A comparison of the workplace perceptions of lived experience and non-lived experience mental health support workers, the good news Open Access

Peer support has gained significant attention in service delivery, and the evidence base suggests that outcomes attained by services involving peer support are at least equivalent to those obtained by standard clinical support (Bellamy, 2017; Pitt et al., 2013). For the purposes of this article, the peer role definition adopted will be that used in earlier research conducted in Australia (Scanlan et al., 2020) “a mental health worker who has lived experience of mental health issues and recovery and is employed to apply their lived experience to support people who access mental health services.”

There are, however, several studies that have found the implementation of peer worker roles to be extremely complicated due in part to the medical model under which professionals, who are usually assumed in the literature not to have lived experience, in health services often work, for example, Davidson et al. (2012). Unequal relationships with other professionals can constrain the position of the peer worker and the valuable contribution that the peer worker can make (Walker and Bryant, 2013). In addition, there is often a disconnect between the perceptions of peer support workers (PSWs) (also known as peer workers) and their clinically trained colleagues’ views of the equality of their working relationship, with peers seeing the relationship as unequal and clinically trained workers seeing the relationship as equal (Gillard et al., 2015). Therefore, it is important to capture peer workers’ perceptions of their role to better identify barriers and facilitators to the successful integration of peer workers into mental health services (Moran et al., 2013; Walker and Bryant, 2013).

All 18 studies identified in a literature review of peer workers’ role perceptions conducted in 2016 (Vandewalle et al., 2016) were qualitative studies, with just three of those studies also having a small quantitative component. This points to a severe paucity of quantitative academic studies in the area. In addition, at the time of writing, there were only two studies that included participants from an Australian non-government specialist mental health organisation (Scanlan et al., 2020; von Hippel et al., 2022) and therefore information specific to the needs of mental health focused community managed organisations (CMOs) in Australia would likely be useful.

However, in addition to people with lived experience working in identified positions, there are also people with lived experience of mental health issues who are providing support but not working in identified positions. In fact, previous research suggests that a significant percentage of mental health professionals might be drawn to work in the area due to their own lived experience (Barnett, 2007; Farooq et al., 2014). There are a number of reasons why people may not disclose their lived experience in the workplace, including being seen as an “impaired professional” or being constricted by an “us and them” divide. One recent study also found that stigma and discrimination were prevalent across government and CMO mental health services (Byrne et al., 2019). Conversely, in a supportive environment, people may feel enabled to accept disclosing their lived experience (King et al., 2020).

Furthermore, a recent exploratory factor analysis of the barriers and facilitators to peer workers in mental health support using a survey that was based on qualitative interviews with PSWs found four factors that described the perceptions of PSWs in mental health settings (Clossey et al., 2019): organisational culture, professional prejudice, non-recovery principles and working alliance. The authors and the consumer research advisory committee within an Australian CMO thought it possible that this survey, perhaps would only require small adaptations to make it feasible and useful in the Australian CMO context.

A recently published article von Hippel et al. (2022) found that having lived experience of mental health issues was protective against client-related burnout in the workplace, but did not directly address workplace barriers and enablers for peers and other people with lived experience in the workplace or a comparison between the attitudes of peers, support workers and people with lived experience. Previous work in an Australian CMO (Scanlan et al., 2020) found no difference in job satisfaction or intention to quit between support workers and peer workers. However, the sample was small, there was no investigation of lived experience per se, and it therefore provides no information regarding people with lived experience of mental health issues who may or may not be working in identified positions. The current data, therefore, presents further evidence of the benefits for people with lived experience working in mental health adding to the larger body of research which demonstrates benefits for people accessing mental health services.

The aims of the current study are to provide initial information on:

• Comparison of the workplace perceptions of peer workers, support workers and other people with lived experience working in a large Australian mental health CMO.

• Whether a US developed barriers and enablers questionnaire may be adapted for use in Australian CMOs.

Participants were employees of a community managed mental health CMO in Australia who provided direct support to the people accessing their services. Although a diagnosis is not necessary to access support from this organisation, its stated mission is to provide services to people who are experiencing severe and persistent mental illness. The participating CMO sent an email to its employees containing a weblink to the survey. Employees who clicked on the link were provided with information about the study before deciding to continue. Employees were eligible for participation if they indicated that they were over the age of 18 and provided direct support to the people who accessed their services.

The scales in the survey were presented in a randomised order, with the exception of the demographic questions, which were always at the end of the survey. At the completion of the study, participants could provide their email address to be included in a prize draw. Email addresses were collected in a separate Excel file so that they could not be linked to survey responses. Six respondents were randomly selected to receive a AU$50 gift voucher. The study was approved by the University of New South Wales Ethics Committee (HC200473) and conformed to the ethical standards set out in the 1964 Declaration of Helsinki.

