Watson, Emma
(2020)
‘The system is mad making’: peer support and the institutional context of an NHS mental health service.
PhD thesis, University of Nottingham.
Abstract
In the past decade, peer support has become a common feature of mental health service provision, both in third sector organisations and in statutory mental health services. Most NHS mental health services now employ peer support workers, who use their lived experience of mental distress and recovery to build supportive relationships based on shared understanding, and to offer hope to people using services. Research suggests that the introduction of peer workers can benefit people receiving services, the peer workers themselves, and the teams/services that they are employed within, as peer workers positively influence the culture of mental health services. Despite research interest in the potential of peer support to transform services, the introduction of peer support workers into formal mental health services has been met with criticism from those who believe that psychiatric conceptualisations of mental health are at odds with its philosophy. In addition, little is known about how peer support brings about the outcomes it has been found to, and what gets in the way.
The aim of this research was to develop an understanding of the process of offering peer support in an NHS context using the experiences of peer workers, as well as my own experiences of working in a peer support leadership role in this setting. This study drew on feminist standpoint theory, survivor research epistemologies and critical realism to inform its epistemological and methodological approach.
Eighteen peer workers from Nottinghamshire Healthcare NHS Foundation Trust were interviewed and their transcripts were studied repeatedly during in-depth analysis, which first coded each transcript, before combining the codes across transcripts to identify emerging patterns and points of divergence. In addition, I used my own auto-ethnographic reflections in my role as peer support development lead as data. Findings are presented creatively, in the form of constructed conversations between peer workers, as well as single narratives, diary entries and creative non-fiction. These devices have been used in order to evoke for the reader a sense of the experience of working as a peer worker within an NHS setting.
The study argues for a shift in focus away from peer workers, and onto the context that they are employed within. It highlights how the institutional context of NHS mental health services contributes to a construction of a specific peer identity which both empowers and stigmatises peer workers. Peer workers described their experiences of building valuable peer to peer relationships, but in the context of the wider system, these were reported to be inconsistently respected, as were the peer workers themselves. There were frequent examples of the structural powerlessness of peer workers, including their low pay and lack of opportunities to progress, as well as difficulties created by the ongoing austerity agenda across mental health services. Despite this, peer workers described their hopes to be a part of a wider change within the NHS, as well as acts of resistance and self-preservation which contributed to this. The culture of NHS mental health services does need to change, but this requires collective and concerted effort in a range of contexts and levels, and should not be the task of individual peer workers who have little power within the wider systems and structures.
The study furthers the understanding of how mechanisms within the medical, hierarchical context of mental health services, underpinned by neoliberal economic models impacts peer workers and their work of peer support, which is an under-explored area of peer support research.
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