“We must be the thorn in the side": experiences with implementing family peer support workers in adult mental health care

“We must be the thorn in the side": experiences with implementing family peer support workers in adult mental health care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “We must be the thorn in the side": experiences with implementing family peer support workers in adult mental health care Aline Pouille, Dries Leclercq, Elke Van Lierde, Nele Feryn, Kim Steeman, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9366429/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract While family peer support workers are increasingly put forward as a means of enhancing family involvement in adult mental health care, research on their impact and implementation remains scarce. This study explores both the added value of, and the preconditions for, the successful implementation of family peer support workers in adult mental health care. A qualitative design was employed, consisting of semi-structured interviews with four family peer support workers, six hospital policymakers, and ten mental health professionals from two hospitals in Flanders, Belgium, that recently employed family peer support workers. Participants perceived family peer support workers as contributing to improved family involvement and more family-sensitive care. However, successful implementation was found to depend on a set of interrelated macro-, meso-, and micro-level preconditions, including: (1) a co-created and well-considered policy vision and implementation framework; (2) a clear yet flexible role description and competency profile; (3) a conducive organisational culture and departmental climate, as well as supportive professional attitudes; and (4) adequate time and resources. These preconditions provide a foundation for the everyday legitimacy of family peer support workers, which is realised through relational trust and collaborative practice. At the same time, their implementation remains pioneering work, characterised by ongoing negotiation, with stigma still surrounding both family involvement and experiential knowledge. Family peer support workers family engagement mental health services implementation organizational culture experiential knowledge Introduction Mental illness does not only affect the individuals experiencing it, but also profoundly impacts their families, close relatives and significant others (further referred to as ‘family/families’) (Sakwape et al., 2025 ; Sampogna et al., 2023 ). Family members face both objective (e.g., time and money devoted to care) and subjective (e.g., anxiety and stress) burden (Javed & Herrman, 2017 ; Sampogna et al., 2023 ; Shalaby & Agyapong, 2020 ) and need to undergo their own family recovery process (Galimidi & Shamai, 2022 ; Rowaert et al., 2022 ; Tingleff et al., 2022 ). This process is not merely an individual adjustment but a relational and systemic process, requiring mental health services to actively involve, inform, and support families as partners in care (Galimidi & Shamai, 2022 ; Javed & Herrman, 2017 ; Tingleff et al., 2022 ; Vanlinthout et al., 2020 ). Besides supporting family recovery processes, family involvement has also shown to improve patients’ well-being, functionality, quality of life and long-term recovery (Javed & Herrman, 2017 ; Leggatt & Woodhead, 2016 ). Family involvement exists along a continuum ranging from basic information sharing to more specialised involvement programmes. Ideally, it should be understood as a collaborative partnership among the triad of patients, mental health care professionals and family members (Rowaert et al., 2022 ; Tham & Solomon, 2024 ; Van Schoors et al., 2023 ). In adult mental health care, family involvement has increasingly been recognized not merely as an adjunct to professional services, but as a fundamental component of recovery-oriented care (Duckworth & Halpern, 2014 ; Javed & Herrman, 2017 ; Sakwape et al., 2025 ). Translating this recognition into consistent, structured practice, however, remains a challenge (Javed & Herrman, 2017 ; Tham & Solomon, 2024 ). This relates to the fact that prevailing organisational cultures, in which biomedical perspectives remain dominant, do not prioritise or structurally support family-minded work. This is further compounded by the shortage or unawareness of clear practice guidelines (Eassom et al., 2014 ; Tham & Solomon, 2024 ; Vanlinthout et al., 2020 ). Hence, there is a need for innovative and practical approaches that facilitate family involvement (Cheng et al., 2022 ; Tham & Solomon, 2024 ). Family Peer Support Workers (FPSWs) represent one such innovation aiming to bridge gaps between patients, families, and care teams by leveraging lived experience and fostering triadic partnerships (Leggatt & Woodhead, 2016 ; Rowaert et al., 2022 ; Tham & Solomon, 2024 ). The concept of ‘family peer support worker’ can be understood using the distinction between experience, experiential knowledge, and experiential expertise (Halloy et al., 2023 ; Kirkegaard, 2022 ). Experience refers to the direct and personal encounter with a situation, such as living with mental illness or supporting a relative who does. Through reflection, dialogue, and engagement with additional sources of understanding such as lectures and books, these individual experiences can be transformed into experiential knowledge . When such knowledge is systematically articulated, transferred, and applied to the benefit of others, it is considered experiential expertise (Halloy et al., 2023 ; Kirkegaard, 2022 ). This expertise is the basis for FPSWs to support family members and enhance family involvement in mental health care (Kirkegaard, 2022 ; Shalaby & Agyapong, 2020 ). Most research on FPSWs has been conducted in child and adolescent mental health care or paediatric settings (e.g., Hopkins et al., 2021 ; Leggatt & Woodhead, 2016 ; Wodinski et al., 2017 ). In adult mental health care, research is more limited and has mainly focused on peer-led family education programs and family-led mutual-support groups. These interventions generally improve families’ knowledge, empowerment, and problem solving-skills, but show mixed effects on burden and overall functioning (Chien et al., 2018 ; Dixon et al., 2011 ; Rowaert et al., 2018 ; Wang et al., 2022 ). Only a few studies specifically focus on formal FPSWs in adult mental health care (Barr et al., 2023 ; Visa & Harvey, 2019 ). As discussed in both paediatric and adult mental health literature, FPSWs enhance social connectedness and provide emotional support, reducing feelings of isolation and stigma among family members. Family members view FPSWs as role models embodying hope that their situation can improve. They report that it is easier to build trust with FPSWs than with clinical professionals, due to their collaborative and reciprocal relational style (Barr et al., 2023 ; Visa & Harvey, 2019 ; Wodinski et al., 2017 ). Additionally, FPSWs are valued for their bridging role between families and the care team (Hopkins et al., 2021 ; Wodinski et al., 2017 ) and for offering practical support and relevant information based on their own experience (Barr et al., 2023 ; Visa & Harvey, 2019 ). Studies highlight the need for FPSWs to be more consistently available for family members, better integrated within services, and supported through supervision and training (Barr et al., 2023 ; Hopkins et al., 2021 ; Visa & Harvey, 2019 ). Finally, these studies warrant that FPSW’s work should be aligned with families’ personal, cultural, linguistic and systemic needs (Barr et al., 2023 ; Leggatt & Woodhead, 2016 ; Visa & Harvey, 2019 ). Despite their benefits, FPSWs are relatively new in adult mental health care, and research on their roles, impact and implementation remains limited (Barr et al., 2023 ; Visa & Harvey, 2019 ). In Flanders, Belgium, psychiatric hospitals have only recently began to integrate FPSWs into their services. This presents a unique opportunity to explore the perspectives of key stakeholders - including FPSWs, hospital policymakers (further referred to as ‘policymakers’), and other staff who collaborate with FPSWs (further referred to as ‘professionals’) - regarding the added value of implementing FPSWs, as well as the associated challenges and facilitators. Methods This study explores the experiences and perspectives of key stakeholders directly involved in the deployment of FPSWs in Flanders (Belgium). Recruitment and sample This research was conducted in two psychiatric hospitals that employed at least one paid FPSW at the time of the study. Both psychiatric hospitals offer a wide range of services, including residential care, outpatient support, day programs, and social reintegration programs to persons with (complex) mental health disorders. Participants were recruited between January and March 2024, through purposive sampling facilitated by organisational gatekeepers (Ahmad & Wilkins, 2025 ). These gatekeepers were internal contact persons within each participating institution, who identified potential participants based on predefined role-specific eligibility criteria. FPSWs were eligible if they held a formal FPSW position within the participating hospitals at the time of the study. Policymakers were defined as staff members involved in the implementation of FPSW roles. Professionals include clinical and support staff (e.g., nurses, patient peer support workers, and other relevant care professionals) who collaborated closely with at least one FPSW. Potential participants gave their consent to the internal contact person to share their contact details with the researchers, after which they were invited for the interview. All participants received and signed an informed consent form explaining the research purpose and their rights. A total of 20 participants were interviewed: four FPSWs, six policymakers, and 10 professionals, of which 13 (including three FPSWs) belonged to organisation A and seven (including one FPSW) belonged to organisation B. Among participating FPSWs, there was heterogeneity in their lived-experience backgrounds, including different relationships with a relative experiencing mental health challenges (e.g., partner, parent, or child). Table 1 offers an overview of the participants. Table 1 Overview of participants Family peer support workers Participant Gender Age range Years of experience as FPSW FPSW 1 Female 45–50 4 years FPSW 2 Female 25–30 1.5 years FPSW 3 Male 50–55 1 year FPSW 4 Female 60–65 4 years Professionals Participant Gender Age Range Function Professional 1 Female 40–45 Head nurse Professional 2 Female 40–45 Head nurse Professional 3 Female 25–30 Psychologist Professional 4 Female 25–30 Nurse Professional 5 Female 25–30 Psychologist Professional 6 Male 45–50 PSW Professional 7 Female 50–55 Psychologist Professional 8 Female 50–55 PSW Professional 9 Female 50–55 Nurse Professional 10 Male 45–50 Department head Hospital policymakers Participant Gender Age Range Function Policymaker 1 Female 45–50 Care coordinator Policymaker 2 Female 45–50 Care manager Policymaker 3 Male 55–60 Chief physician Policymaker 4 Female 30–35 Care coordinator Policymaker 5 Female 35–40 Policy and quality committee member Policymaker 6 Female 45–50 Department coordinator Data collection In-depth interviews were conducted using semi-structured interview guides tailored to participants’ professional roles (FPSWs, policymakers, and professionals), while retaining a shared overarching thematic structure. The themes addressed were (1) motivations to work as, work with, or implement FPSWs; (2) barriers and facilitators related to FPSW implementation; (3) collaboration; and (4) perceived impact. Participants were offered the choice between an in-person interview at a location of their preference or a remote interview. All participants chose the remote option, with interviews conducted via Microsoft Teams (n = 18) or by telephone (n = 2). With consent of the participants the interviews were recorded, transcribed verbatim and pseudonymised. Data analysis The interviews were thematically analysed following the guidelines of Braun and Clarke ( 2006 ). The thematic analysis led to the identification of shared experiences and perspectives, while also noting differences in how these themes were understood and experienced according to participants’ professional roles. Participants were provided with the results of the analysis and confirmed the accuracy of its content. In what follows, we use the term ’participants’ when referring to experiences shared across job profiles, and specify the individual groups (FPSWs, policymakers, and professionals) when describing aspects specific to particular groups. Findings First, the results first present the perceived impact of FPSWs. Second, they elaborate on the interrelated barriers and facilitators to effective FPSW implementation that arose from the data, namely: 1) policy vision and implementation framework, 2) job description and competency profile, 3) organisational culture, departmental climate and professional attitudes and 4) time and resources. 