Key Skills and Challenges in One-on-One Peer Support for Older Adolescents and Young Adults with Serious Mental Health Conditions

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Walker, Brianne LaPelusa, Vanessa V. Klodnick, Rebecca P. Johnson, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6180371/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background Peer support for older adolescents and young adults has become increasingly available as a formal mental health service. Alongside this increasing availability has been a steady accumulation of studies examining the potential for peer support to lead to positive outcomes for peer support users. However, a consistent refrain from the literature on peer support is that research and practice are hampered by a lack of theory-based models that specify the activities and skills of specific peer support roles, and describe how skillful practice is linked to outcomes. As part of a larger study intended to help fill this gap, the current study aimed to define and validate a set of key skills and related challenges in one-on-one peer support for older youth and young adults. Methods The study engaged peer support specialists (PSSs) and peer support users (PSUs) from first episode psychosis (FEP) and non-diagnostic-specific (NDS) programs across the United States in a series of discussion groups focused on the activities, skills and outcomes of effective peer support. Qualitative analysis of the discussion group material led to the specification of six general skill areas and, within each of these, a series of sub-skills and key practice challenges. In a second phase of the study, the PSSs reviewed a document describing these, rated the importance of each of the skills and challenges, and provided open-ended feedback on wording and conceptualization. Based on feedback, wording of practice skills and challenges was finalized, and a set of related organizational challenges connected to each skill area was added to the document. Results All of the mean importance ratings for sub-skills and challenges were above 4.25 on a 5-point scale for which 4 = very important and 5 = extremely important . PSSs from FEP and NDS programs provided similar ratings for sub-skills and challenges, with a few exceptions. Conclusions The final document produced from this study contains information about skills and challenges that has similarities to other studies of PSS skills, but also has unique features. Results from the study have practical implications for training, supervision and organizational development to support the PSS role. youth peer support peer support practice peer support skills peer support on-the-job challenges Background The availability of one-on-one peer support as a formal mental health service has increased rapidly in recent years, particularly in the world’s high-income countries (1–5). While peer support specifically intended for adolescents and young adults is a newer addition to the mental health services array, its growth has accelerated in the past decade (6–9), driven in part by the expansion of first-episode of psychosis (FEP) programs, many of which offer peer support as part of the service array (9–11). This article, as well as the reports referenced here, focuses on peer support that is provided by young adults who are near in age to the young people receiving support, and who have experience receiving mental health treatment. Alongside the increasing availability of peer support has been a steady accumulation of studies examining the potential for one-on-one peer support to lead to positive outcomes for peer support users (e.g., 3,4,8,10-12). However, a consistent refrain from the literature on peer support is that research and practice are hampered by the lack of theory that defines the activities and skills of a peer support role, and explains why skilled performance of the role should lead to positive outcomes (8,14–16). In the last decade, several researchers have proposed theoretical models describing the mechanisms by which peer support for adults produces positive outcomes; however, this work remains at an early stage (e.g., 10,15–19). Theory is particularly underdeveloped regarding peer support for older youth and young adults specifically. Researchers and people connected to implementation of peer support for young people continue to call for theory that specifies peer support roles with clearly defined activities and skills; that proposes mechanisms through which the roles have impact; and that sheds light on questions of whether and how peer support for young adults differs from peer support for other populations (6,8,22,23). Recent research (e.g., 22–26) has begun to address this need by identifying elements of theory—including skills, activities, outcomes and mediators—and proposing mechanisms of change. Among the challenges connected to underdeveloped theory, the lack of clarity regarding the activities and skills of the role may have the largest direct impact on peer support specialists (PSSs, i.e., those providing peer support). There is growing research documenting the ways that this lack of clarity contributes to work-related stress among PSSs, for example by increasing job dissatisfaction, emotional distress and burnout (14,27–29). Young adult PSSs may be particularly likely to encounter confusion about their roles (16,21,28,30–32), which can create or exacerbate challenges not only in PSSs’ work with peer support users (PSUs), but also in their interactions and relationships with supervisors, non-peer co-workers and the family members of PSUs (1,14,33–35). This study is part of a larger project focused on clarifying theory, activities and skills for one-on-one near-age peer support in community-based programs that use a multidisciplinary team approach to serve youth and young adults diagnosed with serious mental health conditions. The study aimed to prioritize the perspectives of PSSs and PSUs in its exploration of these topics, and this aim is reflected the composition of the research team as well as in the study’s methods. Some of the project’s initial findings from its first phase of work have already been reported (24). Specifically, the project used qualitative data from the first phase of its work to develop a theory of change that links skillful PSS practice to PSU outcomes, and describes mechanisms of change. This current article reports in more depth on phase-one data related to PSS skills, and then also reports on phase two of the study, which aimed to validate and refine the phase-one findings related to key PSS skills. Methods The study protocols were approved by the Institutional Review Board (IRB) at Portland State University in accordance with the regulations of the United States Department of Health and Human Services (45-CFR part 46). In accordance with these regulations, electronic informed consent was obtained from all participants involved in the study, and participation was voluntary. The project was conducted by a research team that included both researchers and practitioners with experience studying and/or providing peer support and supervision for peer support. Specifically, young adults who had experience providing peer support, and training and supervising PSSs, were paid staff members of the university centers collaborating on the research. As full partners on the research team, these young adults participated in conceptualizing and carrying out all aspects of the project. Participants For phase one of the study, the research team recruited young adults from across the United States to participate in a series of virtual small-group discussions. The study recruited young people with experience providing and/or using peer support in multidisciplinary community-based programs for young people diagnosed with serious mental health conditions. These included first episode psychosis (FEP) and non-diagnosis-specific (NDS) programs. Research team members sent an announcement and informational flyer to email lists that reached peer support specialists (PSSs) and peer support users (PSUs) across the United States. The announcement and flyer were also sent to individuals connected to local- and state-level peer support initiatives, with the request that they forward the materials to PSSs and PSUs in their own networks. The outreach materials included an electronic link to further study information, and to an online interest form that requested contact information as well as information about PSSs’/PSUs’ background and experience with peer support. A study team member followed up with potential study participants to confirm eligibility, provide information about study risks and benefits, and schedule groups. In phase one, 52 young adults participated in one or more discussion groups, including 17 PSUs (6 from FEP programs; 11 from NDS programs) and 35 PSSs who had provided one-on-one peer support as paid program staff (16 from FEP programs; 19 from NDS programs). All of the FEP and NDS programs served older adolescents and young adults. While the research team did not have access to detailed information about the ages of PSUs served at each program, one large study found that PSUs in FEP programs had a mean age of 20.6 years (11). NDS programs employing PSSs in phase 1 served transition-aged young people up to age 24. Participants in study phase 1 were aged 18-29. Phase 1 participants described their racial/ethnic background as White (n=37), Black (n=7), Latino/a/x (n=6), and Asian (n=2); 18 identified as male, 27 as female and 7 as non-binary. Five months after phase 1 data collection was concluded, the research team successfully re-contacted 31 of the original 35 PSSs (15 from FEP programs and 16 from NDS programs). These PSSs were invited to participate in phase 2, which involved providing feedback on the practice skills and challenges identified in phase 1 via two online surveys that were developed specifically for this project. (The feedback survey task was broken into two parts due to the length of the whole task. See supplementary files 1 and 2 for the full text of the two surveys.) Participants were paid $50 per survey. A total of 30 PSSs (15 from FEP programs and 15 from NDS programs) participated in the first survey, with 27 of these (14 FEP, 13 NDS) also completing the second survey. Data Collection and Analysis PSSs and PSUs in phase 1 participated in small group online discussions with others from similar program types (i.e., NDS and FEP groups were held separately). The discussion groups were about an hour and fifteen minutes long. The project convened 24 discussion groups in total: 17 for PSSs (7 FEP, 10 NDS) and 7 for PSUs (3 FEP, 4 NDS). Three sets of discussion groups were convened, with intervals of about one month between. During the intervals between sets, the project team analyzed data and developed new questions for the subsequent set of discussion groups. Project staff aimed to schedule participants in groups of 3 or 4, and though the modal group size was 3, groups ranged from 1 to 5 participants. The two groups with only one participant occurred due to no-shows, but these were conducted using the same procedures as the larger groups. Each PSS was invited to participate in each set of discussion groups—the mode for their participation was two groups. The discussions for PSUs took place after all of the PSS groups, and there was only one set of discussions for PSUs. In most cases, two project staff facilitated each group, and one of these was a young adult with experience as a PSS. For four of the groups, however, only one facilitator was available. Discussion group participants were offered honoraria of $25 per hour, paid electronically by Venmo or gift card. The study used Zoom to convene and record the discussion groups. During the first set of discussions, the facilitators gave a brief overview of the study, followed by a discussion prompted by the question “What do PSSs do when they are working effectively?” As participants responded, facilitators asked them to explore and define terms that came up, aiming to elicit concrete descriptions and specific examples. This was followed by a similar discussion of a second question, “What kind of impact does this have on PSUs?” During the intervals between sets of discussion groups, the research team conducted preliminary qualitative analysis using discussion group transcripts, and developed questions for the next set of discussion groups, with the goal of having participants “unpack” abstractions and concepts that were emerging as elements in the theory of change. Additional questions were developed focusing on topics or concepts that came up repeatedly and were connected to the larger context within which PSS practice occurs. These questions focused, for example, on PSS supervision and training, organizational policies and support, and relationships with co-workers, managers and PSUs’ family members. The study team used reflexive thematic analysis (RTA, 36–38) to analyze the recorded Zoom transcripts of the discussion groups. The team elected to use RTA to analyze the transcript data because the process explicitly allows for pre-existing concepts and constructs (for this study, existing theory and concepts related to the theory and practice of peer support) to be considered as potential components of the structure of emergent conceptual patterns and themes. In RTA, researchers use a specified inductive process(36), using the data to critically examine and reflect on existing concepts, and to develop new constructs and conceptual structures as relevant. For this study, RTA proved particularly appropriate since the PSSs themselves discussed their practice and PSU outcomes using terminology and constructs commonly