The International Journal of Psychosocial Rehabilitation

Integration of Peer Support Workers
 into Community Mental Health Teams
 

Amy L. Richard, MOT
Department of Occupational Science and Occupational Therapy, University of British Columbia

Lyn E. Jongbloed, Ph. D

Department of Occupational Science and Occupational Therapy, University of British Columbia

 
Andrew MacFarlane, MSW
North East Community Mental Health Team, Vancouver, British Columbia



Citation:
Richard AL, Jongbloed LE & MacFarlane A. 
(2009). ‘Integration of Peer Support Workers into
 Community Mental Health Teams .
  International Journal of Psychosocial Rehabilitation. 14 (1),  99-110
           


            All correspondence can be sent to:
            Amy L. Richard at Amylynn_Richard@hotmail.com 
      


Abstract
Introduction: Although benefits of peer support are known, concerns also exist. Little is known regarding the experiences of occupational engagement as a Peer Support Worker (PSW) within Community Mental Health (CMH) teams.
Objectives: The purpose of this phenomenological study is to improve understanding of PSWs' experiences of perceived value and inclusion as CMH team members.
Method: Five PSWs were interviewed; interview questions related to: role, job security, career development, disclosure, policy, procedures, social inclusion, decision-making, perceived value, and the influence of recovery-models.
Results: Five themes were identified: role and power, institutional organization, access to resources, inter- and intrapersonal factors, and differences over time.
Discussion: Concepts found were compared to previous literature and may exist in additional settings. Considerations are made for practice and research.

Key words: Peer support work, community mental health, team integration         


Introduction
There is an increasing movement in mental health care towards hiring individuals with personal experience with mental illness as Peer Support Workers (PSW) to support and assist current mental health clients in their recovery process. The involvement of PSWs in the system is one of the most visible examples to other service users, their families, and professional services providers that the respective mental health system is committed to inclusion, partnerships with clients, and the adoption of a recovery-oriented mental health system.  Out of the Shadows at Last (Kirby & Keon, 2006), the Final Report of The Standing Senate Committee on Social Affairs, Science and Technology, states that “recovery provides a focus for re-orienting the design and delivery of mental health programs, services, and supports” (p. 45), that recovery is “the primary goal around which the mental health delivery system should be organized” (p. 43), and that “recovery must be placed at the centre of mental health reform” (p. 42).

A commitment to a recovery-oriented system is evident in an organization’s involvement, in both service provision and program development, of consumers and family members.  Anthony (2000) states that, in the establishment of standards for a recovery-oriented system, “consumers are actively sought for employment at all levels of organization” (p. 165).  The simultaneous implicit recognition by clients and their families of working with, or alongside, a peer is that, regardless of their current symptomology, clients can, and do, lead fulfilling and rewarding lives, build relationships and partnerships, and find employment both within the service system and in other areas of competitive employment.   In addition to supportive relationships with family members/friends and mental health professionals, mental health consumers identify supportive relationships with peers as a crucial factor for recovery and, in particular, peers as sources of inspiration, education, and support (Mancini, Hardiman, & Lawson, 2005). 

Literature on the outcomes of employing PSWs on mental health teams has identified numerous benefits of occupational engagement in such a profession. Benefits for the health system include increasing resources, helping clients, decreasing stigma, and promoting PSW (Mowbray, Moxley, & Collins, 1998). Some of the personal benefits identified by PSWs include facilitating recovery, social approval, professional growth, skill development, mutual support, receiving money and work, job security, career direction, and positive feedback (Mowbray, et al., 1998; Salzer & Shear, 2002).

Related to client benefits, randomized controlled trials have shown earlier development of positive relationships with clients, increased contact with clients, and the promotion of empowerment and recovery with the use of peer staff compared to nonpeer staff (Corrigan, 2006; Sells, Davidson, Jewell, Falzer, & Rowe, 2006). However, PSWs may have more time available for client contact, which could have been a confounding variable. Lower rates of re-hospitalization over a three-year period have also been linked to peer-services for people living with both mental illness and addictions (Min, Whitecraft, Rothbard, & Salzer, 2007).