1. Perceived impact of FPSWs Several participants described FPSWs as deeply committed to enriching care practices and supporting families by sharing personal experiences. The FPSW takes that on as a kind of mission. She feels called to do it, so she will do it. That gives you an extra strength. We are less guided by our own experiences, we never experienced that as professionals, but she has. (Policymaker 6) Participants indicated that FPSWs functioned as role models for family members, which policymakers noted as a motivating factor for families to be involved in treatment and a unique added value to professional perspectives. According to all participant profiles, FPSWs developed a range of family-supportive interventions that did not exist before their deployment. They informed and involved family members through brochures, newsletters, and family-oriented activities, and provided emotional and practical support through one-to-one contact and peer support groups. According to FPSWs, family members often express their gratitude for their family-engaging work. They mentioned that family members seem to especially appreciate how honest they can be with the FPSW, indicating they feel safe and unjudged by them. Additionally, several participants discussed that FPSWs create opportunities for reflection within care teams, and raise awareness about families’ needs. Professionals reported that interacting with FPSWs made them more alert to family perspectives and helped increase family-friendliness of wards. So they also bring additional reflection into the team about matters that, for us, may have already been closed off or that we were less aware of. I definitely see that as an added value. (Professional 10) By consistently keeping family involvement on the agenda, ensuring that family-related initiatives and policies are implemented, and representing the family perspective, participants indicated that FPSWs contributed to triadic working within the organisations. If you personify the family and have someone there in a symbolic function representing them, then you can do triadic working even more effectively. (Policymaker 5) 2. Barriers and facilitators for the effective implementation of FPSWs 2.1. Policy vision and implementation framework Most policymakers, FPSWs, and professionals emphasized the importance of a policy vision that reflects a clear commitment to family involvement and the FPSW role. Policymakers underscored the value of a participatory process for developing this policy vision rather than imposing it top-down, as this may foster organisation-wide commitment. If it comes from good stories, good practices, from an eagerness that gets picked up somewhere and starts to take root within a team, then it has a much greater chance of succeeding than when a top-down policy says, ‘Hey, you have to do something with this’. (Policymaker 4) In both organisations, the policy vision was developed by a ‘family working group’ composed of hospital staff, including policymakers, care staff, and patient peer workers. It was operationalised through a quality framework that defined concrete goals and implementation strategies. FPSWs were introduced as key actors within this framework. To ensure that family involvement remains a shared responsibility rather than resting solely on FPSWs, professionals and policymakers emphasized the value of a departmental lead to reinforce collaboration with FPSWs and families across clinical practice. Participants further mentioned that written policy documents help anchor the vision and clarify related actions and expectations organisation-wide. Policymakers of both hospitals indicated that external family organisations advised them on the policy vision and deployment framework, providing guidance on procedures, coaching and resources. This was considered especially helpful during the early months of the implementation, with these organisations providing support to both hospital staff members and the newly employed FPSWs. Participants emphasised the importance of an introductory period for FPSWs to familiarise themselves with the organisation, its departments, and key staff. They noted that ongoing relationship-building and positive collaborative experiences strengthen professionals’ trust in FPSWs and reinforce their mandate. Professionals added that working with (patient or family) peer support workers, helped them see their value in care and understand the FPSW role. I know, many years ago, when our first patient peer support worker was hired (….) that felt threatening at the time. It felt awkward at meetings and consultations. But I think we got used to the idea of a patient peer support worker, and so the step to a FPSW wasn’t really that big. (Professional 2) Additionally, to increase awareness of the FPSW role and mandate, policymakers and FPSWs emphasised the importance of making the role visible within the hospital through various communication channels (e.g., posters, flyers, meetings, and policy updates), allowing an abstract concept to become an integrated discipline. When someone really becomes a face, you notice that the support broadens. Otherwise, it’s just a concept. You have to understand, a ward is already overwhelmed with so many things - regulations, systems, requirements, and forms that need to be filled out. Then you come with just one more thing. I find it very understandable that they think, ‘Well… what is this?’ They have no idea what it could mean for their ward. (Policymaker 2) Participants from both organisations indicated that the implementation framework should prioritise deploying a team of FPSWs rather than a single individual. A team can foster connectedness, shared ownership, and a safe space for support and reflection. It can also serve as a signal from the organisation that the role is valued, supported, and intended to grow. 2.2. Job description and competency profile of the FPWS Participants saw developing an FPSW job description as a “necessary formality”. Policymakers and professionals noted that a clear description clarifies tasks, responsibilities, and role scope, making the purpose explicit, safeguarding boundaries, and preventing drift into ancillary duties. Yet, professionals and FPSWs also underscore the importance of developing the role and set of tasks of FPSWs gradually, based on continued dialogue with different stakeholders and local needs. As long as we keep looking at each other, speaking, dialoguing, and searching together - because it is ultimately a search together - what value can a FPSW have for our department? That is something that must be maintained. (Professional 4) Additionally, policymakers indicated that a clearly defined job profile provides guidance for the recruitment, selection, and training of FPSWs. This includes defining the competencies needed to fulfil expectations related to the job. In this regard, participants focused on a) prior training requirements and b) personal attributes of the FPSWs. Regarding prior training requirements of FPSWS (a), there were differing views. According to policymakers and professionals, completing a peer support training programme may help FPSWs develop the knowledge and skills needed for the role. While some therefor argued that prior peer-support training should be a prerequisite for FPSWs, others - including all FPSWs - emphasised that the limited availability of fitting programs make mandating such formal training a complex issue and prioritized openness to diverse professional and lived-experience backgrounds. Some policymakers highlighted the added value of prior (para)medical training, particularly for policy work and understanding clinical contexts. In contrast, a policymaker suggested that such a background could create confusion about the FPSW role among families. Regarding personal attributes (b) all participant profiles underscored the importance of emotional resilience, sufficient assertiveness and confidence among FPSWs, as they are confronted with sensitive, potentially triggering topics within a often resistant environment. Most important, however, is the lived experience that enables them to connect with family members’ experiences and provide input to enhance family involvement in care. 2.3. Organisational culture, departmental climate and professional attitudes Participants indicated that FPSWs often face resistance regarding family involvement and their role, rooted in interrelated macro-, meso- and micro-level dynamics. First, participants highlighted structural and organizational factors shaping FPSWs’ experiences. FPSWs often serve as one of the few representatives of the family perspective in multidisciplinary discussions, advocating for families in settings traditionally focused on psychological, medical and patient-centred perspectives. FPSWs indicated that they often find it challenging to operate within these organisational cultures, as they are frequently required to act as “ the thorn in the side”. As FPSW 1 explained: “Sometimes we need to raise issues that others find hard to hear. If a family member says they were not heard or seen, we must be able to give that feedback.” This positioning can generate tension and resistance, particularly when FPSWs raise sensitive issues that are perceived as questioning professional practice. A policymaker noted: “You [FPSWs] can often encounter resistance. You frequently end up getting the door slammed in your face or triggering a defensive reaction from professionals, which means you have very little credibility to bring in something very vulnerable, fragile, because that’s what it is, right? You’re talking about something that might not be going well or shortcomings as seen by family members, and that is vulnerable for professionals, because every professional feels, ‘I came here to do good and take care of others’.” (Policymaker 4) Besides organisational culture, the departmental climate appears to play a significant role in the collaboration between FPSWs and professionals as well. Participants mentioned that a wide range of factors, such as treatment duration, the psychotherapeutic framework, the target population, the setting, and the type of intervention, can influence this. For FPSWs, navigating these diverse departmental cultures can be challenging, as each department presents a unique environment and dynamic. Professionals identified patient resistance to family involvement as a key driver of staff resistance to collaborating with FPSWs. Yet, professionals and policymakers also pointed to stigmatizing attitudes of clinical professionals standing in the way of effective collaboration with FPSWs. They expressed colleagues’ perceptions that FPSWs have difficulties in maintaining a meta-perspective, particularly when personal experiences evoke stress or strong emotional responses. They further indicate that this perception can result in scepticism or doubt about the added value of FPSWs and impact how seriously the role is taken. Sometimes you hear prejudices like: ‘Ah, FPSWs have more difficulty stepping back or seeing other perspectives; they are mainly caught up in their own story.’ (Professional 5) Several FPSWs recognized these attitudes, noting that they sometimes felt pitied or perceived as less competent after sharing personal stories. Across participant groups, it was further emphasised that this resistance of professionals may be rooted in their clinical education that insufficiently addresses the importance of family engagement and the value of experiential expertise. This was perceived to reduce both professionals’ sense of urgency and their preparedness to collaborate with families and FPSWs. Both professionals and FPSWs stressed the importance of respectful, connective language and sensitivity to FPSWs’ potential vulnerabilities. Open, curious, and engaged attitudes from both FPSWs and professionals were seen as key levers for productive collaboration, as well as continuous dialogue and communication. To reduce stigma and address concerns about the FPSW role, policymakers and professionals viewed learning networks, through which they could learn from organisations with FPSW experience, as good practice. 2.4. Time and resources Participants indicated that translating a policy vision to concrete actions requires time, particularly in large, bureaucratic hospitals where transitional processes are slowed. Professionals and FPSWs further indicated that budgetary constraints and related shortage of staff limits opportunities for FPSWs and other professionals to integrate a comprehensive family involvement strategy in care. We cannot be equally intensive on every ward with family evenings, family meetings, or discussions with care providers about family involvement. That’s not feasible. So perhaps it’s not so bad if, occasionally… a door remains closed. Because we simply don’t have enough hands. (FPSW 3) As a result, clinical professionals may be resistant to working with FPSWs due to a fear of having to take on additional tasks alongside their usual duties. FPSWs and policymakers alike highlighted the lack of formal guidelines from local authorities on the official recognition and remuneration of FPSWs. Since FPSWs are not included in official pay scales, health care institutions must decide independently on remuneration. Policymakers and FPSWs noted that strain on organizational budgets may result in the underpayment of FPSWs, as institutions must self-finance these “non-existing functions”. But yes, all of that is so difficult to organize within health care, those are all non-existent functions. They are also not subsidized by the government. So the hospital actually has to finance that overarching framework itself, which is why, well… we’ve currently reached our limit. (Policymaker 1) For FPSWs this led to feelings of undervaluation and inequity. That also sends a signal, you know. We don’t receive the same salary as a patient peer support worker, for example, which says something in itself. Then it is expressed as: ‘It is a valuable addition, but we do not consider it as valuable as a patient peer support worker.’ (FPSW 1) Discussion Main results and their implications for practice and policy Despite growing recognition of the importance of family involvement in adult mental health care and the potential of FPSWs in facilitating this, empirical research on their impact and implementation remains scarce (Barr et al., 2023 ; Visa & Harvey, 2019 ). This study addressed this gap by offering a multi-perspective analysis of FPSWs’ implementation, examining the perceived added value, challenges, and preconditions for successful FPSW implementation from the perspectives of multiple stakeholders. FPSWs are seen as uniquely positioned to build trust with family members by drawing on their lived experience and engaging from a position of equality and reciprocity (Barr et al., 2023 ; Hopkins et al., 2021 ; Visa & Harvey, 2019 ). This is especially important, as family members often feel unheard or patronized by clinical professionals in adult mental health care (Barr et al., 2023 ; Tham & Solomon, 2024 ; Visa & Harvey, 2019 ). FPSWs diversify, facilitate and increase communication with family members and are valued for providing both emotional and practical support to family members (Barr et al., 2023 ; Sakwape et al., 2025 ; Visa & Harvey, 2019 ). This support may strengthen family involvement in care, family members’ wellbeing and their capacity to take up caregiving roles, thereby contributing to broader goals of deinstitutionalisation and community-oriented care (Barr et al., 2023 ; Gorman et al., 2023 ; Sakwape et al., 2025 ). FPSWs also reinforce a family perspective in systems historically dominated by psychological, medical and individualistic paradigms (Leggatt & Woodhead, 2016 ; Tingleff et al., 2022 ). In doing so, FPSWs perform an important reflective and bridging function, fostering greater organisational awareness of family needs and encouraging more family-sensitive and triadic practices focused on collaboration between families, patients, and professionals (Harrison et al., 2020 ; Landeweer et al., 2017 ; Tham & Solomon, 2024 ). At the same time, the findings underscore that the successful implementation of FPSWs is contingent on several interrelated macro-, meso-, and micro-level preconditions: 1) a co-created and well-considered policy vision and implementation framework, 2) a clear but flexible role description and competency profile, 3) a conducive organisational culture and departmental climate, as well as supportive professional attitudes and 4) adequate time and resources. First, formal policy frameworks are pivotal to promote a shared, organisation-wide vision on family involvement and FPSWS, as well as to provide concrete actions to implement this vision. However, this study shows that meaningful and effective integration of FPSWs requires iterative co-creation between policy and practice. This involves continuous dialogue between policymakers, FPSWs, and clinical teams to adapt role descriptions, workflows, and collaboration practices to the realities of everyday care (Eassom et al., 2014 ; Tham & Solomon, 2024 ). Second, a key contribution of this study lies in illuminating the tension between formalisation and flexibility in role requirements and development. Role clarity is considered a necessary formality to increase the mandate of FPSWs and align expectations about the role among FPSWs, professionals and policymakers (Whitson et al., 2025 ). Yet, such role clarity should not imply rigidity. Rather, role descriptions must provide a stable mandate while allowing space for contextual adaptation in line with the strengths of individual FPSWs and the evolving needs of organisations. Some argue the value of FPSWs having a priori paramedical training or formal peer support education, as this may enhance role clarity and interprofessional collaboration within formal care systems (Gillard et al., 2017 ; Repper & Carter, 2011 ). However, as confirmed by the FPSWs and some other participants of this study, such requirements also risk overregulating FPSWs, potentially undermining the authenticity, mutuality, and experiential expertise that constitute the core value of peer support grounded in lived experience (Gillard & Holley, 2014 ; Naughton et al., 2015 ; Vandewalle et al., 2016 ). By highlighting the interplay between role requirements, descriptions and ongoing co-construction of this role and its preconditions in practice, this study adds nuance to existing literature. Interestingly, participants in this study highlighted emotional resilience as a personal requirement for FPSWs, given that the role involves navigating emotionally complex situations and organisational contexts that may be ambivalent or resistant to family involvement while simultaneously advocating for family perspectives (Barr et al., 2023 ; Tham & Solomon, 2024 ; Whitson et al., 2025 ). However, contemporary literature increasingly conceptualises resilience as a dynamic process that emerges through supportive relationships and access to contextual resources, rather than as a fixed personal attribute (Grych et al., 2015 ; Sisto et al., 2019 ). From this perspective, resilience is not simply a personal trait: the challenges faced by FPSWs reflect the broader organisational context, and without supportive structures, even highly resilient individuals would struggle. This underscores the importance of cultivating supportive organisational and departmental cultures, alongside structured support mechanisms for FPSWs (Barr et al., 2023 ; Tham & Solomon, 2024 ; Whitson et al., 2025 ). Third, the findings indicate the need for a clear organisation-wide commitment and shared vision on FPSWs and family involvement (Eassom et al., 2014 ). Supportive attitudes among professionals and policymakers are crucial for the effective implementation of FPSWS, whereas scepticism or stigma undermine FPSWs’ legitimacy and contribute to feelings of underappreciation and uncertainty (Barr et al., 2023 ; Sakwape et al., 2025 ; Tham & Solomon, 2024 ; Whitson et al., 2025 ). Importantly, professionals’ perceptions of resistance to working with FPSWs are not solely individual but are embedded in team cultures, treatment paradigms, and structural constraints, such as limited staffing and insufficient professional training in family involvement (Eassom et al., 2014 ; Ong et al., 2021 ; Tham & Solomon, 2024 ; Whitson et al., 2025 ). In light of the continued influence of personal, social, and structural stigma on the acceptance and implementation of FPSWs, organisations are required to take deliberate action to enhance professionals’ awareness and understanding of the FPSW role, strengthen trust in FPSWs, and establish a clear mandate that enables them to realise the full potential of their role (Barr et al., 2023 ; Whitson et al., 2025 ). Finally, effective implementation also requires sufficient time and resources to cultivate a family-sensitive organisational culture, build strong working relationships between FPSWs and clinical teams, and support professionals in adopting family-oriented practices (Gorman et al., 2023 ; Ong et al., 2021 ; Tham & Solomon, 2024 ). FPSWs should be ensured equitable remuneration as a matter of fairness, role legitimacy, and long-term sustainability (Whitson et al., 2025 ). Limitations and recommendations for future research This study reflects the perspectives of FPSWs, other professionals, and hospital policymakers from two psychiatric hospitals regarding the impact and implementation of FPSWs in their respective contexts. However, patients’ and families’ perspectives were not included and should be addressed in future research (Harrison et al., 2020 ). In addition, the use of purposive sampling via gatekeepers may have introduced selection bias (Ahmad & Wilkins, 2025 ). Further research is needed to strengthen empirical understanding of how FPSWs influence clinical processes, family outcomes, and organisational culture over time. Longitudinal designs could, for example, clarify how FPSWs’ reflective role shapes team practices, how family and patient outcomes develop with FPSW involvement, and which organisational configurations most effectively sustain the FPSW role (Whitson et al., 2025 ). Conclusion Ideally, FPSWs would be structurally embedded as integral members of multidisciplinary, recovery-oriented, and systemic mental health care, with clearly delineated - but flexible - role descriptions, adequate remuneration, and appropriate supervision and organisational support; comparable to other professional roles within the system. In such a context, FPSWs would be institutionally recognised as a core discipline within recovery-oriented care (Whitson et al., 2025 ). However, our findings indicate that this level of integration - despite the implementation of FPSWs - has not yet been realised (Javed & Herrman, 2017 ; Tham & Solomon, 2024 ). The implementation of FPSWs continues to be a gradual and, at times, fragile process, characterised by role ambiguity, negotiation, and persistent stigma surrounding both family involvement and experiential knowledge. As a result, embedding FPSWs often entails pioneering work, accompanied by tensions and uncertainties for FPSWs, other professionals and organisations (Whitson et al., 2025 ). The results indicate that sustainable integration depends on alignment across system-level policy and funding frameworks, organisational culture, and concrete role conditions, which together provide a