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The presence of peer workers in multi-disciplinary environments has rapidly increased in recent years, yet the impact of peer work on other mental health roles is largely unknown. This article explores the presence of peer workers within multi-disciplinary environments, with a specific focus on the possible impact of this presence on the culture of disclosure for mental health professionals with lived experiences of mental health challenges. Semi-structured focus groups and interviews were conducted with 132 participants at five organizations across the United States. Participants self-identified as being employed in a range of roles including management, mental health professionals, designated peer workers, and designated peer leadership positions. Findings suggest intentionally employing peers and using peer values to address stigma toward mental health professionals improves the culture of disclosure. In work environments where peer-led initiatives were featured, mental health professionals felt safer disclosing their own lived experience to their colleagues and supervisors. Recommendations include the use of parallel strategies to promote the perceived value of peers and to implement peer-led training for both supervisors and professionals to model a workplace culture that promotes and supports self-disclosure in the organization. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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To Disclose or not to Disclose? Peer Workers Impact on a Culture of Safe Disclosure for
Mental Health Professionals with Lived Experience
Louise Byrne1, 2, Helena Roennfeldt1, Larry Davidson2, Rebecca Miller3 and Chyrell
1 School of Management, College of Business and Law, RMIT University
2 Program for Recovery and Community Health, Dept of Psychiatry, School of
Medicine, Yale
3 Connecticut Mental Health Center, Dept of Psychiatry, School of Medicine, Yale
The presence of peer workers in multi-disciplinary environments has rapidly increased in
recent years, yet the impact of peer work on other mental health roles is largely unknown.
This paper explores the presence of peer workers within multi-disciplinary environments,
with specific focus on the possible impact of this presence on the culture of disclosure for
mental health professionals with lived experiences of mental health challenges. Semi-
structured focus groups and interviews were conducted with 132 participants at five
organizations across the United States. Participants self-identified as being employed in a
range of roles including management, mental health professionals, designated peer workers
and designated peer leadership positions. Findings suggest intentionally employing peers and
using peer values to address stigma towards mental health professionals improves the culture
of disclosure. In work environments where peer-led initiatives were featured, mental health
professionals felt safer to disclose their own lived experience to their colleagues and
supervisors. Recommendations include the use of parallel strategies to promote the perceived
value of peers and to implement peer-led training for both supervisors and professionals to
model a workplace culture that promotes and supports self-disclosure in the organization.
Impact statement
Mental health stigma impacts people employed as mental health professionals. Fear of
disclosing lived experience of mental health challenges to colleagues or supervisors poses a
risk to mental health professionals seeking help when needed. Peer roles can be used to
facilitate the creation of safe spaces for mental health professionals to disclose their own
lived experiences; and in turn may also increase the perceived value of peer workers to
mental health professionals. These strategies may contribute to decreasing stigma,
contributing to safer workplaces for mental health professionals and ultimately, more
effective, appropriate services for users.
Keywords: self-disclosure, disclosure, mental health professionals, peer work, stigma,
organizational culture, systems transformation
To Disclose or not to Disclose? Peer Workers Impact on the Culture of Disclosure for
Mental Health Professionals with Lived Experience
While disclosure of relevant lived experience by professionals in the field of
substance use has a long history, disclosure by mental health professionals has generally been
more fraught, influenced by the ‘blank slate’ idea in psychoanalysis as well as by the
continuing prevalence of mental health stigma (Byrne, Roper, et al., 2019; Frese & Davis,
1997; Nemec et al., 2015). Yet, this issue of disclosure, particularly to colleagues and
supervisors, is significant given that mental health professionals are no less likely to
experience mental health challenges (Edwards & Crisp, 2017) and evidence suggests that it is
often these experiences of mental health challenges that draw professionals to work in this
field (Barnett, 2007; Farooq et al., 2014). In contrast, the growing peer workforce in mental
health, for whom disclosure and the use of personal experience is an explicit part of their role,
(Mead et al., 2013), draws the issue of disclosure by people working in mental health into
high relief.
Frese and colleagues discuss experiences working in the mental health field and also
carrying a diagnosis of mental illness (Frese et al., 2009). Similarly, here are well known
figures (e.g., Deegan, Fisher, Bassman, Linehan) who have shared their experiences in the
mental health system and developed, particularly in Deegan’s case, a career creating tools to
promote better access to recovery-oriented services (Deegan & Affa, 1995; Deegan et al.,
2017). However, their openness and use of personal experience is the exception rather than
the rule.
Much has been written about self-disclosure by therapists within the therapeutic
relationship (Hill et al., 2018; Knox et al., 1997). Here, self-disclosure is defined as the
sharing of personal information by the therapist and is distinguished from immediacy
statements; reactions or feelings in the moment, which are considered a more common and
simpler use of disclosure (Knox & Hill, 2003). Therapist self-disclosure is viewed as a
facilitating factor in some instances, making the relationship feel more mutual, and a
hindering factor in others, especially when there is role confusion generated by personal
disclosure (Audet, 2011).
These experiences are also dependent on the extent of and perceived intention behind
the disclosure (Farber, 2006; McCormic et al., 2018). Although a high percentage of
psychotherapists acknowledge using self-disclosure with their clients, few openly talk about
the practice with colleagues (Harris et al., 2016; Henretty & Levitt, 2010). This has been
described as a culture of “don’t ask, don’t tell” (Psychopathology Committee of the Group for
the Advancement of Psychiatry, 2001). Subsequently, the disclosure of mental health
professionals’ ‘lived experience’ to colleagues and supervisors is a much less commonly
discussed, researched or written about topic.
Mental health professionals have been shown to be reluctant to disclose their mental
health experiences to colleagues (Gras et al., 2015; Harris et al., 2016). The “culture of non-
disclosure” characterized by one survey study of Veterans Health Administration (VHA)
providers, described fear of discrimination on the part of providers if they disclosed lived
experience (Harris et al., 2016). Another survey of 77 providers with lived experience in the
VHA found 36% endorsed “be cautious about disclosure” when asked, and about a third of
the sample reported that none of their colleagues were aware of their lived experience (Boyd,
Zeiss, et al., 2016).
