Community Ment Health J DOI 10.1007/s10597-015-9843-y

ORIGINAL PAPER

Peer Worker Roles and Risk in Mental Health Services: A Qualitative Comparative Case Study Jessica Holley • Steve Gillard • Sarah Gibson

Received: 1 October 2014 / Accepted: 9 February 2015  Springer Science+Business Media New York 2015

Abstract New peer worker roles are being introduced into mental health services internationally. This paper addresses a lack of research exploring issues of risk in relation to the role. In-depth interviews were carried out with 91 peer workers, service users, staff and managers. A grounded analysis revealed protective practice in minimising risk to peer worker well-being that restricted the sharing of lived experience, and a lack of insight into how peer workers might be involved in formal risk management. Alternatively, analysis revealed potential new understandings of risk management based on the distinctive, experiential knowledge that peer workers brought to the role. Keywords Peer support
Well-being
Risk management
Qualitative research

Introduction Peer worker roles—people with experiences of mental health problems, employed to explicitly use those experiences to support others—are being introduced into mental health services in the UK and internationally. Peer support has been recognised as an important facilitator of

J. Holley (&)
S. Gillard
S. Gibson Division of Population Health Sciences and Education, Section of Mental Health, St George’s University of London, Cranmer Terrace, Tooting, Wandsworth, London SW17 0RE, UK e-mail: [email protected] S. Gillard e-mail: [email protected] S. Gibson e-mail: [email protected]

individual mental health recovery (Shepherd et al. 2008). A recent UK mental health policy implementation framework (Burstow et al. 2012) recommended that mental health service organisations provide peer support as a means of improving recovery outcomes. As such, organisational change strategies have been used in England to increase the proportion of people with lived experience in the mental health workforces (Perkins and Slade 2012). A number of recent literature reviews have collated evidence on the employment of peer workers in mental health services (Repper and Carter 2011; Pitt et al. 2013; Walker and Bryant 2013). People using mental health services have reported a number of benefits of receiving peer support which include: reduced social isolation (e.g. Coatsworth-Puspoky et al. 2006); improved quality of life, and increased sense of independence and empowerment (e.g. Ochocka et al. 2006; Corrigan 2006); reduced hospital re-admission rates (e.g., Davidson et al. 2006a, b; Lawn et al. 2008) and increased community tenure (Min et al. 2007). Peer workers were also believed to act as good role models for service users by increasing their hope and motivation in future recovery (e.g., Salyers et al. 2009). Adopting a helper role also benefited peer workers by way of skill development and personal discovery (Salzer and Shear 2002), whilst also increased their confidence (e.g. Straughan and Buckenham 2006), self-esteem (e.g. Colson and Francis 2009) and social networks through fellowship with other peer workers (e.g. Mancini et al. 2005). Peer workers also reported an improvement in financial situations and that they valued the structure, supervision and safety which the job provided in their daily lives (Mowbray et al. 1998), whilst the role also acted as a stepping stone back into other employment (e.g. Doherty et al. 2004). In terms of mental health service delivery, peer workers are thought to improve information sharing by developing a

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non-clinical, non-judgemental and ‘hopeful’ approach to writing notes (Scott et al. 2011). Peer workers may also have a better understanding of the challenges service users face and therefore build a different relationship with them compared to non-peer staff (Coatsworth-Puspoky et al. 2006) which can act as a ‘bridge between the mental health system and the patient to improve service delivery’ (Chinman et al. 2010:185). There have, however, been some concerns surrounding the negotiation of boundaries when peer workers take on more of a friendship role with service users; this leaves uncertainty with how much involvement peer workers should have in service users’ recovery (Mowbray et al. 1998). In one study, participants found it a challenge to know how to disclose, how much to disclose and when it was appropriate to disclose personal information to clients (Kemp and Henderson 2012). Issues have also been raised about how close peer workers should get with other peer workers that they work with and how this could present difficulties when resuming to a more therapeutic relationship within a work context (Coleman and Campbell 2009). Furthermore, service providers in one study expressed their concerns about peer workers being exposed to stress which could result in a recurrence of symptoms and possibly rehospitalization (Chinman et al. 2010). This is further exacerbated by an absence of established ethics and practice standards within the role which not only leads to risk of harm to consumers in receipt of such consumer delivered services but also extends to peer workers as ‘without adequate support and supervision their own mental health and wellbeing may well be compromised’ (Stewart et al. 2008: 350). Repper et al. (2013) argued that this could be detrimental for peer workers and the people they support due to the effect it has upon the sense of hope instilled by the perceived recovery of peer workers. The concerns raised about peer workers reflects the notion that introducing peer workers is less likely to be successful or effective in services that are not already working in a recovery-oriented way and, as such, will not be committed to engaging peer workers in the workforce (McLean et al. 2009; Repper and Carter 2011). Recoveryoriented practices may be undermined where there is a lack of organisational coherence within teams who resort to more conservative practices of risk management (e.g., Robertson and Collinson 2011). This illustrates wider tensions between the implementation of recovery-oriented approaches (such as peer support) and a risk adverse mental health system (e.g., Boardman and Roberts 2014). There is little empirical evidence that explicitly explores either potential risks to peer workers and the people they support, or the challenges posed to peer working by existing risk management practice in mental health services.

