Peer supporters' mental health and emotional wellbeing needs: Key factors and opportunities for co‐produced training

Abstract Introduction Peer supporters are a valuable asset to mental health and support services, but their own mental health needs are often overlooked in research and practice. This study explored peer supporters' perceived challenges of maintaining their mental health and emotional wellbeing and co‐produced training needs. Methods A qualitative approach was used to explore factors affecting peer supporters' mental health and emotional wellbeing. Semi‐structured interviews and focus groups were conducted online with 11 peer supporters across North East England. Results A thematic analysis identified: ‘Lack of training and support’, ‘Role ambiguity’ and ‘Emotional labour’ as challenges experienced by peer supporters in relation to maintaining their mental health and emotional wellbeing. Peer supporters' own lived experiences had the potential to act as a barrier towards providing support to others. Conflict with peer ‘supportees’ sometimes negatively impacted on the peer supporter experience. Participant responses emphasised a need for person‐centred, co‐produced training. Conclusion This work highlights the need for targeted training for peer supporters, including both role‐specific education and strategies to support their mental health and emotional wellbeing. Patient or Public Contribution Participants were contacted and asked to provide feedback on finalised themes to ensure the analysis was congruent with their experiences, further enabling the future development of an emotional wellbeing training programme for peer supporters.

Peer support is recognised as people with lived experience of a particular experience, life circumstance or disability, guiding others experiencing similar difficulties through mutual support. 1,2Effective peer support provision is built upon the foundations of mutuality and shared respect. 3Peer support has previously been divided into three broad categories: (1) informal naturally occurring peer support which is not associated with organisations or services; (2) peer supporters working or volunteering in peer-led programmes or services and (3)   peer supporters employed in traditional health settings. 4cently, there has been an increase in the implementation of peer support within mainstream mental health settings due to a transformational drive towards a recovery-orientated approach to mental health. 2 Countries, including the United Kingdom, now endorse peer support at a policy level by including previous service users in the development and delivery of peer support schemes. 5 Thus, people with mental health difficulties who have previously engaged with services are subsequently provided with an opportunity to be an integral part of future service development and delivery. 6Peer support employed in mental health settings is positively associated with a range of recovery-based outcomes, such as increased hopefulness, 7 self-esteem, 8 self-efficacy and selfdetermination, 3 as well as social inclusion and condition management. 9In addition to the individuals who are the direct recipients of peer support, peer supporters themselves report increased perceptions of a sense of purpose, self-esteem and self-determination. 10As such, the positive impact of peer support is multidirectional.
Notwithstanding, studies exploring the effectiveness of peer support interventions have found little difference in clinical outcomes when comparing peer support-assisted treatment with traditional support services. 8,9though peer support schemes can yield positive outcomes, 3,7,8 implementing peer supporters in support settings can bring significant challenges.Peer support roles within these settings are often illdefined, leading to a multitude of negative implications for peer supporter wellbeing, including anxiety, frustration and a hesitancy to act. 11,12Ill-defined peer roles can also reduce peer supporter acceptance and integration into traditional mental health settings. 13er supporters can encounter challenges when attempting to create and maintain boundaries between themselves and those whom they support, leading to emotional distress. 13,14The emotional labour inherent in peer support can also lead to emotional distress and exhaustion. 14Hence, peer supporters can experience difficulties in maintaining their wellbeing and recovery. 12The combination of emotional labour, role isolation and lack of emotional support can lead to a heightened burnout risk for peer supporters. 14Lack of supervision and support is a commonly reported problem within peer support settings. 12,15,16In addition, peer supporters often report a lack of relevant training for their role, 13,17 and where training is offered, this can be incongruent with peer support values. 18llectively, the accumulated knowledge of challenges experienced by peer supporters is predominantly drawn from evaluations of peer-based interventions which focus on the outcomes from the vantage points of the recipients of peer support and peer support organisations themselves.As such, the focus on peer supporters, and the challenges that they experience, is traditionally of a peripheral nature.More peer supporter-centric research is required to produce a better in-depth contextual understanding of the challenges experienced by peer supporters, and how to best overcome these.
A systematic literature review 13 has shown two common issues in peer supporter training: overprofessionalised training that is incongruent with peer support values, and a lack of role-specific knowledge.Both can have a detrimental impact on peer supporter mental health and emotional wellbeing, 11,12,18 emphasising the need for further co-produced training opportunities 15 that are in line with the values of peer support. 19

| Design
The study employed a qualitative design, using semi-structured interviews and focus groups.This section is presented in line with the Consolidated Criteria for Reporting Qualitative Studies guidelines. 20