The gatekeeping function of psychologists’ ethics code, which requires psychologists
to report on other psychologists and identify ‘impaired professionals’, creates a significant
barrier to disclosure (Boyd, Graunke, et al., 2016; Zerubavel & Wright, 2012). Many state
statutes require contact with the mental health system by mental health professionals to be
documented and reported to the licensing board (Boyd, Graunke, et al., 2016; Virginia State,
n.d.). This is similarly identified by an Australian cohort of mental health professionals, who
indicated legally mandated reporting requirements as a barrier to accessing mental health care
for themselves (Edwards & Crisp, 2017). These kinds of statutes, that make self-disclosure a
potential threat to one’s livelihood, stand as a deterrent to self-disclosure by mental health
professionals in mental health and a potential barrier to help-seeking by contributing to
stigma (Sandhu et al., 2019; White et al., 2006).
While limited research has been conducted into mental health professionals with lived
experience disclosing to colleagues, the concept of the “wounded healer” (Zerubavel &
Wright, 2012) has been more thoroughly explored. One study looking at the wounded healer
found therapists with unprocessed or unacknowledged wounds were likely to engender
relationships in which their stance was more pathologizing of the person accessing services
and promoted a more ‘us-them’ stance (Gelso & Hayes, 2007) with the therapist regarded as
being “healed” and the service user in need of healing (Zerubavel & Wright, 2012). This is
very different from peer support, which promotes mutuality as a key tenet (Mead et al.,
While therapists with undisclosed lived experience did draw upon the experience to
inform their work (without actually disclosing), they were unable to use this experience in a
way to educate others or advocate via role modeling (Zerubavel & Wright, 2012). By
extension, mental health professionals are not provided with guidance on how to use their
experience appropriately or effectively for the benefit of service users. The idea of having
come to terms with one’s own experience enough to draw upon it without it interfering in the
therapeutic work is something that is seemingly a “know it when you see it” phenomenon and
deserving of further consideration (D'Aniello & Nguyen, 2017; McCormic et al., 2018).
Although readying an organization to be open to peer work is more well-documented
than creating a culture of safe disclosure for providers, Welder & Salzer (2016) identify
several steps for encouraging agencies to become more accepting and welcoming to mental
health professionals who are not in designated peer roles. These include identifying policies,
confronting the issue directly, and educating staff and supervisors. Specific strategies include
enhancing employee wellness programs, ensuring health insurance parity, training
supervisors in how to respond to and support the person, and other steps specifically geared
to creating a welcoming culture in the institution (Welder & Salzer, 2016).
Research specifically exploring the influence of peer roles in creating a culture of
disclosure has been absent from the literature. The aim of this study was to better understand
the employment of peer workers in multi-disciplinary environments. Due to the accepted role
of peers in reducing stigma for mental health service users and the prevalence of peers within
participating organizations, it was hypothesized that mental health professionals with a lived
experience would feel enhanced confidence to disclose their experiences. This paper explores
the impact of a peer workforce on the disclosure of lived experience by mental health
professionals and strategies that assist in encouraging disclosure.
In the context of this paper, the term ‘multi-disciplinary environments’ is used to
denote organizations in which people from a variety of disciplines are employed, including
both peer-designated and non-peer designated roles (e.g., psychologists, mental health nurses,
psychiatrists). The term ‘mental health professionals’ is used to describe people employed in
non-peer designated mental health roles. This language choice does not suggest that peer
support is not a discipline in its own right, but simply uses common parlance for broad
identifiability. The term ‘peer leadership positions’ is used to describe people in designated
roles that utilize their lived experience as core to their role and are part of the management
structure of the organization. People in peer leadership positions would be expected to
disclose their lived experience as a central qualification of the role. Finally, participants’
experiences of ‘safety’ or feeling ‘safe’ describe being supported rather than discriminated
against when/if they disclose having a lived experience of mental illness.
The study included five diverse multi-disciplinary organizations within five states of
the United States. Location of states included two in the northeast, one in the south, and two
in the west. Organizational types included: one county-run behavioral health division, one
behavioral health within a managed care fund, one privately owned behavioral health
organization, and two non-profit organizations. Included were a range of organizations who
worked predominantly with people from metropolitan, regional, or rural and remote
locations. Participant numbers across the five sites were distributed as follows: 31 at
organization one, 27 at organization two, 31 at organization three, 23 at organization four and
20 at organization five.
To ensure no inadvertent identification of organizations, the order in which
organizations are described in reporting does not correspond with the order of organizational
types preceding. The states in which organizations are based are also not mentioned in
A total of 132 people from different work roles participated, including: 32 people
employed as mental health professionals, 47 in management positions (not peer designated),
7 in peer-designated leadership positions, 38 in peer designated positions (not management),
and 8 other or unspecified.
People were given the option to identify as male, female, transgender or ‘don’t wish
to identify’. Of the 129 people opting to fill in the demographic, the majority of people
identified as Female (n=84) with around half that number identifying as Male (n=41), and a
small percentage selecting ‘Don’t wish to identify’ (n=3) and Transgender (n=1).
Race and ethnicity were separate on the demographic, with the question regarding
race appearing first on the form. However, all the people identifying as Hispanic added
‘Hispanic’ to ‘other under the question of race. To reflect participants understanding and way
of viewing, race and ethnicity have been reported together. The vast majority of participants
(n=88) identified as Caucasian American/White. Additionally, 15 people identified as African
American/Black One, 10 as multiracial, seven as Asian, six as Hispanic, two as Native
American and one person identified as a Native Hawaiian/Pacific Islander.
Broad initial questions were developed for the focus groups and interviews, relating to
the functions of the peer role, individual worker experience and organizational culture.