used in the literature on peer support. The study approach—with rounds of analysis taking place between sets of discussion groups—allowed for the formulation of new questions that encouraged participants to unpack this terminology using their own words and understanding. To begin the analysis, team members worked individually, reading the transcripts from a completed set of discussion groups, developing preliminary names and definitions of codes for key constructs and concepts, attaching these to exemplar excerpts from the transcripts, and creating “memos” for later group discussion. In the next steps of analysis, team members worked collaboratively and iteratively to integrate and refine the preliminary codes, and to group codes into themes, referring to the exemplar excerpts and discussing memos throughout. Based on these early analyses, the team developed questions for the next set of discussion groups. The questions were designed to encourage participants to reflect on key constructs and themes that had emerged in the analysis to that point. After this set of discussion groups was completed, team members reviewed the transcripts individually creating/attaching codes, identifying exemplar excerpts and grouping/re-grouping codes within themes, and revising code and theme definitions to reflect the additional examples. This process continued until the final set of discussion group transcripts had been fully considered. At that point, the team determined that saturation had been reached. Analysis of phase 1 data led the team to propose a theory of change for one-on-one peer support for older youth and young adults(24). The theory of change identified six general skill areas. Within each skill area, the theory also identified a series of sub-skills and related practice challenges—i.e., difficult situations that come up with some frequency. Phase 2 focused in on these practice skills more specifically. Using the existing analysis of the phase 1 data, the research team prepared a document with descriptions of each of the six general skill areas, together with what the analysis had identified as key sub-skills and key practice challenges within each skill area. These descriptions were entered into an online feedback survey that PSSs were invited to complete. For each general skill area, the survey followed the same pattern. First, the overall description of the skill area was provided, followed by the following text: Key skills in this area are listed below. For each, please indicate how important it is for a PSS to have this skill in order to work effectively with [PSUs] . Respondents were then presented with a matrix that gave a description of each sub-skill and a choice of ratings on a 5-point scale from 1 = not important to 5 = extremely important . Below this matrix, respondents were provided with a text box and the following prompt: If you have comments about the content or wording of any of the skills listed above, please add them here . Also please make a note if you think there are important skills in this area that are *not* listed above. After this, respondents were shown a second matrix introduced with this statement: Challenges in this area of peer support are listed below. Please indicate how important each of them is for peer support work—meaning that it’s a challenge PSSs are likely to encounter in their work, and might have difficulty navigating . This matrix provided the text of each of the key challenges within the general skill area, and asked respondents to rate each one using the same 5-point scale. Finally, respondents were given a text box to comment on the wording of the challenges or to make notes about whether key challenges were missing from the list. As noted previously, this survey was split into two parts, with each requiring between 20 and 30 minutes to complete. Each of the two surveys included an open-ended text box at the end for further comments or reflections. When the feedback survey data collection was completed, the team compiled the ratings and feedback. The team then collaboratively reviewed this material and edited the skills and challenges document in light of the feedback from surveys and, as needed, referred back to data from the original discussion groups. As a result of this review, minor wording changes were made to many of the items. Additionally, one skill aspect and two challenge items were dropped, and two more items (challenge 4.b and challenge 5.d) were edited extensively enough that the team determined that the survey ratings no longer applied to these particular items. The comments that the PSSs provided in response to the open-ended questions on the survey included a large number focused on organizational-level challenges that impact PSSs’ ability to practice skillfully. For example, many of these comments described challenges related to supervision, job conditions, and misunderstanding of the PSS role on the part of co-workers. Other comments focused on how supervisors and other co-workers responded to misunderstandings of the role on the part of PSU’s family members. Organizational-level challenges had not been included on the survey, which focused specifically on PSS practice. However, because participants so frequently mentioned these, the research team returned to the original discussion group analyses and, working with this previously-coded data and the comments from the feedback survey, added a section on “related challenges in the larger context” to each general skill area. Results The finalized wording for the general skills, sub-skills and practice challenges, as well as mean ratings for sub-skills and challenges are provided in Table 1. The table also lists “challenges in the organizational context” for each general skill area. Insert Table 1 here. The mean importance ratings across all sub-skills ranged from 4.44 to 4.94 on the scale for which 4 = very important and 5 = extremely important . Only two of the mean importance ratings were below 4.5: 1c ( Is comfortably able to explain why they are considered a “peer.” ) and 5d (…plan and engage in activities together in the community… ). The two sub-skills with the highest means were from general skill 3, Drawing Out and Supporting PSUs' Preferences, Perspectives and Ideas . Sub-skill 3a focuses on maintaining a non-judgmental attitude and using active listening skills, while sub-skill 3f focuses on acknowledging and owning misunderstandings. The two other highest rated sub-skills were 1f, related to boundaries, and 4e, related to normalizing. Importance ratings for the practice challenges tended to be slightly lower, with means ranging from 4.28 to 4.75, with about half of the means above 4.5 and half below. The highest rated practice challenge, challenge 6d, has to do with maintaining confidentiality. All of the practice challenges connected to general skill 6, Supporting Personal Agency and Empowerment , received relatively high mean importance ratings. The lowest mean rating was for practice challenge 3b, handling situations in which a PSU does not want to communicate. The importance means for sub-skills for the FEP PSSs and the NDS PSSs had similar ranges, with the FEP means ranging from 5.00 (3a, non-judgmental attitude/active listening skills) to 4.25 (5d, activities in the community); and the NDS means ranging from 5.00 (1e, explaining confidentiality/mandatory reporting to PSUs) to 4.22 (1c, explains why they are considered a “peer”). When the rankings of the two groups’ mean importance ratings were compared, the two sub-skills with the greatest discrepancy in ranking were 1e (explaining confidentiality/mandatory reporting to PSUs, NDS rank 1, FEP rank 35) and 3c (handling situations where PSUs are reluctant to engage in conversation or activities, FEP rank 6 and NDS rank 35). The importance means for practice challenges for the FEP and NDS groups likewise spanned similar ranges, with the FEP means ranging from 4.94 (item 6d, maintaining confidentiality) to 4.18 (item 3a, avoiding trying to “fix” or “steer” PSUs); and the NDS means ranging from 4.89 (6a, remains non-judgmental regarding PSUs’ ideas about diagnosis, experiences and treatment) to 4.14 (4c, avoiding inauthentic or excessively positive reflections/responses). The practice challenge with the greatest discrepancy in ranking between the FEP and NDS groups was challenge 5b (responding when PSUs’ goals etc., seem unrealistic or ill-advised, NDS rank 2, FEP rank 27) and challenge 2a (avoiding oversharing, NDS rank 4, FEP rank 21). Many of the responses to the open-ended questions included endorsements of the skills, sub-skills and challenges. For example, responses to these questions for general skill 1 included these: I feel that these skills are all very important. The PSS absolutely needs to be able to communicate what is different from other roles of the treatment team, as most clients I worked with had never worked with a peer before. I feel that the PSS needs to be able to understand their own internal boundaries in order to explain to participants and clinicians why they are a peer. Role differentiation and role boundaries feels crucial when describing your role to clients, as well as when really understanding it yourself (e.g., knowing how much you are responsible for). I do think that peers need to be extremely clear what is in scope for them and have good boundaries when asked to do things out of scope. When I was working at the early psychosis program, it was also unclear what was in scope for me because I never received training on this. Explaining to the participant that you are not a therapist, and what this means, is extremely important. Not allowing peer roles to be treated as gophers, interns, or junior clinicians. Many other comments were reflections or suggestions about particular items or groups of items. The project team integrated this feedback in making revisions. For example: I think suicidality and self-harm might make more sense if moved as an example for the challenge on risk. Self-harm and suicidality can be difficult for peers to discuss because of stigma or their own preconceptions of the topics, but I think the safety challenges (and sometimes confidentiality challenges) that self-harm/suicidality pose make the topics different from the other examples (sexuality, political views) provided. I would call into question the phrasing "manage situations" for the third one, it isn't the situation that I need to manage, but my own expectations, reactions, and responses to the situation. Occasionally I have had clients who insist that there is nothing pleasurable in life, nothing they care about. That is challenging because it seems like there is nothing to "work with". Being able to remain patient -- and, again, follow the client on their journey -- is really important there. Finally, another large portion of the comments focused on how the larger context—particularly including supervisors, co-workers and PSUs’ families, and their understandings and expectations—created challenges for PSS practice. Managing the desire to get a participant to pursue goals or activities, when they are not interested … is a challenge, but it's particularly a challenge if you feel pressure from people above you to make progress or show outcomes or showing impact. That to me feels like more of a challenge. Trying to support a client in a way that feels authentic to my values, while being in an agency setting (going along with when a treatment team is pressuring a PSS to do something) has been a challenge at times. Do you have a supervisor [and] providers who are willing to help support you when they're like “you're working on behalf of this young person, so we have your back also” versus feeling like you're out on an island? I still experience a lot of confusion [from other treatment providers] about what peer support is. This translates to lack of referrals, inappropriate referrals (e.g., wanting peer support to act as a mentor, case manager, skills trainer, etc.), and miscommunication to families/clients about what peer support is. Just dealing with like power dynamics and feeling like you want to protect your client but feel like you're also about to like go against your boss, or something like that. Or lose your job. It can be a challenge. As noted previously, consideration of these kinds of comments led the team to use them, together with information from coded transcripts from the original discussion groups, to develop the “challenges in the larger context” sections shown in Table 1. Discussion This study’s contribution to the literature derives from its research- and theory-driven approach to clarifying young adult PSS skills and challenges from the perspectives of PSSs and PSUs in adolescent and young adult multidisciplinary mental health programs across the United States. The study identified six general skill areas and, within each of these, a series of sub-skills, key practice challenges, and related challenges in the larger organizational context. PSSs from FEP and NDS programs across the United States were engaged across both phases of the study, providing knowledgeable, thoughtful insights and, in phase two, formally endorsing the importance of each of the sub-skills and practice-level challenges. This deep level of ongoing engagement is quite unique among studies on this topic. Study findings regarding practice skills and challenges complement other efforts to build understanding of peer support in mental health and to increase its quality and availability. For example, at the national governmental level, both the Mental Health Commission of Canada (39) and the United States’ Substance Abuse and Mental Health Administration (40) have convened interested parties with relevant experience and expertise