| Participants and procedure
Ethics approval was obtained by Teesside University's research ethics committee.Opportunistic sampling was employed. 21The research team contacted 33 local peer supporter organisations operating in North East England.These organisations offered support across a diverse range of contexts, including veteran support, addiction recovery and migrant support.Eleven individuals who provided peer support agreed to participate in an interview or focus group.This sample size is appropriate for small qualitative studies employing thematic analysis. 22All participants were provided with a participant information sheet and provided their informed consent before being interviewed.Participants were thanked post-interview and provided with contact details of organisations offering information and support.Key participant demographic characteristics and their respective peer support settings are presented below in Table 1.Other questions focussed on challenges experienced in their role, for example, 'What kind of challenges have you experienced as a peer supporter?' (see Table 2 for the full interview schedule).Data collection was undertaken by four researchers experienced in conducting qualitative interviews (L.W., E. L. P., C. O. N. and H. P.).Five one-to-one semi-structured interviews and one focus group were conducted and recorded via Microsoft Teams.Participants were provided with the choice of attending a focus group or semi-structured interview, thereby ensuring they were comfortable, and that data collection was participant-led, congruent with the values of co-production. 19Using focus groups and individual interviews did not result in notable differences in the type of data collected; the same interview schedule was used across interviewees ensuring consistency in the way the data were collected, while combining focus groups with interviews enhanced the richness and quality of the data by offering participants a choice, thereby providing them with an optimised interviewing experience. 23rthermore, as the data collected through both methods yielded similar findings, their trustworthiness was thereby enhanced. 23terview duration ranged from 19 to 116 min (mean duration = 52 min) and the focus group lasted for 60 min.Interviews were transcribed verbatim with any personally identifiable information removed and/or replaced with pseudonyms to ensure anonymity.No financial incentives were provided for participating in this study.

| Data analysis
Data were analysed thematically 24 by members of the research team (L.K., L. W.). First, data familiarity was achieved via reading through the transcripts several times.The second step involved systematically coding interesting features within the data set and creating initial codes.Next, codes were provisionally reorganised by grouping together codes related to similar topics, leading to the creation of themes.At step 4, these themes were reviewed by each analyst on two levels: at the first level, it was examined whether the coded extracts were congruent with each theme, and at the second level, it was determined whether themes were congruent with the data.Step 5 involved further refinement and naming of the identified themes.
Themes were finalised once agreement had been reached between all researchers.Lastly, themes were written up and extracts which most suitably represented the themes were included as illustrative examples.A latent approach was undertaken throughout to obtain a T A B L E 1 Participant demographic characteristics and peer support settings.more extensive understanding of participants' experiences, which may not be possible at a semantic level.

| RESULTS
Three key themes were identified that described challenges to peer  Rachel, a peer supporter for victims of sexual violence, described such an experience: We were supposed to maybe have some from

