More ‘milk’ than ‘psychology or tablets’: Mental health professionals’ perspectives on the value of peer support workers

Abstract Background Though growing numbers of peer support workers are employed in the UK National Health Service (NHS), conflicts persist between core values of peer support and values which exert power within these services. Objectives To explore what NHS mental health professionals value about the peer support worker role. Design Five professionals from different professions and mental health settings were interviewed twice. The first interviews explored their experiences of working with peers. Transcripts were analysed using discourse analysis and psychosocial theory. Second interviews allowed participants to respond to the analysis and influence subsequent analysis. Results Mental health professionals valued peers for the deeply empathic, relational approach they brought, based in their subjective experience. Peer work was also valued for the affect‐focused quality of this work, and the challenge peers pose to existing values in mental health services. The values of peer support troubled dominant ways of working based in forms of knowledge that favour objectivity and hence encountered challenges. Conclusions Peers fulfil the role of amplifying the status of diverse forms of knowledge, values and related ways of working that have become marginalized in NHS mental health services. It is important that peers are not seen as an isolated solution to the marginalization of these forms of knowledge and values, but that their way of working becomes reflected in other roles whilst evoking change throughout these services. Patient or Public Contribution Patient and Public Involvement groups were consulted both in the design and analysis stages of the study.


| INTRODUC TI ON
Service user involvement has featured in UK National Health Service (NHS) mental health policy and planning for almost three decades.
From the NHS and Community Care Act, 1 through to the updated NHS Constitution 2 and the Five Year Forward View for Mental Health Services, 3 it seems clear that service user involvement is here to stay. This paper presents a study of peer support as part of the service user/survivor involvement movement in mental health. Though definitions of peer support in contemporary mental health services vary considerably, all tend to coalesce around certain core features.
Individuals offering peer support must have 'lived experience' of mental health problems (variously defined), which they use to support others through their own mental health problems. Beyond this, definitions differ in emphasis and interpretation. For example, most avoid diagnostic language, though some refer to 'mental illness ', 4 while others instead describe 'challenges' 5 or 'distress'. 6 Murphy and Higgins, 7 and Watson 8 give a finer grained description of this variability through their look at the values and critical ingredients of peer support, finding differences such as the degree of reciprocity in the relationship and the extent to which peer support is seen as a form of activism, seeking social change.
This definitional variability results from the diverse origins of peer support, most of which are grassroots and community-based, grounded in practice and activist movements rather than top-down guidance or policy. 8 For health researchers, this variability is problematic because it renders the role and functions of peer support difficult to operationalize and measure. 7 The worth of peer support is therefore not captured by the quantitative outcome research methodologies that top the post-positivist 'hierarchy of evidence' and wield the most power in health-care cultures. 9, 10 Repper and Carter, 11 in their review of outcome research, cite equivocal results associated with quantitative research and so turn to qualitative research to gain an understanding of the benefits of peer support. Watson 8 points to quantitative studies providing evidence of slightly better outcomes for services which incorporate peer support, but again indicates that this kind of research is hampered by unclear definitions of role and function. Therefore, the evidence base to inform peer support is contested, emerging and tentative.
This variability can also be viewed as integral to the identity and philosophy of peer support. It is person-centred and thus reflects the diversity of those it seeks to help, responding to a wide variety of identities, experiences, relations to and ways of managing distress in different historical and cultural contexts. In this, it differs from many other therapeutic approaches whose credibility within the NHS has required them to become more precisely defined. For example, though most psychological therapies originate in clinical practice, 12 those prioritized in the NHS achieve this priority by building a research evidence base. The most influential forms of research evidence involve experimental designs requiring precise control over independent variables 9 ; in this case, the therapy being offered.
In order to be highly regarded, therapies must therefore be standardized (or 'manualized') so that statistically significant numbers of therapists can be considered to be delivering the same intervention. This restricts the person-centredness of these therapies and leaves little room for therapists to use their personal experience as a therapeutic resource. Therapeutic practice must be similarly standardized so it can be claimed that what is being provided is in fact the same evidence-based therapy. 13 Peer support practice does not fit this model because it prioritizes the interaction of the individual subjective experience of the peer support worker with that of the service user and hence, as described, variability is integral. In this, it is importantly consistent with the values of the recovery movement, which defines individual service user's outcomes not in general terms imposed upon them by others (such as measurable symptom reduction), but instead insisting that recovery outcomes are defined by what holds meaning for the individual. 14 Yet despite its lack of alignment with powerful discourses of evidence-based practice in contemporary health care, there has been an expansion of peer support in the NHS. 8,11,15,16 This may be because other powerful agendas such as human rights 17 and sustainability 18 support the wider use of peer support in mental health services. Whatever the reasons, research indicates that the promotion of peer support in organizational cultures underpinned by values, models and systems of knowledge, which conflict with peer support's core values, has encountered problems. 19,20 In their review of evidence, Vandewalle et al 21 describe how peer support workers often need to justify their role to colleagues and feel misunderstood and not valued. They also found difficulties of integration in teams lacking a recovery-oriented culture and a lack of training and support. These factors acted as barriers to effective peer support where tasks and specialist techniques were prioritized over the formation of interpersonal relationships central to effective peer support.
Given these tensions and barriers and the fact that professional roles are shaped by discourses which appear to conflict with core values of peer support, further research was needed to understand what it is about peer support that mental health professionals value. Whilst there are numerous studies investigating professional's perspectives on other forms of user involvement, [22][23][24][25][26][27][28] few explore the views of other professional groups on peer support. 29,30

