Exploring the Integration of Peer Support Workers and Their Experiential Knowledge in Mental Health Services: An Ethnographic Study from the Dual Perspectives of Peer Support Workers and Professionals in Trieste and its Region

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However, innovative approaches are needed to evaluate the implementation of Peer Support Workers (PSWs) and their impact on mental health services. This study investigates the role of PSWs in Trieste and its region, a pivotal site of Italy’s psychiatric reform, where the deinstitutionalisation movement fostered the transition to a community-based care model. Methods The present study adopted an ethnographic methodology, encompassing a six-month field study involving participant observation and 22 semi-structured interviews with 12 PSWs and 10 mental health professionals. Results This study investigates the role, values, and benefits of peer support in mental health services within a specific Italian region, examining its impact on service users and its contributions to the humanisation and innovation of care. By analysing the perspectives of both PSWs and professionals, this research offers a comprehensive assessment of its significance. It also identifies the critical challenges related to the involvement and recognition of PSWs, employing an anthropological approach to identify operational difficulties and epistemological assumptions, which often constrain the full integration of PSWs. Moreover, the study proposes strategies for strengthening the role of PSWs and enhancing the consideration of experiential knowledge in mental health services. Conclusions In addition to their clinical effectiveness in supporting individuals' recovery, PSWs represent an opportunity for mental health services to critically reflect on their practices and the cultural assumptions underpinning them. These reflections have the potential to create meaningful innovation in psychiatric care Peer support workers People with lived experience Recovery-oriented practices Mental Health Services Community psychiatry Ethnography. INTRODUCTION The World Health Organisation, the Lancet Commission on Global Mental Health and various national and international guidelines emphasise the necessity of reforming mental health services by prioritising care that values lived experience and safeguards individuals' rights [1–4]. A pivotal player in this process is the Peer Support Worker (PSW); PSWs are individuals with lived experience of mental disorders who help others currently facing similar difficulties [5]. The role of PSWs encompasses a wide spectrum of activities, such as providing individual support, facilitating peer support groups or shadowing professionals [5–7]. The efficacy of peer support has thus far demonstrated favourable outcomes concerning clinical [8, 9] and personal recovery, fostering empowerment, self-efficacy, feelings of hope, self-esteem and social integration [8, 10, 11]. Additionally, PSWs enhance the engagement of users with complex needs that traditional services are often unable to address [12–14]. The significance of PSWs is further emphasised by their frequent inclusion in national guidelines and international recommendations [12, 15–21]. Moreover, peer support is often identified as a key element in the transition from traditional mental health services to recovery-oriented services [22]. Conversely, several critical junctures and aspects require further clarification: for example, the nature of PSWs' activities is frequently inadequately defined in studies and trials [8]; in addition, the fidelity of these activities to the values and professional skills of PSWs is seldom evaluated [8, 23–25]. Furthermore, the relationship between the measured outcome and the implementation of PSWs has rarely been examined. Specifically, little research has explored how the effectiveness of PSW’s contribution relates to the preparedness of the setting — in terms of service organisation and training of professionals —­­ to implement peer support [8, 25]. Moreover, further research is needed to determine whether PSWs serve as catalysts for the transformation of mental health services towards a rights-based, person-centred approach or whether their involvement reflects a broader shift in professional practices and perspectives [23–25]. Finally, the literature emphasises the need for qualitative research to identify the factors that facilitate or hinder the implementation of peer support [9]. Research context The study was carried out in the mental health services of the Friuli Venezia Giulia region in Italy, which was the pivotal site in the genesis of the Italian deinstitutionalisation process. This movement had national and international reach and led to a profound transformation in psychiatric healthcare through the abolition of asylums and the development of a rich network of community care focused on promoting patients’ empowerment and self-determination [26–28]. To this day, the city of Trieste, the region's main urban centre, continues to function as a vanguard, as evidenced by its WHO collaborating centre for mental health research [29] and an enhanced community care network [30]. The services in Trieste are defined by a collaborative, multidisciplinary approach involving mental health professionals and patients in designing and delivering care [30]. Furthermore, Trieste's mental health system emphasises the importance of social determinants of health and focuses on integrating mental health services with other social services, providing a multidimensional and person-centred approach to care [29, 31]. The core of the organisation is a network of Community Mental Health Centres that are active 24 hours a day, 7 days a week, with relatively few beds in each of them; this organisation is characterised by an “open door” and “no restraint” approach [31]. The regional government of Friuli Venezia Giulia replicated Trieste's model across the region, resulting in low hospitalisation and compulsory treatment rates, effective job placement and social inclusion [29]. Consequently, Trieste and its region provide an ideal context for investigating the role of PSWs, analysing the factors driving their involvement, the strategies that have been deployed, the critical issues that have emerged in comparison with other contexts, and whether valuable insights can be drawn from this dynamic landscape of innovation. To explore these issues while remaining attentive to the structural dynamics affecting PSWs and professionals, we adopted an ethnographic approach that allows for an in-depth exploration of the lived experiences of PSWs and professionals [32, 33]. Aims 1. Understand the role of PSWs through an in-depth analysis of their current experience in the Friuli Venezia Giulia region. 2. Identify the strengths and challenges of the inclusion of PSWs in mental health services 3. Outline future perspectives and pathways to ensure that PSWs’ engagement is effective for service users and enriching for the service, fostering a recovery-oriented approach. METHODS Study design We conducted the following ethnographic study: (1) Participant observation: the principal researcher undertook a six-month observation period, attending meetings and events organised by the “PSW Regional Network”, participating in an action-oriented training course for professionals, family members, and PSWs, and shadowing two PSWs in Trieste. (2) Concurrently, the principal researcher conducted 22 semi-structured interviews with PSWs and mental health professionals (MHPs). Each interview lasted approximately 60 minutes and was carried out in Italian. The findings were periodically reviewed and discussed by the research team. The subjects addressed during the interviews encompassed the following: the role of PSWs within the service, the perceived benefits, the critical issues encountered, and the resilience strategies employed or deemed appropriate for implementation. The interviews were conducted in April and May 2024. Informed consent for anonymous data processing was obtained before the interviews were recorded. Recruitment and participants The participants were identified via the snowball sampling method [34]. Following grounded theory principles [35], all PSWs working in Friuli Venezia Giulia during the data collection were included, while the sample size for MHPs was adjusted on the basis of the attainment of theoretical saturation. Data analysis All the interviews were transcribed verbatim and anonymised, distinguishing between MHPs and PSWs to provide context for the quotes. Data analysis followed a deductive-inductive approach, employing the framework method [36]. The final set of summary themes was based on a consensus among the study’s authors. Finally, the results were shared and discussed with the participants, who were also involved in reviewing this paper. RESULTS Participants Table 1 summarises the professional profile of the PSWs and MHPs interviewed. Table 1: Participants 12 PSWs 4 PSWs employed on a contract basis in two social cooperatives; 3 PSWs volunteering in associations; 4 PSWs on a traineeship in mental health services. 10 MHPs 3 psychiatrists; 1 psychologist; 2 psychiatric rehabilitation specialists ; 1 social worker; 1 public health physician; 1 nurse; 1 professional educator. Analysis of interviews To facilitate understanding, the results collected were grouped and classified by macro themes, as shown in Table 2. Table 2: Results overview Activities Group activities for service-users; Advocacy and community engagement; Training for MHPs; Sensibilisation of general society; Recovery House; One-to-one meetings. Benefits Foster empathy, understanding and reduction of self-stigma; Promote social inclusion by assisting in daily life activities and facilitating the creation of social networks; Enhance the person’s point of view with professionals; Advocacy for the protection of rights; Foster PSW’s own recovery. Challenges Stigma and prejudice from MHPs; Lack of formal recognition and misuse of PSWs; Power imbalances and resistance to change from MHPs; Instrumentalization and manipulation of PSWs. Strategies for inclusion Ensure a safeguarding work environment; Training for MHPs to work with PSWs; Institutional recognition of PSWs' role; Work in recovery-oriented settings; Synergy between operational motivation and strategic institutional support; Cultural and epistemological change in mental health services. Activity profile PSWs were asked to describe their activities. The results are summarised in Table 3. Table 3: Activity profile Group activities Weekly or biweekly peer support groups; Peer support in Trieste’s psychiatric ward[1] for acute cases; Creative workshops (writing, art, cinema); Group activities for social integration (excursions, dinners, out-of-town trips of one or more days); Weekly meetings in the acute hospital ward. Advocacy and Community engagement Peer support groups in the suburbs of Trieste; Citizenship awareness activities (conferences and meetings open to the public). Teaching Academic courses at the University of Trieste; Training for MHPs. Collaboration with MHPs Weekly reports and monthly meetings with some MHPs: in which the needs identified by the PSWs in the groups they facilitate during the week are reported periodically, as well as cases and events that need special attention from the service. Recovery House Support for daily activities, presence, and active listening with the young residents of a Recovery House; Assistance in recovery programmes such as the Wellness Recovery Action Plan. One-to-one meetings Individual meetings upon request of the service users. Benefits of PSWS 1. Fostering empathy, understanding, and reducing self-stigma PSWs play a crucial role in actively listening to and understanding distress. They recognise the importance of being present, non-judgmental, and validating emotions. As one PSW noted: “PSWs know that it is often unhelpful to say ‘Do it! You can do it!’