to describe competencies for peer support work. National advocacy organizations in the United States such as the National Federation of Families (41) and Mental Health America (42) have likewise developed descriptions of peer support competencies. However, none of these initiatives focused on peer support for youth and young adults specifically. In contrast, the Massachusetts Department of Mental Health worked with the Children’s Behavioral Health Knowledge Center (43) to develop a document describing the “practice profile” for young adult peer support in the context of mental health services. The document identifies the basic functions of peer support and provides details on how these functions are translated into “ideal” practice. Other similar documents, mostly unpublished, have been developed at the state and local program level. Each of the documents cited above groups and describes skills/competencies using different frameworks, making it difficult to succinctly catalog the similarities and differences among them and/or between them and the findings from the current study. However, certain broad categories of skill/competency are shared in virtually all cases, for example: using a style of personal presentation and communication that encourages and supports a PSU to express and explore their own thoughts, ideas and priorities; supporting PSUs to communicate these thoughts to others, including other providers; knowing when and how to share information about one’s own experiences; and using a PSU’s own goals to guide the work. Findings from the current study, and to a certain extent the descriptions of ideal practice presented in the Massachusetts document, highlight other areas skill and experience that appear to be more specific to and/or salient in the work of young adult PSSs. For example, regarding lived experience, both sources begin from the assumption that the PSS is close enough in age to the PSU to be “credible,” and “relatable.” This is important not just because of the shared experience of being young now —in the context of current youth culture, social currents and economic and climate challenges—but also because systems and treatments, as well as the larger society’s understanding and/or stigmatization of involvement in systems and treatments, are continually evolving. Compared to the practice skills/competencies documents for adult peer support, both young adult-focused sources place greater emphasis on skills related to supporting a PSU in their interactions and communications with family members, which seems quite natural given the larger role that families tend to play in the lives of emerging adults. Additionally, both of these sources are relatively unconcerned with the PSS’s role in supporting recovery , with its emphasis on returning to a former level of functioning, instead focusing more on skills related to supporting PSUs in discovery and exploration . As noted by Klodnick et al. (44), this focus for mental health services is appropriate to the developmental stage of young adulthood, during which young people are intensively engaged in building self-knowledge and identity (45). For example, both sources place quite a bit of emphasis on PSS skills for supporting young people to explore their own values, beliefs and attitudes, recognizing that these may evolve over time and may be different from the values and beliefs held by people who are or have been influential in their lives. The main differences between the two young adult-focused sources are to some extent, though not exclusively, matters of emphasis and nuance. Skill area 1 from the current study, Understanding and Describing the Peer Support Specialist Role , focuses on a PSS’s understanding of the PSS role—including how and why the role benefits PSUs—and their ability to communicate relevant aspects of this understanding in the course of their work with PSUs. Several of the skills listed in this area are unique to this study, and stem from the way that skills were developed as part of a larger study focused on theory development. Skill area 5, Supporting Motivation and Activity , describes a facet of PSS work that is focused on supporting a PSU’s identity development by facilitating their interactions in a way that builds awareness of and connections to what the PSU finds truly compelling and motivating—including values, passions and aspirations, as well as people and groups/organizations that are connected to these motivators. Compared to the Massachusetts document, the included skills appear to describe a mode of interaction in which the PSS is more intentional and active, employing reflections and active listening while also being acutely attuned to anything a PSU expresses that is connected to these motivators and offering openings for the PUS to explore further and/or take action if desired. Skill area 6, Supporting Personal Agency and Empowerment , shares a focus with the Massachusetts document on skills for ensuring that the treatment plan and process, including work with the PSS, reflect the PSU’s perspective and priorities. However, the skills from the current study have an explicit empowerment orientation, including an emphasis on supporting PSUs to develop confidence in their own agency, as well as an understanding of the power structures and power differentials in their own lives and how these interact with personal agency. For example, this area includes PSS skill for supporting PSUs in understanding power and how to “work with, negotiate with or confront power structures as they pursue activities and goals.” This skill area also notes PSSs’ role in supporting PSUs to develop and use strategies for advocacy/self-advocacy. The current study’s skills also include a unique focus on supporting a PSU to explore the meanings and values that they attach to their mental health experiences. This focus might seem natural given that about half of the study’s participants were connected to FEP programs, and indeed the FEP discussion groups yielded quite a bit of material on this topic. However, it was also a topic that was relevant to participants in the NDS groups, and in fact, the NDS participants rated this skill’s importance even higher than the FEP participants did. The current study most obviously distinguishes itself from other efforts due to its inclusion of key challenges related to each skill area. At the practice level, these findings describe specific types of situations that are typically difficult to manage and that PSSs are likely to encounter in their work directly with PSUs. These challenges highlight how, even when skills are clearly defined, the PSS role remains complex and difficult, requiring PSSs to be intentionally involved in an ongoing process of deepening their own self-understanding and solidifying their own identity. Detailed information of this nature can be particularly valuable in training and supervision, which can be structured to help PSSs learn to anticipate (and potentially avoid), recognize and respond appropriately to challenging situations. For supervisors in particular, knowing about typical challenges may facilitate their ability to respond to issues that PSSs raise in supervision in a way that sensitive to young adult development and that promotes self-understanding and identity development. Information about practice-level challenges can be useful for supervisors in another way: they are expected to provide guidance about handling such situations despite, in the large majority of cases, never having worked as a PSS themselves. Supervisors can review the challenges to determine their confidence and readiness to provide guidance and support to PSSs, and to seek further training or supervision for themselves to address any areas of uncertainty. When FEP and NDS participants’ ratings for sub-skills and challenges were considered separately, both groups saw each of the sub-skills and challenges as very important. This finding supports the idea that the fundamental PSS skills and challenges are the same across specialized (FEP) and more general (NDS) community mental health programming. Where there were discrepancies (i.e., where importance rankings between FEP PSSs and NDS PSSs were greatest), this could be explained by differences in the populations served. For example, the relatively high importance rating that NDS participants gave to sub-skill 1e (explaining confidentiality/mandatory reporting) likely reflects the fact that these programs tend to serve a higher number of young people with histories of involvement in the child welfare/foster care systems. Similarly, the relatively high importance rating that FEP participants gave to sub-skill 3c (handling situations where PSUs are reluctant to engage in conversation or activities) is consistent with FEP study participants’ comments about how frequently they encounter PSUs who appear to have low levels of motivation for interpersonal engagement. Study findings related to challenges in the organizational context are consistent with themes from studies such as those cited in the introduction. Relative to these sources, findings here present a relatively comprehensive and concrete list of challenges. Also important is the way that these challenges are tied to PSS skill areas, reinforcing the causal connections between organizational context and PSSs’ ability to skillfully carry out their work. Findings from this study should be considered in light of limitations. Most obviously, the study sample cannot be considered representative of PSSs/PSUs generally. While participants represented a range of sociodemographic backgrounds, our sample was mostly White, cisgender and well educated. It is likely that young adults who were relatively “successful” in mental health programs were overrepresented in our samples. i.e., PSUs that stayed in treatment, and PSSs who were perceived by their employers and/or themselves to be good sources of information about the role. Study participants were recruited through existing email lists and it is possible that these individuals have different perspectives from PSUs and PSSs connected to programs that are unconnected to national networks. Finally, it should be remembered that the skills described here are limited to those for working directly with PSUs, and the study does not touch on other kinds of job skills that are needed for the role. Conclusions Results from the study have practical implications for training, supervision and organizational development to support the PSS role. The concrete descriptions of skills and challenges makes practical application of the findings particularly feasible. Taken together, study findings on practice-level skills and challenges support their potential usefulness as a framework for structuring training, supervision and/or ongoing professional development for PSSs. Such trainings could easily be adapted to include special attention to situations most typically encountered in a particular program context (e.g., FEP versus NDS or other types of programs). As noted previously, the findings can also be useful in developing training for supervisors, and may be particularly helpful for supervisors with no experience in the peer role. Finally, the findings on organization-level challenges can be helpful to managers seeking understand the extent to which they are providing a hospitable context for their PSSs’ work. Declarations Ethics approval and consent to participate: The study protocols were approved by the Institutional Review Board (IRB) at Portland State University in accordance with the regulations of the United States Department of Health and Human Services (45-CFR part 46). In accordance with these regulations, electronic informed consent was obtained from all participants involved in the study, and participation was voluntary. Consent for publication: Not applicable Availability of data and materials: The dataset analyzed during the current study available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90IFRE0054). NIDILRR is a Center within the Administration for Community Living (ACL), United States Department of Health and Human Services (HHS). Authors' contributions: JSW Conceptualized the study. JSW, VVK, BP, MH-K and SB collaboratively developed the questions/items for the qualitative/quantitative portions of the study and analyzed the data. BP took the lead for recruitment. BP, MH-K, RPJ, VVK and JSW facilitated/co-facilitated discussion groups. JSW and VVK took the lead in preparing the manuscript, with all authors participating in editing manuscript drafts. All authors read and approved the final version. Acknowledgements: The authors would like to thank the Peer Support Specialists and peer support users who participated in this study. The contents of this article were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90IFRE0054). NIDILRR is a Center within the Administration for Community Living (ACL), United States Department of Health and Human Services (HHS). The contents of this article do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government. References Adams WE. Unintended consequences of institutionalizing peer support work in mental healthcare. Soc Sci Med. 2020;262(July). Burr C, Rother K, Elhilali L, Winter A, Weidling K, Kozel B, et al. Peer support in Switzerland – results from the first national survey. Int J Ment Health Nurs. 2020;29:212–23. Gillard S. Peer support in mental health services: where is the research taking us, and do we want to go there? J Ment Health. 2019;28:341–4. Klee A, Chinman M, Kearney L. 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Emerging adulthood: a theory of development from the late teens through the twenties. Am Psychol. 