Furthermore, a systematic review showed that peer staff, compared to non-peer staff, had more client contact, fewer professional boundaries, and more outreach opportunities (Simpson & House, 2008). Clients receiving peer services were shown to also have improved quality of life and social functioning, fewer life issues, less family burden, longer durations before hospitalization, fewer hospitalizations, and shorter hospital stays, although nonpeer staff had lower employment turnover rates (Simpson & House, 2008). In a separate study, the majority of clients receiving peer counseling were positive about the experience and would recommend the service; however, no non-peer counselor comparison was made and only one peer counselor was involved in this study (Rummel-Kluge, Steigler-Kotzor, Schwarz, Hansen, & Kissling, 2008).

While many benefits of peer support have been described, concerns also exist. One major concern with PSW is research demonstrating that stigma exists even within the mental health system (Chin & Balon, 2006; Nordt, Rossler, & Lauber, 2006). Research studies have suggested that there are few differences between the attitudes of mental health professionals and the general public regarding the predicted outcomes of individuals with mental illness (Hugo, 2001; Lauber, Anthony, Ajdacic-Gross, & Rössler, 2004). In some instances, mental health professionals reported even less positive expectations than community samples (Hugo, 2001; Lauber, et al., 2004).

PSWs have also reported negative experiences of their work. These experiences related to job stress, lack of direction in job skills, lack of support from supervisors or administrators, concerns regarding responsibilities, and boundary issues (Mowbray, et al., 1998). Workers also experienced feelings that they were part of the health care team but always of lower status than other professionals (Mowbray, et al., 1998).

The present literature review demonstrates the importance of investigating the integration of PSW into mental health teams, looking specifically at their perceptions of inclusion and value as a team member to acknowledge areas for improvement. Unfortunately, little research exists on the topic, especially within a Canadian health care system. In the literature, PSWs have recommended increased hours and pay, more contact with peers, more employment opportunities, more opportunities to demonstrate skills, and more social activities as methods to improve the current experience as a PSW (Mowbray, et al., 1998). However, these results are not limited to community services, are based in an American system, and were not based on one-to-one interviews with PSWs which would allow a deeper understanding of their experiences.

In another qualitative American study with PSWs and other staff, a number of difficulties were identified including: variable staff attitudes towards PSW, role conflict and confusion, pre-existing relationships with professionals, alienating policies, inadequate training, lack of communication, disclosure of peer status, peer access to client records, job structure related perceived value, and a lack of social support in the workplace (Gates & Akabas, 2007). The results of the previous study highlight a number of areas that require further investigation. In addition, participants in the study were selected from a wide array of mental health services and facilities, with varying roles, training, policies, and procedures; significant contextual differences between agencies may have caused variations in the experiences of PSWs and these potential differences were not acknowledged. Furthermore, differences in sample sizes existed between groups and one-to-one interviews were conducted only with the nonpeer staff which may have influenced the information obtained from each group. Finally, the study did not focus specifically on CMH treatment.

The present study will provide clinically important information and contribute to this growing body of evidence in Peer Support research, specific to Vancouver CMH practice, which will assist in promoting the integration of PSWs. The present study asked the research question: what are the experiences of PSWs, in terms of their perceived value and inclusion as a team member, in selected Vancouver CMH teams? The purpose of this study is to gain an understanding of PSWs’ perceptions of their value and inclusion in a sample of CMH teams as to provide direction for further research and initial considerations for CMH practice in British Columbia’s lower mainland.

Method

Ethics approval was obtained through the Behavioural Research Ethics Board at the University of British Columbia and Vancouver Coastal Health Research Institute (Vancouver Community). No financial support was provided.

Participants
Using purposeful sampling, PSWs from three CMH teams were invited to participate in the study. Specific teams were selected to obtain samples from people working in different areas of the city (west side, east side, and downtown). Also, these teams had been identified by VCHA’s Peer Support Coordinators as currently having a high number of PSW's employed, compared to other teams in the city. As well, the third author of this study is the Team Leader for one of the selected CMH teams and was therefore interested in the experiences of PSWs from his particular facility.

Posters with a brief summary of the project and contact information for the study authors were displayed at each team site. PSWs were also reminded of the opportunity to participate in the project by Team Leaders of their facilities. The first author also visited two of the teams to describe the project to participants and encourage increased participation, as recruitment was low at these facilities. No reimbursements were provided to participants.

