Study context

The study is reported according to the COREQ checklist Consolidated Criteria for Reporting Qualitative Research). Our research is part of a larger project (ImpPeer-Psy5), exploring the implementation of peer support work in the German mental healthcare system. There are considerable variations in PSW implementation across regions and institutions in Germany, reflecting the diversity of local, regional, and federal regulations and conditions. Public mental health care in Germany is mainly provided through psychiatric hospitals, with approximately 600 hospitals across the country. These hospitals primarily offer inpatient services, followed by a smaller proportion of day clinics, outpatient services, and a very small portion of home treatment services. The services provided by psychiatrists and psychologists/psychotherapists are also regulated by the Fifth German Social Code Book (SGB V) and funded by approximately 90 statutory health insurance companies. Approximately 70% of all expenditure spent on individuals with mental health diagnoses accounts for this sector, which is referred to as the ‘mental healthcare sector’ to differentiate it from the ‘psychosocial sector.’ The latter includes a wide range of complementary, vocational, residential, and psychosocial services regulated by different Social Code Books (mainly SGB IX and XII) and funded by various bodies, such as pension funds or individual social benefits.

The development of the “Experienced Involvement” (EX-IN) training courses for PSWs in Germany was supported by EU funding in 2005. These courses train individuals with lived experiences of mental health diagnosis to become PSWs. Currently, there are 29 EX-IN training sites across the country, and graduates of these programs are certified as PSWs, with their qualifications being recognized by a wide range of mental health service providers. While there are alternatives to EX-IN training, such as peer counseling courses offered by the German Network for Independent Living, EX-IN remains the dominant training paradigm. This led to our study, which aimed to recruit PSWs with varied training backgrounds, being largely dominated by EX-IN graduates due to their greater numbers. While there are no precise data, it is estimated that the majority of the approximately 2500 PSWs in Germany are employed in the latter (SGB IX and XII). However, this study specifically evaluated the implementation of PSW in the mental healthcare sector, primarily focusing on PSWs employed in psychiatric hospital departments, due to the aim of the study and its funding body.

Study design

The methodological design and processes have been recently published [53], justifying the short description in this manuscript. The ImpPeer-Psy5 study used a mixed-method QUAL1-QUAN-QUAL2 design to incorporate diverse methodological approaches and incorporate various perspectives into exchange. Two qualitative parts of the study (QUAL1 and QUAL2) were conducted at the Brandenburg Medical School (MHB), on which this study is based. An ethics vote was obtained for the Impeer-Psy5 study at Brandenburg Medical School (No. E-01-20200826).

For the QUAL1 phase, a collaborative research approach was used, meaning the cooperation of researchers with and without lived experiences with psychiatric care, mental crises, and recovery from them in all research phases and various educational backgrounds. To further explore and deepen the findings from the QUAL1 (and QUAN) phase, various sub-studies were conducted during the QUAL2 phase, one of which focused on the change in MHWs attitudes following the implementation of peer support work. Thus, this sub-study was mainly accomplished by a psychiatrist (GRP), yet also by drawing on collaborative expertise, as its findings were discussed in the overall collaborative research team.

Sampling and recruitment

Participants in both the QUAl1 and QUAL2 phases were recruited with the assistance of the primary peer support work training network in Germany, EX(perienced)-IN(volved), and from smaller peer support organizations and projects such as EUTB, Lebensart Münster, and UPSIDES. Information on the study was also disseminated on social media platforms dedicated to peer support-related topics to broaden the pool of recruitment. A total of 57 participants, comprising 32 PSWs, 19 MHWs, and six service users, were recruited for the QUAL1 phase. Given the research focus of the QUAL2 phase on MHWs’ attitudinal changes, eight representatives from this group were recruited to implement both interviews and a focus group. Four of them were also participants of QUAL1. The remaining QUAL2 participants were selected using a combination of snowball sampling and purposive case selection. Participants were not informed of the study prior to the invitation. Information about the research team was provided in the invitation and at the beginning of each interview and the focus group.