| Objectives
This research explored the ways in which peer support workers are valued by mental health professionals. Frosh's psychosocial formulation of the subject as 'a site, in which there are criss-crossing lines of force, and out of which that precious feature of human existence, subjectivity, emerges' 31 helps explain why the experience of mental health professionals is of interest. Those studies which explore professional's perspectives find that most claim to be pro-peer support and user involvement, 29,30 but are simultaneously subject to forces exerted by models and cultures which conflict with its core values. [32][33][34] Professionals' subjectivity is therefore a site at which particular tensions interact and become manifest, and an examination of their experiences will shed light on these tensions. Frosh's formulation also resonates with the lead author's (TM) experience as a mental health professional and psychologist trying to implement various forms of user involvement and encountering resistance, both within himself in the form of anxiety and in his struggles to integrate this work with other imperatives associated with his professional role. The question therefore arose as follows: 'what is it that mental health professionals value about peer support, given the tensions and difficulties it potentially arouses?'

| ME THODS
This paper presents part of the findings of an interview-based study exploring resistances to user involvement initiatives within NHS mental health services. Interviews initially focused on describing what professionals valued and found meaningful, as this was necessary in order to describe and understand exactly what it was that was being resisted. This paper presents the findings from this initial section of the interviews as it yielded rich data.
Though participants were asked about all forms of service user involvement, they spoke most about peer support. There is arguably an important distinction between peer support and user involvement (in certain settings peer support could be provided by individuals who have not used services), but the findings reflect the participant's understanding of these terms.

| Sampling and recruitment
Five practitioners were interviewed, purposively sampled to include as broad a range of professions and settings as possible (see Table 1).
This was to ensure data represented a broad range of professional and organizational values and discourses. Given the detail of analysis required by the methodology used, which involved close reading of selected sections of text, five participants was considered an adequate number. All participants were employed in adult mental health settings based in the UK NHS and had experience of user involvement work within the previous six months. Participants were recruited via email from within one NHS Trust. The lead author had no working relationship with any of the participants.

| Data collection and analysis
Participants were interviewed twice. The first interviews lasted from forty-five minutes to one hour and twenty minutes. Second interviews lasted from twenty-five to forty-five minutes. The gap between first and second interviews varied from three to five months.
All participants chose to be interviewed at their workplace.
All interviews were conducted by the lead author. The first interviews explored participant's experiences of user involvement work, including when they had found it particularly valuable, and why. Interviewing was influenced by Hollway and Jefferson's 35 Free Associative Narrative Interview approach, which promotes the development of narrative accounts through participants speaking about their experiences as freely as possible in order to allow the traces of discursive influences and the use to which they were put by participants to become evident. Interviews were semi-structured; an interview schedule was used as a guide, but where participants were speaking freely, the schedule was used minimally. The schedule (see Appendix S1) was developed by the researcher in consultation with Patient and Public Involvement (PPI) groups (see section 2.4) and drawing on the lead author's skills as a psychological therapist.
Interviews were audio recorded, transcribed and analysed drawing on Willig's 36 guidelines for Foucauldian Discourse Analysis, whilst utilizing Davies and Harré's 37 concept of positioning and psychosocial theory. 35,38 The lead author transcribed the interviews in order to retain as fully as possible the experience of the original interviews. 39 Willig's guidelines were utilized to identify how discursive resources were used to construct the peer role, and the power and practices available to this role. Key discursive objects (eg expertise, risk, medical model, recovery model) were identified, and extracts which exemplified these discursive objects were selected for closer analysis. A psychosocial approach was used to look at how participants made use of the discursive resources identified to manage the anxieties associated with their work and experiences, to construct an acceptable sense of self within their work role, 35 and their emotional attachment to and investment in particular discourses 38,40,41 This approach enabled an exploration of the interrelation of the subjective experience of participants for their practice ('The little things'), the emotional impact of their experience ('Embodied affect') and the organizational context ('Challenge').
In the second interviews, the analyses of the first interviews were presented back to participants. They were asked to respond, given the opportunity to challenge or clarify interpretations and to add any further information. The second interviews increased rigour by providing a means of testing the meaningfulness and relevance of interpretations. 35,40 The second interviews were audio recorded but not transcribed. They were used to inform the on-going analysis of data from the first interviews, as described in the Results section.
Patient and Public Involvement (PPI) groups were similarly used in the analytic process (see section 2.4).