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Methods A comparative, qualitative case study explored the introduction of peer worker roles in 10 mental health services in statutory (governmental) and voluntary (non-governmental) provider organisations, and in statutory/voluntary organisational partnerships in England. Settings In statutory cases, peer workers were directly employed by Mental Health National Health Service (NHS) Trusts (governmental provider organisations) to work within or alongside existing NHS teams. In voluntary cases, organisations were either professionally-led or peer-led (i.e. run by people with lived experiences of mental health problems). In partnership cases, peer workers were generally employed by a voluntary organisation (in one case by a governmental social services provider) to provide a service to NHS service users. Key features of cases are given in Table 1 below: Sample In each case we set out to recruit two peer workers, service users, non-peer staff colleagues, team/line managers and strategic managers. Participants were recruited through the project lead in each case using a purposive sampling technique that aimed to include participants who would be able to provide a range of relevant data (Creswell 2013). A total of 91 participants were recruited, as described in Table 2 below: Data Collection All participants undertook a two part individual interview. The first part of the interview comprised a structured questionnaire exploring implementation issues related to the peer worker role developed from current literature and expertise within the research team. A comparative, crosscase analysis of this structured data is reported elsewhere (Gillard et al. 2014c). The second part of the interview comprised open-ended questions exploring participants’ personal experiences of the introduction of peer worker roles, what they felt to be the essence of the peer worker role, and what they thought constituted successful introduction of the role. It is data from this in-depth part of the interview that is analysed and reported here. Analysis Analysis proceeded in a number of stages. Transcripts were digitally recorded and transcribed verbatim. Members of the research team undertook a preliminary analysis of the data to

Community Ment Health J Table 1 Case study characteristics Case

Organisation

Setting

Population

Role

STA1

NHS Mental Health Trust

Community Mental Health Team

General adult mental health

Peer Support Worker

STA2

NHS Mental Health Trust

Inpatient Psychiatric Ward

General adult mental health

Peer Support Worker

STA3

NHS Mental Health Trust

Community Mental Health Team/Recovery College

General adult mental health

Recovery Coach/Peer Trainer

PAR1

NHS Mental Health Trust/ Peer-led organisation

Inpatient Psychiatric Ward/community activity groups

General adult mental health

Inpatient Advocacy Worker/ User Involvement Worker

PAR2

NHS Mental Health Trust/ Social Services Community day service

General adult mental health

Support Worker

PAR3

NHS Mental Health Trust/ Peer-led organisation

Inpatient Psychiatric Ward

General adult mental health

Peer Support Worker

VOL1

Peer-led organisation

Community crisis house

General adult mental health

Crisis Support Worker

VOL2

Peer-led organisation

Community arts project

Adult personality disorders

Project Worker

VOL3

Voluntary sector organisation

Community service user network

Black African/Black African Caribbean adult mental health

Project Worker

VOL4

Voluntary sector organisation

Community mental health awareness and wellbeing work

Black and Minority Ethnic adult mental health

Community Activists/ Community Health Educators

STA statutory (governmental) sector organisation, PAR organisational partnership, VOL voluntary (non-governmental, not-for-profit) sector organisation, NHS National Health Service

produce a provisional set of descriptive analytical categories that were then refined through an iterative series of discussions with the full research team. This process was intended to ensure that the range of academic, clinical and service user (consumer) expertise of the research team was integrated into the analysis (see, for example, Gillard et al. 2012). The findings of this initial, descriptive analysis are reported elsewhere (Gillard et al. 2014a). In the next stage ‘constant comparison’ techniques were borrowed from Grounded Theory (Strauss and Corbin 1998) to develop cross-cutting themes that moved the analysis to a more explanatory level (Mason 2002). A set of themes emerged around the mechanisms of peer support, and this analysis has been reported elsewhere (Gillard et al. 2014b). A further set of themes emerged that offered insight into how issues of risk management and crisis were related to the peer worker role; it is this analysis that is reported here. Themes were initially identified by the first author, and then the label, content and meaning of themes refined through a process of writing and re-writing by all authors. Table 3, below, illustrates how our explanatory themes relating to risk were developed from our initial, descriptive analysis:

Results The themes and subthemes shown in the table above are each explored below, illustrated with verbatim quotes from the data. Participant identifiers comprise a case code (see

Table 1) and participant code (peer workers = PW; service users = SU; staff = ST; managers = MA; service managers = SM; commissioners = CO).

Risks to Peer Workers: Boundaries and Well-Being This section illustrates the risks that peer workers may be exposed to as a result of the requirement to use their lived experience as integral to the role; the twin challenges of sharing personal experience as part of a relationship building process, and of exposure to the difficult experiences of others that might have resonance with their own mental health and wellbeing. Peer Working and Staying Well Peer workers and their colleagues were aware of the importance of being well enough to do the job, and of having strategies to stay well once in post: I think it can be hard to deal with and I think just the idea that, you know, you can join an organisation and get a job just because you’ve had a mental health problem is kind of misleading because you’d be not prepared enough for how it could actually make your own mental health problem worse in some ways… You have to be at a sufficient level in your stage of recovery to do it. (PAR3PW01)