The broad initial questions were: what defines peer work, how are peer workers employed at
your organization, what in your opinion allows peer workers to be effective in their roles,
what organizational/practical strategies do you think aids employment of peers?
An expert advisory group (n=12) was convened and consulted to identify appropriate
multi-disciplinary organizations to better understand the employment of peer workers in
multi-disciplinary environments. The advisory group included both peers and ‘allies’: people
in non-designated positions who understand and champion peer work. Advisory group
members were selected to represent a range of relevant perspectives and included researchers
as well as industry representatives and funders. Advisory group members were well known
nationally for their commitment to and expertise in peer workforce development and came
from diverse states across the United States. The advisory group included people from
diverse cultural backgrounds and identifications.
Advisory group members nominated numerous multi-disciplinary organizations
employing peers. Organizations nominated most frequently were approached to be invited to
participate in the study. Letters confirming participation were signed by the executive
management of each organization prior to commencement. Initial questions were also
determined in consultation with the advisory group. In line with grounded theory methods,
the list of questions was expanded and refined as concepts were frequently raised by
participants. The study utilized a qualitative approach, conducting focus groups and
individual interviews, and employed grounded theory methods to allow for exploration of an
area about which little is known (Corbin & Strauss, 2014). Grounded theory methods were
also employed to best represent the experiences of those who have had limited ‘voice’
(Charmaz, 2014), in the case of this study, peer workers and mental health professionals with
lived experience. Both interviews and focus groups were semi-structured. In line with
grounded theory methods, questions were deliberately broad to allow participants to raise
issues they saw as important, and the same initial questions were asked at the beginning of
each focus group and interview (Birks & Mills, 2015).
Separate focus groups were organized and conducted at each site for participants in
the different categories of mental health professionals, management, and peer designated
roles. Most interviews were face to face, with one interview conducted via video call. All but
one focus group was face to face, with one conducted via video conference using the same
procedures. Staff participants in each of the selected organizations were given the option to
attend an individual interview and/or focus group. From the five organizations participating
in the study, eight people chose to participate in an individual interview and 124 participants
attended focus groups. A total of 14 focus groups were conducted.
IRB approval was granted by Yale University. No compensation was offered for
participation; all participants provided written informed consent prior to participation,
including the right to withdraw without penalty at any stage. To preserve confidentiality,
participants were offered private, one on one interviews in addition to focus groups. Focus
groups and interviews were audio recorded. There were no pre-existing relationships between
the research team and participants, and no relationships of unequal power such as
client/patient, student, or subordinate.
To protect against identification of participants or organizations in reporting, all
transcripts from audio recordings were de-identified and coded before analysis began. All
potentially identifiable data was substituted by codes. The coded information was stored
separately from identifiable material and kept in locked, password protected files. The data
remain stored in locked, password protected files until five years after the last date of
publication. The data was stored and managed using QSR International’s NVivo 12 software,
However, all coding was manual. Transcripts were coded by a member of the research
team who had not participated in the data collection. In line with grounded theory methods,
‘open’ line by line coding was first conducted. Codes were then compared relationally and
clustered to identify key concepts (Corbin & Strauss, 2014). Once coding was complete, key
concepts were compared with detailed researcher memos from the site visits. The two sources
were used to refine and confirm key concepts and themes.
Three main categories emerged from the results in relation to disclosure of mental
health professionals: Lived experience within work roles, Workplace Culture, and Role
Clarity. Each category included several themes as detailed in Table 1. Table 1 also provides
some explanation of the themes as well as a breakdown of in how many of the sites themes
emerged and the number of endorsements of each theme per organization. Table 1 includes
the abbreviations: LE to denote lived experience and MHP for mental health professionals.
[Insert Table 1 about here]
Clarity on the role of peers and the perceived value of peer roles was variable across
the organizations. Two of the organizations expressed consistent understanding and high
perceived value for peers across all cohorts of management, mental health professionals, and
designated peer positions. Three of the organizations were more varied across these cohorts
in terms of understanding the functions of peer roles and the value they attached to the roles.
Of interest, mental health professionals at organizations possessing the highest,
unanimous perceived value for peers predominantly still reported not feeling confident or
safe to disclose their own lived experience in the workplace. Conversely, mental health
professionals at two of the organizations with inconsistent views on the perceived value of
peers felt actively empowered to share and even utilize their lived experience. The fifth and
final organization held inconsistent views across cohorts, but mental health professionals
reported not feeling confident to disclose. In this instance, the priority placed on hiring and
integrating peers was considered by some mental health professionals to have hindered
creating a culture in which they might feel safe to disclose.
Table 2. provides a comparison of the different organizations in relation to
understanding and perceived value of lived experience broadly; designated peer roles; and
disclosure of lived experience by mental health professionals.
[Insert Table 2 about here]
In the following section the results have been grouped specific to each organization to
assist in describing the unique culture and priorities within each organization. The
descriptions of the results are drawn directly from and describe or paraphrase the interview
and focus group responses. At times, direct quotes are included to illustrate the themes and
provide an example of the participants’ experiences in their own words.
Organization One
Of the five organizations, Organization One had the strongest consensus from all
cohorts as to the role, function and definition of peer support work. This organization held the
highest perceived value for peer workers across all the categories of respondents, as well as
across demographics such as race and gender. The organization also had the highest level of
satisfaction with peer work from all job roles. There were a multitude of ways in which peers
were employed within this service, with more expansion planned.
This organization had significant peer leadership, with people in designated peer roles
at various levels throughout the organizational hierarchy. Executive management was
personally and professionally committed to the continued development of the peer workforce.
This organization had thoroughly resourced peer work, making a significant financial and
philosophical commitment. This organization also had peers employed over the largest
variety of programs.
