Service Users’ Challenges in Developing Helpful Relationships with Peer Support Workers

This study contributes to the existing literature on peer support and complexities in peer support practices by exploring and describing service users’ perspectives on challenges in developing helpful relationships with peer support workers. Twenty-six service users with mental health and/or substance problems who had collaborated with one or more peer support workers on five or more occasions voluntarily participated across five focus groups. Interviews with these participants were tape-recorded and transcribed verbatim. Data were analyzed using the Braun-Clark approach to thematic analysis, resulting in two major themes: (a) embrace the difference and (b) harness the contextual factors. The findings suggest that peer support by sharing lived experiences does not always result in helpful relationships that promote recovery. How and when aspects of lived experience are shared appears to play an important role in characterizing relationships as helpful or not.


Background
The World Health Organization's (WHO) Mental Health Action Plan (2013-2020) states that a recovery-oriented approach should focus on supporting individuals with mental health problems to achieve their own aspirations and goals (WHO 2013). Recovery-oriented practice focuses on helping and supporting the person in recovery on the personal and social levels. In recovery-oriented practice, both professionals and people in recovery (i.e., service users) are viewed as experts.
Within the field of mental health and substance abuse, peer support has become an essential part of developing and delivering recovery-oriented practice, resulting in formal designs to integrate peer support workers in mental health care provision (Davidson et al. 2012;Repper & Carter 2011). The literature suggests an important building block in the recovery process is supportive relationships with peer support workers as an addition to the standard care provided by healthcare professionals (Farkas & Anthony 2010;Karlsson & Borg 2017;Ljungberg, Denhov & Topor 2016;Watson 2017). Peer support workers are individuals with lived experience of mental health and/or substance abuse issues, who use their own experiences to support others who are currently in crisis or struggling (Repper & Carter 2011).
The literature suggests peer support contributes positively to mental health care. Peer support seems to help service users in getting better access to beneficial help, in the use of emergency services, and in reducing the use of substances (Davidson et al. 2012;Doughty & Tse 2011). Further benefits of peer support relate to the use of healthcare services, including fewer hospital admissions, readmissions, and hospital days (Repper & Carter 2011;Sledge et al. 2011). It was suggested in our earlier work ) that peer support workers not only offer inspiration and hope for the future to service users, but also contribute to service users' integration into the community by being resources and links to available services and to local community networks. Service users with encounters with peer support workers have reported they feel more optimistic (Davidson et al. 2012), independent (Repper & Carter 2011), and able to be their true self . Peer support worker participation in providing mental health care is based on the principle that peer support workers, unlike formal healthcare professionals, are able to establish unique, flexible, and trustworthy relationships with service users because of shared lived experiences Douglas et al. 2012). Shared lived experiences enable peer support workers to develop and uphold relationships with service users via emotional, practical, and social support Douglas et al. 2012;Repper & Watson 2012). Service users have used words such as respect, love, compassion, and warmth when describing helpful relationships with peer support workers . However, some evidence suggests insignificant effects of peer support on service user outcomes. Pitt et al. (2013) conducted a systematic review of randomized trials assessing the effects of employing peer support workers in public services and concluded that employing peer support workers did not result in better or worse psychosocial and mental health symptoms or service use outcomes for service users. Another systematic review and meta-analysis evaluating the effectiveness of peer-delivered interventions in improving clinical and psychosocial outcomes among individuals with severe mental illness or depression offered further support to this claim (Fuhr et al. 2014). In addition, in a study reported earlier , in which we explored service users' experiences of developing relationships and collaborating with peer support workers, we found that having and sharing lived experiences do not necessarily result in recovery-promoting relationships.
Most of the literature on peer support has examined what works in relationships with peer support workers, mostly echoing positive experiences. To gain a broader and deeper understanding of peer support, one must also examine what does not work in relationships with peer support workers (Norcross & Wampold 2011). The literature review by Ljungberg et al. (2016) on non-helpful relationships with mental health professionals emphasizes how personal attributes in mental health professionals, such as uncaring, uncomprehending, paternalistic, and disrespectful, seem to work against developing helpful relationships. Ljungberg et al. (2016) also identified some contextual factors described as non-helpful, such as discontinuity, insufficient time, and coercion. It is necessary to examine whether these factors are also critical forces that create challenges in relationships between service users and peer support workers.
The aim of this paper is to explore and describe service users' challenges in the development and maintenance of helpful relationships with peer support workers within the Norwegian mental health and substance abuse services. More specifically, this paper seeks to offer an in-depth understanding of how service users understand and describe challenges in developing and sustaining relationships with peer support workers. Knowledge about such challenges can provide important insights into the factors that may hinder the development of supportive relationships between peer support workers and service users. Furthermore, it may also enhance insight into how to better support peer support workers in their roles.