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123

2

6

Subtotal

9

9

6

10 34

91

Voluntary 1

Voluntary 2

Voluntary 3

Voluntary 4 Subtotal

Total

22

3 10

2

2

3

2

Partnership 3 10

29

2

Partnership 2 10

6

2

2

2

Subtotal

Team manager

Strategic manager

1

18

2 8

2

2

2

6

2

2

2

4

2

1

2

17

2 6

0

3

1

5

2

2

1

6

2

2

1

14

1 4

1

1

1

5

2

1

2

5

2

2

3

20

2 6

1

1

2

7

2

3

2

7

1

3

4

33

2 11

4

2

3

13

3

6

4

9

5

0

58

8 23

2

7

6

16

7

4

5

19

4

10

5

Women

Men

Coworker

Peer worker

Service user

Gender

Role

9

9

28

NHS 3

Partnership 1

9

10

NHS 2

Case total

NHS 1

Case

Table 2 Key characteristics of the sample

3

0 0

0

0

0

2

2

0

0

1

1

0

0

18–25

Age

10

0 4

1

2

1

2

1

0

1

4

1

1

2

26–35

36

3 15

3

2

7

7

2

4

1

14

5

6

3

36–45

22

3 9

2

3

1

10

5

2

3

3

1

1

1

46–55

13

3 3

0

0

0

4

0

3

1

6

1

2

3

56–65

2

1 1

0

0

0

1

0

1

0

0

0

0

0

Over 65

5

0 2

0

2

0

3

0

0

3

0

0

0

0

Not known

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Community Ment Health J Table 3 Development of themes Descriptive categories (initial analysis)

Explanatory themes (in-depth analysis)

Boundaries

1. Risks to peer workers: boundaries and wellbeing

Relationship issues

Peer workers and staying well

Challenges of the role

Peer working and the risk of becoming unwell Boundaries and the risk to peer worker wellbeing Supporting the peer worker Boundaried practice and the peer worker role

Peer worker wellbeing

2. Peer workers and risk management

Organisational policies and procedures

Peer working and possible risk to service users

Formal support

Service users at risk, preparing peer workers

Informal support

Risk management, peer workers and disclosure

Processes of support Equipped for the peer worker role

Reservations about peer workers involvement in risk management

Training Setting Disclosure Professionalism Tasks and responsibilities Peer expertise (experiential knowledge)

3. Alternative peer-led approaches to managing risk and crisis

Bridging the gap (between service users and team)

Changing the focus of risk

Culture

Enabling service users to own their risks.

Contrasts between voluntary and statutory sectors

Approaches to risk in peer-led services Moving away from a risk-averse culture

Just because if there’s a day that I’m feeling a bit fragile myself it is part of my role on that day to be functioning enough. It is okay to say, ‘Oh, I feel a bit rotten today,’ but it’s not okay to say some of the other stuff that’s going on in my head… sometimes the effort involved to just keep that okay whilst doing what I need to do, is difficult. (VOL2SM01) Peer Working and the Risk of Becoming Unwell Concerns were expressed by peer workers and their colleagues about how the challenging, relational aspects of the role—for example, the sensitive information that may be disclosed to peer workers by service users as lived experience is shared—may trigger some of the peer worker’s own issues, particularly when they were feeling unwell: I think one thing that is kind of quite key is your ability to kind of like, um, detach and be able to deal with a lot of the stuff that you go through with people, what they’re telling you about, because often it’s quite intimate, hard stuff to deal with and you go home feeling a bit like a lot of transference has happened… a fair few people who I’ve worked alongside have ended up in hospital recently… So it’s

kind of like a reflection of the fact that it’s not that easy to deal with in a lot of ways. (PAR3PW01) …things can trigger things sometimes or and maybe you could hear something in support that’s a bit difficult to hear. It could be harder to switch off when you get home… when you’re not feeling great it can affect you. And there’s a lot of dark—at times there are a lot of dark things that you hear, really. (VOL1MA01) Some peer workers explained the need to re-define the way they supported service users in crisis, especially at times when they felt vulnerable themselves or when that crisis was reminiscent of their own lived experience: …she’d contacted me for support and I had to talk about how I couldn’t be a crisis support because of my own, well, (a) because it wasn’t part of what the peer support that we were offering was about… And actually it was a difficult conversation but it put our working relationship on to a better footing and made me realise that probably where I maybe skirted discussing that at the beginning it would have been helpful to have, maybe, it would have been more helpful to have really discussed that in the early stages of working together. (STA1PW02)

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Boundaries and the Risk to Peer Worker Wellbeing This issue of negotiating and maintaining a boundary between the peer worker and service user was regularly alluded to by staff and managers concerned about both level of contact and the potential sensitivity of issues discussed as peer worker and service user shared similar experiences with one another: There is that kind of line to cross. And also, you know, if people become unwell you kind of open yourself up to things. You know, ‘I told you this,’ and then they can, it could get severely messy. (PAR2ST02) I do worry if the service user and the peer worker have the same diagnosis … there is a possibility of them sort of feeding into each other. And then that relationship could possibly get quite sort of enmeshed and quite worrying… (STA3MA02) Both peer workers and their managers recognised the particular importance of maintaining boundaries when peer workers had known service users personally prior to taking on the role: Just how to be available to people without trying to become a friend or being too aloof and there’s challenges there, of course, because people have been here a while, often, when they come into the role, so they will have made friends already and they may have exchanged phone numbers, as friends, so it’s looking around all of those kind of issues which is not easy and there’s not an easy answer to. (PAR2MA01) I’ve come in today and I came in yesterday and I saw a service user, like an inpatient peer service user that knew me from when I was in hospital with them. So he got confused thinking that I was a patient again… I just explained to him I’m not a patient at the moment, I just work here at the moment. And he was fine about it… so it’s quite good to be clear with patients that do know you from before or wherever, outside of work. (PAR3PW02) Supporting the Peer Worker In all of our cases advice and support was in place to help peer workers cope with potential stressors of the role: …what we’ve done is we’ve asked people to submit, for example… things that might—stresses or triggers that might be useful for us to support them really well. That’s been optional, so I think that’s really, really important. (PAR3MA01)