foundation for the everyday legitimacy realised through relational trust, collaborative practice, and a broadly supported mandate (Barr et al., 2023 ; Tham & Solomon, 2024 ; Whitson et al., 2025 ). Without attention to these interacting levels, the transformative potential of FPSWs risks remaining underutilised. Continued investment in implementation processes, reflexive learning, and systematic knowledge exchange is therefore essential to reach a point where FPSWs are no longer positioned as peripheral or experimental actors, but are fully embedded within multidisciplinary, recovery-oriented mental health care. Declarations Ethics approval This study was conducted in accordance with the guidelines of the ethical standards of the Declaration of Helsinki, the General Ethical Protocol of [blinded for review] and the COREQ Checklist for Reporting Qualitative Research (Tong et al., 2007 ; World Medical Association, 2024 ). Internal scientific committees of the participating institutions gave ethical approval for the study. All participants received and signed an informed consent form explaining the research purpose, data management procedures, and their rights. Author Contribution All authors contributed to the study conception and design. Material preparation and data collection were carried out by Dries Leclercq, with support from the other authors. Data analysis was conducted by Dries Leclercq and Aline Pouille, also with support from the other authors. The manuscript was written by Aline Pouille, and revised by all authors. All authors read and approved the final manuscript. Acknowledgement We thank the participating psychiatric hospitals and all participants for generously sharing their experiences. We also gratefully acknowledge the valuable support of the local family organisations Familieplatform VZW and Similes VZW. In particular, we extend our sincere thanks to Greet Pauwels for her substantial support in facilitating recruitment and for her thoughtful feedback throughout the research process. Data Availability The data that support the findings of this study are not publicly available due to confidentiality and privacy considerations. Pseudonymised data may be made available upon reasonable request to the corresponding author, subject to approval and adherence to confidentiality measures. References Ahmad, M., & Wilkins, S. (2025). Purposive sampling in qualitative research: a framework for the entire journey. Quality & Quantity: International Journal of Methodology , 59 (2), 1461–1479. https://doi.org/10.1007/s11135-024-02022-5 Barr, K. R., Townsend, M. L., & Grenyer, B. F. S. (2023). Carer Peer Workers in Borderline Personality Services: Providing Reciprocal Understanding and Personal Strategies to Family Members. Health & Social Care in the Community , 2023 , 1–10. https://doi.org/10.1155/2023/5398996 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. 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BJPsych Int , 14 (1), 1–4. https://doi.org/10.1192/s2056474000001550 Kirkegaard, S. (2022). Experiential knowledge in mental health services: Analysing the enactment of expertise in peer support. Sociology of Health and Illness , 44 (2), 508–524. https://doi.org/10.1111/1467-9566.13438 Landeweer, E., Molewijk, B., Hem, M. H., & Pedersen, R. (2017). Worlds apart? A scoping review addressing different stakeholder perspectives on barriers to family involvement in the care for persons with severe mental illness. BMC Health Services Research , 17 (1). https://doi.org/10.1186/s12913-017-2213-4 Leggatt, M., & Woodhead, G. (2016). Family peer support work in an early intervention youth mental health service. Early Intervention in Psychiatry , 10 (5), 446–451. https://doi.org/https://doi.org/10.1111/eip.12257 Naughton, L., Collins, P., & Ryan, M. (2015). Peer Support Workers: A Guidance Paper . Health Service Excutive. https://hdl.handle.net/10147/576059 Ong, H., Fernandez, P., & Lim, H. (2021). Family engagement as part of managing patients with mental illness in primary care. Singapore Medical Journal , 62 (5), 213–219. https://doi.org/10.11622/smedj.2021057 Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health services. Journal of Mental Health , 20 (4), 392–411. https://doi.org/10.3109/09638237.2011.583947 Rowaert, S., Audenaert, K., Lemmens, G., & Vandevelde, S. (2018). Family Support Groups for Family Members of Mentally Ill Offenders: Family Expectations and Experiences. International Journal of Offender Therapy and Comparative Criminology , 62. https://doi.org/10.1177/0306624X18780943 Rowaert, S., De Pau, M., De Meyer, F., Nicaise, P., Vander Laenen, F., & Vanderplasschen, W. (2022). Voices to be heard: Understanding family perspectives in forensic care trajectories. Frontiers in Psychiatry , 13 , 1022490. https://doi.org/10.3389/fpsyt.2022.1022490 Sakwape, K., Kovane, G. P., Chukwuere, P. C., Moagi, M., & Machailo, R. (2025). The needs of family members caring for people living with mental illness: An integrated review. Health SA Gesondheid , 30 , a2901. https://doi.org/10.4102/hsag.v30i0.2901 Sampogna, G., Brohan, E., Luciano, M., Chowdhary, N., & Fiorillo, A. (2023). Psychosocial interventions for carers of people with severe mental and substance use disorders: a systematic review and meta-analysis. European Psychiatry , 66 (1), e98. https://doi.org/10.1192/j.eurpsy.2023.2472 Shalaby, R. A. H., & Agyapong, V. I. O. (2020). Peer Support in Mental Health: Literature Review. JMIR Mental Health , 7 (6), e15572. https://doi.org/10.2196/15572 Sisto, A., Vicinanza, F., Campanozzi, L. L., Ricci, G., Tartaglini, D., & Tambone, V. (2019). Towards a Transversal Definition of Psychological Resilience: A Literature Review. Medicina , 55 (11), 745. https://www.mdpi.com/1648-9144/55/11/745 Tham, S. S., & Solomon, P. (2024). Family Involvement in Routine Services for Individuals With Severe Mental Illness: Scoping Review of Barriers and Strategies. Psychiatric Services , 75 (10), 1009–1030. https://doi.org/10.1176/appi.ps.20230452 Tingleff, E. B., Rowaert, S., Vinding, S., Vestphal, T. K., Wilson, R., & Gildberg, F. A. (2022). It's still our child. A qualitative interview study with parent carers in forensic mental health. Archives of Psychiatric Nursing , 41 , 124–131. https://doi.org/10.1016/j.apnu.2022.07.017 Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care , 19 (6), 349–357. https://doi.org/10.1093/intqhc/mzm042 Van Schoors, M., Van Lierde, E., Coppens, E., & Steeman, K. (2023). Het betrekken van naasten in de geestelijke gezondheidszorg: van multidisciplinaire richtlijn naar implementatie. https://familieplatform.be/wp-content/uploads/2024/07/2023_VanSchoors_TKP_Het-betrekken-van-naasten-in-de-geestelijke-gezondheidszorg.pdf Vandewalle, J., Debyser, B., Beeckman, D., Vandecasteele, T., Van Hecke, A., & Verhaeghe, S. (2016). Peer workers' perceptions and experiences of barriers to implementation of peer worker roles in mental health services: A literature review. International Journal of Nursing Studies , 60 , 234–250. https://doi.org/10.1016/j.ijnurstu.2016.04.018 Vanlinthout, E., Coppens, E., Opgenhaffen, T., Scheveneels, S., Put, J., & Van Audenhove, C. (2020). Een multidisciplinaire richtlijn om naasten sterker te betrekken in de geestelijke gezondheidszorg . Steunpunt Welzijn Volksgezondheid en Gezin. https://www.psychosenet.be/assets/wbb-publications/49871/Een%20multidisciplinaire%20richtlijn%20voor%20het%20betrekken%20van%20de%20naasten%20in%20de%20geestelijke%20gezondheidszorg.pdf Visa, B., & Harvey, C. (2019). Mental health carers' experiences of an Australian Carer Peer Support program: Tailoring supports to carers' needs. Health & Social Care in the Community , 27 (3), 729–739. https://doi.org/10.1111/hsc.12689 Wang, Y., Chen, Y., & Deng, H. (2022). Effectiveness of Family- and Individual-Led Peer Support for People With Serious Mental Illness: A Meta-Analysis. Journal of Psychosocial Nursing and Mental Health Services , 60 (2), 20–26. https://doi.org/10.3928/02793695-20210818-01 Whitson, S., de Haan, Z., Preece, S., Swinson, M., Williams, S., Smith, K., Bité, J., Zbukvic, I., & Simmons, M. B. (2025). Family Peer Worker Perspectives on the Critical Issues for Family Peer Support in Youth Mental Health Settings. Early Intervention in Psychiatry , 19 (6), e70066. https://doi.org/10.1111/eip.70066 Wodinski, L. M., McCrady, M., Oswald, H. M., Lyste, C. M., N. J. M., & Forbes, K. L. L. (2017). Family bedside orientations: An innovative peer support model to enhance a culture of family-centred care at the Stollery Children’s Hospital. Paediatrics & Child Health , 22 (7), 387–390. https://doi.org/10.1093/pch/pxx117 World Medical Association (2024). Declaration of Helsinki. https://www.wma.net/policies-post/wma-declaration-of-helsinki/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted 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. 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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-9366429","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":626285964,"identity":"05b43d39-f192-473f-b8aa-d4e2da61443a","order_by":0,"name":"Aline Pouille","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9ElEQVRIie3PrwvCQBTA8XdcsPijToT5L5wYhe1fcSxYjQuGiTCLYJ0w/BtM5pMHWgSrwaAIy9oMKt45nZabRsH7cuGF9+HuAHS6XyxH/GSgtMvBe8yZhKaE+ByWCfhA0kkQEnxBSj0abA+wMdlCkOMYrWFlyGnbUxMDSb8WQlxnSPzZaIruKEKg4TLjGiRBJQ/oTATBgiBs7QItBGpRleT8JJcIXftOrmrCJIEnEcdihiS+mtQEKQ9YXC/LvwzmraaxdhmGczUxF/3YOHkbs7jC2fbUadil0Nnt252M7yfP4+noyCdxxd57rx37i22dTqf7s240zVcpcVZUQQAAAABJRU5ErkJggg==","orcid":"","institution":"Ghent University","correspondingAuthor":true,"prefix":"","firstName":"Aline","middleName":"","lastName":"Pouille","suffix":""},{"id":626285965,"identity":"b24b974b-0504-4e46-ac63-6728f380a48a","order_by":1,"name":"Dries Leclercq","email":"","orcid":"","institution":"Ghent University","correspondingAuthor":false,"prefix":"","firstName":"Dries","middleName":"","lastName":"Leclercq","suffix":""},{"id":626285966,"identity":"e3ba0471-11e6-4edb-ba83-d7b81f23773b","order_by":2,"name":"Elke Van Lierde","email":"","orcid":"","institution":"Familieplatform VZW","correspondingAuthor":false,"prefix":"","firstName":"Elke","middleName":"Van","lastName":"Lierde","suffix":""},{"id":626285967,"identity":"3618c21f-4eab-47bb-8af2-2ab874d21a5a","order_by":3,"name":"Nele Feryn","email":"","orcid":"","institution":"Familieplatform VZW","correspondingAuthor":false,"prefix":"","firstName":"Nele","middleName":"","lastName":"Feryn","suffix":""},{"id":626285968,"identity":"80af73ab-c003-4099-b915-af985585f3ac","order_by":4,"name":"Kim Steeman","email":"","orcid":"","institution":"Familieplatform VZW","correspondingAuthor":false,"prefix":"","firstName":"Kim","middleName":"","lastName":"Steeman","suffix":""},{"id":626285969,"identity":"72c50622-d6f5-4bb9-91ce-8d95e0a9e74b","order_by":5,"name":"Sara Rowaert","email":"","orcid":"","institution":"Ghent University","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Rowaert","suffix":""}],"badges":[],"createdAt":"2026-04-09 09:39:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9366429/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9366429/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108048368,"identity":"381e2ff8-81de-4b10-a773-b30a41472d97","added_by":"auto","created_at":"2026-04-28 20:27:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":353888,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9366429/v1/1e94071a-fe4f-467d-8d46-c7dae1f5385c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“We must be the thorn in the side\": experiences with implementing family peer support workers in adult mental health care","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental illness does not only affect the individuals experiencing it, but also profoundly impacts their families, close relatives and significant others (further referred to as \u0026lsquo;family/families\u0026rsquo;) (Sakwape et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Sampogna et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Family members face both objective (e.g., time and money devoted to care) and subjective (e.g., anxiety and stress) burden (Javed \u0026amp; Herrman, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Sampogna et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Shalaby \u0026amp; Agyapong, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and need to undergo their own family recovery process (Galimidi \u0026amp; Shamai, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Rowaert et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tingleff et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This process is not merely an individual adjustment but a relational and systemic process, requiring mental health services to actively involve, inform, and support families as partners in care (Galimidi \u0026amp; Shamai, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Javed \u0026amp; Herrman, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Tingleff et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Vanlinthout et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Besides supporting family recovery processes, family involvement has also shown to improve patients\u0026rsquo; well-being, functionality, quality of life and long-term recovery (Javed \u0026amp; Herrman, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Leggatt \u0026amp; Woodhead, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFamily involvement exists along a continuum ranging from basic information sharing to more specialised involvement programmes. Ideally, it should be understood as a collaborative partnership among the triad of patients, mental health care professionals and family members (Rowaert et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Van Schoors et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In adult mental health care, family involvement has increasingly been recognized not merely as an adjunct to professional services, but as a fundamental component of recovery-oriented care (Duckworth \u0026amp; Halpern, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Javed \u0026amp; Herrman, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Sakwape et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Translating this recognition into consistent, structured practice, however, remains a challenge (Javed \u0026amp; Herrman, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This relates to the fact that prevailing organisational cultures, in which biomedical perspectives remain dominant, do not prioritise or structurally support family-minded work. This is further compounded by the shortage or unawareness of clear practice guidelines (Eassom et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Vanlinthout et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Hence, there is a need for innovative and practical approaches that facilitate family involvement (Cheng et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Family Peer Support Workers (FPSWs) represent one such innovation aiming to bridge gaps between patients, families, and care teams by leveraging lived experience and fostering triadic partnerships (Leggatt \u0026amp; Woodhead, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Rowaert et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe concept of \u0026lsquo;family peer support worker\u0026rsquo; can be understood using the distinction between experience, experiential knowledge, and experiential expertise (Halloy et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kirkegaard, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). \u003cem\u003eExperience\u003c/em\u003e refers to the direct and personal encounter with a situation, such as living with mental illness or supporting a relative who does. Through reflection, dialogue, and engagement with additional sources of understanding such as lectures and books, these individual experiences can be transformed into \u003cem\u003eexperiential knowledge\u003c/em\u003e. When such knowledge is systematically articulated, transferred, and applied to the benefit of others, it is considered \u003cem\u003eexperiential expertise\u003c/em\u003e (Halloy et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kirkegaard, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This expertise is the basis for FPSWs to support family members and enhance family involvement in mental health care (Kirkegaard, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Shalaby \u0026amp; Agyapong, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost research on FPSWs has been conducted in child and adolescent mental health care or paediatric settings (e.g., Hopkins et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Leggatt \u0026amp; Woodhead, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Wodinski et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In adult mental health care, research is more limited and has mainly focused on peer-led family education programs and family-led mutual-support groups. These interventions generally improve families\u0026rsquo; knowledge, empowerment, and problem solving-skills, but show mixed effects on burden and overall functioning (Chien et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Dixon et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Rowaert et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Wang et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Only a few studies specifically focus on formal FPSWs in adult mental health care (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Visa \u0026amp; Harvey, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs discussed in both paediatric and adult mental health literature, FPSWs enhance social connectedness and provide emotional support, reducing feelings of isolation and stigma among family members. Family members view FPSWs as role models embodying hope that their situation can improve. They report that it is easier to build trust with FPSWs than with clinical professionals, due to their collaborative and reciprocal relational style (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Visa \u0026amp; Harvey, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Wodinski et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Additionally, FPSWs are valued for their bridging role between families and the care team (Hopkins et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Wodinski et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and for offering practical support and relevant information based on their own experience (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Visa \u0026amp; Harvey, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Studies highlight the need for FPSWs to be more consistently available for family members, better integrated within services, and supported through supervision and training (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Hopkins et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Visa \u0026amp; Harvey, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Finally, these studies warrant that FPSW\u0026rsquo;s work should be aligned with families\u0026rsquo; personal, cultural, linguistic and systemic needs (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Leggatt \u0026amp; Woodhead, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Visa \u0026amp; Harvey, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite their benefits, FPSWs are relatively new in adult mental health care, and research on their roles, impact and implementation remains limited (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Visa \u0026amp; Harvey, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In Flanders, Belgium, psychiatric hospitals have only recently began to integrate FPSWs into their services. This presents a unique opportunity to explore the perspectives of key stakeholders - including FPSWs, hospital policymakers (further referred to as \u0026lsquo;policymakers\u0026rsquo;), and other staff who collaborate with FPSWs (further referred to as \u0026lsquo;professionals\u0026rsquo;) - regarding the added value of implementing FPSWs, as well as the associated challenges and facilitators.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003eThis study explores the experiences and perspectives of key stakeholders directly involved in the deployment of FPSWs in Flanders (Belgium).\u003c/p\u003e \u003cp\u003eRecruitment and sample\u003c/p\u003e \u003cp\u003eThis research was conducted in two psychiatric hospitals that employed at least one paid FPSW at the time of the study. Both psychiatric hospitals offer a wide range of services, including residential care, outpatient support, day programs, and social reintegration programs to persons with (complex) mental health disorders.\u003c/p\u003e \u003cp\u003eParticipants were recruited between January and March 2024, through purposive sampling facilitated by organisational gatekeepers (Ahmad \u0026amp; Wilkins, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). These gatekeepers were internal contact persons within each participating institution, who identified potential participants based on predefined role-specific eligibility criteria. FPSWs were eligible if they held a formal FPSW position within the participating hospitals at the time of the study. Policymakers were defined as staff members involved in the implementation of FPSW roles. Professionals include clinical and support staff (e.g., nurses, patient peer support workers, and other relevant care professionals) who collaborated closely with at least one FPSW. Potential participants gave their consent to the internal contact person to share their contact details with the researchers, after which they were invited for the interview. All participants received and signed an informed consent form explaining the research purpose and their rights.\u003c/p\u003e \u003cp\u003eA total of 20 participants were interviewed: four FPSWs, six policymakers, and 10 professionals, of which 13 (including three FPSWs) belonged to organisation A and seven (including one FPSW) belonged to organisation B. Among participating FPSWs, there was heterogeneity in their lived-experience backgrounds, including different relationships with a relative experiencing mental health challenges (e.g., partner, parent, or child). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e offers an overview of the participants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOverview of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eFamily peer support workers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eYears of experience as FPSW\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFPSW 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFPSW 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFPSW 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFPSW 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u0026ndash;65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 years\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessionals\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFunction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHead nurse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHead nurse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePsychologist\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePsychologist\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePSW\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePsychologist\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePSW\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u0026ndash;55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDepartment head\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital policymakers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAge Range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFunction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicymaker 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCare coordinator\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicymaker 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCare manager\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicymaker 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChief physician\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicymaker 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCare coordinator\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicymaker 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePolicy and quality committee member\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolicymaker 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDepartment coordinator\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eData collection\u003c/p\u003e \u003cp\u003eIn-depth interviews were conducted using semi-structured interview guides tailored to participants\u0026rsquo; professional roles (FPSWs, policymakers, and professionals), while retaining a shared overarching thematic structure. The themes addressed were (1) motivations to work as, work with, or implement FPSWs; (2) barriers and facilitators related to FPSW implementation; (3) collaboration; and (4) perceived impact. Participants were offered the choice between an in-person interview at a location of their preference or a remote interview. All participants chose the remote option, with interviews conducted via Microsoft Teams (n\u0026thinsp;=\u0026thinsp;18) or by telephone (n\u0026thinsp;=\u0026thinsp;2). With consent of the participants the interviews were recorded, transcribed verbatim and pseudonymised.