| Theme 3: Emotional investment leading to exhaustion
Some peer supporters felt emotionally distressed, exhausted and burnt out due to the emotionally taxing nature of their rolesreferred to herein as the emotional labour of providing peer support.
This theme also highlights how peer supporters' roles required them to rely upon their own lived experience.However, such experiences often encompassed trauma and emotional distress.Having that experience of it, I honestly think that it makes it tougher.Because you put yourself in their situation, you put yourself in their position and that's why you take it home.Now, had you not had those experiences, I think it would be quite easily, easier to just go home, switch off.You don't switch off.I don't switch off ever Jeremy described how one's ability to genuinely empathise with those they support makes their role more challenging.Consequently, the former is unable to 'switch off' from their role, leading to heightened emotional exhaustion and burnout.
Disclosures within peer support could lead to the triggering of memories associated with traumatic events for peer supporters with similar lived experiences, as expressed by Louise: When they're disclosing stuff, I've found sometimes it can be quite triggering for myself, and then it's meaning that I'm having to take a step back and leave it to other people.provided by peer support organisational providers. 13,17It has been argued that peer supporter training is paramount to their emotional wellbeing, asserting that training should cover topics such as looking after oneself as a peer supporter due to peer supporters' heightened vulnerabilities in relation to their own mental health. 12This was echoed in the current study, with some participants recounting how training did not focus on peer supporters' wellbeing, to their detriment.Our study yielded a novel finding, whereby peer supporters' lived experiences were not taken into consideration.
Specifically, female survivors of male-perpetrated sexual violence were only offered peer supporter training by a male, which proved detrimental to their mental health.As no other training was offered, this subsequently prevented some peer supporters from engaging in training, thus inadvertently excluding a valuable population of the peer supporter community.This novel finding highlights the need to ensure peer supporter training is person-centred and tailored to their needs, further evidencing the need for co-produced training programmes in peer support.A lack of support was also identified as a challenge experienced by peer supporters, particularly when combined with the emotional impact, subsequent emotional distress, frustration, and an inability to reduce emotional tension due to lack of support was experienced.It has been found previously that peer supporters often experience inadequate supervision. 6,13,16Sufficient supervision was viewed by peer supporters in the present study as integral to maintaining their emotional wellbeing during their roles.This is consistent with recent research highlighting how peer supporter supervision can reduce emotional exhaustion and burnout while concurrently increasing role clarity and job satisfaction. 14,15is study also provides further evidence of peer supporter ambiguity regarding the scope and parameters of their roles, while expounding upon the myriad negative implications that role ambiguity can have on peer supporters' mental health and emotional wellbeing.Role ambiguity in peer support is a ubiquitous challenge 10,11,18 associated with peer supporter dissatisfaction. 15In our study, peer supporters defined their role as person-centred, fluid, reciprocal and naturally occurring through shared lived experience and the desire to help others towards recovery: a description which is broadly consistent with the core principles of peer support. 1 Here, consistent with previous research, 18 role ambiguity was associated with a lack of boundaries between peer supporters and those they supported.Peer supporters in this study were sometimes contacted outside of their working hours for various reasons.This included peer supporters being subjected to contact from other peers they were supporting, which they considered to be more akin to friendship, as well as contact where the recipients of peer support disclosed suicidal thoughts and feelings.Ultimately, such instances led to a deterioration in peer supporters' emotional wellbeing, at times presenting a threat to their role maintenance.Elsewhere, role ambiguity has been evidenced as detrimental to peer supporters' self-care and associated with heightened burnout risk. 12,18Our study also identified role ambiguity as contributing towards conflict between peer supporters and those they support, manifesting through abusive language and behaviours.Peer supporters have previously reported a lack of confidence in coping with individuals who present with aggressive and agitated behaviours. 10However, to date, there is a lack of research on peer supporters' experiences of conflict and aggressive peers, and the associated impacts on their mental health and emotional wellbeing.Our findings suggest that conflict between peers and their supporters warrants further exploration, to determine its impact on peer supporters' work, and how to best address this issue.Our findings highlight how experiences of conflict and abuse can increase peer supporters' emotional exhaustion, which has been associated with a significant increase in turnover intention. 25,26nally, our study further highlighted the emotional investment leading to exhaustion that peer supporters experience as part of their roles and its detrimental impacts on peer supporters' mental health and emotional wellbeing.Peer supporters described forming intense emotional bonds forged with those they supported and thus experiencing emotional distress when those they supported encountered negative outcomes such as relapse.Emotional distress and a lack of social support are associated with burnout 14 and peer supporter relapse. 9,12In line with previous literature, 12,13 peer supporters in our study experienced emotional distress when hearing traumatic accounts.They struggled with role maintenance due to deteriorations in their mental health and emotional wellbeing associated with role stressors and perceived deficits in available support.As such, while shared lived experiences are often considered to form the bedrock of mutually beneficial peer support relationships, 1 our findings highlight how recurrence of past traumatic experiences triggered vicariously through providing support to others, can present significant challenges to peer supporters' mental health and emotional wellbeing.Additionally, research has evidenced a significant relationship between emotional exhaustion and turnover in peer support, to the same extent as nonconsumer mental health workers. 25,26This highlights the need to provide peer supporters with training on emotional wellbeing and access to social support and supervision, to reduce burnout 14,15 and consequently turnover.

| STRENGTHS AND LIMITATIONS
Peer support research typically focuses on evaluating the effectiveness of peer support interventions for improving recovery outcomes, 3,7 rather than exploring peer supporters' experiences and challenges and subsequent emotional difficulties which can occur. 24us, a key strength of our study is that it underscores the importance of understanding peer supporters' training and emotional needs, many of which are not being met.In contrast, a limitation is that we conducted this research within a small, localised area.
Evidence suggests peer supporters from smaller localities are at heightened risk of boundary blurring, role ambiguity and burnout, 18 and therefore, our study findings may not reflect the challenges faced by peer supporters on a national or international level.Thus, our work is exploratory in nature, and further, larger-scale research is needed, using quantitative or mixed-method approaches.
Notwithstanding, the key themes identified are pertinent to the structures and processes by which peer support is offered.Broadly, while the specific requirements for supporting peer supporters may vary according to specific context-dependent characteristics, the key themes identified are likely to be applicable.