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… obviously it’s managing the risk for the peers… In terms of them going out and seeing people. It depends what they’re doing… if they’re going out and meeting other service users there’s more of a risk. It’s all kind of around the supervision and stuff, really… (STA1CO01) In many cases the provision of reasonable adjustments for peer workers was used as a strategy to manage risk to the peer worker; i.e. to minimise the possibility that peer workers might become unwell at work: Well, things like we would be, we would have extra accommodations for—well, I’ll tell you what’s a good example, our sickness policy… It might be very hard-line and hard-faced in other organisations but we’re dealing with a population of people who come from a very unwell history and acknowledging that the work can make people unwell. (VOL2SM01) …if you’re not feeling a hundred per cent it’s kind of more responsible to say, ‘Actually, I can’t do it tonight.’ And we all swap round so there are times when I’ve thought, ‘Actually supporting someone tonight. I can’t give what I want to give and it would maybe cause me to feel worse,’ (VOL1PW02) Boundaried Practice and the Peer Worker Role However in some cases there was a specific recognition that the boundaries practiced between peer workers and service users might necessarily be different, to those generally maintained by clinical staff, because of the specific requirement to share lived experience in the role: It’s just a kind of case of what you feel, like, everyone’s got their own different, like I’m a pretty open person. I will generally talk about literally everything I’ve been through and not worry but some people don’t like doing that, and, like, our supervisor always says it’s all about your own personal boundaries … (PAR3PW01) …if they become a member of staff, for example, it’s possible that they may become aware of issues of some of the people that they’ve previously been Peers with, about issues of risk, that they might not have been privy to in the past. But it’s hard to get your head round and uhh also the re-negotiation of boundaries and friendships and I get a bee in my bonnet about friendships, because I think friendship’s a good thing and it’s worth trying to traverse that grey area. (VOL4SM01)

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Data from a wide range of participants suggested that— because of the potential risk to peer worker wellbeing arising from the sharing of lived experience—a different set of skills (and training) was required to manage boundaries based on shared lived experience rather than the professionally guided provision of care, including decisionmaking about when to share lived experience, and strategies for disengaging from difficult discussions:

the same experiences. I think then if you’re bonding on level you kind of forget that actually you are staff still and you are managing a process. And this is my experience, if you become overly friendly with somebody then to pull away can issue in all sorts of rejection triggers which you wouldn’t want to happen. So I think that’s quite a curious one because it’s got to be handled so sensitively. (VOL2ST01)

It’s quite important that it’s managed because some people don’t have the ability to be able to do that so it needs to be learnt … thinking about when would be appropriate to … tell a [service user] that you’ve had mental health problems … that’s down to judgment, that’s down to knowing the person you’re working with, being able to get a rapport or a relationship with them, a professional relationship but an honest, genuine relationship and understanding what they’re going through and if it would be helpful or a hindrance for them. (VOL1PW02)

A peer worker noted that the possibility that becoming unwell was a potential risk to themselves as peer worker and to service user alike:

…line managers have to be aware that these things can kind of develop as well and that it’s emotionally very hard for someone who is a good peer worker to be able to step away from someone when it’s getting too much… when you’re trying to establish boundaries that part of our role is sign posting… So it could be that within their role what they do is they say, ‘I can’t help you with this but I know someone who can.’ You know, ‘Maybe you need Talking Therapies… Maybe you need to take a friend with you to go and see your doctor if are having problems with that medication.’ (VOL3MA01)

Peer Workers and Risk Management This section explores the role of peer workers in the formal management of risk within mental health services, considering the way in which peer workers might engage in and implement risk management procedures. The impact of peer worker involvement in risk management on the unique qualities of the role emerged as important for some participants. Peer Working and Possible Risk to Service Users A number of different potential risks to service users arising from the specific qualities of the peer worker role were identified, including a reciprocal risk to service users relating to the challenging maintenance of boundaries referred to above: I think there can be problems with peer workers and service users becoming too close because they share