. Sometimes, what matters most is standing there in silence, without judgment, and conveying the message that ‘it is okay to feel unwell’”. (PSW5). Through their lived experience, PSWs foster hope and help reduce self-stigma, particularly for individuals in the early stages of recovery, who may feel lost and struggle to believe in their resources. The interviewees emphasised the role of PSWs in normalising mental health conditions, as well as their ability to carry out activities that cultivate peer relationships, ultimately encouraging active participation rather than passive service use. 2. Support for social inclusion “We do not do ‘for’ others but ‘with’ others”. (PSW8). According to the data, PSWs create opportunities for relationships founded on shared experiences, avoiding paternalistic and dependency-inducing support. Instead, they empower individuals to reclaim agency over their lives and their recovery, helping them move beyond the ‘patient’ identity. This is particularly important, as, as highlighted by interviewees, one of the key challenges of the recovery journey is “ regaining control over daily life” (PSW5). Furthermore, the study findings also suggest that resources for recovery are not only found within the individual but also enhanced through relationships and participation in group settings. “Participating in group meetings gave us an awareness of our worth. Sharing within the group makes you realise that you are worth it, despite the challenges your story matters”. (PSW5). 3. Enhancing the person’s point of view with professionals The interviewees highlighted the critical mediating role of PSWs in bridging communication between professionals and service users. The power imbalance created by professionals' technical knowledge can sometimes hinder therapeutic effectiveness, as users may struggle to articulate their needs or concerns. For example, when individuals wish to adjust or suspend their medication, they often turn to PSWs, who facilitate discussions with psychiatrists. PSWs emphasised that their role is not about complicity but rather about supporting individuals in recognising and effectively communicating their needs to professionals. MHPs reported that PSWs facilitate professionals in adopting a more human-centred approach, thereby fostering heightened sensitivity towards the individuals with whom they engage. Moreover, PSWs encourage practitioners to embrace risk-taking as part of the empowerment process of the individual, balancing it with necessary support. As one psychiatrist noted: “The PSW has a vision and a sensitivity that we sometimes lack. [...] We worry about our responsibilities, we tend to intervene, to decide for people. I believe that the PSW experience helps me see things more from the patient’s perspective”. (MHP10). 4. Advocacy for the protection of rights The interviewed PSWs consistently emphasised the importance of advocacy in safeguarding service users' rights. This was particularly evident during the participant observation period: in this region, PSWs’ advocacy is reflected both in their daily work within services, promoting a person-centred and rights-based approach, and in their involvement in the design and innovation of services and care practices. Moreover, many engage in activism and public awareness campaigns to inform communities about mental health services, reduce stigma, and promote a multidisciplinary understanding of mental illness. 5. Enhancing PSWs’ own recovery Training and professional engagement in peer support constitute essential parts of PSWs' personal recovery journeys. The process of recognising their own lived experiences as valuable tools for helping others reinforces their sense of empowerment. This transformation involves reframing suffering: rather than viewing mental illness as a stigmatising burden, PSWs reinterpret their experiences as a source of insight and resilience. As one participant shared: “That suffering is enormous, it is heavy and hurts, but when you make sense of things, it becomes your strength”. (PSW8). PSWs’ challenges in mental health services 1. Stigma and prejudice from MHPs A key challenge identified in the study is the persistent stigma and prejudice harboured by some professionals towards PSWs. This is often expressed through overprotective or excessively cautious attitudes. One PSW described feeling like “ a problem to be solved ” (PSW4), as professionals continued to see him primarily as a former service user rather than acknowledging her skills and contributions. Several interviewees suggested that this prejudice stems from the ambiguity and perceived “threat” of PSWs’ role, which challenges the conventional “us - healthy vs. them - sick dichotomy” (PSW9). 2. Lack of formal recognition and misuse of PSW In several interviews, an important theme that emerged was that of the improper activities that PSWs were/could be called upon to perform. For example, we identified (1) peer support as “employment inclusion”: the PSW is assigned menial tasks or duties unrelated to peer support; (2) PSWs as “low-cost” professional substitutes: sometimes, MHPs perceive PSWs as inexpensive replacements for trained professionals or as general-purpose workers who can perform tasks that mental health professionals prefer to avoid: “You have to be very careful because otherwise, they will offload tasks onto you that they should be doing themselves but don’t want to”. (PSW6). Moreover, in Italy, the role of PSWs lacks formal recognition, often resulting in internship-based employment with minimal guarantees. In Trieste, however, PSWs are employed through social cooperatives, offering greater security. Nonetheless, the interviewees emphasised the urgent need for greater institutional recognition. 3. Power imbalances and resistance to change “ Is the service ready? Are we ready to question the services in which we work to involve them more?”. (MHP, March 2024, field diary). The interviewees highlighted that power imbalances between professionals and PSWs remain a major barrier to the full integration of PSWs. While PSWs have the potential to encourage professionals to critically reflect on their roles and practices, a reluctance to do so is often reported. One PSW described the difficulty of expressing a dissenting opinion within professional settings. Additionally, PSWs believe that this resistance stems from rigid role definitions and an unwillingness to move away from vertical and hierarchical dynamics, hindering the therapeutic potential of peer relationships. “Some professionals lack the humility to stop feeling superior to others — because it’s easier to feel legitimised by their professional role”. (PSW8). 4. Instrumentalisation and manipulation of PSWs Numerous interviewees stated the potential risk of instrumentalising PSW as a tool to "hook users" and "increase user compliance" with recovery programmes. Indeed, some PSWs perceive the risk of being manipulated as “ puppets in the hands of the system ” (PSW11). As one PSW described her experience during an internship at a suburban mental rehabilitation service that was inadequately prepared to involve PSWs: “They send me to talk to the users and afterwards I have to report what they tell me because the users speak a little bit more willingly with me than with the educator, so basically I am a pawn, they send me where they do not get”. (PSW10). Additionally, one psychiatrist criticised the potential risk of using PSWs instrumentally to give the service a more humane and avant-garde appearance. Consequently, it appears to be a “ concession” (MHP4) of a space within which PSWs can act and express themselves: “The PSW should not be ‘in the service of the service’. However, often the current reality is like that, and it is difficult for it not to be so [...] it is difficult for one to express criticism, suggestions, observations or to go into conflict because one would be ‘the last wheel on the wagon’ anyway, would not one?”. (PSW1). One MHP identified the risk that, despite the openness of services in contexts such as Trieste, subtle power imbalances and paternalistic attitudes may still limit the innovative potential of peer support, by constraining PSWs within institutional structures. “In the beginning, the director wanted the PSWs and he was the one pushing it, [...] but I have always perceived it as: ‘Do it, but do it like this’ and ‘do it there, where could also improve the image of the service’, [...]. Therefore, perhaps in another context, it could have grown more. In my opinion, those who are ‘hungry’ are also more active [...]; in other contexts where the enemy is very clear, where the enemy does not cooperate with you and does not tell you ‘Do this, do that…I'll pay you’, maybe it is easier to create something real, heartfelt, with motivation”. (MHP7). Strategies for effective implementation The study identified the following strategies as effective measures for safeguarding PSWs during their employment within mental health services and ensuring effective inclusion: 1) Ensuring safeguarding work inclusion The respondents described several strategies implemented in Friuli Venezia Giulia as follows: a. Group and team work: Working in pairs or teams represents the main form of safeguarding, as it provides mutual intervision, helps identify moments of vulnerability and ensures support for the safety of both PSWs and users. b. Periodic supervision by a tutor or psychologist c. Working in contexts separate from where one is/was a user helps PSWs establish professional relationships with mental health service colleagues while “ preserving the right to be ‘treated as a user’ in a different service” (PSW12). This ensures adequate professional detachment, although it is not always practised, as seen in Trieste, where PSWs work in the same services where they are also users. 2) Training MHPs to work with PSWs According to the data, the training of MHPs is not only a measure to safeguard PSWs but also a prerequisite for the effective implementation of PSWs. Another pivotal element that emerged is that training, to be effective, must be conducted by or with individuals with lived experience. Moreover, training has a purpose that goes beyond mere knowledge of peer support and PSWs’ activity profile but should inspire a change in perspective, leading to the overcoming of stigma and prejudice. 3) Institutional recognition of PSWs To effectively and meaningfully implement peer support, institutional recognition by the Ministry of Enterprises and Made in Italy of the professional figure is essential. This would clarify the role of PSWs and enable proper integration of PSWs into services through appropriate contracts, clear job expectations and sufficient organisational support. In 2024, a professional association (AIPESP[2]) was established in Italy to promote the institutional recognition of the PSW role. According to the respondents, such recognition could help safeguard their labour rights, create dedicated job opportunities, and, most importantly, affirm the legitimacy and societal value of their work. 4) Synergy between motivation at the operational level and institutional support Many of the interviewees believe that there is a need for greater synergy between motivation at the “operational” level (on the part of PSWs and professionals) and interest at the “strategic” level. The inclusion of PSWs at the strategic level implies the development of co-produced pathways in which PSWs are called upon, alongside professionals, to build services that meet users' needs and expectations. For example, according to the new regional directives, mental health services in Friuli Venezia Giulia will be required to collaborate primarily with social cooperatives that employ PSWs as part of their staff. 