The current paper presents the results of the PSW job obstacles and barriers survey (PSWJOBS) (Clossey et al., 2019), which was designed for a different service environment in the USA The survey is designed to assess the job obstacles and barriers for PSWs in their workplace. The survey was modified in consultation with a research advisory committee, which is comprised of people with lived experience of mental health issues who have accessed the services of the CMO. The survey used comprised 12 questions out of the original 18. The questions removed include a question regarding medication, which is irrelevant to the service as it does not provide medication, a question about the recovery model as the service is based on the recovery model and questions regarding professionals’ attitudes towards peer workers as the organisation’s consumer advisory group felt they were not relevant for this organisation. These adaptations had the effect of removing the non-recovery principles factor from the PSWJOBS. In addition, although the survey was created to be completed solely by peer workers, the analysis was conducted across all groups as the sample size was small and there are more commonalities among all types of support work than there are differences. The questions were rated on a five-point Likert scale as they were in the original PSWJOBS article. Other scales, measuring client-related burnout, job satisfaction, job engagement, intention to change organisation, intention to change profession and workplace well-being (mental health) have been described elsewhere (von Hippel et al., 2022).

At the completion of the survey, participants indicated their age, gender, tenure working in the mental health sector and in the organisation, and their role in the workplace (peer/non-peer role). Finally, participants were asked, “Do you identify as someone who has lived experience with mental health issues?” (yes or no).

All analyses were conducted using IBM SPSS 28 (IBM Corp, 2021). Principal components analysis with Varimax rotation was used to extract components of the PSWJOBS survey. The significance of mean differences was tested by t-tests and using the result for unequal variances where Levene’s test indicated significantly different variances between groups (heteroscedasticity).

The CMO surveyed has approximately 550 people who work in direct support roles. Of those 220 (40%) people work in identified peer worker roles, whereas 55% of all people at the organisation identified as having lived experience when asked as a part of the “onboarding” process when joining the organisation. There were 175 people (32% response rate) who provided complete data for analysis and of those 106 (61%) were in identified peer worker roles and 110 (63%) identified as having lived experience. Not all people with lived experience were working in identified roles. The factorability of the PSWJOBS survey was strong (Bartlett’s KMO 0.818) and the same three factors retained from the original research were the only factors that had an Eigenvalue greater than one and accounted for 68% of the variance. Cronbach’s alphas for the three scales used were acceptable by commonly used rules of thumb (Taber, 2018), and those for the organisational culture and working alliance factors were similar to those in the original article based on peer workers in Philadelphia (Clossey et al., 2019). Although the alpha for the professional prejudice factor was slightly lower than the score on the original article, Cronbach’s measures are affected by the number of items, and it is probable that the reduction in the number of items in the professional prejudice dimension reduced the score. In Table 1, the Varimax rotated EFA demonstrates the unidimensionality of each of the three factors and adequate reliability of the factors is suggested by the Cronbach’s alphas obtained. The questions in the table are the full question set as presented to the participants.

Mean differences of scores on the factors in Figure 1 show that there were no significant perceived differences between people who were employed as peer workers and those who were in non-identified positions on any of the survey factors, but that people with lived experience perceived the organisational culture as more supportive than people who did not have lived experience. Note that all questions have been calculated to be in a positive direction, a higher score on professionals’ attitudes, for example, means that professionals’ attitudes are seen as being more positive. The same applies to subsequent survey questions in Figures 2 and 3.

Analysis of the mean differences between peer workers and non-peer workers on the other measures collected shows that while people working in identified peer worker positions tended to have higher positive scores on most survey questions, only for job engagement did peer workers have a significantly better experience than non-peer workers.

However, when comparing all those who identified as having lived experience to those who did not so identify there were a number of areas where people with lived experience felt more positive. A person with lived experience was more likely to have felt less workplace-related psychological distress (mental health), be more engaged in their job, and less likely to be thinking of changing jobs to work in a non-mental health-related profession. These results speak quite clearly to advantages for people who have lived experience of mental health issues working in mental health support.

As some peer workers identify as someone with lived experience but are not working in an identified peer role, it is useful to compare those working in identified roles to those working in a standard peer worker role. When only people with lived experience are included in the analysis there are no significant differences between groups (Table 2). People with lived experience had similar impressions of their work regardless of whether they were in an identified position or not.

The vast bulk of research regarding people working in mental health support positions has been conducted outside Australia, usually in clinical services and has peer workers as the focus. Moreover, most studies were qualitative and focused on the barriers that peers encountered in the workplace. The only extant quantitative study conducted in Australia that compared mean scores found that peers’ experiences of the workplace were equivalent to the experiences of identified peer workers (Scanlan et al., 2020).