I would say that there should be risk management procedures so I would say it’s extremely important because as much as we, as Mental Health Service users, would like to be seen as equals in the workplace, we also need to accept and appreciate that depending on the nature of our illness we could become—we could pose a risk to ourselves and to others when we are unwell and there should be procedures in place. (VOL3PW01) A manager was concerned that the lack of a clear chain of responsibility between peer worker and clinical team might leave service users at risk of harm: …she tends to receive quite a lot of texts from service users… Because quite a few of her service users have suicidal thoughts and it would put her into a predicament if she received a text at midnight…Her phone was switched off, run out of battery. A service user said, ‘I’ve just ODed on 30 Paracetamol, or five Paracetamol.’ Then I’ve got to be aware of that and the risk side of that… (STA3MA02) Some managers identified concerns about accountability should something ‘go wrong’ in the peer support relationship that led to relapse or other negative outcome: I suppose there is a bit of a therapeutic risk in having support workers … We can’t be certain that it won’t put too much pressure on someone and that they might have a relapse… We can’t be certain that they won’t form inappropriate or unhelpful relationships with the service users. We can’t offer a hundred per cent guarantee that they won’t use their role as exploitative. It’s possible that that could happen. We’ll do all we can to avoid it, but it could happen. It would be comforting to know that the Trust would support us if something went wrong… And understand that what we’re doing is a positive, forward-looking way of helping people recover… But if something goes wrong… there’s a terrible sort of scurrying round, you know, gnashing of teeth and an investigation is launched, which I suppose it has to be, and a general

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sense of, um, ‘Oh dear, what will the papers say?’ (PAR2SM01)

something should happen I should know, you know, that I would know what to do, because I can feel quite anxious about people. (VOL2PW01)

Service Users at Risk, Preparing Peer Workers Risk Management, Peer Workers and Disclosure The need for peer workers to be fully prepared to support service users who may be at risk to themselves or others was widely acknowledged: I think the peer support worker should be able to know what to do when someone is in crisis. I think it’s all about risk management as well as they are there as a peer support, I think it would be good because obviously mental health there’s a lot of risk assessing. If someone comes to you they’re suicidal and they’ve got a plan that, you know, I’d like to think that the peer support would know how to support that person and what to do and who to call, you know, so that the risks are managed safely…. (STA3ST02) Some services actively involved peer workers in mandatory risk training alongside other members of staff in order to prepare them for difficult situations: So we put in all these different scenarios… because they were doing it as a group they all had different input and we were able to kind of systematically go through all these different things, bring them to life. It’s difficult to really—what’s safeguarding unless you know what the scenario is you’re talking about? … you know the peers had a great sense that they weren’t clinicians so it was just about what the warning bells were for them and what was their route, what was their process? It was a really useful exercise because from that we were able to look at processes, you know, what do you do if this happens? (STA1SM01) Some peer workers described how being trained to deal with day to day risks, such as service users absconding or self-harming, gave them reassurance and confidence in carrying out their role: … perhaps they’re not allowed to leave the hospital because they’ve been known to run out of the hospital before, even if they’re under Section… Or if they, like, self-harm or whatever and you give them a little booklet with a staple in it. If they take that back with them they could do something with it. So we didn’t know these sort of things at the beginning. But we soon learnt about it… It’s like a mini sort of risk assessment check-in as you go on to the ward. (PAR3PW02) …the Mental Health First Aid training helped me, because it made me feel more confident that if

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The role of peer workers in handing over information, to the wider staff team, disclosed to them by service users as a means of managing risk was widely discussed. Our data suggests that, in most cases, peer workers were expected to disclose information where the service user might be at risk: Unless you pose a threat to yourself or anybody else then they involve other people. But I don’t actually know what that entails because I’ve never … that’s never happened to me. But they do say when you attend [the service] if you’re a threat to yourself then we do have to break confidentiality. (VOL1SU02) I think it is a position of responsibility and I think there are some hard things they have to do, like if somebody is, in their opinion, at risk to themselves or others, then they have got a duty to pass that on. (PAR2MA01) Having to break confidentiality was difficult for peer workers who had built a friendship with service users: …she alluded to self-harming or possibly taking her own life… the lady who was the trainee [peer] worker had to say, ‘I’m going to have to stop you there because I need to pass this on to another member of staff.’ Which didn’t go down a storm and she felt very bad afterwards. She felt guilty and that she’d let her friend down… we talked it through and I said, ‘What would you have done if this had come up and you weren’t training to be a [peer] worker, if you felt sufficiently worried?’ And she said, ‘I suppose I’d have still have passed it on I just probably wouldn’t have told her I was going to do that.’ (PAR2MA01) Conversely there was some indication that service users did not object to peer workers sharing information with other members of staff where a trusting relationship had already been established between peer worker and service user: I was sitting with a [service user] in one of my rooms and we were having a discussion and then her care coordinator walked in and she just completely shut down … and then when the care coordinator left she had become kind of another different person … She was very open with me, very comfortable … I’ve kind of seen that now with a lot of my clients … they

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tell me a lot more things that they don’t tell their care coordinator. I’m sure some of them know that we all communicate anyway and we have to write our notes on the computer but it might just be that actually they feel more comfortable telling me certain things … (STA3PW01) Reservations About Peer Workers Involvement in Risk Management Our data suggests that there was some debate when considering whether it was appropriate for peer workers to take on the same responsibilities as other mental health professionals, particularly situations which were considered ‘risky’, such as supporting service users in crisis: …the peer worker shouldn’t be the sole support for somebody if they’re having a mental health crisis… They might have a role to play… It would depend on what the nature of their relationship and the work they were doing with the service user was. So I wouldn’t want to say yes or no… But there’s always a risk with these things that one person gets left sort of holding the baby, as it were…And that shouldn’t, certainly shouldn’t be a peer worker. (STA1CO01) …I was actually on one-to-one with this patient and they asked me to go and do something, which I did. When I came back, they’d ligatured themselves. So I pulled my alarm, did everything right and stuff… But it was at that point that it became apparent that it was too personal to me. It was too close to home… So it was discussed, and I had full backing, and it was decided there was no way I was going to do observations again… I have since done a few, but only with people that are not at high risk. (STA2PW01) There was also some scepticism about whether peer workers should take part in certain risk training as it was seen as inappropriate for people who had previous traumatic experiences using mental health services: …something that’s really interesting to me is a big dilemma is around things like control and restraint…And things like personal safety…learning breakaway techniques and the dilemma that that poses for someone who may well have in, hopefully a while ago, had any sort of restraint experience happen to them or been involved in any sort of violent incident on the ward because you have to be so careful to manage that and the supervision around that for somebody who may re-live those experiences really easily. (CLCO01) One service manager explains why, in their service, they did not believe that formal risk training was useful and was

