This paper focuses primarily on findings related to the first evaluation question: what are the peers doing? Because what peers do is affected by the difficulties they encounter, it also touches on some of the challenges the peers were facing. Similarly, although this paper does not focus on the question of peers’ impact, we do briefly mention findings about peers’ perceived effectiveness in order to explore how the ways they do their work may facilitate that positive impact.
The types of work peers do
During the 11 days recorded in the logs, peers spent 56% of their time working directly with clients (direct work) and 44% doing work that supports their work with clients (indirect work). The percentages of time spent doing direct and indirect work in both inpatient and outpatient settings are shown in Tables
1 and
2.
Table 1
Percentage of time spent on different direct activities
Type of Activity*
| | | |
Advocacy | 16.3% | 33.6 | 37.7 |
Connecting to resources | 36.9 | 78.4 | 67.9 |
Experiential sharing | 68.3 | 153.2 | 82.3 |
Building community | 33.4 | 80.5 | 110.4 |
Relationship building | 65.3 | 149.3 | 103.4 |
Group facilitation | 14.1 | 28.6 | 42.7 |
Skill building/mentoring/goal setting | 38.8 | 79.6 | 70.5 |
Socializing/self-esteem building | 63.9 | 142.7 | 104.1 |
Other | 8.3 | 14.6 | 39.3 |
Table 2
Percentage of time spent on different indirect activities
Type of Activity*
| | | |
Group planning and development | 15.4% | 25.0 | 32.9 |
Administration | 27.2 | 40.0 | 35.8 |
Team communication | 24.3 | 40.5 | 53.5 |
Supervision/training | 8.3 | 13.6 | 28.8 |
Receiving support | 10.8 | 24.6 | 37.5 |
Education/awareness building | 10.4 | 23.2 | 50.8 |
Information gathering and verification | 16.8 | 38.2 | 52.5 |
Other | 11.3 | 20.5 | 31.7 |
The specific activities that made up the general categories of work tracked in activity logs were:
Advocacy
Advocacy was defined in the log instructions as “addressing a problem with or barrier to accessing a service or an infringement of rights.” One participant defined advocacy more broadly as “facilitating whatever the clients want.” In practice, advocacy work encompassed both the work that peers do in fighting for what clients want and the work that they do to provide clients with the wherewithal to fight for themselves. Notes in the peers’ activity logs indicated that they perceived themselves to be engaged in advocacy work when they did things like answer questions or provide information to clients, run a peer support group, work with clients around goal setting and confidence building, and discuss stigma. Helping clients navigate the mental health system appeared to be a large component of advocacy. For example, the data contained numerous examples of peers teaching clients about the mental health system and their rights within the system. While advocacy occupied a relatively small percentage of the peers’ time on the days tracked by the logs, activities falling under the general rubric of advocacy were the focus of many interviews—particularly client interviews—suggesting that advocacy is an extremely important component of what peers do.
Connecting to resources
This type of work was defined in the log instructions as “connecting [client] to desired services/supports.” The data showed that peers work to connect clients to resources both inside and outside the hospital. Inside the hospital, especially on locked units, peers appeared to spend a great deal of time escorting clients off the unit, thus allowing access to valued resources like a smoke, money (at the hospital’s cash office), a cup of coffee, or a breath of fresh air. Other within hospital resources included activity groups and peer support itself. Outside the hospital, peers worked to connect clients to paid and volunteer work opportunities and other activities, to housing, to transportation, to financial resources, and to sources of peer support and other support in the community. Notes in the activity logs showed that peers consider preparing clients for connection and following up after clients have connected to be integral to this type of work.
Experiential sharing
Defined in the log instructions as “sharing common experiences; listening to client’s experiences and sharing one’s own experiences,” experiential sharing occupied the greatest percentage of peers’ time during the days tracked. According to the data collected through interviews and focus groups, drawing upon their own life experiences in order to share their knowledge is a common element in everything that peers do—from running support groups to speaking with clients one-on-one to educating staff. The data suggested that experiential sharing is not just a type of work but also a component of one of the key mechanisms, experience, that links what the peers do to the impact their activities have.
Building community was defined in the log instructions as “connecting to programs to link the client into the community…or doing things that build a sense of community for clients collectively.” In the interview and focus group data, peers’ community building activities encompassed two main aims: to establish a sense of community for clients during their involvement with a unit and to help clients make meaningful lives in the community (outside the unit or hospital). Toward the first aim, many of the peers’ activities revolved around planning and conducting groups, trips, and special events (like holiday parties) for clients. They also included outreach to and orientation of new clients to unit programming. Peers built community when they invited client participation and ran groups in ways that made people feel comfortable and welcome—for example, by providing refreshments. Toward the second aim, peers did things like check in with clients who had recently moved to new community housing and made recommendations for community-based programming. Like advocacy, building community was more salient in the interview data than it was frequent in the logs. Staff participants were particularly attuned to the first aim—ways in which peers were able to create a sense of community for clients.