However, people in mental health professional roles often still felt unwilling to
disclose or use their lived experience. Some of this reluctance was attributed to adverse
reactions from people accessing services, when disclosure by the therapist had been made
after the relationship had existed for some time. There were reports of people accessing
services feeling ‘betrayed’ that the lived experience of the mental health professional had not
been shared earlier. Further, mental health professionals shared the opinion that people
accessing services preferred different types of relationships, and in the context of non-
designated roles, preferred the stronger boundaries with people in ‘traditional’ roles:
I think someone with lived experience in a traditional [mental health professional]
role is extremely valuable but it doesn’t mean that they should cross outside of the
same kind of bounds or job description… There’s a reason those were developed,
there’s a healthy model for the person that you’re engaging with. If as the clinical
person, I keep within this box and you can expect that of me and that’s a professional
safe relationship and then when you have a peer relationship it is modelling the more
natural support in a person’s life… if they came to the professional support and got
the personal [peer] support it would be really confusing… it’s different, it’s just a
strange setup versus the more natural role that a peer can provide (Organization 1.
Focus Group: Mental Health Professionals).
For other mental health professionals, a fear of stigma meant they did not disclose to
colleagues or access help when needed:
I’m not gonna tell you because I’m afraid to tell you, because I’m wearing this
clinical hat and really what I’m doing is really struggling to survive and I’m not
willing to say that out loud to anyone because of the stigma around it (Organization 1.
Focus Group: Mental Health Professionals).
This was partially explained by inadequate or unhelpful organizational responses that actively
discouraged mental health professionals from disclosing, with at times tragic consequences:
I’ve known more traditional providers who have had mental health breakdowns
because of the lack of support and their fear of reaching out. I’ve known two over the
years who have completed suicide because they didn’t have anywhere to get the
support. Because even using their employment assistance program, or their own
health insurance…they don’t want to go and get help in that community because of
fear of people knowing (Organization 1. Focus Group: Mental Health Professionals).
Organization Two
Organization Two had the least consensus on understanding the role of peers. There
were the fewest peer participants in the research and the need for peers was variously
interpreted by different individuals and cohorts. Traditional management participants at this
organization expressed the least understanding of designated peer roles. There was also some
confusion for traditional management and mental health professionals as to how ‘peer
employment’ was defined. While it was more difficult to gain data on peer work in this
organization, there was a strong commitment to lived experience more broadly. This site
emphasized extremely long retention of management, which may or may not have played a
role in the priority on lived experience of mental health professionals, as opposed to peer
roles. Despite mixed views on the value of designated peer roles, expansion of peer roles was
progressing with new roles commencing soon.
This organization was described by all cohorts (management, mental health
professionals, and peers) as a ‘family culture’. It was designed to be open, welcoming and
accepting of difference. Executive management at this organization played a visible role in
contributing to a culture of safe disclosure.
…we have in our lives and our family folks with lived experience, why would it be
any different in our company culture? … Culture is very important; a healthy culture
is very important to the work we do. And part of my job that I see here is I’m a keeper
of the culture (Organization 2. Interview: Traditional management).
Many non-peer participants including mental health professionals and corporate staff spoke
enthusiastically about how they felt safe to discuss their own lived/living experience and to
use it in their roles:
It says a lot about a company when you feel open enough to come to your supervisor
and just be completely and blatantly open with what’s going on with you in your life
(Organization 2. Focus Group: Mental Health Professionals).
These participants expressed gratitude that they could be open about their lived experience,
gain support, and even be valued more highly because of their lived experience. This was a
consistent message across focus groups and interviews. However, it was also acknowledged
that lived experience was still not valued the way formal education was valued, which may
have been related to the lack of peer workforce development at this organization.
Overall, peers did not appear to have as strong a presence within this organization;
however, two of the prominent strategies to encourage the workplace culture of disclosure
were peer-led. Peer leadership roles had been employed for some years and assisted in
reducing stigma by providing training acknowledging that everyone has a lived experience
and how to use this lived experience in relationships with people accessing services. This
organization had also provided external peer-run training on identifying lived experience,
which participants felt had challenged the idea of ‘them and us’ between professionals and
service users. Some mental health professionals were passionately in support of peer work
because of participating in the training:
I’d always seen the peer as something that … there’s a client and then there’s us. You
know, there’s the staff and the client. But after going through that class and putting
myself in their shoes and trying to find my story, and listening to the stories, I find
that we all have a lived experience and we all have a recovery story within us
(Organization 2. Focus Group: Mental Health Professionals).
Organization Three
Organization Three, despite being a long-term employer of peers, had varied views on
peer work from mental health professionals, management and peers. Managers viewed the
peer presence as strong and positive, and largely defined peer work in a way that is consistent
with the literature. However, there were diverse views from people in non-designated roles,
management, and peers as to the need for designated roles and the value of peer work to the
Management spoke about the desire to decrease stigma by encouraging people in non-
designated roles to disclose their lived experience. Many mental health professionals felt
comfortable not only to disclose in the workplace, but also to use their lived experience in
relationships with service users. While most expressed the value of still having designated
peer roles, some shared a belief their own use of lived experience made designated peer roles
less needed:
…it doesn’t necessarily have to be peer designated in order to be something that’s part
of the job and part of what makes somebody a good worker, regardless of the
designation of whether it’s peer… I don’t see people running around saying like “hey
I’m peer designated and hey I’m not peer designated” (Organization 3. Focus Group:
Mental Health Professionals).
Similarly, several traditional management participants were unclear on how necessary
designated roles were, but also acknowledged potential challenges with professionals sharing
their lived experience with people accessing services:
I think sometimes too if you’re not in a peer designated role and you do disclose
things; that can cause tension between you and the person [accessing the service]
(Organization 3. Focus Group: Management).
Mental health professionals mirrored these concerns and described both positive experiences
disclosing their lived experience, and times when the person accessing the service felt some
betrayal that the provider had been ‘hiding’ their lived experience.