just a tokenistic way for other services to feel that they had ‘covered their backs’: I can just imagine someone coming in and wanting to make things more robust…And put in lots of procedures and, you know, bring in the risk management coach and it would just be such a disastrous waste of everyone’s time and really boring and no-one would benefit from it really apart from the organisation feeling that little bit safer, which doesn’t really do any good to anyone… (PAR2SM01) This was further emphasised by a peer worker who explained how, even though it was mandatory training, they had reservations to use it in practice because of the impact this would have on peer-to-peer working relationships: …some of the things like breakaway training, for example, is about how to basically stop someone from being hostile… Like different manoeuvres you can get them into and stuff… and I don’t know how much I’d want to do that. Like, if someone was kicking off I’d probably just not want to get involved at all… I’d just either leave or move off to a different part of the ward… Because I wouldn’t feel like I would trust that person again if I had become hostile and they were one of the people trying to suppress that reaction to something or other. (PAR3PW01)

Alternative Peer-Led Approaches to Managing Risk and Crisis This section illustrates how peer workers—often, but not only in peer-led services—offered an alternative approach to managing risk and crisis. Peer workers used their experiential knowledge—as it differed from the knowledge that other mental health workers brought to their work—to change the way that risk was understood, discussed and managed, and by doing so encouraged an approach to risk that offered an alternative to the risk-adversity often found in statutory mental health services.

Changing the Focus of Risk There was evidence to suggest peer workers not only changed the way in which risk was talked about with service users but that they also dealt with risk in a more positive way. For example, in some services, peer workers brought a different set of priorities compared to other members of staff which were grounded in their own lived experience. As such, peer workers were more likely to see risk concerns that were salient to service users:

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…I think when it comes to risk, and I think, you know—yeah, for me it is about changing the quality of the conversation really; that I think peers bring a different set of, um—what’s the word? I don’t know, it’s hard to pin it down. But I think, as I say, that perhaps there’s a different set of priorities. (STA1SM01) … here we kind of say we accept that talking about feeling suicidal or talking about self-harm is important in kind of being with it and understanding it and that is actually helpful…what it’s like, how it feels, why they do it?… Rather than go, ‘Oh, you don’t really feel like that.’ You know, ‘Think about this. Think about all your children. Think about how your mum would feel if you did that.’ To me that’s not helpful. It’s kind of having somebody who will just listen and be with you. Again, I guess that comes back to having your own experience of something. You can’t necessarily always a hundred per cent understand what someone’s going through, but you can understand what it’s like to be listened to and accepted and that’s really important, I think. (VOL1PW02) Enabling Service Users to Own Their Risks The way in which peer workers talked about risk with service users was also thought to challenge the view that risk assessment and management is something only qualified professionals can carry out, instead, peers helped service users to take control and own their risks: …staff can sometimes struggle particularly around engaging service users in their own risk assessment and management. There’s almost this kind of mystique that exists… something that only very experienced, qualified clinicians can do because it’s some magic art… And then we wonder why we have the incidents that we have… So there’s almost something about peers, um, kind of being able to challenge that and be able to have, perhaps, more open and transparent conversations with service users around them owning their own risks… Because actually, probably if you’ve got to the point of being a peer support worker, probably somewhere down there you’ve had to navigate your way through some risks? (STA1SM02) Approaches to Risk in Peer-Led Services This voluntary peer-led service described how their approach to risk may differ to some statutory services: I guess really it’s about holding a level of risk which you are perhaps more able to hold if you’re not obligated by a statutory kind of guideline. That seems

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very rigid and kind of—I mean, obviously, we have like a moral and an ethical responsibility to people but we don’t have a legal duty of care which allows flexibility… Obviously we take very seriously the kind of risks that people present and we would never be like, ‘Oh, well, we’re going to hold that risk and see what happens.’ We’d never do that. We’d work with people to kind of manage their level of risk… (VOL1PW01) We have a big piece in our staff Code of Conduct about touch which basically says, within very clear boundaries at the workers’ discretion that we do hug our visitors… We don’t do it just indiscriminately all the time. But a lot of organisations have a strictly no touching policy whereas we do sometimes just hold someone’s hand or give them a hug. And that’s a risk a lot of other organisations just wouldn’t take. (VOL1SM01) Moving Away from a Risk-Averse Culture Some participants explained how many services are still currently embedded in a risk-averse culture of practice and suggested that, to enable peer workers to use their lived experience to work in a more positive way with risk, there needs to be a shift in culture: … if you look at a medical model, which obviously the mental health services are quite embedded in, it’s quite easy to become risk averse and that completely impairs and hampers the recovery time. I’m not suggesting we should say that someone, you know, who’s got high forensic history isn’t a risk, but, you know, there is a really fine balance and it is about experience and time that you’ve been exposed and it can help a peer worker see where we’re coming from because I think that’s so important. (STA1ST01) Senior management in one peer-led case directly contrasted the culture of working with risk in the peer-led context with formal, statutory psychiatric services: I think the level of risk that the organisation can work with is pretty high, but no-one’s died here … people can get well here … if I look at what happens in, say, very formal psychiatric settings … which are quite threatening and they’re quite scary, if you’re on a secure ward or whatever where people are desperately ill, but yet you’ve got people who come here who are desperately ill and they can leave here and go home at the end of a night if they’ve been here for the night. So what is it that’s captured here? That’s what’s unique for me. (VOL1CO01)