Participants were included in the study if they spoke English, completed Vancouver Peer Support Training or the equivalent, had experience as a mental health consumer, and had been employed as a PSW at one of three selected Vancouver CMH teams for at least one year. One year was chosen because the PSWs would have had adequate exposure to the team and could comment on their experiences.

Five PSWs participated in the study (three males and two females). Two participants identified themselves in the 30-39 years of age category while the remaining three participants identified themselves in the 50-59 age category. The range of years that the participants reported that they have been working as PSWs was from 3.5 years to 11 years, with a mean of six years. The number of contracts that each participant was currently working ranged from one to six contracts at 20 hours per month for each contract (mean of 2.8 contracts). There was a range from one to four employed community facilities, with a mean of two community facilities per participant. Finally, all participants were recruited from two of the three selected CMH Teams.

Design/Procedure                        
Using a phenomenological approach, semi-structured open-ended audio-taped interviews were conducted off-site by the first author, as to ensure confidentiality to participants. Guiding questions were related to the experiences of participants’ PSW role, job security, career development, disclosure of own mental illness, general and social inclusion within the team, decision making and treatment planning involvement, perceived value from team members, policies and procedures, and the influence of a recovery-oriented system. Interviews took place at a location chosen by participants, including busy coffee shops and a private room in a public library.

Participants were reassured that access to raw data would only be granted to the first and second authors, and not to the third author. This decision was to ensure that the third author (and team director for one of the VCHA CMH Teams) would not be able to identify participants, thereby increasing the validity of participants’ responses.

Data Analysis
Qualitative data analysis occurred in a systematic approach which was adapted from that used in Backman, Del Fabro Smith, Smith, Montie, and Suto (2007) to fit with the present study and a phenomenological design. The first step in the data analysis process was the transcription of interviews. Second, interviews were each reviewed separately by the student researcher to further understanding of participants’ individual experiences. Third, coding of individual transcripts occurred; sentences and paragraphs were coded for each of the five interviews to capture the primary meaning described by each participant. Fourth, grouping of codes occurred to form clusters of data; codes within and across participants that had similarity in meaning were combined. Since data analysis occurred with only one researcher, consultation with the second author also occurred at this stage to obtain feedback on the coding process and incorporate suggestions for grouping. Fifth, clusters were then combined into broader themes and a description of their meaning was given to each theme. In the description process, the researcher focused on the frequency of clusters across participants primarily, as well as the existence of information that was expressed as important to single participants. This process allowed for general experiences to be shared as well as multiple view points to be acknowledged, given the small sample size. Experiences that were solely related to issues of PSW and not related to membership, value, or inclusion within the team (e.g., the clinical importance of disclosing personal experiences of mental illness with clients and experiences of feeling valued by clients rather than staff) were excluded from the data. Sixth, member checking was utilized to improve reliability of findings; all participants were emailed the results of thematic analysis and opportunity was provided to participants to provide feedback on the accuracy of the main themes reflecting their experiences. Input from three participants was received, followed by incorporation of feedback into the findings. Finally, the final development and summary of themes occurred following a second consultation with the second author regarding the analysis process.

Results

Five main themes emerged in the data analysis process.

1. PSWs’ Role and Power
Participants talked about their role at the CMH team as PSWs, with all participants reporting that much of their work takes place within the community and involves providing clients with basic support and helping clients participate in rehabilitation goals and leisure-based activities. One participant talked about new roles that have been provided to them which have contributed to feeling more included in the team, including involvement in program development, promoting the rehabilitation program, interviewing new PSWs, and involvement with accreditation: “I mean that’s something, that you’re being asked to participate in [accreditation], that’s pretty important”. The participant also discussed the importance of having their ideas acknowledged within their roles: “It just really felt demeaning to be told that you’re part of this [project] and then the person went ahead and did whatever they wanted. Don’t ask for my opinion if you don’t care”.

Participants discussed involvement with treatment planning, reporting that they are not involved in the initial process, but most participants were positive about this involvement. One aspect of their involvement in treatment planning which was discussed by four participants was goal setting. The importance of supervisors allowing flexibility and incorporating client and PSW feedback into the goal planning process was important for participants. Half the participants described feeling, at times, that their supervisors had too much goal planning power.

I really like [the flexibility in goal planning] because there are set goals and agreements, but also there is a little bit of freedom to find something that [the client] really likes. So helping be part of that process, I think that’s really useful.