2000;55:469–80. Tables Table 1 PSS General Skill Areas, Sub-Skills and Related Practice and Contextual Challenges Description Mean Importance Rating 1)Understanding and Describing the Peer Support Specialist Role PSSs are clear about the purpose of the PSS role. They accurately and succinctly describe their role, including issues related to confidentiality and relational boundaries, to PSUs and others (e.g., colleagues, community members). Sub-Skills. A PSS… a. Understands and can describe the purpose of the PSS role and how skilled practices benefit PSUs. 4.64 b. Understands and communicates clearly what distinguishes the PSS role from other roles on the treatment team, and what distinguishes the PSS role from that of a friend. 4.68 c. Understands and explains why they are considered a “peer.” 4.45 d. Introduces their role concisely and provides ongoing role clarification as needed by providing further details or answering questions about their role. 4.59 e. As part of introducing their role, clearly describes confidentiality between themselves and a PSU, as well as situations such as mandatory reporting when confidentiality may be broken. 4.68 f. Describes boundaries that limit what they can/cannot do as part of the PSS role. 4.86 Related Practice Challenges a. Understanding and communicating how the PSS role is distinct from other peer-like roles such as mentor, peer mentor, skills trainer, etc. 4.32 b. Being internally confident about boundaries and clarifying/re-establishing them if a PSU appears to have expectations for the PSS that are outside of the PSS role. 4.64 c. Determining how much personal information about lived/living experience is helpful to share and comes across as authentic when introducing/describing the role. 4.59 Related Challenges in the Larger Context a. Remaining confident about the PSS role’s scope, purpose, practices and skills, even when supervisors or co-workers are unclear or present different views about these. * b. Managing situations when family’s or other team members’ misunderstanding of the PSS role leads them to expect that the PSS will do things that are not part of the role. * 2)Being a Peer, Being Genuine and Drawing on Personal Experience PSSs present themselves and talk about personal experiences with intention, in a way that is genuine and helpful to PSUs. Sub-Skills. A PSS… a. Cultivates a manner of self-presentation and speaking that is genuine and not overbearing or self-centering. 4.65 b. Offers knowledge, observations or anecdotes from personal experience for PSUs to consider, without implying that PSUs should believe, feel or act the same way. 4.58 c. Is open and genuine about personal experiences without distressing PSUs or themselves. 4.68 d. Serves as an example of a young adult who has experienced—and may continue to experience—mental health challenges, and who has had success—and setbacks—in navigating life and employment while managing their mental health and wellness. 4.70 Related Practice Challenges a. Recognizing and managing if oversharing personal experience, for example, i. as a way to prove worthiness as a peer; ii. in a way that overwhelms a PSU, diminishes the PSU’s own experiences, or distresses the PSS; or iii. to serve the PSS’s own purposes, such as venting, or prompting a PSU to provide emotional support. 4.58 b. Feeling comfortable discussing past, current or ongoing struggles or setbacks with PSUs in a way that is genuine but also does not discourage or distress the PSS or PSU. 4.55 c. Being internally aware about when and how much lived/living experience to share with PSUs, and managing situations when a PSU presses a PSS to share more about their experiences than the PSS is comfortable with. 4.41 d. Managing situations when a PSS does not share key aspects of identity or experience with a PSU (e.g., difference in gender or sexual orientation, race/ethnicity, socioeconomic status), so that it may be difficult for a PSS to understand a PSU or for a PSU to feel understood. Being comfortable acknowledging differences and talking about them with PSUs when they come up. 4.61 Related Challenges in the Larger Context a. Managing situations where managers, supervisors or non-peer colleagues i. ask the PSS to share their lived/living experiences in settings or in ways that the PSS is not comfortable with; ii. share PSS lived experience with PSUs, colleagues, and/or community members; or iii. ask PSS inappropriate questions about their mental health and treatment. * 3)Drawing Out and Supporting PSUs' Preferences, Perspectives and Ideas PSSs support PSUs to explore their own values, preferences, thoughts and ideas. PSSs do this in a way that is non-judgmental and shows genuine curiosity and interest in what PSUs express. PSSs do not try to convince PSUs what to do, say or think. PSSs follow PSUs’ lead regarding if and when to meet, and what to do or talk about. Sub-Skills. A PSS… a. Maintains a non-judgmental attitude, using active listening skills to support PSUs in sharing and exploring their experiences, values, ideas, preferences and perspectives. 4.94 b. Makes reflections that fit well within the conversation and accurately restates or summarizes key content that PSUs bring up. 4.56 c. Gauges when a PSU doesn’t want to participate in certain activities or talk about certain things, or when they do not want to talk at all. 4.63 d. Makes observations and offers ideas for a PSU to consider, without putting pressure on them to agree. 4.56 e. Identifies and remembers key content from conversations or interactions with PSUs, and bring this into later conversations when relevant. 4.50 f. Is comfortable acknowledging when they have misunderstood what a PSU is communicating. Acknowledges misunderstandings as needed and then returns the focus of the conversation to the PSU’s thoughts and ideas. 4.91 Related Practice Challenges a. Resisting a desire to fix things for the PSU, or steer them towards what the PSS thinks they should think or do. 4.31 b. Remaining patient, empathic and non-directive when a PSU is reluctant or unable to share their thoughts, ideas or preferences. 4.28 c. Remaining empathic and non-directive when PSUs raise topics that the PSS finds difficult or uncomfortable, or when they do not share ideas or opinions expressed by a PSU (e.g. topics connected to sexuality, privilege/oppression, substance use, political views, religious beliefs). 4.66 d. Handling situations when a PSS has concerns that a PSU’s thinking or reasoning may lead them to do something that is risky or harmful—including suicidality or self-harm—or that sets them back from their own goals. Knowing when it’s appropriate to break confidentiality to ensure safety. 4.34 Related Challenges in the Larger Context a. Navigating situations when clinicians or family members put pressure on a PSS to “make” a PSU change their thinking or behavior. * 4)Providing Empathy and Validation PSSs attend to, empathize with and validate PSUs’ emotional expression and tone–positive, negative and mixed. Across their interactions and communication together, PSSs create opportunities for PSUs to explore topics or ideas that are important or meaningful to them. Sub-Skills. A PSS… a. Provides validation and empathy that is rooted in the PSU’s perspective. 4.74 b. Recognizes and validates when PSUs indicate things that are important or meaningful to them. Creates opportunities them to explore these topics if they want to. 4.77 c. Recognizes and responds to emotional content PSUs express—including positive, negative and mixed emotions in conversations or actions. 4.71 d. Assesses and/or asks when it would be helpful to go deeper into emotionally significant topics and help PSUs explore further. 4.61 e. Normalizes PSUs’ experiences appropriately through reflections, observations, etc. 4.84 f. Is comfortable discussing safety concerns and developing safety strategies, and confident about when and how to contact other providers due to safety concerns. 4.57 g. Manages their own reactions to what PSUs may disclose, including vicarious trauma and distress. Knows how to seek support for themselves in processing these experiences and creating boundaries. 4.77 Related Practice Challenges a. Responding and managing (and knowing how to seek supervision/support) when feeling overwhelmed or unable to genuinely understand or validate emotional experiences or ideas that PSUs talk about, such as those connected to trauma; racism, sexism, homophobia, transphobia or other forms of oppression; and extreme or unusual experiences related to mental health. 4.58 b. Offering a normalizing perspective when appropriate, without discounting a PSU’s experiences. ** c. Knowing how to avoid making reflections or responses that come across as inauthentic, exaggerated or misaligned with what PSUs are communicating, including over-empathizing or being excessively enthusiastic or positive. 4.35 d. Handling situations when a PSU thinks (or appears to think) that the PSS can’t really understand them due to different styles of communication, personal experiences, identities, cultures and values, socio-economic status, etc. 4.42 e. Knowing how to pace or structure time with a PSU so that, if needed, there is time to debrief, address safety concerns and/or discuss ways the PSU could follow up with the PSS or other providers. 4.65 f. Recognizing when topics may be too activating or unhelpful to explore with PSUs in peer support, and knowing when and how to assist a PSU in getting additional support from other providers. 4.58 Related Challenges in the Larger Context a. Navigating differences in perceptions between young people (i.e., PSSs/PSUs) and older adults (supervisors, co-workers, PSUs’ family members) regarding statements, behavior or activity that is normal, versus what is dangerous, threatening or risky. * b. Navigating clinical staff’s lack of clarity about whether the empathy and validation provided by PSSs is therapeutic, and how this differs from providing psychotherapy. * 5)Supporting Motivation and Activity PSSs are attentive to things PSUs say and do that provide information about what motivates them, including values, commitments and passions, as well as relationships and activities that bring satisfaction or joy. PSSs support PSUs in exploring these motivators from their own perspectives. When PSUs show interest, PSSs partner with PSUs to develop activities, plans or goals based on what emerges. Sub-Skills. A PSS… a. During conversations and activities with a PSU, notices and offers openings for PSUs to recognize and explore their motivators, including i. aspirations, interests and passions; ii…personal, family and cultural values and commitments; and iii. activities and relationships that bring joy, satisfaction, pleasure, or a sense of accomplishment or achievement. 4.73 b. During conversations and activities with a PSU, notices and offers openings for PSUs to recognize and explore their ideas and preferences related to wellbeing, including self-care, wellness, personal safety and harm reduction. 4.59 c. During conversations and activities with a PSU, notices and offers openings for PSUs to build recognition about the people, groups and organizations that support their aspirations, values and wellbeing, or that could do so. 4.59 d. When PSUs show interest, works with them to plan and engage in activities that reflect PSU motivators and preferences (i.e., as explored in conversations described above). 4.40 e. Uses opportunities that arise during conversations, interactions or activities to reflect PSUs’ awareness of their personal growth, learning, progress and success, even when changes, progress or accomplishments are small. 4.73 Related Practice Challenges a. Managing any desire to “get” a PSU to pursue goals or activities when they are not internally motivated to do this. 4.59 b. Knowing how to respond when a PSU has passions, goals or sources of pleasure that the PSS sees as harmful, unrealistic or undesirable. 4.50 c. Remaining patient, empathic and non-directive when a PSU does not talk much, does not bring up motivators, values, commitments and activities, and/or generally does not seem to express interest, joy, excitement or motivation. 4.32 d. Understanding the difference between reflecting/supporting a PSU’s own perceptions of their strengths, growth, learning and progress, versus giving praise or affirmation from the point of view of the PSS or other people. ** Related Challenges in the Larger Context a. Responding to supervisors, other treatment team members or family members when they expect or direct a PSS to pursue goals or activities that are not in alignment with a PSU’s preferences or motivators. * b. Negotiating situations when organizational rules or culture dictate what sorts of PSU activities are meaningful or important, thereby limiting the support that PSSs can offer when PSUs are motivated to engage in other kinds of activities. * 6)Supporting Personal Agency and Empowerment PSSs are attentive to opportunities to support PSUs in exploring options and making choices about mental health treatment and other aspects of their lives. Sub-Skills. A PSS… a. Is attuned when a PSU expresses thoughts related to having a mental health diagnosis and mental or emotional experiences that are unusual and/or stigmatized, and provides an opportunity for them to explore these thoughts further if they wish. This includes exploring the meanings and values that PSUs attach to their experiences. 4.82 b. Is attuned when a PSU touches on topics related to mental health treatment and other strategies for improving/maintaining wellness and mental health, and provides an opportunity for them to explore these thoughts further if they wish. 4.68 c. Is attentive when a PSU is considering a decision or change, helps them to recognize options, explore choices and take action that is aligned with their values and goals. 