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We have a big piece in our staff Code of Conduct about touch which basically says, within very clear boundaries at the workers’ discretion that we do hug our visitors … we don’t do it just indiscriminately all the time. But a lot of organisations have a strictly no touching policy whereas we do sometimes just hold someone’s hand or give them a hug. And that’s a risk a lot of other organisations just wouldn’t take. (VOL1SM01) In another peer-led case members of the team explained how, in the absence of NHS procedures, a shared approach to managing risk had been developed across the team, built on the collective experience of the whole team: … one of my issues in general is this sort of feeling responsible for people and that is one of the hardest things, is the anxiety. I can feel quite anxious about people and I will worry, when you finish nine o’clock at night or something if someone disappears off, ‘Oh, God are they all right? Are they going to go and kill themselves?’ Literally, I mean we don’t have the containment, we don’t. It’s an innovative, daring, if you want to use the word, project and we have to be really honest about what we’re able to provide and basically we are providing people something and, you know, you have to be real about people’s lives. I mean, we have had people who’ve come and they’re obviously really struggling and that is really difficult. And I mean it’s a shared thing. We share it. (VOL2PW01) … when we started there was no training that was designed for it. So we had Mental Health First Aid, for example, but it didn’t quite fit … it was woefully inadequate so we were kind of, we had on-the-go training … so it’s important that they have some sense of training but, actually, a lot of it comes from our own experience anyway. (VOL2SM01)

Discussion The study has identified issues relating to (1) risks that arise—primarily for peer workers—because of the particular nature of the relationship (based on shared lived experience, rather than the application of professional expertise), and (2) how the management of risk (as it is generally understood in mental health services) is applied in practice by peer workers (and how they are supported in that practice). In both cases there is evidence that a risk adverse culture in responding to these challenges can inhibit the peer specific qualities of the role, but there is also evidence that illustrates (3) the emergence of alternative or peer-led approaches to managing risk.

Peer Worker Wellbeing, Protective Practice and the Sharing of Lived Experience We presented above focused evidence of the specific challenges—to peer worker wellbeing—of using lived experience in the peer worker role, and of the need for training and supervision in developing a specific skill set in negotiating the ‘grey area’ between the provider-recipient relationship and friendship (Kemp and Henderson 2012). Elsewhere we have reported findings suggested that building relationships based on shared lived experience— in order to both role model recovery and to act as a bridge to mental health services—is a core mechanism underlying the peer worker role (Gillard et al. 2014b). As such the need to provide specific training and support to address those challenges would seem imperative. We found evidence of a number of policies and procedures, both formal and informal, designed to prepare and support peer workers wellbeing in the role, mirroring existing literature which has stressed the supervision and support needed to ensure that peer workers’ own mental health and wellbeing is not compromised (Stewart et al. 2008). In our study we found that this support could take the form of reasonable adjustments to, for example, sickness policies or working pattern. Other research has shown how flexible terms and conditions of employment can be appreciated, enabling peer workers to work when they feel well while also reducing pressure resulting from the role (Repper and Carter 2011). However it has also been shown how such ‘protective’ adjustments can reinforce difference in status between peer workers and mental health professionals (Gillard et al. 2013) and the ‘othering’ of peer workers within the team (Berry et al. 2011), thereby inhibiting peer workers in using their lived experience in their work. By implication, our analysis cautions against an over-reliance on reasonable adjustment as the primary strategy for reducing the risk of peer workers becoming unwell at work (rather than as a means to improve access to the workplace, as is the intended function of reasonable adjustment). In our data reservations were also expressed about both codes of conduct designed to uniformly establish and maintain boundaries, and any mandatory requirement that peer workers share information with the wider team disclosed to them by the people they support, on the basis that this could erode commonality between peer workers and service users. A wider literature exploring risk-adversity in mental health services suggests that defensive practice of this sort can undermine the needs of the service users whom this same practice is designed to protect (Clifford 2011). On balance, our analysis suggests that, in many contexts at least, there remains a deficit in understanding the demands of sharing lived experience in the peer worker role, and how this might be best supported, and that in the

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absence of this knowledge the organisational or team response is often over-protective of the peer worker, potentially deterring them from applying their specific insight, as peers, in their work.

knowledge deficit here, in some contexts, resulting in a lack of clarity around both the role peer workers might play in the management of risk and the training they should receive to do so.