Participants talked about the decision to disclose their experiences of mental illness to clients, with all participants reporting that disclosure is generally left to their discretion and that they feel positive about this decision-making power. Participants also talked about broader decision making within the team, including the importance of PSW representation in committees: “I think having as many intelligent consumer voices on committees, or peer support [voices], are really valuable, especially if it is considered valuable”. One participant was positive of their committee involvement while two participants felt that PSWs are not adequately represented: “I can’t think of any actual committees or programs that [PSWs are] actually participating which [they] aren’t [participating] strictly as consumer contractors”.

2. Institutional Organization      
Participants discussed numerous factors related to institutional organization of PSW that have influenced their value and inclusion as a team member, including a lack of union membership to manage institutional issues and promote PSWs as staff members: “In some ways we’re not technically employees, we’re not union. Some people consider [PSW] more of an honorarium”. Increased pay scales, opportunities for raises, and the provision of benefits (such as life and dental insurance) were suggested by three participants. A fourth participant discussed issues surrounding delayed monthly payments affecting their perceived value as a PSW. Disability pay was discussed by one participant who experienced difficulties with PSW pay not being automatically exempt from their disability. One participant, however, had a different outlook on unionization and changes in pay, reporting that higher wages could influence their abilities to relate to clients.

I know what time of the month it is because of how tight people’s finances are or whatever.  I haven’t lost touch with those types of things and I think we might lose some of that connection [with higher wages].

Participants also discussed the contract system; three participants felt that removing the contract system and providing opportunity for full-time hours could increase team participation and PSW value. However, the majority of participants also stressed the importance of having options to work less than full-time hours for those satisfied with part-time work, and one participant felt that full-time hours would affect PSWs ability to be flexible in adapting to client schedules.

I wouldn’t want to see only bigger contracts because then that would exclude people that want to work smaller contracts. I would be afraid that they’d built it into one way that wouldn’t work for everyone.

Participants reported overall positive experiences related to job security. Four participants stating that they feel secure with their peer support positions: “I’d say of all the places I’ve ever worked, I feel the safest here, as far as turnover goes”. However, experiences related to career development were lacking for most participants: “[There is] nothing, nothing, nothing. Once a PSW, always a PSW”. Although most participants reported some educational opportunities, all but one participant reported that inclusion in this area could be improved. Issues were related to lack of paid education time, eligibility for courses, advertising of courses to PSWs, acknowledgement for attending workshops, and education aimed towards team members working outside of the field of medicine: “We’re not involved as much [as other team members]. We’re not eligible for a lot of the education opportunities”.

3. PSW Access to Organizational Resources                                    
All participants discussed experiences related to access to resources and client information within the team. Most participants discussed a lack of working spaces at the team: “I wish we actually had a physical place in the mental health teams to call our own to help us ground ourselves there better, it would make it easier to just be there and communicate our needs”.  However, one participant reported that lack of space is a universal issue and that PSWs are less likely than others to be working inside of the facility. All PSWs reported that they had access to computers; however, four reported that this access is primarily to use client computers which have created issues with availability and PSWs feeling excluded as staff members: “[I would like] having a computer that we could definitely use. Sometimes when I’ve used [a computer], I’ve used the client computers but again you kind of feel like a client”. Other examples of feeling excluded for participants were a lack of access to administrative materials and being required to wait in the teams’ waiting area prior to meetings. In general, PSWs expressed mostly positive experiences related to staff room access, stating that all participants were allowed to use this resource. Other positive experiences by some participants involved being assisted by staff with accessing community resources.

Access to client information was discussed by participants; all participants reported that they have little access to client information and no access to client files at the team. Two participants felt that this did not usually affect their experiences as a team member, “[I am not told client information if] it’s not my business so it’s not that important, just what I need to know to help them”, with the exception of being unaware when clients have been hospitalized or placed into a shelter. The remaining participants felt that this level of access to client information was limiting in their role: “I guess it’s like shadow boxing. Where you’re just left really in the dark about what’s happening [with a client] and you kind of have to feel your way around”.

4. Inter- and Intrapersonal Factors
 A number of interpersonal and intrapersonal factors related to PSW experiences as team members were discussed during interviews. Some participant discussed individual characteristics of PSWs which they related to their experiences in the team. These included the attitude, level of assertiveness, and age of the PSW.