Relationship building
This type of work was defined in the log instructions as “developing trust and rapport [with clients].” The interview and focus group data suggested that relationship building included the work of initiating relationships with clients, of establishing relationships, and of maintaining relationships. Among the specific activities that made up this type of work were the introductions of peers and clients (usually either initiated by the peer or by another staff member), conversations between peers and individual clients in which peers gave advice, acted as a sounding board, or simply listened, taking clients out to smoke or to walk, making (and keeping) appointments with clients, checking in with clients who had not been in recent contact, and visiting clients who had recently transitioned from hospital to community or vice versa. Peers also built collective relationships with groups of clients, generally in group settings. Relationship building was the second most frequent type of work accounted for in the logs, and was also very salient in the interview and focus group data.
Group facilitation and group planning and development
These two types of work were defined in the log instructions as “leading a group activity” and “planning or organizing a group,” respectively. Peers planned and conducted groups that were specifically focused on mental health (e.g., WRAP groups, recovery groups) and groups that might be mental health promoting, but were focused on other activities (e.g., music or art groups, exercise groups). Peers planned and facilitated groups on their own, but also worked with other staff collaboratively to develop groups and group activities and to co-facilitate groups. The work of planning and developing groups required a series of steps from conception to execution, including using models to conceive groups, designing group activities to respond to client needs and requests, finding written materials to supplement group activities, making arrangements (booking space, procuring refreshments, etc.), publicizing the group, and inviting client participation. Group work was extremely salient in the interview data, particularly among clients and particularly in inpatient settings.
Skill building/mentoring/goal setting
This type of work was defined in the log instructions as “developing [client] skills and goals.” The data suggested that this work related to tangible, instrumental skills and goals, such as resume writing or meditation, to issue-specific skills and goals, such as providing advice about specific clinical or government programs, and to very abstract skills and goals, like helping clients to feel hopeful. Peers worked with clients both to develop and meet clients’ personal goals—for example, pertaining to housing or employment—and to set shared goals for the peer/client relationship. Some of the specific activities that made up this type of work included the facilitation of peer support and recovery groups, one-on-one conversations in which peers provided advice and encouragement to clients—for example, coaching them about how to interact with providers or going online with them to look for volunteer work, and activities directed at building client confidence and increasing client familiarity with resources in order to facilitate informed choice.
Socialization/self-esteem building
Defined in the log instructions as “coaching related to social communication skills, social skills or encounters,” the data suggested that socialization and self-esteem building work was embedded in most of the direct work, both individual and group, in which peers were engaged. It was inherent in how peers initiated contact with clients and in the ways in which they worked to support and sustain their relationships with clients. In outpatient programs, this type of work often entailed making dates to meet clients in the community for coffee and conversation. In inpatient settings, it meant escorting clients off the unit for coffee or a meal or performing what clients called “good deeds” or thoughtful gestures, like buying refreshments for a group, that boost client self-esteem. This category of work was very difficult to distinguish from other types already described, especially relationship building and skill building/mentoring/goal setting.
Administration
The administrative work performed by peers included activities like responding to email and telephone messages, preparing for and wrapping up after groups and special events, doing odd jobs around the office (e.g., answering phones for an absent colleague), and documenting (e.g., writing progress notes). Peers also found themselves doing administrative tasks related to their employment at the hospital. Administrative work was the most frequent indirect activity tracked in the logs, but was not at all salient in the interview and focus group data.
Team communication
Team communication was defined in the log instructions as “team meetings or other communication with team members.” Neither the logs nor the other data suggested that peers spend much, if any, time in traditional team meetings (though there is some indication that peers in some units may be starting to attend such meetings). Most “team” communication actually took place one-on-one between peers and individual staff members. The communication activities captured by the logs included the conversations between peers and staff members related to groups or events they were working together to plan or conduct, conversations in which peers conveyed information about clients to staff, conversations in which peers went to staff to troubleshoot on a client’s behalf or to air a client’s concerns, and conversations in which peers and other staff were strategizing or debriefing about a client or group of clients. These conversations generally took place in person, though peers also used email to conduct some communications.
Supervision/training
This type of work was defined in the log instructions as “meetings to discuss [peer’s] performance and role or completing hospital-mandated training.” Information gathered in our focus groups suggested that peers had engaged in a number of structured training and supervision activities earlier in their employment. Perhaps because data collection took place over the summer, however, this activity had low frequency and little salience in our data.
Receiving support
The log instructions defined this type of work as “help seeking from ‘intentional allies’ and other colleagues.” The frequency of this type of work was very low in the logs. These data, and the interview and focus group data, suggested that peers seek only specific instrumental and task-related support—for example, the kinds of activities described in team communication—from their fellow staff members. A few peers had established good collaborative working relationships with the recovery facilitators assigned to their units. However, most peers appeared to receive only very limited personal support from colleagues, including other peers.
Education/awareness building
This type of work was defined in the log instructions as “education for the public and the hospital community.” The interview and focus group data presented examples of peers engaged in structured and unstructured educational activities like organizing recovery events, providing feedback on unit programming, and otherwise sharing their expertise with colleagues. Peers played a role in the hospital’s new staff orientation activities and presented on peer support in other venues. The frequency of education/awareness building work was very low in the logs. However, this was a type of work that the peers were very interested in and seems to hold great potential for expansion.