| Reflexivity
Reflexive note taking was used extensively throughout the research process. Berger's 42 three-part log approach was used to structure these notes, focussing on the interviewer's initial interpretations of data and on his subjective emotional responses. These emotional responses were used to guide the selection of text for closer analysis.

| Patient and public involvement (PPI)
Two PPI groups were consulted, using INVOLVE 43 guidance. One group consisted of service users who were members of a forum informing mental health service developments, so had an interest in improving the quality of user involvement. The other was a multidisciplinary group of mental health professionals and hence corresponded to the participant group. Both groups were consulted during the planning and design of the project. As described above, both groups were consulted during analysis. Key extracts were presented, along with a draft analysis. The groups were invited to respond to both extracts and analyses, and these responses guided subsequent analysis.

| Ethical Approvals
Ethical approval was obtained from the University Research Ethics Committee and through the Integrated Research Application System (IRAS Id: 237366).

| RE SULTS
The results are presented in three sections reflecting key aspects of the peer role and positioning within services, which emerged during analysis. The extracts were chosen using the process described above whereby initial selection was informed by the researcher's af-  That professionals will prioritize care plans over milk is also indicated by the peer's concern that raising the same issue during their discharge would be perceived as 'silly'. P1 presents the discharge process as a context in which specialized professional discourses carry weight whilst others, symbolized by milk, are less important, even silly. Voicing these other discourses as a service user, dramatically disempowered in this situation, was not possible. However, this individual's shift into the peer role enabled them to voice these discourses, and this is heard and valued by professionals such as P1.

| The 'Little' Things
This shift from 'silly' to 'really important' shows how the peer role elevates the validity of the discourses signified by milk so they can compete with professional discourses.
Because 'milk' felt so symbolically significant here, TM pre-

| Challenge
This extract was selected because, as a mental health professional himself, the researcher empathized with the sense of embarrass- It is also important to note the ambivalence and tension here.
Though P3 clearly valued the challenge, she experienced being challenged as uncomfortable. This may have been because she was part of the same organization as the doctor and so probably also identified to some extent with their position. Whilst the challenge was welcomed, the associated emotional experience might not have been. If such emotions are not reflected upon and understood they could be avoided by, for example, excluding the peer from such consultations. This would be an example of unexamined affect leading to resistance to meaningful integration of peers.

| D ISCUSS I ON
Perhaps the most useful definition emerging from the study data is that what professionals value about the peer support role is the ability to offer 'milk', contrasted with the 'psychology or tablets' prior-

| Limitations and strengths
Though attempts were made to recruit professionals from a range of settings and different professions, the work context of the participants remains specific. All worked within one mental health Trust in the NHS. The experiences of those working in different context will differ, and hence, the themes and issues identified here cannot be generalized. In addition, the recruitment strategy purposively selected professionals who were open to speak about user involvement and peer support. It is likely that this resulted in the over-representation of practitioners in favour of user involvement.
A further study would benefit from more reflexivity around recruitment, including asking participants why they decided to take part.
The second interview provided a means of testing analytic interpretations by checking the degree to which relevant groups recognized them and found them meaningful. 35,40 However, further meetings with participants would have produced richer data.
Much psychosocial research involves multiple interviews, which enable a deeper reflexive dialogue to develop. 55,56 This would have allowed greater exploration and elaboration of the most relevant and meaningful discursive aspects as they emerged and provided a way of both testing and extending the interpretations produced here regarding the complexities surrounding peer support, the hopes it may carry for clinicians, the ambivalent feelings they may have about it and how all of these are produced by the social context of the work. A greater appreciation of these complexities will be necessary for the future success of peer support in the NHS.

ACK N OWLED G M ENTS
Thank you to Harriette Cusdin (Lead Occupational Therapist) and Joanna Stevens (Consultant Art Therapist), Clinical Advisors. And thank you to the Langley Green and Hastings Working Together Groups, and the Bluebell House staff team for their advice and helpful thoughts and comments.

CO N FLI C T S O F I NTE R E S T
Both authors confirm no conflicts of interest.

D I SCL A I M ER
This paper represents independent research funded by the NIHR.
The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.