5) Enhancing experiential knowledge in decision-making spaces and research context The interviewees emphasised the need to recognise experiential knowledge as equally important as technical-academic expertise, arguing that its integration could enhance clinical practices by making them more responsive to individuals' lived experiences. “The experience of these individuals should be made comparable to that of the professional. What you read in a book and what you experience firsthand could be two parallel systems of knowledge”. (MHP4) 6) Cultural and epistemological change in mental health services The key issue that emerged from the interviews and participant observation is that the inclusion of PSWs in mental health services requires a profound cultural shift. This change involves rediscovering a genuine commitment to supporting individuals and their lived experiences and, according to some, recognising that many forms of suffering in mental health are primarily social and cannot be addressed only through a narrow biomedical approach. “If you deal with mental health, you cannot but deal with social justice. Let’s talk about social justice! We are talking about abuse, violence, discrimination, marginality, and abandonment. [...] That is, you cannot but reflect on the fact "What can I do to give these people a perspective?” ». (MHP8) [1] “Servizio psichiatrico di diagnosi e cura (SPDC)” [2] AIPESP is the acronimous of “Associazione Italiana Persone Esperte in Supporto tra Pari” (trad. Italian association of PSWs). For fourther information please consult https://aipesp.it/ DISCUSSION Positive impact of peer support The profile of PSWs in Friuli Venezia Giulia aligns with the values and practices reported in other international studies. Notably, it plays a pivotal role in facilitating service users' recovery, contributing to personal recovery outcomes, sense of self-efficacy and self-esteem [ 8 ] and empowerment [ 10 , 37 ]; reducing self-stigma [ 10 ] and loneliness [ 38 ]; and fostering feelings of hope and enhanced quality of life [ 5 , 6 , 8 , 13 , 39 ]. Furthermore, in this local context, PSWs have a clear community-oriented approach: the emphasis on group activities and the special focus on rebuilding social ties demonstrate that the work is aimed not only at individual recovery but also at community empowerment, driven by a strong commitment to advocating for the rights and participation of people with mental disorders. [ 9 , 10 ]. Consequently, PSWs emerge as key players in the social inclusion of people with complex needs, facilitating the construction or restructuring of a social network and acting as intermediaries between the person and their community of reference [ 12 , 13 , 40 ]. Moreover, PSWs can change the narrative and imaginary around mental illness, becoming a powerful tool to eradicate stigma and prejudice within both communities and mental health services, and proving that individuals’ participation and engagement could be a valuable alternative to paternalistic and dependency-inducing care. PSWs therefore help the individual create a space for the disclosure of suffering, constructing an acceptable representation of one's experience of distress [ 10 ], which recalls the medical anthropology concept of symbolic efficacy [ 41 ]. According to this concept, healing involves the construction of a representational space that gives meaning to one's experience of illness [ 41 ]. Furthermore, PSWs seem to impact the implementation of quality mental health care practices, such as care humanisation, person-centred and rights-based approaches [ 1 , 7 ], and mediation between service users and professionals [ 1 , 10 , 42 , 43 ]. Finally, our study highlighted the positive impact of peer support on PSWs’ own recovery [ 7 , 44 ]. Challenges for implementation This ethnographic study identified several critical issues related to the involvement of PSWs in mental health services, echoing those reported in the extant literature [ 13 , 45 , 46 ]. Among these, stigma and prejudice are undoubtedly significant, as they often persist as dismissive and biased attitudes from many professionals [ 8 ]. Furthermore, our study highlights the risk of instrumentalizing and manipulating PSWs, i.e., using PSWs to obtain users’ compliance with therapies or as a label of the quality of the service and its recovery-oriented practices [ 38 , 47 ]. Another limitation lies in the reluctance of professionals to recognise the inherent power asymmetry with service users (including PSWs), as well as the hierarchical structure of mental health services and the social control mandate embedded within these systems [ 2 , 12 , 48 ]. Without addressing these dynamics, we believe that the ultimate authority is likely to remain firmly in the hands of professionals [ 12 , 38 , 48 ]. Consequently, our study emphasises the importance of supporting PSWs within mental health services. We have identified several strategies to protect PSWs in their work, such as training, teamwork, supervision and support from the trusted social and health network, as well as the essential training of health personnel and a clear definition of PSWs’ professional profile [ 8 , 40 , 45 , 49 , 50 ]. Another key issue emerging from our study is the institutional recognition of PSWs. This is essential for securing appropriate contractual status, ensuring fidelity to their role and competencies and reducing burnout by establishing clear expectations and organisational support [ 51 ]. While we consider this process nearly unavoidable, we also acknowledge, in line with other studies, the risk that professionalisation may undermine the peer nature of relationships and lead to the institutional assimilation of PSWs [ 10 , 25 ]. Institutional recognition, however, is not merely a bureaucratic necessity; it must be accompanied by strong managerial commitment and adequate resource allocation to foster an environment conducive to effective collaboration. Without these conditions, the inclusion of PSWs risks being superficial, reinforcing conventional service models rather than fostering genuine peer support-oriented programmes. In this sense, assuming that PSW integration alone can radically transform traditional services — particularly those not oriented toward a person-centred and community-based approach [ 25 ] — may inadvertently lead to the development of standardised programmes delivered by PSWs rather than initiatives truly grounded in peer support principles [ 23 , 24 ]. Implementation perspectives for research and services According to our results, we suggest that PSWs’ involvement should not be limited to daily practices at an operational level but should actively involve PSWs in decision-making processes within services and academic research groups. [ 38 , 52 ]. This would imply an organisational commitment that can guide resource allocation, service design, evaluation and management for and with PSWs [ 51 ]. Furthermore, while we recognise the fundamental importance of evaluating the effectiveness of peer support work in mental health services, such an evaluation requires either preliminary studies or a clear definition of the context in which peer support is assessed and the outcomes measured within the trial [ 8 , 23 – 25 ]. Additionally, we contend that the evaluation of peer support effectiveness should not be confined solely to clinical recovery criteria, but should also encompass measures of personal recovery, quality of life, social inclusion, self-determination and, crucially, its impact on service practices and organisation [ 12 , 23 ]. Moreover, we argue that while the work of PSWs can encourage professionals to reflect on and humanise their practices, cultural change is a necessary condition for PSWs to perform their roles effectively [ 8 , 50 , 53 ]. Such a change would enable PSWs to freely express their perspectives and contribute to the innovation of services. Cultural change relies on developing an integrated and complex understanding of illness and care, one that is deeply attuned to the social determinants of health [ 54 ] and health inequalities [ 3 , 4 ]. More importantly, it requires an acknowledgement that this complexity can only surface through listening to and valuing lived experiences [ 48 ]. The effective engagement of PSWs can be a cornerstone of this transformation, offering an opportunity to catalyse these reflections, as it provides a chance to shift the lens through which mental health suffering is understood. Finally, we believe that cultural change necessitates an epistemic shift: one that equips professionals not only with the emotional disposition but also with the tools to prioritise individuals’ lived experiences, allowing them to co-construct their path of healing using resources provided by services [ 38 ]. In summary, paraphrasing Diana and Nikolas Rose, this shift must transition from “involving individuals in services” to “involving services in the lived world of individuals” [ 48 ]. CONCLUSIONS The ethnographic nature of this study highlights several critical factors that define the modalities of engaging PSWs in mental health and, consequently, their effectiveness within and for services [ 8 , 9 , 25 ]. The study explores the role of PSWs in a context where it has never been previously described, highlighting its local specificities and international affinities. Through this research, we emphasise the importance of ensuring that care practices arising from the involvement of individuals with lived experience are grounded in a reflective process. This process should encourage services to critically examine their organisational models and the cultural production inherent in their practices. The introduction of PSWs, and more broadly, of experiential knowledge, can serve as a pivotal moment in a broader rethinking of medicine and the biomedical model of care. This reconceptualisation has the potential to become what could be described as — paraphrasing Franco Basaglia — “a practical inversion imbued with utopian elements”[ 55 ]. Declarations Competing Interests The authors have no competing interests to declare that are relevant to the content of this article Acknowledgement The authors thank the interview participants for sharing their thoughts and experiences. They also wish to express their gratitude to Dr Chiara Laurini for her invaluable support, and to Dr Izabel Marin for her valuable assistance throughout the research process. 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NICE clinical guideline 178: Psychosis and schizophrenia in adults: Treatment and management. Mental Health Commission of Canada: Peer Support. https://mentalheal thcommission.ca/what‑we‑do/access/peer‑support/. Biringer E, Davidson L, Sundfør B, Ruud T, Borg M (2016) Experiences of support in working toward personal recovery goals: a collaborative, qualitative study. BMC Psychiatry 16:426 Bologna L, Simmons MB (2018) A Systematic Review of the Attributes and Outcomes of Peer Work and Guidelines for Reporting Studies of Peer Interventions. Psychiatr Serv 69:961–977 Gillard S, Foster R, Gibson S, Goldsmith L, Marks J, White S (2017) Describing a principles-based approach to developing and evaluating peer worker roles as peer support moves into mainstream mental health services. Ment Health Soc Incl 21:133–143 Gillard S, Foster R, White S, et al (2024) Implementing peer support into practice in mental health services: a qualitative comparative case study. 