Conceptualizing relationship building between peer support workers and persons in recovery in a community-based mental healthcare setting in Hong Kong

Abstract

Background: Peer support has become an increasingly prevalent mental health service worldwide. While the relationship between the change agent and recipient has been proven to be positively related to the outcomes in one-to-one intervention, existing theories and knowledge on peer support mechanisms tend to overlook the empirically-based, relational aspects of the peer support service. Specifically, there is a lack of focus on the stages of relationship development between peer support workers (PSWs) and persons in recovery (PIRs), as well as the key characteristics that surround the relationships. Meanwhile, the existing theoretical orientations for explaining the constructs of relationship building have been based on the client-therapist relationship in traditional psychotherapies. Therefore, this study explored the development of the relationship between PSWs and PIRs over time in a one-to-one community-based mental health peer support service in Hong Kong. The study aimed to identify the characteristics of the relationship between PSWs and PIRs and conceptualize the factors contributing to and challenging the peer support relationship.

Methodology: This longitudinal, qualitative study adopted a constructivist grounded theory approach. 10 PSW-PIR pairs (five PSWs and 10 PIRs), three key informants (former PSWs), and five supervisors were recruited through purposive and theoretical sampling. Data collection was conducted through a dual approach of naturalistic observation and individual semi-structured interviews. Focus group interviews and individual interviews were conducted to ensure the trustworthiness of the findings. This study conducted 12 naturalistic observations at three time points (the first, third, and ninth face-to-face peer support sessions) and 38 semi-structured interviews at two time points (the third and ninth peer support sessions). Three key informant interviews were conducted, along with three focus group interviews and six individual semi-structured interviews for member checking and triangulation.

Key findings: The peer support journey of PSWs and PIRs unfolded through a dynamic four-stage progression - Connection, Closeness, Companionship, and Continuity (the 4Cs). The 4Cs stages of peer relationship development differed from the existing goal-directed and individualist stages, as they were imbued with relational and collectivist undertones. This reflected the nuanced interplay of roles and boundaries within the peer support context. Digging deeper, the complexities of the peer support dynamic were conceptualized across three key facets: PSW, PIR, and agency factors. The study underscored the importance of non-peer staff and supervisors recognizing the distinctive nature and profound significance of the peer support service.

Significance: This study makes a unique contribution to the literature by employing a robust multi-method approach. The 4Cs model of peer relationship development is an innovative addition to the historical and theoretical development of the therapeutic relationship. The study conceptualizes the factors contributing to and challenging peer relationship development into the theoretical framework of peer relationship building, distinguishing it from the prevailing framework of change mechanisms. It also raises awareness of the importance of maintaining the integrity of the peer support service and promoting its integration into the broader mental healthcare and social welfare system.