Design
By focusing on subjective experiences and meanings, the research perspective takes a hermeneutic phenomenological approach (Borg, Karlsson & Kim 2010;Finley 2011). Five focus group interviews were conducted to provide the data for the study. Thematic analysis was performed to explore the participants' understandings and descriptions of challenges in relationships with peer support workers (Brown & Clarke 2006). An advisory group of seven people with experience as peer support workers, service users, researchers, or health professionals was established to enable the project to be participatory in design and progress. The advisory group participated in all phases of the project, including providing recommendations on the recruitment of participants and the types of questions to address in the focus group interviews, as well as providing feedback on the results of the data analysis.

Participants and recruitment
Persons over the age of 18 with mental health and/or substance problems, who had collaborated with one or more peer support workers on five or more occasions during the six months previous to the study, were invited to participate. We identified five mental health service units (services in three municipalities, one specialized service, and one user-run service) that employed peer support workers; these were contacted for participant recruitment. Initial contact with these service units was made via either phone calls or emails, which were followed by sending information about the study objectives to the contact persons. The contact persons shared this information with potential participants, who then contacted one of the researchers. The interview times and places were arranged with the service users who were willing to participate.
A total of 26 service users (9 men and 17 women) voluntarily participated in this study. Their years of birth ranged from 1930 to 1999, with the highest proportion born between 1950 and 1959 (n = 8). All participants described their ethnicity as Norwegian. The majority of the participants were single (n = 19), while four had a boy/girlfriend, two were married, and one was cohabiting. Their educational background was as follows: secondary school (n = 9), high school (n = 11), and university college/university (n = 6). As for their living situation, most of the participants were renting (n = 14), followed by those who had a home of their own (n = 10). One person lived with parents, and one had another kind of arrangement. Regarding employment status, 10 reported having some type of arrangement but did not specify what kind. The remaining 16 participants described their employment status as follows: regular employment (n = 2), voluntary work (n = 3), on a temporary contract (n = 8), and being a student (n = 3). The five focus groups ranged in size from four to seven participants, with each group created based on place of residence, resulting in five different localities in Norway.

Data collection
Data were collected from May 6 to June 16, 2016. Two researchers, one with lived experience, conducted the focus group interviews. Each interview lasted between 60 to 120 minutes and was conducted with the aid of a semi-structured interview guide developed in consultation with the advisory group. It explored topics such as the participants' experiences in collaborating with peer support workers, what had been helpful, what had not been helpful, specific examples of collaboration and differences between support by a peer support worker and by a health professional. In the focus group interviews, we explored various aspects of participants' experiences with peer support workers. In the context of this paper, we focus on what the participants experienced as challenging. A full description of the data collection can be found in our report .
The peer support workers described in this study had various roles and positions. Some positions were permanent, others temporary, although most were employed part-time to work with individual service users. Some worked in clubhouses, some in community settings, and some in mental health facilities. Some worked in service user organizations, and some also had a special role in service development. Data pertaining to characteristics of the peer support workers involved in providing services to the participants was not collected. The only information collected regarding peer support workers is that each of the 26 participating service users had one or more peer support workers with whom the service user met five times or more. In Norway, persons with lived experience of mental health issues who wish to become peer support workers usually receive training prior to either full-or part-time employment in mental health care.