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Accessed 19 Jan 2025 Cleary M, Raeburn T, Escott P, West S, Lopez V (2018) ‘Walking the tightrope’: The role of peer support workers in facilitating consumers’ participation in decision-making. Int J Ment Health Nurs 27:1266–1272 Poremski D, Kuek JHL, Yuan Q, Li Z, Yow KL, Eu PW, Chua HC (2022) The impact of peer support work on the mental health of peer support specialists. Int J Ment Health Syst 16:51 Kemp V, Henderson AR (2012) Challenges faced by mental health peer support workers: Peer support from the peer supporter’s point of view. Psychiatr Rehabil J 35:337–340 Repper J, Carter T (2011) A review of the literature on peer support in mental health services. J Ment Health 20:392–411 Slade M, Amering M, Farkas M, Hamilton B, O’Hagan M, Panther G, Perkins R, Shepherd G, Tse S, Whitley R (2014) Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems. World Psychiatry 13:12–20 Rose D, Rose N (2023) Is ‘another’ psychiatry possible? Psychol Med 53:46–54 Davidson L, Bellamy C, Guy K, Miller R (2012) Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry 11:123–128 Brown LD, Vasquez D, Wolf J, Robison J, Hartigan L, Hollman R (2024) Supporting Peer Support Workers and Their Supervisors: Cluster-Randomized Trial Evaluating a Systems-Level Intervention. Psychiatr Serv 75:514–520 Reeves V, McIntyre H, Loughhead M, Halpin MA, Procter N (2024) Actions targeting the integration of peer workforces in mental health organisations: a mixed-methods systematic review. BMC Psychiatry 24:211 Zisman-Ilani Y, Byrne L (2023) Shared Decision Making and Peer Support: New Directions for Research and Practice. Psychiatr Serv 74:427–428 Gillard S, Foster R, White S, et al (2022) The impact of working as a peer worker in mental health services: a longitudinal mixed methods study. BMC Psychiatry 22:373 Breilh J (2023) The social determination of health and the transformation of rights and ethics: A meta-critical methodology for responsible and reparative science. Glob Public Health 18:2193830 Basaglia F, Ongaro FB (2024) Crimini di pace. Baldini & Castoldi Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Sep, 2025 Read the published version in Community Mental Health Journal → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6247366","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":432423967,"identity":"08b001d1-0758-4fb0-a124-68adbd229bf4","order_by":0,"name":"Giulia Pollice","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYDACZgbGAwkgBjtzwwEGBhuQCBjw4NHCANHCzAjSkobQglsPUAsDVAuQPIwQxqVF3p3H4MCDGoY8fmbGxgM/Ks4nbmfnTnxcUcEgY49Di+FhoJaEYwzFks2MDQd7ztxO3NnMu9nwzBncDjNsBmlhY0jccJix4TBj220gg3ebZGMbIS3/YFr+nYNq+YdbizwzUEtiG0xLwwGolgbcWgyY2QoOJPZJQP1yLNkYqGWzYcMxCR6eAzhs6T+88eGPbzZ5/OzNhz/8qLGT3XD+7MaHDTU29uwNOGyBGCWRgC4hgcNZQFugRmFoGQWjYBSMglEABwBW7FwZ7/uyKwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Modena and Reggio Emilia","correspondingAuthor":true,"prefix":"","firstName":"Giulia","middleName":"","lastName":"Pollice","suffix":""},{"id":432423968,"identity":"b4b12955-5fd1-4336-aaf0-0a16368271bd","order_by":1,"name":"Chiara Francesca Bodini","email":"","orcid":"","institution":"Centro di Salute Internazionale e Interculturale - APS","correspondingAuthor":false,"prefix":"","firstName":"Chiara","middleName":"Francesca","lastName":"Bodini","suffix":""},{"id":432423969,"identity":"8191e0dc-2b79-4c0b-a2cb-d5de64cbc972","order_by":2,"name":"Marco Menchetti","email":"","orcid":"","institution":"University of Bologna","correspondingAuthor":false,"prefix":"","firstName":"Marco","middleName":"","lastName":"Menchetti","suffix":""},{"id":432423970,"identity":"1b32dd0d-6813-471f-98ff-a662e9db8df2","order_by":3,"name":"Delia Da Mosto","email":"","orcid":"","institution":"Centro di Salute Internazionale e Interculturale - APS","correspondingAuthor":false,"prefix":"","firstName":"Delia","middleName":"Da","lastName":"Mosto","suffix":""},{"id":432423971,"identity":"176251f1-42a7-4708-aaa0-4b9272b22f0a","order_by":4,"name":"Luca Negrogno","email":"","orcid":"","institution":"Istituzione G.F. Minguzzi, Città Metropolitana di Bologna","correspondingAuthor":false,"prefix":"","firstName":"Luca","middleName":"","lastName":"Negrogno","suffix":""},{"id":432423972,"identity":"282b51bf-d88a-4641-a532-ccaba95cc5e7","order_by":5,"name":"Lorenzo Betti","email":"","orcid":"","institution":"Centro di Salute Internazionale e Interculturale - APS","correspondingAuthor":false,"prefix":"","firstName":"Lorenzo","middleName":"","lastName":"Betti","suffix":""},{"id":432423973,"identity":"824c1e4b-1cc8-4a86-8b93-8dc48b9807ac","order_by":6,"name":"Morena Furlan","email":"","orcid":"","institution":"Central Health Directorate Friuli Venezia Giulia","correspondingAuthor":false,"prefix":"","firstName":"Morena","middleName":"","lastName":"Furlan","suffix":""},{"id":432423974,"identity":"bbf8906e-4fc3-4e83-ba7d-0171e41cd37c","order_by":7,"name":"Ivo Quaranta","email":"","orcid":"","institution":"University of Bologna","correspondingAuthor":false,"prefix":"","firstName":"Ivo","middleName":"","lastName":"Quaranta","suffix":""}],"badges":[],"createdAt":"2025-03-17 19:53:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6247366/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6247366/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10597-025-01513-5","type":"published","date":"2025-09-16T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101515450,"identity":"6235ba5d-062c-48f0-9ece-73d8ef34d7e4","added_by":"auto","created_at":"2026-01-30 16:05:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":958418,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6247366/v1/dbc3141b-6a97-449b-aee4-55836b7a865f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the Integration of Peer Support Workers and Their Experiential Knowledge in Mental Health Services: An Ethnographic Study from the Dual Perspectives of Peer Support Workers and Professionals in Trieste and its Region","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe World Health Organisation, the Lancet Commission on Global Mental Health and various national and international guidelines emphasise the necessity of reforming mental health services by prioritising care that values lived experience and safeguards individuals' rights [1–4]. A pivotal player in this process is the Peer Support Worker (PSW); PSWs are individuals with lived experience of mental disorders who help others currently facing similar difficulties [5]. The role of PSWs encompasses a wide spectrum of activities, such as providing individual support, facilitating peer support groups or shadowing professionals [5–7]. The efficacy of peer support has thus far demonstrated favourable outcomes concerning clinical [8, 9] and personal recovery, fostering empowerment, self-efficacy, feelings of hope, self-esteem and social integration [8, 10, 11]. Additionally, PSWs enhance the engagement of users with complex needs that traditional services are often unable to address [12–14]. The significance of PSWs is further emphasised by their frequent inclusion in national guidelines and international recommendations [12, 15–21]. Moreover, peer support is often identified as a key element in the transition from traditional mental health services to recovery-oriented services [22]. Conversely, several critical junctures and aspects require further clarification: for example, the nature of PSWs' activities is frequently inadequately defined in studies and trials [8]; in addition, the fidelity of these activities to the values and professional skills of PSWs is seldom evaluated [8, 23–25]. Furthermore, the relationship between the measured outcome and the implementation of PSWs has rarely been examined. Specifically, little research has explored how the effectiveness of PSW’s contribution relates to the preparedness of the setting — in terms of service organisation and training of professionals —­­ \u0026nbsp;to implement peer support [8, 25]. Moreover, further research is needed to determine whether PSWs serve as catalysts for the transformation of mental health services towards a rights-based, person-centred approach or whether their involvement reflects a broader shift in professional practices and perspectives [23–25]. Finally, the literature emphasises the need for qualitative research to identify the factors that facilitate or hinder the implementation of peer support [9].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was carried out in the mental health services of the Friuli Venezia Giulia region in Italy, which was the pivotal site in the genesis of the Italian deinstitutionalisation process. This movement had national and international reach and led to a profound transformation in psychiatric healthcare through the abolition of asylums and the development of a rich network of community care focused on promoting patients’ empowerment and self-determination [26–28]. To this day, the city of Trieste, the region's main urban centre, continues to function as a vanguard, as evidenced by its WHO collaborating centre for mental health research [29] and an enhanced community care network [30]. The services in Trieste are defined by a collaborative, multidisciplinary approach involving mental health professionals and patients in designing and delivering care [30]. Furthermore, Trieste's mental health system emphasises the importance of social determinants of health and focuses on integrating mental health services with other social services, providing a multidimensional and person-centred approach to care [29, 31]. The core of the organisation is a network of Community Mental Health Centres that are active 24 hours a day, 7 days a week, with relatively few beds in each of them; this organisation is characterised by an “open door” and “no restraint” approach [31]. The regional government of Friuli Venezia Giulia replicated Trieste's model across the region, resulting in low hospitalisation and compulsory treatment rates, effective job placement and social inclusion [29].\u003c/p\u003e\n\u003cp\u003eConsequently, Trieste and its region provide an ideal context for investigating the role of PSWs, analysing the factors driving their involvement, the strategies that have been deployed, the critical issues that have emerged in comparison with other contexts, and whether valuable insights can be drawn from this dynamic landscape of innovation.\u003c/p\u003e\n\u003cp\u003eTo explore these issues while remaining attentive to the structural dynamics affecting PSWs and professionals, we adopted an ethnographic approach that allows for an in-depth exploration of the lived experiences of PSWs and professionals [32, 33].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;\u0026nbsp;Understand the role of PSWs through an in-depth analysis of their current experience in the Friuli Venezia Giulia region.\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;\u0026nbsp;Identify the strengths and challenges of the inclusion of PSWs in mental health services\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp; \u0026nbsp;\u0026nbsp;Outline future perspectives and pathways to ensure that PSWs’ engagement is effective for service users and enriching for the service, fostering a recovery-oriented approach.