| CONCLUSION
Further research is needed to: (1) explore peer supporters' experiences in relation to the barriers they face as part of their role, particularly in relation to their mental health and emotional wellbeing, and (2) create a better understanding of how to address this gap in peer supporter training.Therefore, this study aimed to answer the following research question: what barriers do peer supporters experience in relation to maintaining their mental health and emotional wellbeing, and how could these be addressed through co-produced training? 2 | METHODS was devised, informed by the existing literature on peer supporters, as well as the research team's expertise in this areatwo members of the research team had worked previously as peer supporters.The schedule covered topics such as peer supporter roles, experiences of peer support and perceived further training and emotional support needs, and was agreed upon by the research team.Discussions within the research team as part of the development of the interview schedule covered what was already known in the literature on peer supporter training and their emotional support needs, and time was then given to the members of the research team who worked as peer supporters to add any aspects that had not been covered in the literature, but rather, had arisen as part of their own experiences.Questions included: 'What training did you have (if any) as a peer supporter?';'What has worked well in the past with regards to peer supporter training?' and questions in relation to co-produced training, for example, 'Would you be interested in helping us design or deliver some training?' supporters' mental and emotional wellbeing, and co-produced training needs.These themes are inherently interwoven and likely cumulative; each theme representing a different manifestation of emotionally taxing experiences for peer supporters.The first theme, 'Insufficient support for peer supporters', highlighted the lack of appropriate training provided to peer supporters and emphasised the need for additional focus on their own wellbeing due to the emotional labour of the role.This theme also highlighted how peer supporters perceived that their supervision and social support needs were not consistently met by their organisations.The second theme, 'Where does peer support begin and end?', was identified as an unintended negative consequence of the flexible, person-centred and reciprocal nature of peer support provision.Role ambiguity was associated with difficulties in implementing and maintaining boundaries.The third theme, 'Emotional investment leading to exhaustion', highlighted the ways in which peer supporter roles can contribute towards emotional exhaustion and distress.The theme also details how exposure to traumatic disclosures from peers can be detrimental to peer supporters' mental health and emotional wellbeing.

3. 1 |
Theme 1: Insufficient support for peer supporters This theme highlighted peer supporters' perceived lack of receiving appropriate training and the challenges this presented in relation to their mental health and emotional wellbeing.Some peer supporters discussed barriers to accessing training with organisations and individual peer supporters held different views on the suitability of the content of the training offered.Peer supporters discussed experiencing minimal social support and supervision in some services, which led to emotional distress, exhaustion and frustration.Jeremy discussed his training experience: 'Coming into the role it was just really, you know, covering the basics; DBS check; safeguarding; Prevent.But as a way of you know, training for the role, none'.Although Jeremy discussed that he had received some training, he highlighted the lack of role-specific training offered by the organisation.Participants also emphasised the importance of tailoring training opportunities to the population and the individual barriers that certain subsections of the peer support community may experience.