Data collection and analysis

Details of the data collection and analysis can be found in the methodological publications mentioned above [53]. The QUAL1 phase was conducted from 1^st February to July 30, 2021, and the QUAL2 phase from 1^st September to December 15, 2022. To facilitate a dialogical interview setting, the interviews of QUAL1 were conducted in pairs, comprising two team members: one with and one without lived experience. Interviews of QUAL2 were conducted by one interviewer (GRP), except for the focus group, which was accomplished in pairs (GRP and MK). Interviews took place online due to the COVID19 situation and had an average duration of one hour. The interviews were recorded, transcribed, and analyzed iteratively by a single team member and by the entire research group. Based on the central themes and questions that emerged during this QUAL1 phase, an interview guide was developed for the QUAL2 phase, including the main and sub-questions, such as: What does the implementation of PSWs in psychiatry means for you? What do PSWs contribute to the understanding of psychiatry? What is the PSWs’s understanding of psychiatry and mental illnesses? Do PSWs contribute to paradigm changes in mental health? (S2 File—Interview guide).

These and other questions served to implement five interviews and one focus group by GRP, supported in the case of the focus group by one researcher with lived experience (MK) who also helped with the recruitment and data analysis. No other participant was involved in the assessments. Both the interviews and focus group took place online and were recorded, transcribed, and analyzed both inductively creating new codes and deductively using some codes from the QUAL1 phase, thereby using a modified version of thematic analysis adapted for collaborative research [54]: first, the QUAL2 material was coded inductively. The emerging codes were merged with suitable codes from the QUAL1 phase code tree (S1 File–Code system), and the transcripts of both the QUAL1 and 2 phase were recoded. Data were managed and analyzed using MAXQDA software. Based on the merged code tree and the discursive process carried out between the members of the collaborative research team, thematic analysis was completed, organizing the main codes and subcodes in thematic groups. Transcripts and codes were not returned to the interviewees. In this paper, only the codes that refer to the changes in attitudes of MHWs are presented, and other parts of the analysis will be presented in subsequent papers. We understand attitude as the disposition to evaluate and/or, afterwards, act according to this evaluation in a certain way in response to a specific event, which is influenced by past experience, is not necessarily conscious, and generally serves as the way each person deals with reality and its immediate future. Therefore, attitudes may not be interpreted as perceivable behavior resulting from particular situations but primarily as an axiology, that is, as a personal set of values intervening in and evaluating the situation from this determined standpoint. The theoretical background of our concept will be presented in the framework text (in review).

The “What”: PSWs’ impact on MHWs’ attitudes

The “How”: how are these changes brought about?

What is changing?

The existing body of research demonstrates that PSWs have a favorable influence on treatment outcomes [10]. However, as previously noted in the introduction, the specific impact of PSWs on the attitudes of MHWs and the broader institutional culture has not been specifically explored.

Most of our results suggest that the presence of PSWs may encourage a greater recovery orientation among MHWs, a finding consistent with other studies [8,55] and reviews [30,40]. Thus, the MHWs in our study report that working with PSWs makes them pay more attention to the contextual aspects of the users’ lives, which are often overlooked. Users’ experiences of mental crises have become more important to them. In this context, Gillard used the term “body of practice” to frame this kind of impact of PSWs on mental health care teams, thereby increasing their skills [25]. Thus, being better able to understand the user’s experience, MHWs may acquire a perspective of care that goes beyond a mainly diagnostic gaze, instead focusing more on a person’s life context. Moore et al. refer to something similar when they talk about “the ‘little’ things” that PSWs are able to give voice to – aspects that are important to users that are easily overlooked [43].

Another outcome concerns the communication and use of language by MHWs. In our interviews, the presence of PSWs motivated more cautious use of language, leading to a more appreciative and less stigmatizing manner. This not only refers to situations with users but also to situations in which MHWs communicate with each other, in which the vocabulary used usually tends to be less carefully chosen. The language was changed and became less technical, as described by Hollway et al., adding that such a technical language usually serves as an emotional barrier against users, as a kind of defense mechanism on the part of MHWs [56]. In an alternative interpretation, the use of managerial or medical language by MHWs is a symbolic scenario that reflects power dynamics in a discursive manner [57]. In our interviews, MHWs’ ‘technical’ ways of thinking and speaking were perceived as a means of maintaining the distinction between ‘them and us’ or ‘sick and healthy,’ potentially resulting into a lack of engagement with users or their exclusion [43]. In this way, the presence of PSWs seems to improve communication with users, promoting better mutual understanding, a finding that has also been presented by Eassom et al. [45] and other researchers [46].