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted the following ethnographic study: (1) Participant observation: the principal researcher undertook a six-month observation period, attending meetings and events organised by the “PSW Regional Network”, participating in an action-oriented training course for professionals, family members, and PSWs, and shadowing two PSWs in Trieste. (2) Concurrently, the principal researcher conducted 22 semi-structured interviews with PSWs and mental health professionals (MHPs). Each interview lasted approximately 60 minutes and was carried out in Italian. The findings were periodically reviewed and discussed by the research team. The subjects addressed during the interviews encompassed the following: the role of PSWs within the service, the perceived benefits, the critical issues encountered, and the resilience strategies employed or deemed appropriate for implementation. The interviews were conducted in April and May 2024. Informed consent for anonymous data processing was obtained before the interviews were recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants were identified via the snowball sampling method [34]. Following grounded theory principles [35], all PSWs working in Friuli Venezia Giulia during the data collection were included, while the sample size for MHPs was adjusted on the basis of the attainment of theoretical saturation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the interviews were transcribed verbatim and anonymised, distinguishing between MHPs and PSWs to provide context for the quotes. Data analysis followed a deductive-inductive approach, employing the framework method [36]. The final set of summary themes was based on a consensus among the study’s authors. Finally, the results were shared and discussed with the participants, who were also involved in reviewing this paper.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 summarises the professional profile of the PSWs and MHPs interviewed.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"638\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 100%;\"\u003e\n \u003cp\u003eTable 1: Participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.4796%;\"\u003e\n \u003cp\u003e12 PSWs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86.5204%;\"\u003e\n \u003cp\u003e4 PSWs employed on a contract basis in two social cooperatives;\u003c/p\u003e\n \u003cp\u003e3 PSWs volunteering in associations;\u003c/p\u003e\n \u003cp\u003e4 PSWs on a traineeship in mental health services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 13.4796%;\"\u003e\n \u003cp\u003e10 MHPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86.5204%;\"\u003e\n \u003cp\u003e3 psychiatrists;\u003c/p\u003e\n \u003cp\u003e1 psychologist;\u003c/p\u003e\n \u003cp\u003e2 psychiatric rehabilitation specialists\u0026nbsp;;\u003c/p\u003e\n \u003cp\u003e1 social worker;\u003c/p\u003e\n \u003cp\u003e1 public health physician;\u003c/p\u003e\n \u003cp\u003e1 nurse;\u003c/p\u003e\n \u003cp\u003e1 professional educator.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eAnalysis of interviews\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo facilitate understanding, the results collected were grouped and classified by macro themes, as shown in Table 2.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"103%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 100px;\"\u003e\n \u003cp\u003eTable 2: Results overview\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003eActivities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eGroup activities for service-users;\u003c/p\u003e\n \u003cp\u003eAdvocacy and community engagement;\u003c/p\u003e\n \u003cp\u003eTraining for MHPs;\u003c/p\u003e\n \u003cp\u003eSensibilisation of general society;\u003c/p\u003e\n \u003cp\u003eRecovery House;\u003c/p\u003e\n \u003cp\u003eOne-to-one meetings.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003eBenefits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eFoster empathy, understanding and reduction of self-stigma;\u003c/p\u003e\n \u003cp\u003ePromote social inclusion by assisting in daily life activities and facilitating the creation of social networks;\u003c/p\u003e\n \u003cp\u003eEnhance the person\u0026rsquo;s point of view with professionals;\u003c/p\u003e\n \u003cp\u003eAdvocacy for the protection of rights;\u003c/p\u003e\n \u003cp\u003eFoster PSW\u0026rsquo;s own recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003eChallenges\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eStigma and prejudice from MHPs;\u003c/p\u003e\n \u003cp\u003eLack of formal recognition and misuse of PSWs;\u003c/p\u003e\n \u003cp\u003ePower imbalances and resistance to change from MHPs;\u003c/p\u003e\n \u003cp\u003eInstrumentalization and manipulation of PSWs.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003eStrategies for inclusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eEnsure a safeguarding work environment;\u003c/p\u003e\n \u003cp\u003eTraining for MHPs to work with PSWs;\u003c/p\u003e\n \u003cp\u003eInstitutional recognition of PSWs\u0026apos; role;\u003c/p\u003e\n \u003cp\u003eWork in recovery-oriented settings;\u003c/p\u003e\n \u003cp\u003eSynergy between operational motivation and strategic institutional support;\u003c/p\u003e\n \u003cp\u003eCultural and epistemological change in mental health services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eActivity profile\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePSWs were asked to describe their activities. The results are summarised in Table 3.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"663\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 663px;\"\u003e\n \u003cp\u003eTable 3: Activity profile\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003eGroup activities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 487px;\"\u003e\n \u003cp\u003eWeekly or biweekly peer support groups;\u003c/p\u003e\n \u003cp\u003ePeer support in Trieste\u0026rsquo;s psychiatric ward[1] for acute cases;\u003c/p\u003e\n \u003cp\u003eCreative workshops (writing, art, cinema);\u003c/p\u003e\n \u003cp\u003eGroup activities for social integration (excursions, dinners, out-of-town trips of one or more days);\u003c/p\u003e\n \u003cp\u003eWeekly meetings in the acute hospital ward.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003eAdvocacy and Community engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 487px;\"\u003e\n \u003cp\u003ePeer support groups in the suburbs of Trieste;\u003c/p\u003e\n \u003cp\u003eCitizenship awareness activities (conferences and meetings open to the public).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003eTeaching\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 487px;\"\u003e\n \u003cp\u003eAcademic courses at the University of Trieste;\u003c/p\u003e\n \u003cp\u003eTraining for MHPs.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003eCollaboration with MHPs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 487px;\"\u003e\n \u003cp\u003eWeekly reports and monthly meetings with some MHPs: in which the needs identified by the PSWs in the groups they facilitate during the week are reported periodically, as well as cases and events that need special attention from the service.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003eRecovery House\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 487px;\"\u003e\n \u003cp\u003eSupport for daily activities, presence, and active listening with the young residents of a Recovery House;\u003c/p\u003e\n \u003cp\u003eAssistance in recovery programmes such as the \u003cem\u003eWellness Recovery Action Plan.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 176px;\"\u003e\n \u003cp\u003eOne-to-one meetings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 487px;\"\u003e\n \u003cp\u003eIndividual meetings upon request of the service users.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eBenefits of PSWS\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.\u0026nbsp; \u0026nbsp;\u0026nbsp;Fostering empathy, understanding, and reducing self-stigma\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePSWs play a crucial role in actively listening to and understanding distress. They recognise the importance of being present, non-judgmental, and validating emotions. As one PSW noted:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;PSWs know that it is often unhelpful to say \u0026lsquo;Do it! You can do it!\u0026rsquo;. Sometimes, what matters most is standing there in silence, without judgment, and conveying the message that \u0026lsquo;it is okay to feel unwell\u0026rsquo;\u0026rdquo;. (PSW5).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThrough their lived experience, PSWs foster hope and help reduce self-stigma, particularly for individuals in the early stages of recovery, who may feel lost and struggle to believe in their resources. The interviewees emphasised the role of PSWs in normalising mental health conditions, as well as their ability to carry out activities that cultivate peer relationships, ultimately encouraging active participation rather than passive service use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u0026nbsp; \u0026nbsp;\u0026nbsp;Support for social inclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We do not do \u0026lsquo;for\u0026rsquo; others but \u0026lsquo;with\u0026rsquo; others\u0026rdquo;. (PSW8).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the data, PSWs create opportunities for relationships founded on shared experiences, avoiding paternalistic and dependency-inducing support. Instead, they empower individuals to reclaim agency over their lives and their recovery, helping them move beyond the \u0026lsquo;patient\u0026rsquo; identity. This is particularly important, as, as highlighted by interviewees, one of the key challenges of the recovery journey is \u0026ldquo;\u003cem\u003eregaining control over daily life\u0026rdquo;\u003c/em\u003e (PSW5). Furthermore, the study findings also suggest that resources for recovery are not only found within the individual but also enhanced through relationships and participation in group settings.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Participating in group meetings gave us an awareness of our worth. Sharing within the group makes you realise that you are worth it, despite the challenges your story matters\u0026rdquo;. (PSW5).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.\u0026nbsp; \u0026nbsp;\u0026nbsp;Enhancing the person\u0026rsquo;s point of view with professionals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interviewees highlighted the critical mediating role of PSWs in bridging communication between professionals and service users. The power imbalance created by professionals\u0026apos; technical knowledge can sometimes hinder therapeutic effectiveness, as users may struggle to articulate their needs or concerns. For example, when individuals wish to adjust or suspend their medication, they often turn to PSWs, who facilitate discussions with psychiatrists. PSWs emphasised that their role is not about complicity but rather about supporting individuals in recognising and effectively communicating their needs to professionals.\u003c/p\u003e\n\u003cp\u003eMHPs reported that PSWs facilitate professionals in adopting a more human-centred approach, thereby fostering heightened sensitivity towards the individuals with whom they engage. Moreover, PSWs encourage practitioners to embrace risk-taking as part of the empowerment process of the individual, balancing it with necessary support. As one psychiatrist noted:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The PSW has a vision and a sensitivity that we sometimes lack. [...] We worry about our responsibilities, we tend to intervene, to decide for people. I believe that the PSW experience helps me see things more from the patient\u0026rsquo;s perspective\u0026rdquo;. (MHP10).