Despite the strong emphasis on lived experience within this organization, for some
participants in non-designated roles there were still experiences of being stigmatized because
of disclosure:
I very recently had someone be like “well you’re sick and you can’t do this and I
don’t know why you thought you could do any of this, like you’re mentally ill” …
and then you feel less confident in the services you’re providing… It’s always kind of
a gamble (Organization 3. Focus Group: Management).
While the value of peer work was promoted by traditional management and mental health
professionals, peers were vocal about feeling unsure of their place in the organization. Peers
were not always confident that use of lived experience by mental health professionals was
effective and questioned the efficacy of combatting stigma with disclosure that could be
‘turned on and off’. Other peers were supportive of mental health professionals using their
lived experience but held concerns when this was not guided by peers.
Like Organization Two, new peer roles were still being developed, with many new
roles commencing soon. Also, like Organization Two (the only other site where lived
experience seemed to be prioritized above peer work), Organization Three boasted
particularly long retention of executive management, which was highlighted in both focus
groups and interviews. Although the mental health professionals at this site felt confident and
supported to disclose and utilize their lived experience in work roles, unlike the management
participants, they reported high turn-over and low retention.
Organization Three did have strong peer involvement from inception of the
organization and strong peer influence in earlier decades. Reportedly peers were involved
within the organization before peer credibility had developed, at a time when the emphasis on
lived experience rather than designated peer roles was seen to ‘protect’ people from the
potential stigma of being identified publicly. Some participants felt this belief had persisted
and encouraged the emphasis on lived experience generally, rather than designated peer roles
specifically. As with Organization Two, stigma reduction involved peer-led training focused
on acknowledging that everyone has a lived experience and how to identify and use lived
experience to create connection with people accessing services.
Organization Four
This site corresponded most to Organization One. The basic premise of what peers do,
and their perceived value was consistent across the three cohorts – significantly more so than
Organizations Two, Three and Five. Mental health professionals here were enthusiastic about
the benefits of peers both to people accessing services and themselves. Professionals at this
site defined peer work accurately and with passion. They were vocal in defence of peer work
and the benefits to organizations, people accessing services and themselves as a result of peer
Of interest, like people employed in non-designated roles at Organization One, there
was little disclosure of lived experience from mental health professionals at Organization
Four. Here though, the reasons focused more on the continuing prevalence of stigma and
discrimination and less on the needs and preferences of people accessing services. Mental
health professionals at Organization Four largely felt that being able to disclose and even use
their lived experience would benefit people accessing services but stated there was a long
way to go before they would feel safe to do so.
The role of supervisors in encouraging disclosure in the workplace was strongly
emphasized by mental health professionals at this organization.
It depends on who your supervisor is. I had one I would not tell him any sort of
anything. Not even like if I’m dying sick, I will show up but not tell him I’m dying
sick, versus the new one that I have, I can be open and it’s okay. But it all depends on
who is at the end of the rope (Organization 4. Focus Group: Mental Health
I have to just say this. And, people in my team will relate. We have like one of the
best supervisors ever. Because she... not only does she empathize, she empowers us. I
mean, she listens. If you say you need two hours, take it. You know, she wants you to
take care of yourself… And it’s wonderful. You don’t have that every day so when
you do, you say hallelujah, thank you Jesus (Organization 4. Focus Group: Mental
Health Professionals).
Organization Five
Management and peers at this organization had strong consensus and high levels of
satisfaction. People in non-designated roles were not as unreservedly enthusiastic and offered
both positives and negatives in their views about the impact of peer designated roles. This
organization had made a significant commitment to peers, arguably at the expense of mental
health professionals. One mental health professional described a program that had existed
some years ago, before the wide-scale employment of peers, in which people in non-
designated roles were offered a safe space to explore their own lived experience and
encouraged via other methods to discuss and gain support. There was a perception this
initiative had disappeared around the time peers became embedded in the organization.
…people were always encouraged which I thought was great, if they had struggles, if
they had lived experience, to be able to talk about that and I think there were actually
opportunities for people to get together and talk about struggles that they’d had
(Organization 5. Focus Group: Mental Health Professionals).
Much like Organization One, Organization Five employed significant peer leadership,
with peers at various levels throughout the hierarchy of this organization. Commitment to
peer work was a ‘given’ and further expansion of peers was cited. Mental health professionals
at this organization felt the peers had significantly more freedom than they did. Mental health
professionals felt they were discouraged from disagreeing with organizational policy and
approach, while peers were encouraged to provide a critical view. Although there was some
dissatisfaction about their own positions, mental health professionals did describe benefits of
peers both to themselves as professionals and to people accessing services. These participants
discussed peers contributing to stigma reduction within services and the wider community, as
well as the self-stigma of people accessing services, but not in reducing the stigma they felt
as professionals within the organization.
Mental health professionals at Organization Five concurred with participants at other
sites that there were risks in disclosing lived experience to service users and similarly raised
the potential for service users to feel betrayal at what was viewed as a lack of ‘transparency’.
Some participants held concerns about how they would be viewed as professionals if they
were to self-disclose.
Would their opinion or view of me change if I share too much… would they take me
as serious? I don’t know (Organization 5. Focus Group: Mental Health Professionals).
Mental health professionals at this site also viewed the attitude of the direct supervisor as
essential to feeling safe to disclose. People in non-designated roles expressed trepidation in
disclosing and were more likely to test the waters and see how the supervisor responded to
less significant sharing of personal/life struggles. The supervisor expressing empathy and
understanding would lead to further sharing. Where a supervisor was willing to talk openly
about their own challenges, participants were much more willing to share. Supervisors
sharing their own lived experience was identified by these participants as the most effective
strategy in building trust.
It was hypothesized that mental health professionals with a lived experience would
feel enhanced confidence in disclosing their experiences to colleagues and supervisors in
agencies where peer work and peer leadership were valued. Although the assumption had
been that employment of peer workers would automatically contribute to a culture of
disclosure for mental health professionals, based on the participants’ statements, this did not
seem to be the case. Further, peer work was not uniformly valued or promoted within these
organizations. Instead, according to the participants’ experiences and views it appeared
organizations had taken an ‘either/or’ approach to the promotion of lived experience: either
strongly committing to the employment and support of peer workers or developing a
workplace culture in which mental health professionals were encouraged to disclose. In the
organizations where disclosure for mental health professionals was reportedly promoted, peer
work was seen to be less understood, embedded or struggling to gain credibility.