4 |
DISCUSSIONThis study explored key factors affecting peer supporters' mental health and emotional wellbeing, and opportunities for co-produced training.Three themes were identified: (1) Insufficient support for peer supporters; (2) Where does peer support being and end? and (3) Emotional investment leading to exhaustion.Collectively, our findings highlight a general lack of peer support-specific training and the detrimental impacts of this on peer supporters' mental health and emotional wellbeing.Our findings evidence the presence of role ambiguity within peer supporter settings and the negative impact this can have on peer supporters' ability to implement and maintain boundaries, often culminating in experiences of heightened stress and exhaustion.Additionally, our findings highlight the emotional labour of peer support provision and how taxing this can be on peer supporters' own mental health and emotional wellbeing.This study adds to the growing body of literature on peer supporter experiences, highlighting the importance of recognising the mental health and emotional wellbeing challenges that peer supporters face.Peer supporters discussed the implications of having a lack of role-specific training and subsequently having to rely on their own lived experience to guide them.Prior research has shown a lack of opportunity for peer supporters to access role-specific training The study's findings highlight several key challenges in relation to peer supporters' mental health and emotional wellbeing.Moving forward, a key recommendation arising from our findings is for organisations which provide peer support to offer more training opportunities for peer supporters which are relevant to their role, appropriate and accessible.Training opportunities should include guidance and practical strategies for how peer supporters can KANE ET AL.| 2393 maintain their own mental health and emotional wellbeing.To ensure such training programmes meet peer supporters' needs, coproduction should be used, which may help reduce the risk of some peer supporters being excluded due to their own lived experience, as found in the present study, and ensure topics such as conflict, abuse and suicidal ideations are addressed, reducing their negative impact on peer supporter wellbeing.Training programmes may benefit from also focussing on defining peer roles clearly and providing suggestions for how to establish and maintain boundaries with those who they will support.Increased access to social and emotional support for peer supporters may reduce feelings of burnout, exhaustion and role captivity.Given the clear benefits of peer support to both the supporter and the supported, it is important that future research consider protective factors to maintain peer supporters' mental health and wellbeing to eliminate or minimise exposure to commonly experienced stressors and the effectiveness of co-produced training programmes.
some of our women if they wanted to go forward to do the peer support leader program, but some of our women didn't want to do that because it was facilitated by a man and there was no other option to do that.So, I think that was a barrier that got in the way of them being able to access that training.'Oh well, we'll give you a ring in the week', and 'then that phone call never comes'.Here, Thomas highlighted how some peer supporters perceived their own support and emotional wellbeing needs to be overlooked by their organisations.This theme illustrated the value of co-producing training programmes to meet peer supporters' role-specific and emotional emotional distress due to a perceived inability to set clear limits within the peer support role.Furthermore, Jeremy described how he had experienced abuse from those he supported: 'He was fed up and he was leaning on, but when he doesn't get his own way sometimes, when he's drunk, he'll send emails that are quite abusive'.Then, going on to discuss the emotional toll such [organisation] of part of their peer support training, or training for Louise's statement underlines the lack of training content focussing on peer supporters looking after their own wellbeing.This was echoed by other participants.For example, Richard discussed receiving little to no social support or supervision and the detrimental impact this had on his mental health and emotional wellbeing: 'The best thing I can think of is […] having someone there with that experience to talk through it and get to the bottom of what went on, what's come up for [peer supporters]'.Richard evidenced the detrimental impact peer support could have on wellbeing and highlighted the importance of discussing stressful events with someone with lived experience to reduce the negative impact on his own mental health and emotional wellbeing.Jeremy similarly emphasised the emotional impact of peer support work, combined with a lack of social support or supervision:'And all that's built up and you take that home and you do get frustrated, but where do you put your frustrations?There's nowhere'.tionalsupervision and social support relied on others for such support.As highlighted by Andrew: 'Luckily, I've got a bit of support behind me.I've got a sponsor who I can phone, I've got staff here that I talk to.But some people haven't got that support behind them as volunteers'.On the other hand, Thomas described how his organisation had become less supportive: It's starting to become the sort of thing where they'll say, nated in role ambiguity, with peer supporters having difficulty in establishing and maintaining where their role responsibilities as a peer supporter began and ended.Peer supporter role ambiguity was linked to heightened experiences of stress, abuse and conflict with those they support, often resulting in emotional distress, exhaustion and burnout.Rachel defined peer support as flexible, person-centred, and occurring naturally: 'I think for peer supporters it is what you make it out to be, what is needed at that time for that person'.Rachel describes a person-centred approach, with peer support being flexible and adaptable to an individual's needs.Such sentiments were also shared by Jason: 'People get support without knowing it and give support without knowing they are giving support'.Jason also described the benefits of naturally occurring peer support.Extending upon this, Lisa described how formal peer support, akin to professional services, may be intimidating to some: ambiguity and the impact this had on him: 'Over the last week I've had two phone calls, one on Saturday at around 11:30 to try and help one who was suicidal, and he was threatening to kill himself and then the Tuesday before as well'.Challenges in relation to blurred boundaries between friendship and professional relationships triggered feelings of We didn't recognise that there were triggers, there were red flags, there were warning flags.[…] It was like an abusive relationship; you hope it's going to get better.Somebody says sorry and you think it's going to get better, and it didn't Such experiences of conflict and abuse heightened peer supporters' emotional distress and exhaustion.As Amanda described, at times, the abuse experienced was akin to an abusive relationship.Amanda further highlighted the negative impact this had on members of the group: 'That was quite unpredictable, and I think the impact that it had on the group was quite marked in terms of how safe they felt and how secure'.A lack of boundaries facilitated emotionally volatile outbursts which significantly affected peer supporters' own emotional wellbeing.Overall, this theme evidenced how the core values of peer support leave it vulnerable to role ambiguity, making it difficult for peer supporters to implement boundaries.Over time, role ambiguity and lack of boundaries led to peer supporters experiencing emotional distress, and at times abuse and conflict.Experiences of such abuse and conflict led to peers feeling unsafe and emotionally exhausted.
Then I feel worse because I'm having to get other people to cover me Such exposure could lead to deteriorations in peer supporters' mental health.However, Louise went on to describe how peer support also helped maintain her recovery, evidencing the paradoxical nature of peer support: 'It kind of helps me in my recovery as well, both for my mental health and my addiction, because being able to support others and see them improve kind of encourages me to keep