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.\u0026nbsp; \u0026nbsp;\u0026nbsp;Advocacy for the protection of rights\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interviewed PSWs consistently emphasised the importance of advocacy in safeguarding service users\u0026apos; rights. This was particularly evident during the participant observation period: in this region, PSWs\u0026rsquo; advocacy is reflected both in their daily work within services, promoting a person-centred and rights-based approach, and in their involvement in the design and innovation of services and care practices. Moreover, many engage in activism and public awareness campaigns to inform communities about mental health services, reduce stigma, and promote a multidisciplinary understanding of mental illness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5.\u0026nbsp; \u0026nbsp;\u0026nbsp;Enhancing PSWs\u0026rsquo; own recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTraining and professional engagement in peer support constitute essential parts of PSWs\u0026apos; personal recovery journeys. The process of recognising their own lived experiences as valuable tools for helping others reinforces their sense of empowerment. This transformation involves reframing suffering: rather than viewing mental illness as a stigmatising burden, PSWs reinterpret their experiences as a source of insight and resilience. As one participant shared:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;That suffering is enormous, it is heavy and hurts, but when you make sense of things, it becomes your strength\u0026rdquo;. (PSW8).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003ePSWs\u0026rsquo; challenges in mental health services\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.\u0026nbsp; \u0026nbsp;\u0026nbsp;Stigma and prejudice from MHPs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA key challenge identified in the study is the persistent stigma and prejudice harboured by some professionals towards PSWs. This is often expressed through overprotective or excessively cautious attitudes. One PSW described feeling like \u0026ldquo;\u003cem\u003ea problem to be solved\u003c/em\u003e\u0026rdquo; (PSW4), as professionals continued to see him primarily as a former service user rather than acknowledging her skills and contributions. Several interviewees suggested that this prejudice stems from the ambiguity and perceived \u0026ldquo;threat\u0026rdquo; of PSWs\u0026rsquo; role, which challenges the conventional \u003cem\u003e\u0026ldquo;us - healthy vs. them - sick\u0026nbsp;\u003c/em\u003edichotomy\u0026rdquo; (PSW9).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.\u0026nbsp; \u0026nbsp;\u0026nbsp;Lack of formal recognition and misuse of PSW\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn several interviews, an important theme that emerged was that of the improper activities that PSWs were/could be called upon to perform. For example, we identified (1) peer support as \u0026ldquo;employment inclusion\u0026rdquo;: the PSW is assigned menial tasks or duties unrelated to peer support; (2) PSWs as \u0026ldquo;low-cost\u0026rdquo; professional substitutes: sometimes, MHPs perceive PSWs as inexpensive replacements for trained professionals or as general-purpose workers who can perform tasks that mental health professionals prefer to avoid:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You have to be very careful because otherwise, they will offload tasks onto you that they should be doing themselves but don\u0026rsquo;t want to\u0026rdquo;. (PSW6).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMoreover, in Italy, the role of PSWs lacks formal recognition, often resulting in internship-based employment with minimal guarantees. In Trieste, however, PSWs are employed through social cooperatives, offering greater security. Nonetheless, the interviewees emphasised the urgent need for greater institutional recognition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.\u0026nbsp; \u0026nbsp;\u0026nbsp;Power imbalances and resistance to change\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003cem\u003eIs the service ready? Are we ready to question the services in which we work to involve them more?\u0026rdquo;. (MHP, March 2024, field diary).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe interviewees highlighted that power imbalances between professionals and PSWs remain a major barrier to the full integration of PSWs. While PSWs have the potential to encourage professionals to critically reflect on their roles and practices, a reluctance to do so is often reported. One PSW described the difficulty of expressing a dissenting opinion within professional settings. Additionally, PSWs believe that this resistance stems from rigid role definitions and an unwillingness to move away from vertical and hierarchical dynamics, hindering the \u003cem\u003etherapeutic potential\u003c/em\u003e of peer relationships.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Some professionals lack the humility to stop feeling superior to others \u0026mdash; because it\u0026rsquo;s easier to feel legitimised by their professional role\u0026rdquo;. (PSW8).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4.\u0026nbsp; \u0026nbsp;\u0026nbsp;Instrumentalisation and manipulation of PSWs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNumerous interviewees stated the potential risk of instrumentalising PSW as a tool to \u0026quot;hook users\u0026quot; and \u0026quot;increase user compliance\u0026quot; with recovery programmes. Indeed, some PSWs perceive the risk of being manipulated as \u0026ldquo;\u003cem\u003epuppets in the hands of the system\u003c/em\u003e\u0026rdquo; (PSW11). As one PSW described her experience during an internship at a suburban mental rehabilitation service that was inadequately prepared to involve PSWs:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;They send me to talk to the users and afterwards I have to report what they tell me because the users speak a little bit more willingly with me than with the educator, so basically I am a pawn, they send me where they do not get\u0026rdquo;. (PSW10).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, one psychiatrist criticised the potential risk of using PSWs instrumentally to give the service a more humane and avant-garde appearance. Consequently, it appears to be a \u0026ldquo;\u003cem\u003econcession\u0026rdquo;\u0026nbsp;\u003c/em\u003e(MHP4) of a space within which PSWs can act and express themselves:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The PSW should not be \u0026lsquo;in the service of the service\u0026rsquo;. However, often the current reality is like that, and it is difficult for it not to be so [...] it is difficult for one to express criticism, suggestions, observations or to go into conflict because one would be \u0026lsquo;the last wheel on the wagon\u0026rsquo; anyway, would not one?\u0026rdquo;. (PSW1).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne MHP identified the risk that, despite the openness of services in contexts such as Trieste, subtle power imbalances and paternalistic attitudes may still limit the innovative potential of peer support, by constraining PSWs within institutional structures.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;In the beginning, the director wanted the PSWs and he was the one pushing it, [...] but I have always perceived it as: \u0026lsquo;Do it, but do it like this\u0026rsquo; and \u0026lsquo;do it there, where could also improve the image of the service\u0026rsquo;, [...]. Therefore, perhaps in another context, it could have grown more. In my opinion, those who are \u0026lsquo;hungry\u0026rsquo; are also more active [...]; in other contexts where the enemy is very clear, where the enemy does not cooperate with you and does not tell you \u0026lsquo;Do this, do that\u0026hellip;I\u0026apos;ll pay you\u0026rsquo;, maybe it is easier to create something real, heartfelt, with motivation\u0026rdquo;. (MHP7).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eStrategies for effective implementation\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study identified the following strategies as effective measures for safeguarding PSWs during their employment within mental health services and ensuring effective inclusion:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1)\u0026nbsp; \u0026nbsp;\u0026nbsp;Ensuring safeguarding work inclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe respondents described several strategies implemented in Friuli Venezia Giulia as follows:\u003c/p\u003e\n\u003cp\u003ea.\u0026nbsp; \u0026nbsp;\u0026nbsp;Group and team work: Working in pairs or teams represents the main form of safeguarding, as it provides mutual \u003cem\u003eintervision,\u003c/em\u003e helps identify moments of vulnerability and ensures support for the safety of both PSWs and users.\u003c/p\u003e\n\u003cp\u003eb.\u0026nbsp; \u0026nbsp;\u0026nbsp;Periodic supervision by a tutor or psychologist\u003c/p\u003e\n\u003cp\u003ec.\u0026nbsp; \u0026nbsp;\u0026nbsp;Working in contexts separate from where one is/was a user helps PSWs establish professional relationships with mental health service colleagues while \u0026ldquo;\u003cem\u003epreserving the right to be \u0026lsquo;treated as a user\u0026rsquo; in a different service\u0026rdquo;\u003c/em\u003e (PSW12). This ensures adequate professional detachment, although it is not always practised, as seen in Trieste, where PSWs work in the same services where they are also users.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2)\u0026nbsp; \u0026nbsp;\u0026nbsp;Training MHPs to work with PSWs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the data, the training of MHPs is not only a measure to safeguard PSWs but also a prerequisite for the effective implementation of PSWs. Another pivotal element that emerged is that training, to be effective, must be conducted by or with individuals with lived experience. Moreover, training has a purpose that goes beyond mere knowledge of peer support and PSWs\u0026rsquo; activity profile but should inspire a change in perspective, leading to the overcoming of stigma and prejudice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3)\u0026nbsp; \u0026nbsp;\u0026nbsp;Institutional recognition of PSWs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo effectively and meaningfully implement peer support, institutional recognition by the Ministry of Enterprises and Made in Italy of the professional figure is essential. This would clarify the role of PSWs and enable proper integration of PSWs into services through appropriate contracts, clear job expectations and sufficient organisational support. In 2024, a professional association (AIPESP[2]) was established in Italy to promote the institutional recognition of the PSW role. According to the respondents, such recognition could help safeguard their labour rights, create dedicated job opportunities, and, most importantly, affirm the legitimacy and societal value of their work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4)\u0026nbsp; \u0026nbsp;\u0026nbsp;Synergy between motivation at the operational level and institutional support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany of the interviewees believe that there is a need for greater synergy between motivation at the \u0026ldquo;operational\u0026rdquo; level (on the part of PSWs and professionals) and interest at the \u0026ldquo;strategic\u0026rdquo; level. The inclusion of PSWs at the strategic level implies the development of co-produced pathways in which PSWs are called upon, alongside professionals, to build services that meet users\u0026apos; needs and expectations. For example, according to the new regional directives, mental health services in Friuli Venezia Giulia will be required to collaborate primarily with social cooperatives that employ PSWs as part\u0026nbsp;of\u0026nbsp;their\u0026nbsp;staff.