supervision, expressing the value for the PSW to receive collegial support and guidance under the auspices of the user organizations. One manager emphasized how substantial support is needed for the PSW to handle a challenging role, and to be supported as a profession:
I think it is extremely important that they are reinforced as a professional group, and therefore receive external guidance together (A6).
However, in one case, no supervision had been provided, causing an extra burden on the supervisor who had had to spend “more talking time with the PSW than with any other staff” (A5).
Experiences of Peer Support
This main category involves the managers' experiences and perceptions of different aspects of the implementation process: the PSW in the client work, in the working team and the design of the project organizations.
The PSW in the Client Work
The category the PSW in the client work includes managers' descriptions of positive as well as problematic aspects of the PSWs contacts with service users. In view of the SIS framework (table 2) this category can be understood to concern issues of organizational fit as well as experience of the model.
Typically, managers stated that they had limited knowledge of specific service user experiences of the PSW. Still, they typically reported having received positive feedback from staff members, reporting that the PSW were in demand, that service users appreciated “speaking to someone who understands” (C18). It was noted how the PSW conveyed to the service users “hope by their mere presence” (B12) how “illness experiences [may be] a resource for oneself as well as for others” (C18) and that “it is possible to make something positive out of the difficult” (B8). Initial fears among staff that there would be much “illness talk” (A1) in the conversations had proved unfounded. Instead it was noted how the holistic perspective of the PSW gave them a stronger focus on “wellness factors” (B12) than other staff.
In many cases, the mangers noted how they were surprised at the ability and competence of the PSW:
I did not have very high expectations…, I was probably set on that this is a person who has a chronic psychiatric illness and that it was actually not so long since he was ill and required inpatient care… So I actually did not think he had the level he actually has (B8).
It was noted that the PSW had been able to earn the trust of service users in ways that no other staff member had and that meetings with the PSW had been requested by service users who had never asked for any other staff. Some reported how ordinary staff, on several occasions, had not succeeded in reaching certain individuals, but how the PSW who had posed a question from another perspective had received an immediate response. By some, it was also noted how the “other perspective” (B12) of the PSWs is important to bring to decision-making processes regarding the care and support of service users. In addition, it was noted how the shared experience enabled the PSW “to be braver” (C18) than ordinary staff and to “tiptoe less” (C18) around difficult subjects. Lack of courage was observed to constitute an “Achilles heel” (C18) for professionals who tend to avoid such subjects for fear of making things worse.
However, at the same time that managers highlight the alliance building power of sharing personal experiences and of daring to talk about the most difficult matters, the importance of the PSW setting boundaries “between personal and private” (C15, C18, A4, A6) was commonly underscored as vital and experienced as a major challenge. Some staff expressed concerns to the manger regarding the support provided by the PSW, for example having provided “too much support” (C15).
The PSW in the Working Team
The category the PSW in the workplace involves the managers’ descriptions of their experiences of having the PSW in the service in relation to issues of working climate, staff attitudes, service provision and organization. In relation to the SIS framework, experience of an intervention provides an organizational level implementation component determining readiness for further implementation.
Some managers reported that staff who were initially skeptical to peer support were still cautious in their judgement. It was noted by one of the experienced managers that it is important “always to keep the demarcation alive between what staff does and what the PSW does in order to avoid a competitive situation” (B12). It was observed that a PSW could build deeper relationships with service users. One manager reported how this creates tension that has "led staff to denigrate the PSW for being too unrestrained” when they ought to have welcomed this “knowledge contribution in the service” (B12). Correspondingly, “finding the role” and seeing to that the PSW does not “take over the tasks of other staff members” (C16) was described as a major challenge, one that was part of the particular focus for responsible managers.
When talking about experiences from the peer support project, managers often highlighted positive, personal characteristics of the PSW. In a few cases, personal characteristics of the PSW were described as problematic, and often those traits were related to the mental health problem of the PSW such as being “too emotional” (A5) or having “difficulties with change” (A3).
Overwhelmingly however, managers gave voice to positive experiences and in many cases, having a PSW in the service had far exceeded their expectations. Initial fears that the PSW would disturb the conversational climate in the team had proved unfounded. Typically, the PSW had come into the team without difficulties and had eased the burden of staff as well as managers.
It was noted how the PSWs had supported user involvement in the services, giving guidance on how to think and work and contributing ideas and supporting initiatives that would support self-help and recovery. Many managers express how the PSW has provided the staff with new perspectives and generated shifts in staff attitudes. One manager noted how the jargon was affected and that the presence of the PSW “makes it harder to talk in derogatory terms about the service users” (C13). In many cases, the managers described how staff actively consulted the PSW and received guidance on difficult matters regarding specific service users. In the following quote, a variety of positive effects and contributions are expressed:
Peer support changes attitudes and the whole atmosphere at the units. For example, staff express that at treatment conferences they twist and turn the perspectives a little more, they problematize a little more and they actively demand a PSWs’ point of view. The PSW is seen as an important source of knowledge, that is important to highlight. They provide new ideas and ways of thinking. Several people have noticed that conversational tones and topics discussed in the staff room have also been enriched (B10).