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe interviews were thematically analysed following the guidelines of Braun and Clarke (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). The thematic analysis led to the identification of shared experiences and perspectives, while also noting differences in how these themes were understood and experienced according to participants\u0026rsquo; professional roles. Participants were provided with the results of the analysis and confirmed the accuracy of its content. In what follows, we use the term \u0026rsquo;participants\u0026rsquo; when referring to experiences shared across job profiles, and specify the individual groups (FPSWs, policymakers, and professionals) when describing aspects specific to particular groups.\u003c/p\u003e"},{"header":"Findings","content":" \u003cp\u003eFirst, the results first present the perceived impact of FPSWs. Second, they elaborate on the interrelated barriers and facilitators to effective FPSW implementation that arose from the data, namely: 1) policy vision and implementation framework, 2) job description and competency profile, 3) organisational culture, departmental climate and professional attitudes and 4) time and resources.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e1. Perceived impact of FPSWs\u003c/h3\u003e\n\u003cp\u003e Several participants described FPSWs as deeply committed to enriching care practices and supporting families by sharing personal experiences.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThe FPSW takes that on as a kind of mission. She feels called to do it, so she will do it. That gives you an extra strength. We are less guided by our own experiences, we never experienced that as professionals, but she has.\u003c/em\u003e (Policymaker 6)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants indicated that FPSWs functioned as role models for family members, which policymakers noted as a motivating factor for families to be involved in treatment and a unique added value to professional perspectives.\u003c/p\u003e \u003cp\u003eAccording to all participant profiles, FPSWs developed a range of family-supportive interventions that did not exist before their deployment. They informed and involved family members through brochures, newsletters, and family-oriented activities, and provided emotional and practical support through one-to-one contact and peer support groups.\u003c/p\u003e \u003cp\u003eAccording to FPSWs, family members often express their gratitude for their family-engaging work. They mentioned that family members seem to especially appreciate how honest they can be with the FPSW, indicating they feel safe and unjudged by them. Additionally, several participants discussed that FPSWs create opportunities for reflection within care teams, and raise awareness about families\u0026rsquo; needs. Professionals reported that interacting with FPSWs made them more alert to family perspectives and helped increase family-friendliness of wards.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSo they also bring additional reflection into the team about matters that, for us, may have already been closed off or that we were less aware of. I definitely see that as an added value.\u003c/em\u003e (Professional 10)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBy consistently keeping family involvement on the agenda, ensuring that family-related initiatives and policies are implemented, and representing the family perspective, participants indicated that FPSWs contributed to triadic working within the organisations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIf you personify the family and have someone there in a symbolic function representing them, then you can do triadic working even more effectively.\u003c/em\u003e (Policymaker 5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e2. Barriers and facilitators for the effective implementation of FPSWs\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Policy vision and implementation framework\u003c/h2\u003e \u003cp\u003eMost policymakers, FPSWs, and professionals emphasized the importance of a policy vision that reflects a clear commitment to family involvement and the FPSW role. Policymakers underscored the value of a participatory process for developing this policy vision rather than imposing it top-down, as this may foster organisation-wide commitment.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIf it comes from good stories, good practices, from an eagerness that gets picked up somewhere and starts to take root within a team, then it has a much greater chance of succeeding than when a top-down policy says, \u0026lsquo;Hey, you have to do something with this\u0026rsquo;.\u003c/em\u003e (Policymaker 4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn both organisations, the policy vision was developed by a \u0026lsquo;family working group\u0026rsquo; composed of hospital staff, including policymakers, care staff, and patient peer workers. It was operationalised through a quality framework that defined concrete goals and implementation strategies. FPSWs were introduced as key actors within this framework. To ensure that family involvement remains a shared responsibility rather than resting solely on FPSWs, professionals and policymakers emphasized the value of a departmental lead to reinforce collaboration with FPSWs and families across clinical practice. Participants further mentioned that written policy documents help anchor the vision and clarify related actions and expectations organisation-wide.\u003c/p\u003e \u003cp\u003ePolicymakers of both hospitals indicated that external family organisations advised them on the policy vision and deployment framework, providing guidance on procedures, coaching and resources. This was considered especially helpful during the early months of the implementation, with these organisations providing support to both hospital staff members and the newly employed FPSWs.\u003c/p\u003e \u003cp\u003eParticipants emphasised the importance of an introductory period for FPSWs to familiarise themselves with the organisation, its departments, and key staff. They noted that ongoing relationship-building and positive collaborative experiences strengthen professionals\u0026rsquo; trust in FPSWs and reinforce their mandate. Professionals added that working with (patient or family) peer support workers, helped them see their value in care and understand the FPSW role.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI know, many years ago, when our first patient peer support worker was hired (\u0026hellip;.) that felt threatening at the time. It felt awkward at meetings and consultations. But I think we got used to the idea of a patient peer support worker, and so the step to a FPSW wasn\u0026rsquo;t really that big. (Professional 2)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdditionally, to increase awareness of the FPSW role and mandate, policymakers and FPSWs emphasised the importance of making the role visible within the hospital through various communication channels (e.g., posters, flyers, meetings, and policy updates), allowing an abstract concept to become an integrated discipline.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWhen someone really becomes a face, you notice that the support broadens. Otherwise, it\u0026rsquo;s just a concept. You have to understand, a ward is already overwhelmed with so many things - regulations, systems, requirements, and forms that need to be filled out. Then you come with just one more thing. I find it very understandable that they think, \u0026lsquo;Well\u0026hellip; what is this?\u0026rsquo; They have no idea what it could mean for their ward. (Policymaker 2)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants from both organisations indicated that the implementation framework should prioritise deploying a team of FPSWs rather than a single individual. A team can foster connectedness, shared ownership, and a safe space for support and reflection. It can also serve as a signal from the organisation that the role is valued, supported, and intended to grow.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Job description and competency profile of the FPWS\u003c/h2\u003e \u003cp\u003eParticipants saw developing an FPSW job description as a \u003cem\u003e\u0026ldquo;necessary formality\u0026rdquo;.\u003c/em\u003e Policymakers and professionals noted that a clear description clarifies tasks, responsibilities, and role scope, making the purpose explicit, safeguarding boundaries, and preventing drift into ancillary duties. Yet, professionals and FPSWs also underscore the importance of developing the role and set of tasks of FPSWs gradually, based on continued dialogue with different stakeholders and local needs.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eAs long as we keep looking at each other, speaking, dialoguing, and searching together - because it is ultimately a search together - what value can a FPSW have for our department? That is something that must be maintained. (Professional 4)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdditionally, policymakers indicated that a clearly defined job profile provides guidance for the recruitment, selection, and training of FPSWs. This includes defining the competencies needed to fulfil expectations related to the job. In this regard, participants focused on a) prior training requirements and b) personal attributes of the FPSWs.\u003c/p\u003e \u003cp\u003eRegarding prior training requirements of FPSWS (a), there were differing views. According to policymakers and professionals, completing a peer support training programme may help FPSWs develop the knowledge and skills needed for the role. While some therefor argued that prior peer-support training should be a prerequisite for FPSWs, others - including all FPSWs - emphasised that the limited availability of fitting programs make mandating such formal training a complex issue and prioritized openness to diverse professional and lived-experience backgrounds. Some policymakers highlighted the added value of prior (para)medical training, particularly for policy work and understanding clinical contexts. In contrast, a policymaker suggested that such a background could create confusion about the FPSW role among families.\u003c/p\u003e \u003cp\u003e Regarding personal attributes (b) all participant profiles underscored the importance of emotional resilience, sufficient assertiveness and confidence among FPSWs, as they are confronted with sensitive, potentially triggering topics within a often resistant environment. Most important, however, is the lived experience that enables them to connect with family members\u0026rsquo; experiences and provide input to enhance family involvement in care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Organisational culture, departmental climate and professional attitudes\u003c/h2\u003e \u003cp\u003eParticipants indicated that FPSWs often face resistance regarding family involvement and their role, rooted in interrelated macro-, meso- and micro-level dynamics.