The current study included a comparison of the experiences of people who identify as having lived experience of mental health issues to those without lived experience, as well as the experiences of people in identified peer worker positions. The findings for both peer workers and others with lived experience were surprisingly positive in the light of the extant international literature, particularly for those with lived experience.

Risk and safety are often raised as barriers to people with lived experience attaining meaningful employment; however, these findings suggest that people with lived experience working in a supportive environment reported lower psychological distress than those who have no declared personal experience, and earlier work also suggests they may also be more resistant to client-related burnout (von Hippel et al., 2022). The findings that people with lived experience felt better supported by the organisation, had markedly lower workplace-related psychological distress and were more engaged with their employment than those who did not so identify strongly suggests that there may be considerable advantages, for both the organisation and the people employed, to employ people who identify as having lived experience of mental health issues in a properly supportive environment.

It is notable that the organisation that took part in this study has a long-implemented inclusion strategy (Beattie et al., 2013). It is also significant, if perhaps unsurprising, that people with lived experience were less likely to think of working in another profession, which supports the finding that support workers who identify as having lived experience are more resistant to client-related burnout than those who do not so identify (von Hippel et al., 2022).

There are issues with the term “lived experience”. It is a broad term, and there can be some confusion between having lived experience and being a peer worker. A paper by the National Mental Health Commission appears to conflate those two terms, for example, and assumes that people with lived experience will always be employed as peer workers (Byrne et al., 2021). Mental health issues can be seen as a concealable stigma, and there is a large body of work suggesting that the identity management involved in not disclosing a concealable stigma has a number of significant negative impacts, including well-being in the workplace (Jones and King, 2014). The current study suggests, however, that whether or not a person is working in an identified position they have similarly positive views of their work and organisation. Although identified peer positions have been found to assist with discrimination in the mental health workplace and to help with acceptance of disclosure (Byrne et al., 2022), previous work has also found that there is a stigma borne by people who are in an identified position (Byrne et al., 2019; Stromwall et al., 2011).

The current study suggests that, perhaps with appropriate support, it is possible not only to negate the effect of this type of stigma but to make having a lived experience of mental health issues a positive experience for the worker. This result must, however, be tempered in that the sample size is small for this particular analysis and the work has only been conducted in one large Australian CMO. Further work expanding this study to other workplaces and having a larger sample of people with lived experience working in both identified and non-identified support worker roles would be a useful addition to the knowledge of the perceptions of people with lived experience in the mental health workforce.

Finally, the modified PSWJOBS scale shows acceptable factorability and reliability even though the population group surveyed here was a very distinct group compared to the peers surveyed in the development of the instrument in Philadelphia, USA. This suggests that the barriers and enablers identified as workplace factors have more general applicability than peers only to peer workers in the USA This could be a focus of future work in the area, with a larger sample incorporating large enough groups among peers, people with lived experience and non-peers to create an acceptable model.

This paper provides important insights about the experience of people with lived experience employed in one CMO in Australia. It highlights that people’s employment experience, in formalised peer worker roles, as well as support worker and other roles employing people with lived experience, is positive when the organisational culture is supportive. While on many measures there was no difference between workers with lived experience and those without, in such an environment, people with lived experience were more likely to be more engaged in their job, report experiencing less psychological distress and were less likely to think about changing jobs. These are important considerations when developing responses to significant and growing workforce challenges for community mental health services. Establishing a supportive organisational culture, most importantly supportive of lived experience roles, could be the response needed to address that challenge effectively and workplaces in which people with lived experience can thrive.

Lived experience is an extremely broad term and the people who are identified as having lived experience were not asked the exact nature of that lived experience. Given that the bulk of the literature on peers in the workplace focuses on the barriers that are in place, the intended original focus of this research was on people working in identified positions. However, the results were unexpectedly neutral for peer workers and quite obviously positive for the larger group of people with lived experience. The authors felt that this was an important insight for the sector and worthwhile to report.

Future work should explore the definition of lived experience and how that, and the effect of working in an identified peer position relate to a positive or negative experience of the workplace.

The sample is drawn from a single, if large, CMO. CMOs in Australia not only function under what the authors would argue is a substantially different philosophy to public mental health services, but often individual organisations are run under slightly different recovery focused philosophies, each with its strengths and weaknesses as a support model. To address this, further work in the area would benefit from having multiple organisations and perhaps multiple types of organisations take part in the research.

The authors would like to thank Associate Professor Courtney von Hippel of the University of Queensland and Professor Loren Brener of the University of New South Wales for their support.