4.82 d. Models and offers strategies for accessing sources and information about various options and choices. 4.55 e. Offers strategies that can help a PSU effectively advocate for their own choices, preferences and goals. 4.59 f. Assists PSUs in understanding power differentials (e.g., between individuals with different identities or roles, or between individuals and organizations, institutions or systems) and how these may impact their ability to make progress on their goals. Provides PSUs with information and strategies on how to work with, negotiate with or confront power structures as they pursue activities and goals. 4.73 Related Practice Challenges a. Remaining comfortable, empathic and non-judgmental when a PSU’s interpretation of their mental health experiences or choices regarding treatment are difficult for a PSS to understand or accept. 4.68 b. Being able to talk with PSUs—and manage own reactions—about situations in which a lack of power and/or resources poses significant barriers to PSUs’ efforts towards their goals. 4.64 c. Supporting a PSU in situations in which other treatment team members, or other key people in a PSU’s life, may be pressuring a PSU to accept a specific interpretation of their mental experiences, or to accept specific treatment recommendations. 4.64 d. Keeping what a PSU says confidential, unless the PSU specifically provides permission to share; and making sure PSUs understand any exceptions when confidentiality might be broken. 4.75 Related Challenges in the Larger Context a. Responding appropriately when treatment team members or family members expect a PSS to speak for a PSU about topics or issues that the PSU has not given permission for the PSS to discuss with others. * b. Managing and responding to situations when treatment team members or family members pressure a PSS to undercut a PSU’s agency, for example by asking the PSS to “get” a PSU to comply with the team’s/family’s view of treatment or medication. * * These key challenges in the organizational context were not included on the survey and were thus not rated by respondents. ** These items were substantially changed from their original forms, so the ratings provided in the survey do not apply to the revised items. Additional Declarations No competing interests reported. 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Johnson","email":"","orcid":"","institution":"Texas Institute for Excellence in Mental Health, The University of Texas at Austin","correspondingAuthor":false,"prefix":"","firstName":"Rebecca","middleName":"P.","lastName":"Johnson","suffix":""},{"id":468197881,"identity":"f0d43298-b1c5-4d1b-b5b7-f7a83464eee6","order_by":4,"name":"Maria Hermsen-Kritz","email":"","orcid":"","institution":"Systems of Care Institute, Portland State University","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Hermsen-Kritz","suffix":""},{"id":468197882,"identity":"0209eee1-7c1d-40ad-9397-0c8c4ddb8477","order_by":5,"name":"Shannon Blajeski","email":"","orcid":"","institution":"School of Social Work, Portland State University","correspondingAuthor":false,"prefix":"","firstName":"Shannon","middleName":"","lastName":"Blajeski","suffix":""}],"badges":[],"createdAt":"2025-03-07 18:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6180371/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6180371/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84286478,"identity":"5b14ff29-90a0-4a4b-8922-e22fc4c6a225","added_by":"auto","created_at":"2025-06-10 07:49:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":719742,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6180371/v1/1b34556b-48a8-4161-b607-f911cec567ec.pdf"},{"id":84285055,"identity":"77f1eb87-7cf1-45e1-86ae-87fe261e364b","added_by":"auto","created_at":"2025-06-10 07:25:15","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":279764,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1PSSskillssurveyPart1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6180371/v1/204d16b60d92eb2b24ff9512.pdf"},{"id":84285061,"identity":"b6bd4eaf-8482-4506-967a-59d4904d753f","added_by":"auto","created_at":"2025-06-10 07:25:16","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":266988,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2PSSSkillsSurveyPart2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6180371/v1/20f530fac85a043aeb5b28e0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Key Skills and Challenges in One-on-One Peer Support for Older Adolescents and Young Adults with Serious Mental Health Conditions","fulltext":[{"header":"Background","content":"\u003cp\u003eThe availability of one-on-one peer support as a formal mental health service has increased rapidly in recent years, particularly in the world\u0026rsquo;s high-income countries (1\u0026ndash;5). While peer support specifically intended for adolescents and young adults is a newer addition to the mental health services array, its growth has accelerated in the past decade\u0026nbsp;(6\u0026ndash;9), driven in part by the expansion of first-episode of psychosis (FEP) programs, many of which offer peer support as part of the service array (9\u0026ndash;11). This article, as well as the reports referenced here, focuses on peer support that is provided by young adults who are near in age to the young people receiving support, and who have experience receiving mental health treatment.\u003c/p\u003e\n\u003cp\u003eAlongside the increasing availability of peer support has been a steady accumulation of studies examining the potential for one-on-one peer support to lead to positive outcomes for peer support users (e.g., 3,4,8,10-12). However, a consistent refrain from the literature on peer support is that research and practice are hampered by the lack of theory that defines the activities and skills of a peer support role, and explains why skilled performance of the role should lead to positive outcomes (8,14\u0026ndash;16). In the last decade, several researchers have proposed theoretical models describing the mechanisms by which peer support for adults produces positive outcomes; however, this work remains at an early stage (e.g., 10,15\u0026ndash;19).\u003c/p\u003e\n\u003cp\u003eTheory is particularly underdeveloped regarding peer support for older youth and young adults specifically. Researchers and people connected to implementation of peer support for young people continue to call for theory that specifies peer support roles with clearly defined activities and skills; that proposes mechanisms through which the roles have impact; and that sheds light on questions of whether and how peer support for young adults differs from peer support for other populations (6,8,22,23). Recent research (e.g., 22\u0026ndash;26) has begun to address this need by identifying elements of theory\u0026mdash;including skills, activities, outcomes and mediators\u0026mdash;and proposing mechanisms of change.\u003c/p\u003e\n\u003cp\u003eAmong the challenges connected to underdeveloped theory, the lack of clarity regarding the activities and skills of the role may have the largest direct impact on peer support specialists (PSSs, i.e., those providing peer support). There is growing research documenting the ways that this lack of clarity contributes to work-related stress among PSSs, for example by increasing job dissatisfaction, emotional distress and burnout (14,27\u0026ndash;29). Young adult PSSs may be particularly likely to encounter confusion about their roles (16,21,28,30\u0026ndash;32), which can create or exacerbate challenges not only in PSSs\u0026rsquo; work with peer support users (PSUs), but also in their interactions and relationships with supervisors, non-peer co-workers and the family members of PSUs (1,14,33\u0026ndash;35).\u003c/p\u003e\n\u003cp\u003eThis study is part of a larger project focused on clarifying theory, activities and skills for one-on-one near-age peer support in community-based programs that use a multidisciplinary team approach to serve youth and young adults diagnosed with serious mental health conditions. The study aimed to prioritize the perspectives of PSSs and PSUs in its exploration of these topics, and this aim is reflected the composition of the research team as well as in the study\u0026rsquo;s methods. Some of the project\u0026rsquo;s initial findings from its first phase of work have already been reported (24). Specifically, the project used qualitative data from the first phase of its work to develop a theory of change that links skillful PSS practice to PSU outcomes, and describes mechanisms of change. This current article reports in more depth on phase-one data related to PSS skills, and then also reports on phase two of the study, which aimed to validate and refine the phase-one findings related to key PSS skills.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe study protocols were approved by the Institutional Review Board (IRB) at Portland State University in accordance with the regulations of the United States Department of Health and Human Services (45-CFR part 46). In accordance with these regulations, electronic informed consent was obtained from all participants involved in the study, and participation was voluntary.\u0026nbsp;The project was conducted by a research team that included both researchers and practitioners with experience studying and/or providing peer support and supervision for peer support. Specifically, young adults who had experience providing peer support, and training and supervising PSSs, were paid staff members of the university centers collaborating on the research. As full partners on the research team, these young adults participated in conceptualizing and carrying out all aspects of the project.\u003c/p\u003e\n\u003ch2\u003eParticipants\u003c/h2\u003e\n\u003cp\u003eFor phase one of the study, the research team recruited young adults from across the United States to participate in a series of virtual small-group discussions. The study recruited young people with experience providing and/or using peer support in multidisciplinary community-based programs for young people diagnosed with serious mental health conditions. These included first episode psychosis (FEP) and non-diagnosis-specific (NDS) programs. Research team members sent an announcement and informational flyer to email lists that reached peer support specialists (PSSs) and peer support users (PSUs) across the United States. The announcement and flyer were also sent to individuals connected to local- and state-level peer support initiatives, with the request that they forward the materials to PSSs and PSUs in their own networks. The outreach materials included an electronic link to further study information, and to an online interest form that requested contact information as well as information about PSSs\u0026rsquo;/PSUs\u0026rsquo; background and experience with peer support. A study team member followed up with potential study participants to confirm eligibility, provide information about study risks and benefits, and schedule groups.\u003c/p\u003e\n\u003cp\u003eIn phase one, 52 young adults participated in one or more discussion groups, including 17 PSUs (6 from FEP programs; 11 from NDS programs) and 35 PSSs who had provided one-on-one peer support as paid program staff (16 from FEP programs; 19 from NDS programs). All of the FEP and NDS programs served older adolescents and young adults. While the research team did not have access to detailed information about the ages of PSUs served at each program, one large study found that PSUs in FEP programs had a mean age of 20.6 years (11). NDS programs employing PSSs in phase 1 served transition-aged young people up to age 24. Participants in study phase 1 were aged 18-29. Phase 1 participants described their racial/ethnic background as White (n=37), Black (n=7), Latino/a/x (n=6), and Asian (n=2); 18 identified as male, 27 as female and 7 as non-binary.\u003c/p\u003e\n\u003cp\u003eFive months after phase 1 data collection was concluded, the research team successfully re-contacted 31 of the original 35 PSSs (15 from FEP programs and 16 from NDS programs). These PSSs were invited to participate in phase 2, which involved providing feedback on the practice skills and challenges identified in phase 1 via two online surveys that were developed specifically for this project. (The feedback survey task was broken into two parts due to the length of the whole task. See supplementary files 1 and 2 for the full text of the two surveys.) Participants were paid $50 per survey. A total of 30 PSSs (15 from FEP programs and 15 from NDS programs) participated in the first survey, with 27 of these (14 FEP, 13 NDS) also completing the second survey.\u003c/p\u003e\n\u003ch2\u003eData Collection and Analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003ePSSs and PSUs in phase 1 participated in small group online discussions with others from similar program types (i.e., NDS and FEP groups were held separately). The discussion groups were about an hour and fifteen minutes long. The project convened 24 discussion groups in total: 17 for PSSs (7 FEP, 10 NDS) and 7 for PSUs (3 FEP, 4 NDS). Three sets of discussion groups were convened, with intervals of about one month between. During the intervals between sets, the project team analyzed data and developed new questions for the subsequent set of discussion groups. Project staff aimed to schedule participants in groups of 3 or 4, and though the modal group size was 3, groups ranged from 1 to 5 participants. The two groups with only one participant occurred due to no-shows, but these were conducted using the same procedures as the larger groups. Each PSS was invited to participate in each set of discussion groups\u0026mdash;the mode for their participation was two groups. The discussions for PSUs took place after all of the PSS groups, and there was only one set of discussions for PSUs. In most cases, two project staff facilitated each group, and one of these was a young adult with experience as a PSS. For four of the groups, however, only one facilitator was available. Discussion group participants were offered honoraria of $25 per hour, paid electronically by Venmo or gift card.