Many managers gave concrete examples of knowledge provided by the PSW, specifying how the PSW had helped the staff understand how mental health problems could be experienced from the inside and raising their awareness on how to recognize and interpret signs of illness:
The PSW gave us a lot with his openness, a lot of information about how the disease goes, what conditions you might have, how we should for example interpret certain behaviors, certain situations for people. (A4).
Another example of this valued perspective was provided by the manager of a clinic who noted how the PSW had a holistic and “forward looking” (C18) perspective on service users’ situation that is often lacking among staff who, on a daily basis, deal with people in acute crisis” C16). Managers often described the presence and perspectives of the PSW as “eye opening” (B10) and as “providing a totally new way of thinking” (B12). Some noted how the PSW provides a critical eye on the service and has spurred self-reflexivity among staff making them “question what they did earlier” (A6), sometimes by “expressing opinions that are not always comfortable” (A6). Throughout, such scrutiny was described in positive terms, as in the quote below:
It feels like a reinforcement and complement … that our services in some way get better and we are even monitored and questioned in another way when he asks his questions and approaching things differently. It really adds something (A5).
Some managers remarked how staff often give themselves “interpretive prerogative” (C18) of service users’ behaviors and tend to be “too solution focused” (B10) and sometimes over-caring in their eagerness to help, and that the PSW had helped them hold back from handing out solutions to service users’ problems.
Moreover, it was noted by one manager that the PSW had made it easier for staff “to dare to open up” (B11) and talk about their own experiences of mental health problems by normalizing such conversation. Another manager held that ordinary staff should be more open with their own experiences in order to avoid a “too strong focus on [the PSW as an] individual person” (C16)
Some experienced the project as sufficiently structured and others that structure was lacking. As for practical and administrative issues, many expressed how they would have liked more guidance and regulation on issues such as employer responsibilities, wage determination and sick leave. Some experienced the short time span of the project as stressful. It was observed by one manager that “implementation work takes time” (B11) and by another that more time would be needed for them to “try properly” (A6). In light of the SIS framework, these views can be understood to reflect various levels of readiness and consequently of organizational fit.
Thoughts on the Future
The category thoughts on the future involves ideas for further implementation, on perceptions of barriers and prerequisites and lessons learned.
In most cases, managers expressed a wish for continuing with peer support. Some reported that at the end of the project, they felt ready to manage it on their own, while others expressed that they hoped for a continuation, citing a need for further support from NSPH. In these cases, they reported the time-limited project implied uncertainties and created stress, making it difficult for the managers to make plans and for the PSW to have control over their future. They expressed a vagueness about future opportunities that prohibited long-term and systematic planning:
In order for us to plan and for her to be part of our planning, I would like to know if we have a future together or if things are just sliding along haphazardly. (B11).
In many cases, managers expressed a desire to employ the PSW permanently, so that they had job security and that the position would be sustainable, however financial resources had not been determined. Many also reported facing major reductions and recruitment freezes, ruling out any such employments. Without an organizational decision to dedicate specific funds they feared that employment of a PSW would come at the expense of another member of staff. As one manager noted: ”if we are to keep her, we have to remove someone else, and who then is going to go? (A6)”
However, amongst the managers with long experience and commitment, there was a perception that a PSW indeed could be hired instead of someone from another occupational category when a vacancy occurred, noting that service needs and goals have changed during the last decades.
These managers underscore the importance of setting aside funds centrally, for providing legitimacy and demonstrating that PSWs are valued as important members of teams:
It is not enough to just say that you are for something, giving a pat on the back that you are doing a good job, you also need some financial incentives to show that you are serious about this. (B10).
Further, another committed manager expresses that although participation in fully funded projects serves to “generate a need that makes it difficult to let the PSW go when the project ends … it is now high time that these uncertain projects are transformed into regular employment ”(B8).
The dynamic challenge that managers face in Navigating liminal spaces when implementing peer support in mental health services was the overarching theme as presented in table 3. The theme was developed in response to the various “grey zones” that the categories included. These became evident when exploring expectations and definition of peer support work, where roles were unclear in relation to professional identity and to the practical structure of the position. The role and identity of the PSW can thus be described as inhabiting a ‘liminal space’ in that it exists in-between the role of the service user and the role of the professional. Similarly, it was apparent how this in-between existence and this inherent uncertainty was evident at all levels from the micro to macro, regarding instrumental (practical, administrative, organizational) issues as well as matters of knowledge legitimacy and cultural values. The implications for implementing peer support while navigating various ambiguous or transitional fields will be further elaborated below.