In regards to social opportunities, all PSWs reported a lack of opportunity to socialize with the team, partially attributed to PSW often working away from the facility. Two participants noted that they feel disconnected from staff at times when they do spend breaks at the team:

“When I’m at the team and there’s staff and PSWs, the PSWs tend to be together and the staff will to be together. There’s definite walls”. Some participants noted a social division between different staff members at the team, including separation of PSWs, the rehabilitation team, receptionists, and case managers. Furthermore, annual events were important as all participants stated that they have had experiences related to feeling excluded and included as a team member based on invitations to events such as team retreats and Christmas parties: “[We’re included in social events] but they need to ask if we can go, if we can attend a party, like a Christmas party for the staff. I just find it ridiculous”.

When there are team retreats and sort of functions designed to bring the team closer together the PSWs are usually excluded. We’re not permitted to go to [the yearly retreats]. I think we should have the option of being invited, because there is talk that we’re just like staff but it doesn’t seem like it in most cases.

Participants discussed generally positive interpersonal experiences with staff and perceived attitudes of staff related to PSWs. The individual characteristics of the staff members that participants attributed to these positive experiences included staff members who were outspoken about recovery, welcoming to peer support staff, able to recognize the PSWs at the team, and being aware of the skills of PSWs. Positive feedback from team members was mentioned by three PSWs as a contributor to feeling valued: “The [staff] that do [respect you], they give you feedback that you’re able to do things or you found out things that they didn’t know. They just consider you another hand to help out”. Two participants referred to the importance of being trusted by colleagues, and were both generally positive about the level of trust at their team: “[The team] gives us a lot of trust.” All participants were generally positive regarding their experiences with direct supervisors, reporting having supervisors who advocate for PSWs, demonstrate trust in the PSWs, and are approachable, social, flexible, and receptive to feedback and opinions of the PSWs.

However, most participants talked about occasional negative experiences with staff members such as feeling that staff members are not always trusting of PSWs around client documentation, not feeling valued by the majority of team members, witnessing staff ignorance related to PSW level of recovery, being greeted differently by staff when introduced as PSW, and feeling viewed as a client. Most participants also talked about staff having varying levels of comfort working with PSWs:  “Some mental health professionals are still not comfortable with feeling fully professionally aligned with people coming from our perspective. Others are very progressive, very relaxed about it”.

Participants talked about generally positive experiences with communication, with two discussing the importance of direct communication between PSWs and staff members. All participants discussed communicating through monthly peer support meetings and one participant reported that they feel especially valued when managers also attend these meetings: “Some of the managers of the teams sit in on our conversations, on our peer support meetings, and that’s really good. A lot of them don’t”. In addition, all participants attended monthly meetings with team members and there were differences in opinions regarding increased participation in these meetings; one participant felt excluded by being limited to only one meeting per month while another felt more attendance would be difficult: “A lot of the staff meetings, we’re not allowed to attend. I find that you don’t get to know a lot about what’s going on [at the team]”; “[More involvement in team meetings] could be a mixed blessing because doing contract work is no picnic when you’re juggling [contracts] and [taking] public transit, without a cell phone.” Furthermore, one participant reported that although PSWs are attending team meetings, they are not actively included in the conversations.

Participants talked about the importance of building working relationships and mutual respect: “As [team members] work with us more closely they get a sense of our style of work and I think in many cases they begin to develop some very well earned respect for us”. However, some participants reported that they have previously experienced issues with a lack of familiarity between staff and PSWs and would like to continue to improve this area: “One thing that frequently used to come up was I’d be sitting either in the staff room or in the photocopy room and people would have no idea of who you are”. Participants reported that being employed for a significant length of time, spending time at the team, being involved with educational opportunities and social events, and being offered to participate in educational opportunities were factors related to familiarity with staff. Two participants differentiated between disciplines regarding relationship building opportunities: “I think our greatest allies are the Occupational Therapists and the way they’re trained. First of all, most often, they’re our supervisors so they know PSWs. They’re also trained about taking risks and growing, and recovery is possible”. One participant discussed “strange roles” that have occurred due to being co-workers with someone who had previously been involved with their mental health treatment.