Risk Management, Risk Adversity and Responsibility

Alternative Peer-Based Knowledge, Alternative Approaches of Managing Risk

In some of our cases reservation was expressed about whether it was appropriate for peer workers to be involved in the management of high risk situations, and peer workers were encouraged to defer to other members of the team for their own and others’ safety. It has been suggested that a ‘culture of blame’ pervades mental health services where accountability for managing risk can shape decision-making around service users’ care (Sawyer 2008). In addition it has been argued that jurisdiction over a specialist body of knowledge shapes professional role identity (Waring and Currie 2009) and that mental health workers’ knowledge of, and expertise in managing risk, in large part defines their professional jurisdiction (Clifford 2011). This dual dynamic of accountability and professional jurisdiction might explain the reluctance to allow peer workers responsibility for managing risk. Nonetheless we also observed peer workers being expected to take part in mandatory risk training, sometimes including training in the use of more coercive risk management practices. While some peer workers resisted this as undermining the trust that was at the basis of the relationships they built with service users, others reported feeling more autonomous, confident and assured in their role as a result. Other research has cautioned against the ‘socialisation’ of peer workers into the working culture around them, through generic training and an overly procedural approach to the role, because of the possibility that the distinctiveness of the role might be lost as a result (Schmidt et al. 2008). As such there were tensions in our data; that while in some of our cases peer workers were expected to be trained to manage risk in the same way as mental health professionals, they could also be discouraged from doing so in practice because of perceived problems of accountability and jurisdiction, and might in any case resist doing so as it is damaging of their role. In the UK the psychiatry profession has warned that risk adversity in mental health services might ‘stifle creativity and innovation’ and can be ‘detrimental to recovery and rehabilitation’ (Royal College of Psychiatrists 2008; 2010). It has been suggested that peer workers employed in statutory services might exercise a choice over whether or not to be involved in coercive risk management practices such as physical restraint or the compulsory administration of medication (Repper et al. 2013), and we observed peer workers and colleagues caught in this ‘should we, shouldn’t we’ dilemma in our study. Again our analysis suggests that there is a

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In some of our cases, particularly in the voluntary sector where services were peer-led, there was evidence that peer workers talked about risk differently with service users by bringing their own lived experience to the conversation, invoking their own challenging experiences of mental ill health to help service users express their fears and concerns about difficult and distressing situations. Promoting openness and transparency in the mental health care planning process in the UK has been identified as essential to risk management practice (Department of Health 2007: 28–29), while there is some evidence that encouraging consideration of risks that are specifically salient to service users helps them to remain at lower risk (Kaliniecka and Shawe-Taylor 2008). The peer-led organisations in our study also demonstrated awareness that the sum of lived experience across the organisation represented a resource or a cultural capital. This shared lived experience served to hold risk, not just in the one-to-one relationship between the peer worker and service user, but in providing support to, and sharing responsibility with the peer worker. Indeed shared lived experience imbued the organisation itself as a ‘safe space’, even when people were experiencing extremes of crisis and distress. There was acknowledgement that, while retaining moral and ethical responsibility, peer workers in peer-led organisations were not bound by the same legal duty of care as a statutory service provider and as such were able to work more flexibly, enabling service users to own their own risks as part of a therapeutic process (Morgan 2000). It has been suggested that encouraging a personal sense of autonomy in this way is not only of therapeutic value in its own right but supports a virtuous circle of improved relationships between staff and service users (Sweeney et al. 2014). The challenges of statutory requirement notwithstanding, the application of the experiential knowledge that peer workers can bring to the management of risk is a potential asset in statutory sector mental health services (Coatsworth-Puspoky et al. 2006). Other research has indicated the value the professional mental health team places on the insight to risk management that peer colleagues offer (Gillard et al. 2013), while there is growing expectation in the UK that peer workers review risk assessments as part of the multi-disciplinary team as part of the care planning process (Repper et al. 2013). Our research has suggested that importing the culture of the peer-led service provider

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into a statutory sector context—in the partnership cases we considered—was at least provoking those different conversations about risk. Strengths and Limitations The data for this study were collected from a range of service delivery settings and organisational contexts. While such heterogeneity can limit the specificity of findings, this has enabled us to make use of different perspectives on risk in relation to the peer worker role—and variance in peer workers’ level of involvement in the management of risk— to envisage alternative, peer-driven approaches to working with risk in mental health services. That some services were new in introducing peer workers into their workforce compared to other services enabled us to observe their ‘trial and error’ approach to understand how the challenges and issues that arose as the peer worker role developed were worked out in practice. Another possible limitation of the study is that there was not a specific set of questions in the interview schedule that allowed us to systematically explore issues of risk with all our participants. However, that fact that risk emerged strongly as a theme in many of our interview transcripts was indicative of the importance of exploring the issue in more depth. As is the case in the wider literature on recovery and mental health, thinking about the management of risk in the context of innovative practice is often conspicuous by its absence (e.g., Davidson et al. 2006a, b; Boardman and Roberts 2014). What this paper has illustrated is that, in the absence of integrated thinking about risk and peer support, services can fall back on protective or risk adverse practices that inhibit the application of lived experience in the peer worker role. There exists a wealth of distinctive, experiential knowledge among those delivering peer support services that potentially informs an alternative, peer-driven approach to risk in mental health services. Conflict of interest

None

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