Analytic strategy
The transcripts were analyzed for recurring themes within the focus area following the Braun-Clarke (2006) approach to thematic analysis. Thematic analysis was the preferred method of data analysis because it allows the researcher to identify a number of themes related to the research questions, which adequately reflect the textual data, instead of seeking to identify the overall topic of the text (Howitt & Cramer 2011). The transcripts were read and a number of themes were identified by the first author. Reviewing, defining, and labeling themes was conducted by the first author, with supervision by and in-depth discussion with the second author. To ensure the accuracy of the analysis and to avoid potential bias, extensive discussions among the members of the research team took place regarding the meanings embedded in the data and the identification, interpretation, and organization of themes. Our focus on delineating the themes was on the kinds of challenges experienced by the participants in their relationships with peer support workers. The themes were extracted through our interpretations of what sorts of challenges the participants experienced and how they experienced them. The research team grouped related themes under two major themes. Interpretation of the themes is illustrated by verbatim extracts from the transcripts.

Ethical considerations
The study was reviewed and granted ethical approval by the Norwegian Centre for Research Data. Before participants gave their consent, they were informed about the study objectives, both orally and with the aid of an information sheet. It was emphasized they could withdraw at any time without providing a reason and have their information deleted. All forms of personal identity were removed from the transcript data to make it impossible to reveal the identities of the participants or of the peer support workers mentioned by the participants. All the participants had the capacity to provide consent.

Results
Thematic analysis resulted in two major themes: (a) embrace the differences and (b) harness the contextual factors. Table 1 provides a summary of the master themes, component themes, and sub-themes.

A. Embrace the differences
All participants emphasized that lived experience was not enough to develop a supportive relationship. The underlying reason was the belief that, although the service user and peer support worker share lived experience, they are still two different individuals at the core. Consequently, some participants emphasized peer support workers need to be open and respectful of the individual's needs and preferences. Furthermore, some participants highlighted it was important to be able to work with different peer support workers. Some participants also valued the need for peer support workers to embrace the assumption there are different paths to recovery. Failure to embrace these differences was described as a factor contributing to challenging relationships. The participants emphasized that peer support workers need to be sensitive and flexible. Meeting a service user, just as another person, without considering individual differences was described as potentially challenging and difficult. One participant stated, 'I'm not saying that everyone could handle this. But being provoked worked very well for me. Fuss and beating about the bush didn't work for me. I need the words to be clear, no beating about the bush.' Some participants also remarked on the need for peer support workers to adjust their approaches to the same person every now and then. For example, another participant stated, 'I don't always need to be confronted … It doesn't always need to be an aggressive approach … Sometimes short and simple questions are the push I need in order to move forward.' When describing a place where peer support workers usually gave hugs to make service users feel welcome, some participants reinforced the importance of peer support workers adjusting their approach from person to person, and from time to time, even with the same person. One participant mentioned. 'You need to be aware that not everyone likes to be hugged. I had a friend who was very open in most ways, but not when it came to hugging. That was one thing she didn't like.' Another participant said, 'Some days it's okay to get a hug, and some days it isn't.' Flexibility and sensitivity were called for across persons and across circumstances.

Service users need different peer support workers
Not having the freedom to choose between peer support workers was seen as an unnecessary barrier. The participants emphasized that when it came to collaborating on certain things, some peer support workers were more helpful than others. Partcipants were in the best position to choose for themselves: 'They're actually here to help us. So if you feel like one of them could be more helpful, today, then you'll go to that person.' Another participant said, There are some peer support workers I can use, if it's about networking, going out somewhere, but I might not choose him to help me with my finances, or go to a meeting at NAV [Norwegian Labour and Welfare Administration], or something else, it will usually not be him.
One participant mentioned the importance of being able to choose between male and female peer support workers.
Having a peer support worker of the opposite sex could be rather problematic; he felt that he usually had more difficulty trusting and sharing with a woman.
I feel it's easier with men. It's been a challenge for me to find a female, to share with… Because there are some things that are just easier to share with a person of the same sex. This has been a challenge for me. Because it's easier for me to relax around men. It's more difficult for me to share with and trust a female.
Being able to choose specific peer support workers was also important for practical reasons.