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5)\u0026nbsp; \u0026nbsp;\u0026nbsp;Enhancing experiential knowledge in decision-making spaces and research context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe interviewees emphasised the need to recognise experiential knowledge as equally important as technical-academic expertise, arguing that its integration could enhance clinical practices by making them more responsive to individuals\u0026apos; lived experiences.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The experience of these individuals should be made comparable to that of the professional. What you read in a book and what you experience firsthand could be two parallel systems of knowledge\u0026rdquo;. (MHP4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6)\u0026nbsp; \u0026nbsp;\u0026nbsp;Cultural and epistemological change in mental health services\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe key issue that emerged from the interviews and participant observation is that the inclusion of PSWs in mental health services requires a profound cultural shift. This change involves rediscovering a genuine commitment to supporting individuals and their lived experiences and, according to some, recognising that many forms of suffering in mental health are primarily social and cannot be addressed only through a narrow biomedical approach.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;If you deal with mental health, you cannot but deal with social justice. Let\u0026rsquo;s talk about social justice! We are talking about abuse, violence, discrimination, marginality, and abandonment. [...] That is, you cannot but reflect on the fact \u0026quot;What can I do to give these people a perspective?\u0026rdquo; \u0026raquo;. (MHP8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e[1] \u0026ldquo;Servizio psichiatrico di diagnosi e cura (SPDC)\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e[2] \u0026nbsp;AIPESP is the acronimous of \u0026ldquo;Associazione Italiana Persone Esperte in Supporto tra Pari\u0026rdquo; (trad. Italian association of PSWs). For fourther information please consult https://aipesp.it/\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003ePositive impact of peer support\u003c/h2\u003e \u003cp\u003eThe profile of PSWs in Friuli Venezia Giulia aligns with the values and practices reported in other international studies. Notably, it plays a pivotal role in facilitating service users' recovery, contributing to personal recovery outcomes, sense of self-efficacy and self-esteem [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and empowerment [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]; reducing self-stigma [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and loneliness [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]; and fostering feelings of hope and enhanced quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Furthermore, in this local context, PSWs have a clear community-oriented approach: the emphasis on group activities and the special focus on rebuilding social ties demonstrate that the work is aimed not only at individual recovery but also at community empowerment, driven by a strong commitment to advocating for the rights and participation of people with mental disorders. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Consequently, PSWs emerge as key players in the social inclusion of people with complex needs, facilitating the construction or restructuring of a social network and acting as intermediaries between the person and their community of reference [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Moreover, PSWs can change the narrative and \u003cem\u003eimaginary\u003c/em\u003e around mental illness, becoming a powerful tool to eradicate stigma and prejudice within both communities and mental health services, and proving that individuals\u0026rsquo; participation and engagement could be a valuable alternative to paternalistic and dependency-inducing care. PSWs therefore help the individual create a space for the disclosure of suffering, constructing an \u003cem\u003eacceptable representation\u003c/em\u003e of one's experience of distress [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which recalls the medical anthropology concept of \u003cem\u003esymbolic efficacy\u003c/em\u003e [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. According to this concept, healing involves the construction of a \u003cem\u003erepresentational space\u003c/em\u003e that gives meaning to one's experience of illness [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Furthermore, PSWs seem to impact the implementation of quality mental health care practices, such as care humanisation, person-centred and rights-based approaches [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and mediation between service users and professionals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Finally, our study highlighted the positive impact of peer support on PSWs\u0026rsquo; own recovery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eChallenges for implementation\u003c/h2\u003e \u003cp\u003eThis ethnographic study identified several critical issues related to the involvement of PSWs in mental health services, echoing those reported in the extant literature [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Among these, stigma and prejudice are undoubtedly significant, as they often persist as dismissive and biased attitudes from many professionals [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, our study highlights the risk of instrumentalizing and manipulating PSWs, i.e., using PSWs to obtain users\u0026rsquo; compliance with therapies or as a label of the quality of the service and its recovery-oriented practices [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Another limitation lies in the reluctance of professionals to recognise the inherent power asymmetry with service users (including PSWs), as well as the hierarchical structure of mental health services and the social control mandate embedded within these systems [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Without addressing these dynamics, we believe that the ultimate authority is likely to remain firmly in the hands of professionals [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConsequently, our study emphasises the importance of supporting PSWs within mental health services. We have identified several strategies to protect PSWs in their work, such as training, teamwork, supervision and support from the trusted social and health network, as well as the essential training of health personnel and a clear definition of PSWs\u0026rsquo; professional profile [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Another key issue emerging from our study is the institutional recognition of PSWs. This is essential for securing appropriate contractual status, ensuring fidelity to their role and competencies and reducing burnout by establishing clear expectations and organisational support [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. While we consider this process nearly unavoidable, we also acknowledge, in line with other studies, the risk that professionalisation may undermine the peer nature of relationships and lead to the institutional assimilation of PSWs [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Institutional recognition, however, is not merely a bureaucratic necessity; it must be accompanied by strong managerial commitment and adequate resource allocation to foster an environment conducive to effective collaboration. Without these conditions, the inclusion of PSWs risks being superficial, reinforcing conventional service models rather than fostering genuine peer support-oriented programmes. In this sense, assuming that PSW integration alone can radically transform traditional services \u0026mdash; particularly those not oriented toward a person-centred and community-based approach [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] \u0026mdash; may inadvertently lead to the development of standardised programmes delivered by PSWs rather than initiatives truly grounded in peer support principles [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eImplementation perspectives for research and services\u003c/h3\u003e\n\u003cp\u003eAccording to our results, we suggest that PSWs\u0026rsquo; involvement should not be limited to daily practices at an operational level but should actively involve PSWs in decision-making processes within services and academic research groups. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. This would imply an organisational commitment that can guide resource allocation, service design, evaluation and management for and with PSWs [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. Furthermore, while we recognise the fundamental importance of evaluating the effectiveness of peer support work in mental health services, such an evaluation requires either preliminary studies or a clear definition of the context in which peer support is assessed and the outcomes measured within the trial [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Additionally, we contend that the evaluation of peer support effectiveness should not be confined solely to clinical recovery criteria, but should also encompass measures of personal recovery, quality of life, social inclusion, self-determination and, crucially, its impact on service practices and organisation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Moreover, we argue that while the work of PSWs can encourage professionals to reflect on and humanise their practices, cultural change is a necessary condition for PSWs to perform their roles effectively [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Such a change would enable PSWs to freely express their perspectives and contribute to the innovation of services. Cultural change relies on developing an integrated and complex understanding of illness and care, one that is deeply attuned to the social determinants of health [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] and health inequalities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. More importantly, it requires an acknowledgement that this complexity can only surface through listening to and valuing lived experiences [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. The effective engagement of PSWs can be a cornerstone of this transformation, offering an opportunity to catalyse these reflections, as it provides a chance to shift the lens through which mental health suffering is understood. Finally, we believe that cultural change necessitates an epistemic shift: one that equips professionals not only with the emotional disposition but also with the tools to prioritise individuals\u0026rsquo; lived experiences, allowing them to co-construct their path of healing using resources provided by services [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In summary, paraphrasing Diana and Nikolas Rose, this shift must transition from \u0026ldquo;involving individuals in services\u0026rdquo; to \u0026ldquo;involving services in the lived world of