In terms of the apparent preference for some organizations to focus on the lived
experience of people in mental health roles at the expense of peer development, the data was
not clear. The role of peer as ‘change agent’ is reported in previous research as challenging
for organizations (Kent, 2018). Some mental health professionals expressed a belief that
everyone should have opportunity to be a ‘dissenting voice’ but they did not feel mental
health professionals had this opportunity, whereas peers did. It is possible that non-designated
roles, bound by greater restriction and mandated activity, produce a workforce that is more
likely to conform than contest (Grendar et al., 2018; Levett-Jones & Lathlean, 2009). Further
research could provide a more understanding of whether people in non-designated roles
provide a less disruptive way for organizations to include lived experience perspectives and
the reasons behind preferences.
With regards to disclosure by mental health professionals, we propose a distinction be
made between mental health professionals using lived experience in relationship with people
accessing services and the right as employees to feel safe to disclose and seek support within
the workplace from supervisors and colleagues. We acknowledge that the former is contested
and as participants described, complicated by numerous factors including the preference of
the person accessing services. Further, mental health professionals’ willingness to disclose
lived experience may be significantly affected by historical prohibitions of self-disclosure to
service users (Jancin, 1999; Psychopathology Committee of the Group for the Advancement
of Psychiatry, 2001).
Prevailing stigma may prevent mental health professionals from receiving the care
they need (White et al., 2006). However, the right to discuss health issues, including mental
health, and to not be discriminated against, is enshrined in anti-discrimination policy
(Americans with Disabilities Act, 1990). Recent studies reveal that only six out of 69
participants were aware of these rights under the disability discrimination legislation and only
three had asked for reasonable accommodations (Kottsieper, 2017). Clear distinctions in the
context of disclosure and anti-discrimination policy support the suggestion that mental health
professional disclosure to colleagues and supervisors should be considered separately from
disclosure to people accessing services. In relation to mental health professionals disclosing
their lived experience to people accessing services, some participant views correspond with
literature arguing for maintaining professional boundaries (Audet, 2011) and included
concerns about how appropriate the disclosure and sharing might be without appropriate
training or guidance.
However, other participants, predominantly mental health professionals, were of the
belief that sharing their lived experience with service users was beneficial. This sentiment is
reflected in a few preliminary studies that suggest possible positive impact on social inclusion
and recovery for people accessing services when mental health professionals are ‘out’ with
their own lived experience (Holttum, 2017). Further, research that explores the differences
between peer and clinical roles and the diverse considerations for each role when considering
disclosure, may provide guidance on what is appropriate in relation to disclosure for the
distinct roles.
While promotion of lived experience disclosure for mental health professionals has
not automatically occurred in these organizations as a result of peer employment, strategies
identified as encouraging an environment in which people feel safe to disclose did include
peer designed and delivered training. Use of peer-led training on identifying lived experience
and how to use it was considered to challenge the ‘them /us’ thinking of some mental health
professionals and contribute to more effective therapeutic interactions. Previous research on
reducing stigma in mental health services similarly found the them/us divide, or
disidentification, was challenged by education that emphasized people across diverse
positions and social roles having a lived experience (Harris et al., 2019).
Considering the contentious nature of provider disclosure to service users, as
indicated by participants, there may be further potential for peers to guide mental health
professionals in the appropriate use of lived experience. The acknowledged expertise of peer
workers in use of personal story supports this notion (Byrne, Roennfeldt, et al., 2019;
Miyamoto & Sono, 2012). Similarly, supervisors sharing their own challenges to engender
trust was raised as a positive factor in facilitating disclosure. By extension, it may be feasible
to utilize peers to create or co-create training for supervisors in how to disclose and use their
personal story effectively and provide support for others in the process of disclosure.
Findings in relation to the loss of dedicated strategies for mental health professionals
at some organizations when peers were introduced, may indicate usefulness in taking a
whole-of-workplace approach to stigma reduction and the perceived value of lived
experience. Similarly, parallel processes promoting disclosure of mental health professionals
and encouraging understanding of the role and value of peer work may benefit both cohorts.
As previous research has identified, peer work is supported and successful when the
organization demonstrates commitment to peer roles and principles (Ibrahim et al., 2019).
This commitment includes: addressing workplace culture and the preparedness of the
organization to accept and value peer work (Jones et al., 2019), the employment of peers in
‘leadership’ roles including management positions (Byrne, Roennfeldt, et al., 2019), and
human resources policies and processes, including recruitment and role descriptions (Byrne et
al., 2018). We propose attention to these issues to improve integration of peers while
simultaneously providing initiatives to create spaces where disclosure by mental health
professionals is supported.
Use of peers in reducing stigma faced by mental health professionals is supported by
the significant body of research on the value of people being ‘out’ of the proverbial closet as
having lived experience (Corrigan & Al-Khouja, 2018; Rüsch et al., 2014). Participants of
this study align with previous research suggesting mental health professionals first seek what
they define as ‘safe’ spaces before disclosing and seeking support within their organization
(Infranco, 2012). Peer support being used to facilitate the creation of safe spaces for mental
health professionals to disclose and gain support may also serve to increase the perceived
value of peer workers to mental health professionals.
Ultimately, it is worth considering: how effective and ‘safe’ are services for users, if
discriminatory beliefs about people with lived experience are still so prevalent that members
of the mental health workforce continue to fear disclosure? Implications for the effectiveness
of service delivery and the well-being of both service users and mental health workers
suggest the usefulness of research to better understand these issues. Several suggestions for
future research have been proposed. Further, it is recommended that future research should
consider a more contextualized, intersectional analysis that examines ways in which lived and
learned identities and experiences of oppression intersect and thus influence or impact the
culture of disclosure. Disclosure or non-disclosure could also be considered in the context of
both individual and collective disclosure and the results of either collective empowerment or
increased stigmatization of lived experience in the workplace.