Service users need different paths
A dominant theme in the participants' descriptions of challenges in relationships with peer support workers was related to certain attributes or attitudes of peer support workers towards service users, such as acting disrespectfully, conveying disrespectful attitudes, or being authoritarian.
All-knowing peer support workers. Participants reported negative experiences with peer support workers who had predefined solutions on pathways to recovery. Some participants described previous challenging relationships with peer support workers due to the workers believing their own solutions to be the only optimal solutions. One stated, 'It was like everything she said was right. Then I started to think, you know what, that isn't right. That was difficult.' Another participant said, 'It's very important for those with lived experience not to … because even if you have a solution, you don't have all the solutions. That is important.' Peer support workers with a non-negotiable view or who were unable to go beyond their own narrow understanding of a solution were described as problematic.
Authoritarian peer support workers. Some peer support workers were also described as problematic due to authoritarian attitudes and behaviors. Participants talked about typical situations where peer support workers' own paths to recovery were imposed in such a way they felt they were being forced to walk in their footsteps, instead of developing their own paths. Not having the opportunity to create and follow their own ways to recovery was something participants found very difficult.
It got really bad. It became a huge conflict … and then, she came knocking on my door and was wondering what was wrong and stuff. And, if she didn't get an answer on the phone, then she would come knocking on my door after a few calls, demanding that we go for a walk. But then I screamed, 'this is my way, not your way, this is my process, not your process'.
Being treated in accordance with peer support workers' predefined solutions, rather than being met and understood as individuals, was experienced as humiliating. Peer support workers who took an authoritative stance in the relationship or who believed they alone had the answer to recovery were seen as barriers to self-determination.

B. Harness the contextual factors
This major theme addresses contextual factors as challenges in developing relationships between peer support workers and service users. The contextual factors are those pertaining to peer support workers and those existing in the practice environment.

Peer support workers' recovery processes matter
Some participants reflected on issues with employing peer support workers based solely on the criterion of having lived experience, without considering their other qualities and experiences. In this case, the specific contextual factor refers to the readiness of peer support workers to be supportive and helpful in the context of their own recovery processes and experiences. Participants reported it was important for peer support workers to have reached a certain stage in their own recovery process before being employed. If not, participants believed the relationship could be difficult because they were likely to feel insecure with such peer support workers or to lack confidence in the workers abilities to handle various situations. One participant stated, You can't just have lived experience, you also kind of have to have moved in…inside… because of, relapse and things like that … they need to be able to believe in themselves, when they're going to be around other addicts… we need to know that they're reliable. Some participants mentioned the need for a peer support worker to get to a certain stage in her or his own recovery for the person not to share his or her lived experiences in unhelpful ways. One participant commented on this aspect as follows: 'We talked a lot about her experiences … she didn't listen to me. And she really needed to talk about herself in relation to anger and resentment, and it was a lot about her.' Some participants, when describing peer support workers' personal recovery processes, emphasized it was a central factor in creating a challenging relationship because it could result in them remembering or even craving old habits. This was evident when peer support workers used terms, signs, or symbols from the addiction context. This was illustrated by one participant: There have been some occasions where it hasn't always been positive, where you feel like they haven't gotten too far themselves so they can help me for instance. I feel like they give me associations back to being high, because of the way they talk and act. Some participants also emphasized it was important for peer support workers to have reached a certain stage in their own recovery journey to have the awareness and open-mindedness to communicate and have flexible collaboration with service users.

Regulations that stand in the way
Another recurring theme in participants' descriptions of challenging relationships dealt with regulations, which often related to how peer support workers were expected to behave outside services or workplaces and outside typical working hours. Two accounts exemplify ways in which regulations became barriers to helpful support. One participant reflected back to a difficult time where a female peer support worker was not allowed to check on him/her due to a regulation prohibiting home visits. The participant said, 'She knew how sick I was, but I couldn't have anyone over. And she couldn't come and visit. For me this is wrong. And later when she met me, she said how much she wanted to come see me.' Although the peer support worker saw a need to check on the person and regarded this as a need, she found it difficult to break the rules of the services and follow her inner voice of what was best in that situation. Some participants described a place where peer support workers, as well as other health professionals, were not allowed to be the first person to greet in public. This was seen as problematic, as one of the participants clearly stated, 'I think it's ridiculous that the person isn't allowed to say hi.'