individuals\u0026rdquo; [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe ethnographic nature of this study highlights several critical factors that define the modalities of engaging PSWs in mental health and, consequently, their effectiveness within and for services [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The study explores the role of PSWs in a context where it has never been previously described, highlighting its local specificities and international affinities. Through this research, we emphasise the importance of ensuring that care practices arising from the involvement of individuals with lived experience are grounded in a reflective process. This process should encourage services to critically examine their organisational models and the cultural production inherent in their practices. The introduction of PSWs, and more broadly, of experiential knowledge, can serve as a pivotal moment in a broader rethinking of medicine and the biomedical model of care. This reconceptualisation has the potential to become what could be described as \u0026mdash; paraphrasing Franco Basaglia \u0026mdash; \u0026ldquo;a practical inversion imbued with utopian elements\u0026rdquo;[\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare that are relevant to the content of this article\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the interview participants for sharing their thoughts and experiences. They also wish to express their gratitude to Dr Chiara Laurini for her invaluable support, and to Dr Izabel Marin for her valuable assistance throughout the research process. The authors are additionally grateful to Prof. Gian Maria Galeazzi for his valuable advice\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative data (interview transcripts and field notes) generated and analysed during the current study are not publicly available due to concerns regarding participant confidentiality and privacy. However, anonymised data extracts may be made available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHIC DECLARATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Bioethics Committee of the University of Bologna (reference 0101688 of 9/04/24). All participants signed written informed consent forms to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWorld Health Organization (2019) QualityRights materials for training, guidance and transformation. WHO, Geneva\u003c/li\u003e\n \u003cli\u003eRose D (2014) The mainstreaming of recovery. J Ment Health 23:217\u0026ndash;218\u003c/li\u003e\n \u003cli\u003eNapier AD, Ancarno C, Butler B, et al (2014) Culture and health. The Lancet 384:1607\u0026ndash;1639\u003c/li\u003e\n \u003cli\u003ePatel V, Saxena S, Lund C, et al (2018) The Lancet Commission on global mental health and sustainable development. 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Ment Health Soc Incl 21:133\u0026ndash;143\u003c/li\u003e\n \u003cli\u003eGillard S, Foster R, White S, et al (2024) Implementing peer support into practice in mental health services: a qualitative comparative case study. BMC Health Serv Res. https://doi.org/10.1186/s12913-024-11447-5\u003c/li\u003e\n \u003cli\u003ePortacolone E, Segal SP, Mezzina R, Scheper-Hughes N, Okin RL (2015) A Tale of Two Cities: The Exploration of the Trieste Public Psychiatry Model in San Francisco. Cult Med Psychiatry 39:680\u0026ndash;697\u003c/li\u003e\n \u003cli\u003eSashidharan SP (2022) Why Trieste matters. Br J Psychiatry 220:52\u0026ndash;53\u003c/li\u003e\n \u003cli\u003eMuusse C, Kroon H, Mulder CL, Pols J (2020) Working on and with Relationships: Relational Work and Spatial Understandings of Good Care in Community Mental Healthcare in Trieste. Cult Med Psychiatry 44:544\u0026ndash;564\u003c/li\u003e\n \u003cli\u003eMezzina R (2016) Creating mental health services without exclusion or restraint but with open doors Trieste, Italy. Inf Psychiatr 92:747\u0026ndash;754\u003c/li\u003e\n \u003cli\u003eBono M, Lapierre J, Morin P (2024) Caring for People and Territories: Brief Historical Review of the Intersectoral Social Innovation Experience of Trieste and Its Habitat Micro-Area Program. Can J Nonprofit Soc Econ Res 15:13 pp-13 pp\u003c/li\u003e\n \u003cli\u003eMezzina R (2014) Community mental health care in Trieste and beyond: an \u0026ldquo;open door-no restraint\u0026rdquo; system of care for recovery and citizenship. J Nerv Ment Dis 202:440\u0026ndash;445\u003c/li\u003e\n \u003cli\u003eSavage J (2000) Ethnography and health care. BMJ 321:1400\u0026ndash;1402\u003c/li\u003e\n \u003cli\u003eSavage J (2006) Ethnographic evidence: The value of applied ethnography in healthcare. J Res Nurs 11:383\u0026ndash;393\u003c/li\u003e\n \u003cli\u003eParker C, Scott S, Geddes A (2019) Snowball Sampling. SAGE Res. Methods Found.\u003c/li\u003e\n \u003cli\u003eGlaser B, Strauss A (2017) Discovery of Grounded Theory: Strategies for Qualitative Research. https://doi.org/10.4324/9780203793206\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3:77\u0026ndash;101\u003c/li\u003e\n \u003cli\u003ePeck CKH, Thangavelu DP, Li Z, Goh YS (2023) Effects of peer-delivered self-management, recovery education interventions for individuals with severe and enduring mental health challenges: A meta-analysis. J Psychiatr Ment Health Nurs 30:54\u0026ndash;73\u003c/li\u003e\n \u003cli\u003eThomas EC, Simmons MB, Mathai C, Salzer MS (2023) Peer-Facilitated Decision Making in Mental Health: Promises, Pitfalls, and Recommendations for Research and Practice. Psychiatr Serv 74:401\u0026ndash;406\u003c/li\u003e\n \u003cli\u003ePitt VJ, Lowe D, Prictor M, Hetrick S, Ryan R, Berends L, Hill S (2013) A systematic review of consumer-providers\u0026rsquo; effects on client outcomes in statutory mental health services: The evidence and the path beyond. J Soc Soc Work Res 4:333\u0026ndash;356\u003c/li\u003e\n \u003cli\u003eWhite S, Foster R, Marks J, Morshead R, Goldsmith L, Barlow S, Sin J, Gillard S (2020) The effectiveness of one-to-one peer support in mental health services: a systematic review and meta-analysis. BMC Psychiatry 20:534\u003c/li\u003e\n \u003cli\u003ePizza G (2005) Antropologia medica. Saperi, pratiche e politiche del corpo. Carrocci\u003c/li\u003e\n \u003cli\u003eComprehensive mental health service networks: Promoting person-centred and rights-based approaches. https://www.who.int/publications/i/item/9789240025844. 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J Ment Health 20:392\u0026ndash;411\u003c/li\u003e\n \u003cli\u003eSlade M, Amering M, Farkas M, Hamilton B, O\u0026rsquo;Hagan M, Panther G, Perkins R, Shepherd G, Tse S, Whitley R (2014) Uses and abuses of recovery: implementing recovery-oriented practices in mental health systems. World Psychiatry 13:12\u0026ndash;20\u003c/li\u003e\n \u003cli\u003eRose D, Rose N (2023) Is \u0026lsquo;another\u0026rsquo; psychiatry possible? Psychol Med 53:46\u0026ndash;54\u003c/li\u003e\n \u003cli\u003eDavidson L, Bellamy C, Guy K, Miller R (2012) Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry 11:123\u0026ndash;128\u003c/li\u003e\n \u003cli\u003eBrown LD, Vasquez D, Wolf J, Robison J, Hartigan L, Hollman R (2024) Supporting Peer Support Workers and Their Supervisors: Cluster-Randomized Trial Evaluating a Systems-Level Intervention. Psychiatr Serv 75:514\u0026ndash;520\u003c/li\u003e\n \u003cli\u003eReeves V, McIntyre H, Loughhead M, Halpin MA, Procter N (2024) Actions targeting the integration of peer workforces in mental health organisations: a mixed-methods systematic review. BMC Psychiatry 24:211\u003c/li\u003e\n \u003cli\u003eZisman-Ilani Y, Byrne L (2023) Shared Decision Making and Peer Support: New Directions for Research and Practice. Psychiatr Serv 74:427\u0026ndash;428\u003c/li\u003e\n \u003cli\u003eGillard S, Foster R, White S, et al (2022) The impact of working as a peer worker in mental health services: a longitudinal mixed methods study. BMC Psychiatry 22:373\u003c/li\u003e\n \u003cli\u003eBreilh J (2023) The social determination of health and the transformation of rights and ethics: A meta-critical methodology for responsible and reparative science. Glob Public Health 18:2193830\u003c/li\u003e\n \u003cli\u003eBasaglia F, Ongaro FB (2024) Crimini di pace. Baldini \u0026amp; Castoldi\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Peer support workers, People with lived experience, Recovery-oriented practices, Mental Health Services, Community psychiatry, Ethnography.","lastPublishedDoi":"10.21203/rs.3.rs-6247366/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6247366/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003e Peer support, endorsed by the WHO and national guidelines, is increasingly recognised and promoted worldwide. However, innovative approaches are needed to evaluate the implementation of Peer Support Workers (PSWs) and their impact on mental health services. This study investigates the role of PSWs in Trieste and its region, a pivotal site of Italy\u0026rsquo;s psychiatric reform, where the deinstitutionalisation movement fostered the transition to a community-based care model.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe present study adopted an ethnographic methodology, encompassing a six-month field study involving participant observation and 22 semi-structured interviews with 12 PSWs and 10 mental health professionals.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThis study investigates the role, values, and benefits of peer support in mental health services within a specific Italian region, examining its impact on service users and its contributions to the humanisation and innovation of care. By analysing the perspectives of both PSWs and professionals, this research offers a comprehensive assessment of its significance. It also identifies the critical challenges related to the involvement and recognition of PSWs, employing an anthropological approach to identify operational difficulties and epistemological assumptions, which often constrain the full integration of PSWs. Moreover, the study proposes strategies for strengthening the role of PSWs and enhancing the consideration of experiential knowledge in mental health services.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn addition to their clinical effectiveness in supporting individuals' recovery, PSWs represent an opportunity for mental health services to critically reflect on their practices and the cultural assumptions underpinning them. These reflections have the potential to create meaningful innovation in psychiatric care\u003c/p\u003e","manuscriptTitle":"Exploring the Integration of Peer Support Workers and Their Experiential Knowledge in Mental Health Services: An Ethnographic Study from the Dual Perspectives of Peer Support Workers and Professionals in Trieste and its Region","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-25 05:05:04","doi":"10.21203/rs.3.rs-6247366/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"02db2033-b396-4b9b-9b38-60dde19c2f88","owner":[],"postedDate":"March 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-30T16:05:52+00:00","versionOfRecord":{"articleIdentity":"rs-6247366","link":"https://doi.org/10.1007/s10597-025-01513-5","journal":{"identity":"community-mental-health-journal","isVorOnly":false,"title":"Community Mental Health Journal"},"publishedOn":"2025-09-16 00:00:00","publishedOnDateReadable":"September 16th, 2025"},"versionCreatedAt":"2025-03-25 05:05:04","video":"","vorDoi":"10.1007/s10597-025-01513-5","vorDoiUrl":"https://doi.org/10.1007/s10597-025-01513-5","workflowStages":[]},"version":"v1","identity":"rs-6247366","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6247366","identity":"rs-6247366","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}