While this study has a large sample size in terms of the key participants (n=132) it is
limited by a relatively small number of organizations, and to only five states in one English-
speaking country – the United States. Transferability and cultural representation are therefore
limited. Further exploration of the experiences of mental health professionals across a
broader range of countries and organizations, including how disclosure is handled or
received, is needed to deepen understanding of the issues and guide effective strategies for
decreasing stigma.
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Table 1.
Themes and number of endorsements across sites
Category Theme Description Sites that
per site
(LE) within
work roles
Use of LE by
mental health
MHP discussed the strengths of
using LE in their roles as well as
5 Site 1=3
Site 3=10
Site 4=1
Site 5=5
Value of Peer
Peer work was described as having
benefits for peer workers, traditional
staff and people accessing services.
5 Site 1=22
Site 2=17
Site 3=11
Site 4=15
Site 5=19
of lived
Lived experience was considered in
a broader context, not defined by
mental health experience or
designated roles
4 Site 1=3
Site 2=11
Site 3=4
Site 5=2
Stigma The impact of identifying as having
a ‘mental illness’ was discussed and
the associated negative perception.
Experiences of discrimination and
perception of stigmatised identities.
5 Site 1=3
Site 2=3
Site 3=7
Site 4=6
Site 5=5
Peer leadership was described as
leaders who were respected in high
profile positions within the
organization, also links with well-
known and prominent peers outside
the organization
4 Site 1=4
Site 2=2
Site 3=1
Site 4=1
Site 5=2
Safe to
Culture described as feeling ‘safe’,
comfortable and there is acceptance
of lived experience as valued, and
disclosure is supported.
5 Site 1=8
Site 2=19
Site 3=7
Site 4=2
Site 5=10
Openness and
Organizations were described in
terms of openness in sharing
experiences and transparency by
employees and management.
5 Site 1=2
Site 2= 5
Site 3 =2
Site 4=1
Site 5=4
Whole of
education and
Whole of organization training
where staff are exposed to LE
delivered training and LE concepts
was helpful in building trust,
collaborative relationships and
greater understanding.
5 Site 1=5
Site 2=4
Site3= 5
Site4= 3
Site5= 2
Management Commitment, championing and
vision of management was critical to
5 Site 1=8
Site 2=3
establish a positive and inclusive
culture for peer roles, involves
understanding peer concepts.
Site 3=5
Site 4=4
Site 5=4
Role clarity Understand-
ing of Peer
The importance of a clear
understanding of the role of peer
workers by traditional staff and
management was discussed. Lack of
clarity was raised as a barrier in
effective relationships
5 Site 1=9
Site 2=6
Site 3=4
Site 4=6
Site 5=5
Unique Role Peer work described as distinct from
MHP roles. Peer work also seen as
complimentary to traditional roles.
Peer work identified as having a
distinct focus, distinct use of
language, defining features of
practice and unique skill set
5 Site 1=18
Site 2=6
Site 3=15
Site 4=5
Site 5=4
Job satisfaction was described as
feeling respected and involved
understanding of both peer and
MHP roles that led to an
appreciation of both roles and
effective collaboration
4 Site 1= 6
Site 3=2
Site 4=6
Site 5=5
Table 2.
Comparison of Organizations
Table 2.
Organization/Site Understanding/Value
of lived Experience
of peer work
of disclosure by
health professionals
1 High High Low
2 High Low High
3 High Medium High
4 High High Low
5 High High Low
Note: General interview questions one and three: ‘defining peer work’, and ‘what makes peer
workers effective’, led to discussion of, and ultimately sub-questions about the topics of
valuing lived experience, valuing peer work, and understanding disclosure.
The ratings in Table 2. were determined by comparing the overall understanding of different
categories or groups of workers at each organization (i.e. people employed as mental health
professionals, management, or in peer designated roles) with the degree to which group
understanding correlated with definitions in the existing literature. Further, the degree of
consensus across the worker groups at each organization were also compared e.g.: for the
item ‘understanding/value of peer work’, an organization with strong correlation to existing
definitions and strong consensus across all three worker groups were rated as having a ‘high’
overall understanding. Those organizations with strong correlation to existing literature and
consensus across two of the worker groups were rated as ‘medium’, and those organizations
where only one worker group confirmed the definitions in existing literature were rated as
having a ‘low’ collective understanding.
... A qualitative study from the United Kingdom demonstrated that attitudes of not psychiatrist healthcare professionals towards colleagues with a mental illness were positive; however, they did report that other colleagues held negative attitudes [38]. Lessening the stigma at the workplace among psychiatrists could allow us to intervene since, in work environments, where peer-led initiatives are featured, mental health professionals feel safer when they can disclose their own lived experiences to their colleagues [39]. ...