\u003c/p\u003e\n\u003cp\u003eThe study used Zoom to convene and record the discussion groups. During the first set of discussions, the facilitators gave a brief overview of the study, followed by a discussion prompted by the question \u003cem\u003e\u0026ldquo;What do PSSs do when they are working effectively?\u0026rdquo;\u003c/em\u003e As participants responded, facilitators asked them to explore and define terms that came up, aiming to elicit concrete descriptions and specific examples. This was followed by a similar discussion of a second question, \u003cem\u003e\u0026ldquo;What kind of impact does this have on PSUs?\u0026rdquo;\u003c/em\u003e During the intervals between sets of discussion groups, the research team conducted preliminary qualitative analysis using discussion group transcripts, and developed questions for the next set of discussion groups, with the goal of having participants \u0026ldquo;unpack\u0026rdquo; abstractions and concepts that were emerging as elements in the theory of change. Additional questions were developed focusing on topics or concepts that came up repeatedly and were connected to the larger context within which PSS practice occurs. These questions focused, for example, on PSS supervision and training, organizational policies and support, and relationships with co-workers, managers and PSUs\u0026rsquo; family members.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study team used reflexive thematic analysis (RTA, 36\u0026ndash;38) to analyze the recorded Zoom transcripts of the discussion groups. The team elected to use RTA to analyze the transcript data because the process explicitly allows for pre-existing concepts and constructs (for this study, existing theory and concepts related to the theory and practice of peer support) to be considered as potential components of the structure of emergent conceptual patterns and themes. In RTA, researchers use a specified inductive process(36), using the data to critically examine and reflect on existing concepts, and to develop new constructs and conceptual structures as relevant. For this study, RTA proved particularly appropriate since the PSSs themselves discussed their practice and PSU outcomes using terminology and constructs commonly used in the literature on peer support. The study approach\u0026mdash;with rounds of analysis taking place between sets of discussion groups\u0026mdash;allowed for the formulation of new questions that encouraged participants to unpack this terminology using their own words and understanding.\u003c/p\u003e\n\u003cp\u003eTo begin the analysis, team members worked individually, reading the transcripts from a completed set of discussion groups, developing preliminary names and definitions of codes for key constructs and concepts, attaching these to exemplar excerpts from the transcripts, and creating \u0026ldquo;memos\u0026rdquo; for later group discussion. In the next steps of analysis, team members worked collaboratively and iteratively to integrate and refine the preliminary codes, and to group codes into themes, referring to the exemplar excerpts and discussing memos throughout. Based on these early analyses, the team developed questions for the next set of discussion groups. The questions were designed to encourage participants to reflect on key constructs and themes that had emerged in the analysis to that point. After this set of discussion groups was completed, team members reviewed the transcripts individually creating/attaching codes, identifying exemplar excerpts and grouping/re-grouping codes within themes, and revising code and theme definitions to reflect the additional examples. This process continued until the final set of discussion group transcripts had been fully considered. At that point, the team determined that saturation had been reached.\u003c/p\u003e\n\u003cp\u003eAnalysis of phase 1 data led the team to propose a theory of change for one-on-one peer support for older youth and young adults(24). The theory of change identified six general skill areas. Within each skill area, the theory also identified a series of sub-skills and related practice challenges\u0026mdash;i.e., difficult situations that come up with some frequency. Phase 2 focused in on these practice skills more specifically. Using the existing analysis of the phase 1 data, the research team prepared a document with descriptions of each of the six general skill areas, together with what the analysis had identified as key sub-skills and key practice challenges within each skill area. These descriptions were entered into an online feedback survey that PSSs were invited to complete.\u003c/p\u003e\n\u003cp\u003eFor each general skill area, the survey followed the same pattern. First, the overall description of the skill area was provided, followed by the following text: \u003cem\u003eKey skills in this area are listed below. For each, please indicate how important it is for a PSS to have this skill in order to work effectively with [PSUs]\u003c/em\u003e. Respondents were then presented with a matrix that gave a description of each sub-skill and a choice of ratings on a 5-point scale from 1 = \u003cem\u003enot important\u003c/em\u003e to 5 = \u003cem\u003eextremely important\u003c/em\u003e. Below this matrix, respondents were provided with a text box and the following prompt: \u003cem\u003eIf you have comments about the content or wording of any of the skills listed above, please add them here\u003c/em\u003e. \u003cem\u003eAlso please make a note if you think there are important skills in this area that are *not* listed above.\u0026nbsp;\u003c/em\u003eAfter this, respondents were shown a second matrix introduced with this statement: \u003cem\u003eChallenges in this area of peer support are listed below. Please indicate how important each of them is for peer support work\u0026mdash;meaning that it\u0026rsquo;s a challenge PSSs are likely to encounter in their work, and might have difficulty navigating\u003c/em\u003e. This matrix provided the text of each of the key challenges within the general skill area, and asked respondents to rate each one using the same 5-point scale. Finally, respondents were given a text box to comment on the wording of the challenges or to make notes about whether key challenges were missing from the list. As noted previously, this survey was split into two parts, with each requiring between 20 and 30 minutes to complete. Each of the two surveys included an open-ended text box at the end for further comments or reflections.\u003c/p\u003e\n\u003cp\u003eWhen the feedback survey data collection was completed, the team compiled the ratings and feedback. The team then collaboratively reviewed this material and edited the skills and challenges document in light of the feedback from surveys and, as needed, referred back to data from the original discussion groups. As a result of this review, minor wording changes were made to many of the items. Additionally, one skill aspect and two challenge items were dropped, and two more items (challenge 4.b and challenge 5.d) were edited extensively enough that the team determined that the survey ratings no longer applied to these particular items.\u003c/p\u003e\n\u003cp\u003eThe comments that the PSSs provided in response to the open-ended questions on the survey included a large number focused on organizational-level challenges that impact PSSs\u0026rsquo; ability to practice skillfully. For example, many of these comments described challenges related to supervision, job conditions, and misunderstanding of the PSS role on the part of co-workers. Other comments focused on how supervisors and other co-workers responded to misunderstandings of the role on the part of PSU\u0026rsquo;s family members. Organizational-level challenges had not been included on the survey, which focused specifically on PSS practice. However, because participants so frequently mentioned these, the research team returned to the original discussion group analyses and, working with this previously-coded data and the comments from the feedback survey, added a section on \u0026ldquo;related challenges in the larger context\u0026rdquo; to each general skill area.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe finalized wording for the general skills, sub-skills and practice challenges, as well as mean ratings for sub-skills and challenges are provided in Table 1. The table also lists \u0026ldquo;challenges in the organizational context\u0026rdquo; for each general skill area.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsert Table 1 here.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean importance ratings across all sub-skills ranged from 4.44 to 4.94 on the scale for which 4 = \u003cem\u003every important\u003c/em\u003e and 5 = \u003cem\u003eextremely important\u003c/em\u003e. Only two of the mean importance ratings were below 4.5: 1c (\u003cem\u003eIs comfortably able to explain why they are considered a \u0026ldquo;peer.\u0026rdquo;\u003c/em\u003e) and 5d \u003cem\u003e(\u0026hellip;plan and engage in activities together in the community\u0026hellip;\u003c/em\u003e). The two sub-skills with the highest means were from general skill 3, \u003cem\u003eDrawing Out and Supporting PSUs\u0026apos; Preferences, Perspectives and Ideas\u003c/em\u003e. Sub-skill 3a focuses on maintaining a non-judgmental attitude and using active listening skills, while sub-skill 3f focuses on acknowledging and owning misunderstandings. The two other highest rated sub-skills were 1f, related to boundaries, and 4e, related to normalizing.\u003c/p\u003e\n\u003cp\u003eImportance ratings for the practice challenges tended to be slightly lower, with means ranging from 4.28 to 4.75, with about half of the means above 4.5 and half below. The highest rated practice challenge, challenge 6d, has to do with maintaining confidentiality. All of the practice challenges connected to general skill 6, \u003cem\u003eSupporting Personal Agency and Empowerment\u003c/em\u003e, received relatively high mean importance ratings. The lowest mean rating was for practice challenge 3b, handling situations in which a PSU does not want to communicate.\u003c/p\u003e\n\u003cp\u003eThe importance means for sub-skills for the FEP PSSs and the NDS PSSs had similar ranges, with the FEP means ranging from 5.00 (3a, non-judgmental attitude/active listening skills) to 4.25 (5d, activities in the community); and the NDS means ranging from 5.00 (1e, explaining confidentiality/mandatory reporting to PSUs) to 4.22 (1c, explains why they are considered a \u0026ldquo;peer\u0026rdquo;). When the rankings of the two groups\u0026rsquo; mean importance ratings were compared, the two sub-skills with the greatest discrepancy in ranking were 1e (explaining confidentiality/mandatory reporting to PSUs, NDS rank 1, FEP rank 35) and 3c (handling situations where PSUs are reluctant to engage in conversation or activities, FEP rank 6 and NDS rank 35).\u003c/p\u003e\n\u003cp\u003eThe importance means for practice challenges for the FEP and NDS groups likewise spanned similar ranges, with the FEP means ranging from 4.94 (item 6d, maintaining confidentiality) to 4.18 (item 3a, avoiding trying to \u0026ldquo;fix\u0026rdquo; or \u0026ldquo;steer\u0026rdquo; PSUs); and the NDS means ranging from 4.89 (6a, remains non-judgmental regarding PSUs\u0026rsquo; ideas about diagnosis, experiences and treatment) to 4.14 (4c, avoiding inauthentic or excessively positive reflections/responses). The practice challenge with the greatest discrepancy in ranking between the FEP and NDS groups was challenge 5b (responding when PSUs\u0026rsquo; goals etc., seem unrealistic or ill-advised, NDS rank 2, FEP rank 27) and challenge 2a (avoiding oversharing, NDS rank 4, FEP rank 21).\u003c/p\u003e\n\u003cp\u003eMany of the responses to the open-ended questions included endorsements of the skills, sub-skills and challenges. For example, responses to these questions for general skill 1 included these:\u003c/p\u003e\n\u003cp\u003eI feel that these skills are all very important. The PSS absolutely needs to be able to communicate what is different from other roles of the treatment team, as most clients I worked with had never worked with a peer before. I feel that the PSS needs to be able to understand their own internal boundaries in order to explain to participants and clinicians why they are a peer.\u003c/p\u003e\n\u003cp\u003eRole differentiation and role boundaries feels crucial when describing your role to clients, as well as when really understanding it yourself (e.g., knowing how much you are responsible for).\u003c/p\u003e\n\u003cp\u003eI do think that peers need to be extremely clear what is in scope for them and have good boundaries when asked to do things out of scope. When I was working at the early psychosis program, it was also unclear what was in scope for me because I never received training on this. Explaining to the participant that you are not a therapist, and what this means, is extremely important.\u003c/p\u003e\n\u003cp\u003eNot allowing peer roles to be treated as gophers, interns, or junior clinicians.