\u003c/p\u003e \u003cp\u003eFirst, participants highlighted structural and organizational factors shaping FPSWs\u0026rsquo; experiences. FPSWs often serve as one of the few representatives of the family perspective in multidisciplinary discussions, advocating for families in settings traditionally focused on psychological, medical and patient-centred perspectives. FPSWs indicated that they often find it challenging to operate within these organisational cultures, as they are frequently required to act as \u0026ldquo;\u003cem\u003ethe thorn in the side\u0026rdquo;.\u003c/em\u003e As FPSW 1 explained: \u003cem\u003e\u0026ldquo;Sometimes we need to raise issues that others find hard to hear. If a family member says they were not heard or seen, we must be able to give that feedback.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eThis positioning can generate tension and resistance, particularly when FPSWs raise sensitive issues that are perceived as questioning professional practice. A policymaker noted:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;You [FPSWs] can often encounter resistance. You frequently end up getting the door slammed in your face or triggering a defensive reaction from professionals, which means you have very little credibility to bring in something very vulnerable, fragile, because that\u0026rsquo;s what it is, right? You\u0026rsquo;re talking about something that might not be going well or shortcomings as seen by family members, and that is vulnerable for professionals, because every professional feels, \u0026lsquo;I came here to do good and take care of others\u0026rsquo;.\u0026rdquo; (Policymaker 4)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBesides organisational culture, the departmental climate appears to play a significant role in the collaboration between FPSWs and professionals as well. Participants mentioned that a wide range of factors, such as treatment duration, the psychotherapeutic framework, the target population, the setting, and the type of intervention, can influence this. For FPSWs, navigating these diverse departmental cultures can be challenging, as each department presents a unique environment and dynamic.\u003c/p\u003e \u003cp\u003eProfessionals identified patient resistance to family involvement as a key driver of staff resistance to collaborating with FPSWs. Yet, professionals and policymakers also pointed to stigmatizing attitudes of clinical professionals standing in the way of effective collaboration with FPSWs. They expressed colleagues\u0026rsquo; perceptions that FPSWs have difficulties in maintaining a meta-perspective, particularly when personal experiences evoke stress or strong emotional responses. They further indicate that this perception can result in scepticism or doubt about the added value of FPSWs and impact how seriously the role is taken.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSometimes you hear prejudices like: \u0026lsquo;Ah, FPSWs have more difficulty stepping back or seeing other perspectives; they are mainly caught up in their own story.\u0026rsquo;\u003c/em\u003e (Professional 5)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeveral FPSWs recognized these attitudes, noting that they sometimes felt pitied or perceived as less competent after sharing personal stories.\u003c/p\u003e \u003cp\u003eAcross participant groups, it was further emphasised that this resistance of professionals may be rooted in their clinical education that insufficiently addresses the importance of family engagement and the value of experiential expertise. This was perceived to reduce both professionals\u0026rsquo; sense of urgency and their preparedness to collaborate with families and FPSWs.\u003c/p\u003e \u003cp\u003eBoth professionals and FPSWs stressed the importance of respectful, connective language and sensitivity to FPSWs\u0026rsquo; potential vulnerabilities. Open, curious, and engaged attitudes from both FPSWs and professionals were seen as key levers for productive collaboration, as well as continuous dialogue and communication. To reduce stigma and address concerns about the FPSW role, policymakers and professionals viewed learning networks, through which they could learn from organisations with FPSW experience, as good practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Time and resources\u003c/h2\u003e \u003cp\u003eParticipants indicated that translating a policy vision to concrete actions requires time, particularly in large, bureaucratic hospitals where transitional processes are slowed. Professionals and FPSWs further indicated that budgetary constraints and related shortage of staff limits opportunities for FPSWs and other professionals to integrate a comprehensive family involvement strategy in care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe cannot be equally intensive on every ward with family evenings, family meetings, or discussions with care providers about family involvement. That\u0026rsquo;s not feasible. So perhaps it\u0026rsquo;s not so bad if, occasionally\u0026hellip; a door remains closed. Because we simply don\u0026rsquo;t have enough hands.\u003c/em\u003e (FPSW 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAs a result, clinical professionals may be resistant to working with FPSWs due to a fear of having to take on additional tasks alongside their usual duties.\u003c/p\u003e \u003cp\u003e FPSWs and policymakers alike highlighted the lack of formal guidelines from local authorities on the official recognition and remuneration of FPSWs. Since FPSWs are not included in official pay scales, health care institutions must decide independently on remuneration. Policymakers and FPSWs noted that strain on organizational budgets may result in the underpayment of FPSWs, as institutions must self-finance these \u003cem\u003e\u0026ldquo;non-existing functions\u0026rdquo;.\u003c/em\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eBut yes, all of that is so difficult to organize within health care, those are all non-existent functions. They are also not subsidized by the government. So the hospital actually has to finance that overarching framework itself, which is why, well\u0026hellip; we\u0026rsquo;ve currently reached our limit.\u003c/em\u003e (Policymaker 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor FPSWs this led to feelings of undervaluation and inequity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThat also sends a signal, you know. We don\u0026rsquo;t receive the same salary as a patient peer support worker, for example, which says something in itself. Then it is expressed as: \u0026lsquo;It is a valuable addition, but we do not consider it as valuable as a patient peer support worker.\u0026rsquo;\u003c/em\u003e (FPSW 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eMain results and their implications for practice and policy\u003c/p\u003e \u003cp\u003eDespite growing recognition of the importance of family involvement in adult mental health care and the potential of FPSWs in facilitating this, empirical research on their impact and implementation remains scarce (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Visa \u0026amp; Harvey, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). This study addressed this gap by offering a multi-perspective analysis of FPSWs\u0026rsquo; implementation, examining the perceived added value, challenges, and preconditions for successful FPSW implementation from the perspectives of multiple stakeholders.\u003c/p\u003e \u003cp\u003eFPSWs are seen as uniquely positioned to build trust with family members by drawing on their lived experience and engaging from a position of equality and reciprocity (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Hopkins et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Visa \u0026amp; Harvey, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). This is especially important, as family members often feel unheard or patronized by clinical professionals in adult mental health care (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Visa \u0026amp; Harvey, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). FPSWs diversify, facilitate and increase communication with family members and are valued for providing both emotional and practical support to family members (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sakwape et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Visa \u0026amp; Harvey, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). This support may strengthen family involvement in care, family members\u0026rsquo; wellbeing and their capacity to take up caregiving roles, thereby contributing to broader goals of deinstitutionalisation and community-oriented care (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Gorman et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sakwape et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). FPSWs also reinforce a family perspective in systems historically dominated by psychological, medical and individualistic paradigms (Leggatt \u0026amp; Woodhead, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Tingleff et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In doing so, FPSWs perform an important reflective and bridging function, fostering greater organisational awareness of family needs and encouraging more family-sensitive and triadic practices focused on collaboration between families, patients, and professionals (Harrison et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Landeweer et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAt the same time, the findings underscore that the successful implementation of FPSWs is contingent on several interrelated macro-, meso-, and micro-level preconditions: 1) a co-created and well-considered policy vision and implementation framework, 2) a clear but flexible role description and competency profile, 3) a conducive organisational culture and departmental climate, as well as supportive professional attitudes and 4) adequate time and resources.\u003c/p\u003e \u003cp\u003eFirst, formal policy frameworks are pivotal to promote a shared, organisation-wide vision on family involvement and FPSWS, as well as to provide concrete actions to implement this vision. However, this study shows that meaningful and effective integration of FPSWs requires iterative co-creation between policy and practice. This involves continuous dialogue between policymakers, FPSWs, and clinical teams to adapt role descriptions, workflows, and collaboration practices to the realities of everyday care (Eassom et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSecond, a key contribution of this study lies in illuminating the tension between formalisation and flexibility in role requirements and development. Role clarity is considered a necessary formality to increase the mandate of FPSWs and align expectations about the role among FPSWs, professionals and policymakers (Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Yet, such role clarity should not imply rigidity. Rather, role descriptions must provide a stable mandate while allowing space for contextual adaptation in line with the strengths of individual FPSWs and the evolving needs of organisations. Some argue the value of FPSWs having \u003cem\u003ea priori\u003c/em\u003e paramedical training or formal peer support education, as this may enhance role clarity and interprofessional collaboration within formal care systems (Gillard et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Repper \u0026amp; Carter, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). However, as confirmed by the FPSWs and some other participants of this study, such requirements also risk overregulating FPSWs, potentially undermining the authenticity, mutuality, and experiential expertise that constitute the core value of peer support grounded in lived experience (Gillard \u0026amp; Holley, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Naughton et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Vandewalle et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). By highlighting the interplay between role requirements, descriptions and ongoing co-construction of this role and its preconditions in practice, this study adds nuance to existing literature.