5. Differences over time
Positive changes over time related to feelings of value and inclusion within the team was referred to by all participants, although most referred to these changes as a “slow process”: “I feel that as PSWs, we are becoming part of the team. It is a very slow process of integration because a lot of boundaries are being kind of redrawn involving us”. Examples of changes that PSWs reported noticing over time included: more inclusion to social events, more inclusion in committee, greater direct communication between PSWs and other team members, greater access to space within the team facility, greater inclusion in team meetings, and more clinical involvement. Three of the participants referred to the importance of changes in the integration of PSWs occurring in a partnership between PSWs and other staff members: “No one claims to have all the answers here, so we’re kind of growing our way forward together”; “It all seems very positive right now. I guess were kind of growing together”.                                                                                   

Discussion
The present study aimed to improve the understanding of PSWs’ experiences as team members working within Vancouver CMH teams, focusing specifically on their perceived value and inclusion. Primary themes which emerged from participant interviews were: role and power as a PSW, institutional factors influencing their work, access to resources available to the team, interpersonal and intrapersonal factors which have influenced their experiences, and differences over time related to their integration into the team.

Similarities exist between the experiences of PSWs in the present study to those found in American studies, as many participants suggested that more inclusion in social activities, increased hours and pay, good communication, access to client information, and social support within the team are helpful in improving their experiences (Mowbray, et. al, 1998; Gates & Akabas, 2007). Participants also reported that differences among staff, in their comfort level of working with PSWs, exist and influence their experiences within the team, results similar to the findings of Gates and Akabas (2007).

Clinical Implications
Overall, the experiences of the PSWs were generally positive in regards to their role and power within the team, noting the importance of some flexibility in their work. Occupational Therapists and other clinicians working with PSWs in CMH health teams may want to promote open dialogue, acknowledge differing ideas, and provide positive feedback to PSWs to potentially encourage feelings of value and inclusion. PSWs also generally reported positive changes in their integration over time, noting that these changes are slow but moving in a positive direction. This finding provides some preliminary evidence that Vancouver Coastal Health Authority’s (VCHA) CMH teams should continue in their current efforts to improve PSW integration.

Although variation did exist within the sample, most participants felt that there is room for improvement in Vancouver’s CMH teams and that the current contract systems, low pay, and lack of benefits are negatively impacting their experience as an integrated team members. PSWs working in Vancouver CMH Teams are employed only within a contract system, working approximately 20 hours per month for each individual contract (D. Sesula, personal communication, November, 2008). In part, these contract systems were originally developed to allow PSWs to be employed while continuing to earn Disability Benefits, under the British Columbia Employment and Assistance for Persons with Disabilities, without exceeding the exemption limit of 500 dollars per month (D. Sesula, personal communication, August, 2009). However, this government policy has since changed and currently PSW earnings are exempt from those counted towards Disability Pay (British Columbia Government, 2005, May 1).  This policy change allows VCHA more flexibility in reconsidering the current contract system. However, based on the interviews with the PSWs in the present study, changes in this system could potentially be negative if options for part-time hours were not ensured.

The importance of trust was discussed by participants, and research in hospital settings has also demonstrated statistically significant relationships between an organizations’ social capital, including trust and value, and worker job satisfaction (Ommen, et al., 2009). Thus, initiations aimed at understanding and developing trust between PSWs and team members may be one method of improving teamwork and cohesion with PSWs in Vancouver CMH teams.

Results from the present study also suggest that some PSWs perceived inclusion may increase if they are less restricted in resource access, such as education, client information, computers, and physical space within the team. Improvement in social involvement within the team and addressing negative attitudes of staff members were suggested, although most interpersonal experiences within the team were positive for participants. PSWs also acknowledged the importance of good communication and relationship building, including ensuring familiarity with staff and including PSWs in staff meetings. Ensuring invitation of PSWs to annual staff events is one change that could be utilized to potentially increase some PSWs’ inclusion and working relationships.