Embracing and nurturing diversity in relationships
The study's findings regarding challenges experienced by service users in their relationships with peer support workers emphasize the similarities with those in the relationship between service users and healthcare professionals. In both types of relationships, it seems critical to tailor approaches to individual needs and goals. In addition, certain attributes of professionals or peers providing support, such as inflexibility and authoritarianism, also seem to create challenges for service users. Although having and sharing lived experiences can support a person's recovery Douglas et al. 2012;Repper & Carter 2011), this is not always the case; there are critical challenges faced by service users in getting relationships with peer-support workers to be helpful. In this study, participants emphasized the need for sensitivity and open-mindedness in peer support practices and they noted it could be challenging to have relationships that were not tailored to individual service users' needs and goals. Flexibility in approaches with the same person on different occasions was also stressed. Previous research regarding service users' relationships with healthcare professionals has also noted the tendency not to embrace the individual's uniqueness and differences. Ljungberg et al. (2016) highlight how mental health professionals acting in this way were perceived as non-helpful by individuals with serious mental illness. This study offers more support to the claim that nurturing diversity in recovery is essential (Borg & Kristiansen 2004;Deegan 1997b;Ness et al. 2014).
In recovery, an opportunity to choose is seen as essential (Chamberlain 1997;Davidson 2003;Deegan 1997a;Deegan 1997b). In this study, having choices was associated with having the opportunity to choose among peer support workers. The importance of choice was related to the service users' belief that some peer support workers were more competent in specific matters and that service users should be given choices in getting help and support from peer support workers with certain expertise or abilities needed in specific situations. Similar to previous research with other mental health professionals (Borg & Davidson 2008;Ljungberg et al. 2016), being insensitive to the persons' needs or problems was seen as challenging and could hinder the development of nurturing and helpful relationships. Service users' acknowledgement of the importance of having the freedom to choose among peer support workers reinforces a critical issue previously noted by other recovery-oriented professionals. Alignment between the opinions and beliefs of service users concerning what 'good help' is and the helpers' own ideas and preferences seems critical (Borg & Kristiansen 2004).
Specific attributes and behaviors of peer support workers were found to be unhelpful in the service users' recovery processes. Non-helpful attributes included peer support workers having predefined solutions on recovery and nonnegotiable views about how to proceed. These attributes are well known from previous recovery research, where the need for flexibility, choice, and open-mindedness in mental health professionals is emphasized (Borg 2007;Rethink 2009;Slade & Longdon 2015). Authoritarian peer support workers were another issue identified. Authoritarianism of this type is often seen when people view their own successes as ideals to be emulated and applied in similar situations. This was also a behavior consistent with the professionals labeled as 'paternalistic and disrespectful professionals' in the review by Ljungberg et al. (2016). One can argue the attributes and behaviors identified in both groups are not in line with recovery-oriented practices. In recovery, the emphasis is placed on recognizing the knowledge of the person seeking help and enabling the person to use that knowledge. Sundet (2007) demonstrated helpful professionals, according to clients, were those who could listen and could follow, rather than lead. The value of being a good follower and listener was much appreciated by the participants in this study regarding peer support workers. It is important for both peer support workers and service users to recognize that the main supportive resources the workers bring into their relationships with service users are based on their own lived experiences during their recovery journeys, which are individual-specific and unique sets of experiences, rather than generalizable or transferable ones. In this sense, the major emphasis has to be the shared understanding of the role of peer support workers as providing emotional and social support based on their first-person experiences. What this implies is that the contours of relationships between service users and peer support workers need to be different from those between service users and mental health professionals. The key to arriving at a mutual understanding of expectations and roles seems to lie in the training and preparation of peer support workers.