\u003c/p\u003e \u003cp\u003eInterestingly, participants in this study highlighted emotional resilience as a personal requirement for FPSWs, given that the role involves navigating emotionally complex situations and organisational contexts that may be ambivalent or resistant to family involvement while simultaneously advocating for family perspectives (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). However, contemporary literature increasingly conceptualises resilience as a dynamic process that emerges through supportive relationships and access to contextual resources, rather than as a fixed personal attribute (Grych et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Sisto et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). From this perspective, resilience is not simply a personal trait: the challenges faced by FPSWs reflect the broader organisational context, and without supportive structures, even highly resilient individuals would struggle. This underscores the importance of cultivating supportive organisational and departmental cultures, alongside structured support mechanisms for FPSWs (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThird, the findings indicate the need for a clear organisation-wide commitment and shared vision on FPSWs and family involvement (Eassom et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Supportive attitudes among professionals and policymakers are crucial for the effective implementation of FPSWS, whereas scepticism or stigma undermine FPSWs\u0026rsquo; legitimacy and contribute to feelings of underappreciation and uncertainty (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sakwape et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Importantly, professionals\u0026rsquo; perceptions of resistance to working with FPSWs are not solely individual but are embedded in team cultures, treatment paradigms, and structural constraints, such as limited staffing and insufficient professional training in family involvement (Eassom et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Ong et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In light of the continued influence of personal, social, and structural stigma on the acceptance and implementation of FPSWs, organisations are required to take deliberate action to enhance professionals\u0026rsquo; awareness and understanding of the FPSW role, strengthen trust in FPSWs, and establish a clear mandate that enables them to realise the full potential of their role (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinally, effective implementation also requires sufficient time and resources to cultivate a family-sensitive organisational culture, build strong working relationships between FPSWs and clinical teams, and support professionals in adopting family-oriented practices (Gorman et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Ong et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). FPSWs should be ensured equitable remuneration as a matter of fairness, role legitimacy, and long-term sustainability (Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLimitations and recommendations for future research\u003c/p\u003e \u003cp\u003eThis study reflects the perspectives of FPSWs, other professionals, and hospital policymakers from two psychiatric hospitals regarding the impact and implementation of FPSWs in their respective contexts. However, patients\u0026rsquo; and families\u0026rsquo; perspectives were not included and should be addressed in future research (Harrison et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In addition, the use of purposive sampling via gatekeepers may have introduced selection bias (Ahmad \u0026amp; Wilkins, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Further research is needed to strengthen empirical understanding of how FPSWs influence clinical processes, family outcomes, and organisational culture over time. Longitudinal designs could, for example, clarify how FPSWs\u0026rsquo; reflective role shapes team practices, how family and patient outcomes develop with FPSW involvement, and which organisational configurations most effectively sustain the FPSW role (Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIdeally, FPSWs would be structurally embedded as integral members of multidisciplinary, recovery-oriented, and systemic mental health care, with clearly delineated - but flexible - role descriptions, adequate remuneration, and appropriate supervision and organisational support; comparable to other professional roles within the system. In such a context, FPSWs would be institutionally recognised as a core discipline within recovery-oriented care (Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). However, our findings indicate that this level of integration - despite the implementation of FPSWs - has not yet been realised (Javed \u0026amp; Herrman, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The implementation of FPSWs continues to be a gradual and, at times, fragile process, characterised by role ambiguity, negotiation, and persistent stigma surrounding both family involvement and experiential knowledge. As a result, embedding FPSWs often entails pioneering work, accompanied by tensions and uncertainties for FPSWs, other professionals and organisations (Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe results indicate that sustainable integration depends on alignment across system-level policy and funding frameworks, organisational culture, and concrete role conditions, which together provide a foundation for the everyday legitimacy realised through relational trust, collaborative practice, and a broadly supported mandate (Barr et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Tham \u0026amp; Solomon, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Whitson et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Without attention to these interacting levels, the transformative potential of FPSWs risks remaining underutilised. Continued investment in implementation processes, reflexive learning, and systematic knowledge exchange is therefore essential to reach a point where FPSWs are no longer positioned as peripheral or experimental actors, but are fully embedded within multidisciplinary, recovery-oriented mental health care.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003eThis study was conducted in accordance with the guidelines of the ethical standards of the Declaration of Helsinki, the General Ethical Protocol of [blinded for review] and the COREQ Checklist for Reporting Qualitative Research (Tong et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; World Medical Association, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Internal scientific committees of the participating institutions gave ethical approval for the study. All participants received and signed an informed consent form explaining the research purpose, data management procedures, and their rights.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation and data collection were carried out by Dries Leclercq, with support from the other authors. Data analysis was conducted by Dries Leclercq and Aline Pouille, also with support from the other authors. The manuscript was written by Aline Pouille, and revised by all authors. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank the participating psychiatric hospitals and all participants for generously sharing their experiences. We also gratefully acknowledge the valuable support of the local family organisations Familieplatform VZW and Similes VZW. In particular, we extend our sincere thanks to Greet Pauwels for her substantial support in facilitating recruitment and for her thoughtful feedback throughout the research process.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data that support the findings of this study are not publicly available due to confidentiality and privacy considerations. Pseudonymised data may be made available upon reasonable request to the corresponding author, subject to approval and adherence to confidentiality measures.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAhmad, M., \u0026amp; Wilkins, S. (2025). 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Family bedside orientations: An innovative peer support model to enhance a culture of family-centred care at the Stollery Children\u0026rsquo;s Hospital. \u003cem\u003ePaediatrics \u0026amp; Child Health\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(7), 387\u0026ndash;390. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/pch/pxx117\u003c/span\u003e\u003cspan address=\"10.1093/pch/pxx117\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Medical Association (2024). \u003cem\u003eDeclaration of Helsinki.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wma.net/policies-post/wma-declaration-of-helsinki/\u003c/span\u003e\u003cspan address=\"https://www.wma.net/policies-post/wma-declaration-of-helsinki/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"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":"Family peer support workers, family engagement, mental health services, implementation, organizational culture, experiential knowledge","lastPublishedDoi":"10.21203/rs.3.rs-9366429/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9366429/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWhile family peer support workers are increasingly put forward as a means of enhancing family involvement in adult mental health care, research on their impact and implementation remains scarce. This study explores both the added value of, and the preconditions for, the successful implementation of family peer support workers in adult mental health care. A qualitative design was employed, consisting of semi-structured interviews with four family peer support workers, six hospital policymakers, and ten mental health professionals from two hospitals in Flanders, Belgium, that recently employed family peer support workers. Participants perceived family peer support workers as contributing to improved family involvement and more family-sensitive care. However, successful implementation was found to depend on a set of interrelated macro-, meso-, and micro-level preconditions, including: (1) a co-created and well-considered policy vision and implementation framework; (2) a clear yet flexible role description and competency profile; (3) a conducive organisational culture and departmental climate, as well as supportive professional attitudes; and (4) adequate time and resources. These preconditions provide a foundation for the everyday legitimacy of family peer support workers, which is realised through relational trust and collaborative practice. At the same time, their implementation remains pioneering work, characterised by ongoing negotiation, with stigma still surrounding both family involvement and experiential knowledge.\u003c/p\u003e","manuscriptTitle":"“We must be the thorn in the side\": experiences with implementing family peer support workers in adult mental health care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-28 20:27:35","doi":"10.21203/rs.3.rs-9366429/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":"a6f66a67-82c8-4ca5-a021-bc0800ea5520","owner":[],"postedDate":"April 28th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-13T14:43:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-13T14:21:44+00:00","index":26,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T16:04:08+00:00","index":23,"fulltext":""},{"type":"reviewerAgreed","content":"284350184363726403830430981586352565517","date":"2026-04-30T14:30:34+00:00","index":21,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T15:19:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-28 20:27:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9366429","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9366429","identity":"rs-9366429","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}