Defined in the log instructions as “seeking up-to-date information about policies and public benefits to better inform clients,” this type of work was fairly frequent in the log accounts. Activities that relied on this type of work, like providing information and responding to clients’ questions about available services, supports, and opportunities, were extremely salient in the interview data, particularly in the client interviews. Peers described using the internet and attending workshops as prime sources of information. There was some suggestion in the data that peers may do a great deal of this type of work on their own time—that is, as unpaid labour.
Analysis of the interview and focus group data revealed that in addition to the work tracked in the activity logs, peers also engage in types of work that are less visible but equally important because they make possible the direct and indirect work peers do for which they are held accountable. The first of these types of work was forging collegiality. Just as peers strive to initiate, establish, and maintain relationships with clients, so too did they work to build collegial relationships with other staff. Toward this end, peers spent time learning the culture of the units and programs in which they were working, including learning to understand the priorities, values, knowledge, territories, constraints, and stresses of the disciplinary staff with whom they work. Peers were able to use this knowledge to make themselves useful—for example, by performing a task in order to cover for an absent or harried colleague or by intervening with a client in order to diffuse a potentially disruptive situation—and to show respect or deference to other staff—for example, by seeking advice from colleagues before implementing an idea or by passing along information about a client that a staff member needed to do his or her own job. The formal and structured collaborative work that peers did with other staff helped to promote collegiality, as did their involvement in the informal and unstructured social events (e.g., water cooler chat, holiday parties) that brought co-workers together.
Peers also performed work aimed at legitimizing the peer role. Indeed, the peers were acutely aware that they were “pioneers” in a new role at the hospital. Among the pressures they experienced were not only those related to doing their jobs well, but also to justifying the very existence of the job. Thus, they had to define and negotiate the peer role—what they would and would not do, what they could and could not do — in a context that mixed high expectations and stigma-based stereotyping and discrimination. Peers worked to manage expectations—their own and those of others; to avoid errors that they perceived may make the peer role vulnerable; and to “pick their battles”—judging when to respond to discriminatory words or actions (directed against clients or themselves) and when to let them go.
Both forging collegiality and legitimizing the peer role may be understood as strategies peers used to negotiate some of the challenges of the peer role. Specifically, this work becomes part of what one participant described as the “dance” peers must perform in order to respond to varying forms of individual and institutional resistance to their employment — a lack of awareness and understanding of the peer role, clashes between the peers’ philosophy and the hospital’s traditional biomedical ideology, territoriality and defensiveness on the part of some disciplinary staff, and stigma and discrimination directed toward both clients and peers.
How peers have positive impact
The data collected to answer the evaluation’s second question, about the impact peers were having, found both clients and staff members believed that peers were having positive effects on the quality of life, and of care, for clients in the domains of information and other resources, engagement, morale, empowerment and hope. Analysis directed at exploring how peers were achieving these results suggested five key characteristics of the ways peers were doing their jobs that facilitated their perceived effectiveness:
Experience
Peers draw upon their own life experiences, especially experiences of distress, poverty, and oppression, on the one hand, and experiences of recovery and resilience, on the other. These experiences have led them to have a body of knowledge that is extremely useful to clients. The fact that they have had these experiences means that they are able to understand clients in a way that is real and empathetic. Because of their own experiences, they are able to make meaningful connections with clients.
Approach
Peers initiate contact with clients in a way that is respectful and calm. They encourage client engagement without pressure, and accept the nature and extent of engagement that clients wish to have. Their manner of approach appears to send a message to clients that it is about them (the clients), not about the peer or the requirements of the institution.
Presence
Peers are able to be with clients in a way that demonstrates genuine concern. They listen actively and pay attention to clients. Their responsiveness and kindness validates clients. On restricted units the physical presence of peers allows clients greater freedom and more access to valued resources than they would otherwise enjoy.
Role modeling
Peers serve as symbols and examples to both clients and other staff. They provide “someone to look up to” for clients who are seeking ways of living that will help them to meet their goals. For staff, they stand as exemplars of “recovery in action,” and their skills and knowledge serve as examples to staff looking for a new way in which to work. Role modeling is something that happens naturally and informally in private interactions, but there are also times when it is used formally in public forums.
Collaboration
In almost of all of their activities, peers are working with other people, either clients or staff. While peers stand somewhat outside the institutional hierarchy, and thus are able to be “independent,” they also lack any real power, so much of what they can accomplish requires the cooperation of others. Their role is very much defined by their connectedness. Thus, peers spend a lot of time promoting or supporting that cooperation—doing things like information sharing, finding allies, etc.
There are two other process characteristics that are most apparent in the “invisible” work that peers do: challenge and compromise. Challenge refers to the promise (or threat) of change that peers bring to the status quo. Challenge is embedded in the very existence of the peer role, but is especially apparent in the work of advocacy and education/awareness building that they do. Compromise represents the ways in which peers must restrain or moderate challenge in order to maintain their legitimacy.