Harness the contextual factors-A potential source of challenges in relationships
This study reveals various ways some contextual factors could form the basis for perceived challenges in relationships. One of these was the ability and qualifications of peer support workers to be helpful and supportive in their work. The criterion of having lived experience of mental health or substance abuse issues could not be sufficient by itself to be supportive and helpful, as it seems the stages in which peer support workers are in their own recovery influence the ways they are able to provide support to others. The service users in this study underlined the importance of considering the peer support workers' own personal recovery process and the need to facilitate services with choice and respectful values. Consistent with previous research with other mental health professionals (Ljungberg et al. 2016), the results of this study reveal how the inability to master the balancing act between sharing emotions (i.e., experiences) and not sharing too much could be experienced as difficult to manage. With theories and models of recovery fostering new standards for best practice (Dalum et al. 2015;Davidson et al. 2009;Karlsson & Borg 2017;Slade & Longdon 2015), recruiting peer support workers to deliver recovery-oriented practices is becoming more popular. Although this is a positive development, the results of this study point to the need for caution when recruiting peer support workers based solely on the criterion of having lived experience, which was also supported in our earlier report . Becaues the readiness and competency of peer support workers seem to affect the quality of their relationships with service users and their 'supportiveness', it is critical to develop guidelines and standards for peer support practice within the context of recovery. Borg & Kristiansen (2004) emphasized one characteristic of a helpful relationship is when helpers are seen as those who go beyond the common expectations associated with the helpers' role. Although institutional regulations as guidelines for the conduct of peer support workers are necessary to assure professionalism and service users' safety, their strict application in practice may not always benefit service users. A specific incident experienced by a service user in this study illustrates the possibility that peer support workers' conduct in adhering to institutional regulations may in fact be unhelpful to service users or may be perceived by service users as uncaring. This finding is a reminder of the importance of having regulations that do not stand in the way of developing recovery-promoting support Rethink 2010). Furthermore, this raises an interesting question about what one actually means when referring to 'being professional' and what issues and regulations are considered relevant or important in peer support work.

Strengths and limitations
In this study, the user-involved research design allowed for the input of lived experiences to be a part of the design, and thus, it may have facilitated more insightful and in-depth knowledge (Askheim & Borg 2010). On the other hand, there may be reason to reflect on whether or not the recruitment process and contexts of the focus groups and the researchers' background and positions had an impact on the data collected and the process of analysis. Recruitment took place with the aid of contact persons, so some participants might have felt obliged to participate. Due to an awareness that the researchers display a positive attitude towards peer support, there is a possibility that the perspectives of service users who hold negative beliefs about peer support and peer support workers were under-represented.

Implications for practice
The findings in this study indicate both relational and contextual awareness are essential for peer support workers to develop recovery-promoting relationships with service users. Such relationships require peer support workers who value careful listening, open-mindedness, and choice. Attributes and behaviors representing predefined solutions on recovery; non-negotiable views, such as believing one's own solutions to be optimal; and taking an authoritative stance in the relationship seem to be detrimental to developing helpful and supportive relationships with peer support workers. At the same time, one needs to consider the contextual factors that may hinder the development of recoverypromoting relationships. Supporting peer support workers through supervision, encouragement, and assistance in their development as a helpful helper for people going through similar experiences is also a key issue. The findings also indicate the need to examine carefully the process of preparing peer support workers for their role. There seems to be a need to address, for example, how peer support workers should be offered supervision and monitoring and how peer support workers need to be supported to develop relationship-building strategies, behaviors, and expertise. In addition, there needs to be a greater degree of clarification regarding ethical and value-oriented guidelines for peer support work, similar to those for health workers in general.

Conclusions and Further Recommendations
This study contributes to the existing literature on peer support practices and their complexities by exploring and describing service users' perspectives on challenges in developing and maintaining helpful relationships with peer support workers. The study has shown the major challenges in relationships between service users and peer support workers were associated with the experiences, behaviors, and attributes of peer support workers and the contextual forces related to peer support workers and their practice. These are in line with factors that influence building relationships in general, but they seem particularly critical for helpful relationships between service users and peer support workers. There is a need for further studies exploring what works and what does not work in regards to the peer support worker's role in delivering recovery-oriented practices and developing recovery-promoting relationships. Some interesting areas for further exploration are the power distribution between peer support workers and service users; the role of diversity in peer support work; the effects of variations in recruitment, training, and supervision of peer support workers; and further clarification of the effects of contextual factors.