Another result that leads to greater recovery orientation in professional teams is greater flexibility when using diagnostic categories. However, we did not find this aspect in the literature. With this, some participants tried to compare situations with and without PSWs, where in the latter, many diagnoses tended to be considered static or fixed. On the other hand, PSWs are an example of how, on the one hand, diagnostic categories evolve and that users are not only defined by the symptomatic deficits that define them; on the other hand, they serve as hope-givers for users and professionals, as they represent a history of recovery. Finally, these changes in attitude can lead to institutional changes beyond individuals. A more recovery-oriented institutional culture can be a favorable environment that allows MHWs to gain more insight into their own affectedness. As described by Byrne et al., PSWs can motivate disclosure regarding their own questions in relation to the well-being and psychological crises of professional staff [50]. This again clashes with the usual position of professionals who traditionally stand on one side of the divide vis-à-vis users, who are the ones who are affected by mental problems. As discussed earlier, a greater culture of disclosure has the potential to loosen this divide [49].

Various authors have demonstrated that the implementation of peer support work highly depends on how PSWs and other MHWs relate to each other, understanding the success or failure of peer support implementation as emerging from a complex interplay of power imbalances between these professional groups [47]. In this context, as stated above, medicalized attitudes based on the predominance of fixed diagnostic categories and psychopharmacological approaches seem to be a dominant obstacle to mutual understanding between them and PSWs [21,23]. Thus, the change in attitudes of MHWs is pivotal to the implementation of peer support work, opening up the dilemma of when these changes must occur to make this implementation happen, a dilemma that will be further detailed in the concluding section.

How change happens?

Our findings show that MHWs’ attitudes typically undergo transformations due to reflective processes that follow their interactions with PSWs. Our research uncovered three ways in which these reflections occur: initially, the mere “physical presence” of PSWs appears to trigger change, as also described by some participants in Moore et al.’s study [43], who reflected on uncomfortable emotional responses on the occasion of PSW’s “simple physical presence”. This process may occur explicitly or implicitly so that changes may also occur without the individual being consciously aware of them. Second, our study participants cited a “role-modeling” function for PSWs, which also led to imitating PSWs’ approach to users. Although the literature usually emphasizes this function only in relation to users of mental healthcare services, it also holds true for MHWs [25,58]. Krumm et al. also found this point reported directly from MHWs [32]: PSWs exemplify a specific attitude or approach, and MHWs adopt this style into their own repertoire. Third, PSWs appear to elicit attitudinal changes in MHWs through direct explicit forms of feedback or critique. The literature indicates that PSWs do not necessarily have to say much, as their hybrid role - as former users employed in mental health care teams - already challenges the usual routines to a considerable extent [51]. In accordance with our findings, other studies describe this function as “corrective,” which may trigger resentment and other strong emotions among MHWs [52]. As a result, PSWs often have to contend with disinterest, stigma, rejection, ignorance, and discrimination from colleagues.

We argue that MHWs’ attitudinal transformations are rooted in reflexive processes. As indicated by our research and other studies [41], the successful implementation of these changes requires openness and willingness to change on the part of MHWs. Consequently, MHWs who are open to collaborating with PSWs are typically more open to altering their prior perspectives on mental health care, particularly their role as a ‘repairer’ of biological disruptions. It appears that this mindset is more common among MHWs who are more open to their own experiences of crisis and/or recovery [20]. Our study also highlights these interactions and the role of self-criticism in facilitating change: some MHWs criticize the current system, perceiving the implementation of PSWs as a further step toward a larger transformation towards a more recovery-oriented mental healthcare system [21]. A risk that should be mentioned here is that in institutions where resistance to attitudinal changes is greater either because of little experience with PSWs or because of a greater weight of the medical model, PSWs may end up integrating into the traditional structure and adapting to it, thus reinforcing the power structures based on this medicalized model [59].

Consent for publication

All participants provided formal consent and approved participation and publication of the results.