Full-text available
Objective: Stigma towards people with mental health problems is a growing issue across the world, to which healthcare providers might contribute. The aim of the present study was to explore psychiatrists' attitudes towards their patients and link them to psychosocial and professional factors. Methods: An online questionnaire was used to approach the in- and outpatient psychiatric services across Hungary. A total of 211 trainees and specialists in adult and child psychiatry participated in our study. Their overall stigmatizing attitudes were measured, with focus on attitude, disclosure and help-seeking, and social distance dimensions by using the self-report Opening Minds Stigma Scale for Health Care Providers (OMS-HC). Multiple linear regression analyses were performed to elucidate the dimensions of stigma and its association with sociodemographic, professional and personal traits. Results: Stigmatizing attitudes of close colleagues towards patients were statistically significant predictors of higher scores on the attitude [B = 0.235 (0.168-0.858), p = 0.004], the disclosure and help-seeking subscales [B = 0.169 (0.038-0.908), p = 0.033], and the total score of the OMS-HC [B = 0.191 (0.188-1.843), p = 0.016]. Psychiatrists who had already sought help for their own problems had lower scores on the disclosure and help-seeking subscale [B = 0.202 (0.248-1.925), p = 0.011]. The overall stigmatizing attitude was predicted by the openness to participate in case discussion, supervision or Balint groups [B = 0.166 (0.178-5.886), p = 0.037] besides the more favorable attitudes of their psychiatrist colleagues [B = 0.191 (0.188-1.843), p = 0.016]. Conclusions: The favorable attitudes of psychiatrists are associated with their own experiences with any kind of psychiatric condition, previous help-seeking behavior and the opportunity to work together with fellow psychiatrists, whose attitudes are less stigmatizing. The perception of fellow colleagues' attitudes towards patients and the openness to case discussion, supervision and Balint groups were the main two factors that affected the overall attitudes towards patients; therefore, these should be considered when tailoring anti-stigma interventions for psychiatrists.
... In contrast, Organization B, which made LE-informed training and supervision available to staff outside of designated roles, saw improvements across the workforce in sharing for purposes other than help-seeking. This supports the value of whole-of-workforce approaches [26], in "cultivating spaces for sharing" (Orlando, MHPLE, Organization B). Similarly, "messaging" from senior leadership supporting the value of LE endorsed participants' own belief in their experiences as an asset to their work. ...
Full-text available
Personal experience with mental health (MH) challenges has been characterized as a concealable stigma. Identity management literature suggests actively concealing a stigma may negatively impact wellbeing. Reviews of workplace identity management literature have linked safety in revealing a stigma to individual performance, well-being, engagement and teamwork. However, no research to date has articulated the factors that make sharing MH challenges possible. This study employed a comparative case study design to explore the sharing of MH challenges in two Australian MH services. We conducted qualitative analyses of interviews with staff in direct service delivery and supervisory roles, to determine factors supporting safety to share. Workplace factors supporting safety to share MH challenges included: planned and unplanned “check-ins;” mutual sharing and support from colleagues and supervisors; opportunities for individual and team reflection; responses to and management of personal leave and requests for accommodation; and messaging and action from senior organizational leaders supporting the value of workforce diversity. Research involving staff with experience of MH challenges provides valuable insights into how we can better support MH staff across the workforce.
... After the rise of the recovery movement, its notions seems to be plateauing and the current model of recovery makes mental health distress an explicit problem of individualized identity, rather than an effect of structural inequality (Harper and Speed, 2013). Although the assumption had been that the employment of peer workers automatically contributed to a broader culture of change and disclosure for mental health professionals, this seems not to be sufficient (Byrne et al., 2021). Whereas traditional professionals harnessing experiential knowledge built on to these efforts, they also faced challenges to further sensitize their environment while undergoing a personal-professional transformation. ...
Purpose This study aims to explore the perspectives of mental health professionals who are in a process of integrating their own experiential knowledge in their professional role. This study considers implications for identity, dilemmas and challenges within the broader organization, when bringing experiential knowledge to practice. Design/methodology/approach As part of a participatory action research approach, qualitative methods have been used, such as in-depth interviews, discussions and observations during training and project team. Findings The actual use of experiential knowledge by mental health care professionals in their work affected four levels: their personal–professional development; the relation with service users; the relation with colleagues; and their position in the organization. Research limitations/implications Because of its limited context, this study may lack generalisability and further research with regard to psychologists and psychiatrists, as well as perceptions from users, is desirable. Social implications According to this study, social change starts from a bottom-up movement and synchronously should be facilitated by top-down policy. A dialogue with academic mental health professionals seems crucial to integrate this source of knowledge. Active collaboration with peer workers and supervisors is desired as well. Originality/value Professionals with lived experiences play an important role in working recovery-oriented, demonstrating bravery and resilience. Having dealt with mental health distress, they risked stigma and rejections when introducing this as a type of knowledge in current mental health service culture. Next to trainings to facilitate the personal–professional process, investments in the entire organization are needed to transform governance, policy and ethics.
Full-text available
Employees’ mental health issues present significant challenges for organizations globally. Despite various human resource management (HRM) interventions, systemic stigmatization of people with mental health challenges endures. We propose drawing on an innovative HRM practice in the mental health sector, by introducing designated lived experience (LE) roles into organizations to achieve cultural shifts that benefit the entire workforce. A sector-wide survey was conducted across the mental health sector within an Australian state. A whole-workforce approach was taken by seeking perspectives from employees in both LE roles and traditional roles. Complete responses were obtained from 327 participants (116 in LE roles and 211 in traditional roles). Results showed that across the entire workforce, top leader commitment to LE roles led to more clarity about LE roles, resulting in improved individual outcomes of authentic self-expression, and organizational outcomes of service delivery. LE role clarity was particularly important in organizational contexts where social integration of LE roles was low. Our study puts lived experience at the forefront of HRM scholarly debate, highlighting how employing LE roles can achieve better performance, diversity and inclusion outcomes especially for those with mental health challenges, and support the development of more healthy and inclusive organizations.
Full-text available
Researchers often have personal experiences that motivate engagement with a research topic. We performed the first systematic investigation of self-relevant research (SRR; “me-search”) among psychologists. The prevalence of SRR and attitudes towards SRRers were examined in a representative North American sample (N = 1,778) of faculty, graduate students, and others affiliated with accredited doctoral programs in clinical, counseling, and school psychology. Over half of participants had engaged in SRR. When judging experimentally manipulated vignettes, those who did not engage in SRR made more stigmatizing judgements of SRR and SRR disclosure than those who engaged in SRR. Psychologists and trainees had more negative attitudes towards SRR on mental health topics (suicide, depression, schizophrenia) than physical health topics (cancer). We discuss the implications of negative evaluations of SRR and mental illness on the health of applied psychology.
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