\u003c/p\u003e\n\u003cp\u003eMany other comments were reflections or suggestions about particular items or groups of items. The project team integrated this feedback in making revisions. For example:\u003c/p\u003e\n\u003cp\u003eI think suicidality and self-harm might make more sense if moved as an example for the challenge on risk. Self-harm and suicidality can be difficult for peers to discuss because of stigma or their own preconceptions of the topics, but I think the safety challenges (and sometimes confidentiality challenges) that self-harm/suicidality pose make the topics different from the other examples (sexuality, political views) provided.\u003c/p\u003e\n\u003cp\u003eI would call into question the phrasing \u0026quot;manage situations\u0026quot; for the third one, it isn\u0026apos;t the situation that I need to manage, but my own expectations, reactions, and responses to the situation.\u003c/p\u003e\n\u003cp\u003eOccasionally I have had clients who insist that there is nothing pleasurable in life, nothing they care about. That is challenging because it seems like there is nothing to \u0026quot;work with\u0026quot;. Being able to remain patient -- and, again, follow the client on their journey -- is really important there.\u003c/p\u003e\n\u003cp\u003eFinally, another large portion of the comments focused on how the larger context\u0026mdash;particularly including supervisors, co-workers and PSUs\u0026rsquo; families, and their understandings and expectations\u0026mdash;created challenges for PSS practice.\u003c/p\u003e\n\u003cp\u003eManaging the desire to get a participant to pursue goals or activities, when they are not interested \u0026hellip; is a challenge, but it\u0026apos;s particularly a challenge if you feel pressure from people above you to make progress or show outcomes or showing impact. That to me feels like more of a challenge.\u003c/p\u003e\n\u003cp\u003eTrying to support a client in a way that feels authentic to my values, while being in an agency setting (going along with when a treatment team is pressuring a PSS to do something) has been a challenge at times.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDo you have a supervisor [and] providers who are willing to help support you when they\u0026apos;re like \u0026ldquo;you\u0026apos;re working on behalf of this young person, so we have your back also\u0026rdquo; versus feeling like you\u0026apos;re out on an island?\u003c/p\u003e\n\u003cp\u003eI still experience a lot of confusion [from other treatment providers] about what peer support is. This translates to lack of referrals, inappropriate referrals (e.g., wanting peer support to act as a mentor, case manager, skills trainer, etc.), and miscommunication to families/clients about what peer support is.\u003c/p\u003e\n\u003cp\u003eJust dealing with like power dynamics and feeling like you want to protect your client but feel like you\u0026apos;re also about to like go against your boss, or something like that. Or lose your job. It can be a challenge.\u003c/p\u003e\n\u003cp\u003eAs noted previously, consideration of these kinds of comments led the team to use them, together with information from coded transcripts from the original discussion groups, to develop the \u0026ldquo;challenges in the larger context\u0026rdquo; sections shown in Table 1.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study\u0026rsquo;s contribution to the literature derives from its research- and theory-driven approach to clarifying young adult PSS skills and challenges from the perspectives of PSSs and PSUs in adolescent and young adult multidisciplinary mental health programs across the United States. The study identified six general skill areas and, within each of these, a series of sub-skills, key practice challenges, and related challenges in the larger organizational context. PSSs from FEP and NDS programs across the United States were engaged across both phases of the study, providing knowledgeable, thoughtful insights and, in phase two, formally endorsing the importance of each of the sub-skills and practice-level challenges. This deep level of ongoing engagement is quite unique among studies on this topic.\u003c/p\u003e\n\u003cp\u003eStudy findings regarding practice skills and challenges complement other efforts to build understanding of peer support in mental health and to increase its quality and availability. For example, at the national governmental level, both the Mental Health Commission of Canada (39) and the United States\u0026rsquo; Substance Abuse and Mental Health Administration (40) have convened interested parties with relevant experience and expertise to describe competencies for peer support work. National advocacy organizations in the United States such as the National Federation of Families (41) and Mental Health America (42)\u0026nbsp;have likewise developed descriptions of peer support competencies. However, none of these initiatives focused on peer support for youth and young adults specifically. In contrast, the Massachusetts Department of Mental Health worked with the Children\u0026rsquo;s Behavioral Health Knowledge Center (43) to develop a document describing the \u0026ldquo;practice profile\u0026rdquo; for young adult peer support in the context of mental health services. The document identifies the basic functions of peer support and provides details on how these functions are translated into \u0026ldquo;ideal\u0026rdquo; practice. Other similar documents, mostly unpublished, have been developed at the state and local program level.\u003c/p\u003e\n\u003cp\u003eEach of the documents cited above groups and describes skills/competencies using different frameworks, making it difficult to succinctly catalog the similarities and differences among them and/or between them and the findings from the current study. However, certain broad categories of skill/competency are shared in virtually all cases, for example: using a style of personal presentation and communication that encourages and supports a PSU to express and explore their own thoughts, ideas and priorities; supporting PSUs to communicate these thoughts to others, including other providers; knowing when and how to share information about one\u0026rsquo;s own experiences; and using a PSU\u0026rsquo;s own goals to guide the work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFindings from the current study, and to a certain extent the descriptions of ideal practice presented in the Massachusetts document, highlight other areas skill and experience that appear to be more specific to and/or salient in the work of young adult PSSs. For example, regarding lived experience, both sources begin from the assumption that the PSS is close enough in age to the PSU to be \u0026ldquo;credible,\u0026rdquo; and \u0026ldquo;relatable.\u0026rdquo; This is important not just because of the shared experience of being young \u003cem\u003enow\u003c/em\u003e\u0026mdash;in the context of current youth culture, social currents and economic and climate challenges\u0026mdash;but also because systems and treatments, as well as the larger society\u0026rsquo;s understanding and/or stigmatization of involvement in systems and treatments, are continually evolving. Compared to the practice skills/competencies documents for adult peer support, both young adult-focused sources place greater emphasis on skills related to supporting a PSU in their interactions and communications with family members, which seems quite natural given the larger role that families tend to play in the lives of emerging adults. Additionally, both of these sources are relatively unconcerned with the PSS\u0026rsquo;s role in supporting \u003cem\u003erecovery\u003c/em\u003e, with its emphasis on returning to a former level of functioning, instead focusing more on skills related to supporting PSUs in \u003cem\u003ediscovery\u003c/em\u003e and \u003cem\u003eexploration\u003c/em\u003e. As noted by Klodnick et al. (44), this focus for mental health services is appropriate to the developmental stage of young adulthood, during which young people are intensively engaged in building self-knowledge and identity (45). For example, both sources place quite a bit of emphasis on PSS skills for supporting young people to explore their own values, beliefs and attitudes, recognizing that these may evolve over time and may be different from the values and beliefs held by people who are or have been influential in their lives.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe main differences between the two young adult-focused sources are to some extent, though not exclusively, matters of emphasis and nuance. Skill area 1 from the current study, \u003cem\u003eUnderstanding and Describing the Peer Support Specialist Role\u003c/em\u003e, focuses on a PSS\u0026rsquo;s understanding of the PSS role\u0026mdash;including how and why the role benefits PSUs\u0026mdash;and their ability to communicate relevant aspects of this understanding in the course of their work with PSUs. Several of the skills listed in this area are unique to this study, and stem from the way that skills were developed as part of a larger study focused on theory development. Skill area 5, \u003cem\u003eSupporting Motivation and Activity\u003c/em\u003e, describes a facet of PSS work that is focused on supporting a PSU\u0026rsquo;s identity development by facilitating their interactions in a way that builds awareness of and connections to what the PSU finds truly compelling and motivating\u0026mdash;including values, passions and aspirations, as well as people and groups/organizations that are connected to these motivators. Compared to the Massachusetts document, the included skills appear to describe a mode of interaction in which the PSS is more intentional and active, employing reflections and active listening \u003cem\u003ewhile also\u0026nbsp;\u003c/em\u003ebeing acutely attuned to anything a PSU expresses that is connected to these motivators and offering openings for the PUS to explore further and/or take action if desired. Skill area 6, \u003cem\u003eSupporting Personal Agency and Empowerment\u003c/em\u003e, shares a focus with the Massachusetts document on skills for ensuring that the treatment plan and process, including work with the PSS, reflect the PSU\u0026rsquo;s perspective and priorities. However, the skills from the current study have an explicit empowerment orientation, including an emphasis on supporting PSUs to develop confidence in their own agency, as well as an understanding of the power structures and power differentials in their own lives and how these interact with personal agency. For example, this area includes PSS skill for supporting PSUs in understanding power and how to \u0026ldquo;work with, negotiate with or confront power structures as they pursue activities and goals.\u0026rdquo; This skill area also notes PSSs\u0026rsquo; role in supporting PSUs to develop and use strategies for advocacy/self-advocacy. The current study\u0026rsquo;s skills also include a unique focus on supporting a PSU to explore the meanings and values that they attach to their mental health experiences. This focus might seem natural given that about half of the study\u0026rsquo;s participants were connected to FEP programs, and indeed the FEP discussion groups yielded quite a bit of material on this topic. However, it was also a topic that was relevant to participants in the NDS groups, and in fact, the NDS participants rated this skill\u0026rsquo;s importance even higher than the FEP participants did.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current study most obviously distinguishes itself from other efforts due to its inclusion of key challenges related to each skill area. At the practice level, these findings describe specific types of situations that are typically difficult to manage and that PSSs are likely to encounter in their work directly with PSUs. These challenges highlight how, even when skills are clearly defined, the PSS role remains complex and difficult, requiring PSSs to be intentionally involved in an ongoing process of deepening \u003cem\u003etheir own\u003c/em\u003e self-understanding and solidifying \u003cem\u003etheir own\u003c/em\u003e identity. Detailed information of this nature can be particularly valuable in training and supervision, which can be structured to help PSSs learn to anticipate (and potentially avoid), recognize and respond appropriately to challenging situations. For supervisors in particular, knowing about typical challenges may facilitate their ability to respond to issues that PSSs raise in supervision in a way that sensitive to young adult development and that promotes self-understanding and identity development. Information about practice-level challenges can be useful for supervisors in another way: they are expected to provide guidance about handling such situations despite, in the large majority of cases, never having worked as a PSS themselves. Supervisors can review the challenges to determine their confidence and readiness to provide guidance and support to PSSs, and to seek further training or supervision for themselves to address any areas of uncertainty.