Limitations and Suggestions for Future Research    
The results of the present study add to the current body of evidence related to PSWs’ integration into CMH teams and provide initial practice considerations for VCHA. However, there are a number of limitations to the present study. The experiences of the PSWs varied greatly across teams and participants and the results of this qualitative study are not generalizable to all PSWs. Variable venues for data collection, with some of the coffee shops being loud and crowded, may have contributed to more difficulty with interview conversation. In addition, the limited experience of the student researcher in qualitative data collection and analysis may have influenced the results of the study. One must also be cautious of overgeneralizing the results as the present study had a small sample size and only had participants from two of the Vancouver CMH teams. More research is necessary to improve the amount of evidence in the area of PSWs’ team integration and to also acknowledge the experiences of a larger proportion of the PSWs working in CMH teams. Quantitative research, looking at specific issues that have been noted in the present study and previous literature, such as institutional factors and access to resources, is one consideration for obtaining the opinions and concerns of larger sample sizes of PSWs.

 In addition, the present study had only one researcher to code interviews. However, member checking and consultation with second author were utilized to increase the reliability of the findings. Future studies could further increase reliability by ensuring that multiple researchers are available to participate in thematic analysis.

The PSWs in this study may have been further along in team integration due to their length of employment at the teams being on average six years, and they may not recall many experiences as a newly employed PSWs. In addition, the present study noted multiple changes over time in the integration of PSW into CMH teams. Thus, PSWs who are being newly integrated into practice may also have differing experiences in their initial experiences. Future research should include PSWs who are in the earlier stages of team integration, to investigate if there are any differences in experiences.

Finally, the results of this study incorporate only the experiences and concerns of PSWs. Obtaining information from policy makers, other team members, and clients may be beneficial in fully understanding the issues affecting PSWs in practice. With a better understanding of these issues, changes in practice would be more feasible and effective.

Reflexivity
The first author is at least a decade younger than all participants. She is also being educated in Occupational Therapy, during a timeframe in which recovery model and psychosocial rehabilitation are large influences in Occupational Therapy practice. She also spent time with PSWs during fieldwork placements and have attended multiple workshops on recovery, stigma, and peer support, one of which was introduced to one of the participants in an educational role. These experiences may have influenced her interview questions and analysis of results differently as she began this project in support of the theoretical foundations behind PSW.

She also has limited experience in practice and health policy settings, outside of OT program, and therefore is not familiar with all of the practices and policies that have been in practice since PSW began in Vancouver CMH. Finally, having a Team Director for a CMH team as a third author for the study may have influenced participant responses. The present study tried to limit this by ensuring that the Team Director was not provided with any raw data. However, some participants may have provided different responses than they may have otherwise.

Conclusion
Overall, five PSWs from VCHA’s CMH teams were interviewed for the present study and many positive experiences were reported as they related to their perceived value and inclusion; however, negative experiences were also noted. Five themes which impacted participants’ experiences were found among participants. Participants discussed the importance of their role and power within the team, such as having ideas acknowledged, being actively involved in goal planning, and ensuring their voices are part of the mental health system. Institutional organization was discussed, including financial rewards for their work, the benefits and disadvantages of unionization, and the current contract system. PSWs’ access to organizational resources, including physical space, computers, and documentation were important to many participants. The influence of inter- and intrapersonal factors on their perceived value and inclusion were shared, and the value of opportunities for socializing, for attending and actively participating in meetings, receiving positive feedback, and the development of trust among PSWs’ as well as with other team members were all highlighted. Finally, slow but positive changes over time in the perceived value and inclusion of PSWs within the teams were noted by participants. 

The results of the present study, combined with previous research, provide initial considerations and a number of directions for future researchers. With more information, VCHA, and other health authorities, can continue to improve the experiences of PSWs as mental health team members. As noted by one participant in this study, “[PSW] is kind of ground that we are all exploring together”.

 


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Acknowledgment:
We thank Regina Casey (Occupational Therapist), and Debbie Sesula and Renea Mohammed (Peer Support Coordinators for VCHA) for feedback on study design. We also sincerely thank the PSWs who participated in the study and the remainder of the Vancouver CMH teams who supported this project.

Author Contributions

Amy L. Richard, Occupational Therapy student researcher, was involved in all aspects of the project. Lyn Jongbloed, second author and faculty supervisor for this study, is credited for input on study design and data analysis, and timely review and critical scrutiny of manuscript. Andrew MacFarlane, third author and clinical supervisor for this study, is credited for conceptualization of the project, as well as some feedback on study design and critical scrutiny of manuscript.


 

                                                                                       





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