\u003c/p\u003e\n\u003cp\u003eWhen FEP and NDS participants\u0026rsquo; ratings for sub-skills and challenges were considered separately, both groups saw each of the sub-skills and challenges as very important. This finding supports the idea that the fundamental PSS skills and challenges are the same across specialized (FEP) and more general (NDS) community mental health programming. Where there were discrepancies (i.e., where importance rankings between FEP PSSs and NDS PSSs were greatest), this could be explained by differences in the populations served. For example, the relatively high importance rating that NDS participants gave to sub-skill 1e (explaining confidentiality/mandatory reporting) likely reflects the fact that these programs tend to serve a higher number of young people with histories of involvement in the child welfare/foster care systems. Similarly, the relatively high importance rating that FEP participants gave to sub-skill 3c (handling situations where PSUs are reluctant to engage in conversation or activities) is consistent with FEP study participants\u0026rsquo; comments about how frequently they encounter PSUs who appear to have low levels of motivation for interpersonal engagement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStudy findings related to challenges in the organizational context are consistent with themes from studies such as those cited in the introduction. Relative to these sources, findings here present a relatively comprehensive and concrete list of challenges. Also important is the way that these challenges are tied to PSS skill areas, reinforcing the causal connections between organizational context and PSSs\u0026rsquo; ability to skillfully carry out their work.\u003c/p\u003e\n\u003cp\u003eFindings from this study should be considered in light of limitations. Most obviously, the study sample cannot be considered representative of PSSs/PSUs generally. While participants represented a range of sociodemographic backgrounds, our sample was mostly White, cisgender and well educated. It is likely that young adults who were relatively \u0026ldquo;successful\u0026rdquo; in mental health programs were overrepresented in our samples. i.e., PSUs that stayed in treatment, and PSSs who were perceived by their employers and/or themselves to be good sources of information about the role. Study participants were recruited through existing email lists and it is possible that these individuals have different perspectives from PSUs and PSSs connected to programs that are unconnected to national networks. Finally, it should be remembered that the skills described here are limited to those for working directly with PSUs, and the study does not touch on other kinds of job skills that are needed for the role.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eResults from the study have practical implications for training, supervision and organizational development to support the PSS role. The concrete descriptions of skills and challenges makes practical application of the findings particularly feasible. Taken together, study findings on practice-level skills and challenges support their potential usefulness as a framework for structuring training, supervision and/or ongoing professional development for PSSs. Such trainings could easily be adapted to include special attention to situations most typically encountered in a particular program context (e.g., FEP versus NDS or other types of programs). As noted previously, the findings can also be useful in developing training for supervisors, and may be particularly helpful for supervisors with no experience in the peer role. Finally, the findings on organization-level challenges can be helpful to managers seeking understand the extent to which they are providing a hospitable context for their PSSs\u0026rsquo; work.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: The study protocols were approved by the Institutional Review Board (IRB) at Portland State University in accordance with the regulations of the United States Department of Health and Human Services (45-CFR part 46). In accordance with these regulations, electronic informed consent was obtained from all participants involved in the study, and participation was voluntary.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The dataset analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding: National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90IFRE0054). \u0026nbsp;NIDILRR is a Center within the Administration for Community Living (ACL), United States Department of Health and Human Services (HHS).\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: JSW Conceptualized the study. JSW, VVK, BP, MH-K and SB collaboratively developed the questions/items for the qualitative/quantitative portions of the study and analyzed the data. BP took the lead for recruitment. BP, MH-K, RPJ, VVK and JSW facilitated/co-facilitated discussion groups. JSW and VVK took the lead in preparing the manuscript, with all authors participating in editing manuscript drafts. All authors read and approved the final version.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors would like to thank the Peer Support Specialists and peer support users who participated in this study. The contents of this article were developed under a grant from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR grant number 90IFRE0054). NIDILRR is a Center within the Administration for Community Living (ACL), United States Department of Health and Human Services (HHS). The contents of this article do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAdams WE. Unintended consequences of institutionalizing peer support work in mental healthcare. Soc Sci Med. 2020;262(July).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurr C, Rother K, Elhilali L, Winter A, Weidling K, Kozel B, et al. Peer support in Switzerland \u0026ndash; results from the first national survey. Int J Ment Health Nurs. 2020;29:212\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGillard S. Peer support in mental health services: where is the research taking us, and do we want to go there? J Ment Health. 2019;28:341\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlee A, Chinman M, Kearney L. 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Accessed 5 Feb 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11:589\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;2:77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMental Health Commission of Canada. Guidelines for the practice and training of peer support. 2013\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.mentalhealthcommission.ca\u003c/span\u003e\u003cspan address=\"http://www.mentalhealthcommission.ca\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 5 Feb 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubstance Abuse and Mental Health Services Administration. Core competencies for peer workers in behavioral health services. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/core-competencies_508_12_13_18.pdf\u003c/span\u003e\u003cspan address=\"https://www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/core-competencies_508_12_13_18.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 5 Feb 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Federation of Families. National Core Competencies 202. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ffcmh.org/certification-competencies\u003c/span\u003e\u003cspan address=\"https://www.ffcmh.org/certification-competencies\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 5 Feb 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMental Health America. Nationally certified peer specialist core competencies. 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://flcertificationboard.org/wp-content/uploads/MHA-NCPS-Training-and-Test-Self-Assessment-1.pdf\u003c/span\u003e\u003cspan address=\"https://flcertificationboard.org/wp-content/uploads/MHA-NCPS-Training-and-Test-Self-Assessment-1.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 5 Feb 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChildren\u0026rsquo;s Behavioral Health Knowledge Center. Young adult peer mentoring practice profile. 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cbhknowledge.center/practice-profiles/young-adult-peer-mentoring/\u003c/span\u003e\u003cspan address=\"https://www.cbhknowledge.center/practice-profiles/young-adult-peer-mentoring/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 5 Feb 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlodnick VV, Malina C, Fagan MA, Johnson RP, Brenits A, Zeidner E, et al. Meeting the developmental needs of young adults diagnosed with serious mental health challenges: the Emerge Model. J Behav Health Serv Res. 2021;48:77\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnett JJ. Emerging adulthood: a theory of development from the late teens through the twenties. Am Psychol. 2000;55:469\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":" \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 \u003cdiv class=\"SimplePara\"\u003ePSS General Skill Areas, Sub-Skills and Related Practice and Contextual Challenges\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDescription\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean Importance Rating\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e1)Understanding and Describing the Peer Support Specialist Role\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003ePSSs are clear about the purpose of the PSS role. They accurately and succinctly describe their role, including issues related to confidentiality and relational boundaries, to PSUs and others (e.g., colleagues, community members).\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSub-Skills. A PSS\u0026hellip;\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Understands and can describe the purpose of the PSS role and how skilled practices benefit PSUs.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.64\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Understands and communicates clearly what distinguishes the PSS role from other roles on the treatment team, and what distinguishes the PSS role from that of a friend.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.68\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Understands and explains why they are considered a \u0026ldquo;peer.\u0026rdquo;\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.45\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. Introduces their role concisely and provides ongoing role clarification as needed by providing further details or answering questions about their role.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.59\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ee. As part of introducing their role, clearly describes confidentiality between themselves and a PSU, as well as situations such as mandatory reporting when confidentiality may be broken.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.68\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ef. Describes boundaries that limit what they can/cannot do as part of the PSS role.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.86\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Practice Challenges\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Understanding and communicating how the PSS role is distinct from other peer-like roles such as mentor, peer mentor, skills trainer, etc.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.32\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Being internally confident about boundaries and clarifying/re-establishing them if a PSU appears to have expectations for the PSS that are outside of the PSS role.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.64\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Determining how much personal information about lived/living experience is helpful to share and comes across as authentic when introducing/describing the role.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.59\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Challenges in the Larger Context\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Remaining confident about the PSS role\u0026rsquo;s scope, purpose, practices and skills, even when supervisors or co-workers are unclear or present different views about these.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e*\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Managing situations when family\u0026rsquo;s or other team members\u0026rsquo; misunderstanding of the PSS role leads them to expect that the PSS will do things that are not part of the role.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e*\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e2)Being a Peer, Being Genuine and Drawing on Personal Experience\u003c/span\u003e\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003ePSSs present themselves and talk about personal experiences with intention, in a way that is genuine and helpful to PSUs.\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSub-Skills. A PSS\u0026hellip;\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Cultivates a manner of self-presentation and speaking that is genuine and not overbearing or self-centering.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.65\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Offers knowledge, observations or anecdotes from personal experience for PSUs to consider, without implying that PSUs should believe, feel or act the same way.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.58\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Is open and genuine about personal experiences without distressing PSUs or themselves.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.68\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. Serves as an example of a young adult who has experienced\u0026mdash;and may continue to experience\u0026mdash;mental health challenges, and who has had success\u0026mdash;and setbacks\u0026mdash;in navigating life and employment while managing their mental health and wellness.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.70\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Practice Challenges\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Recognizing and managing if oversharing personal experience, for example,\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003ei. as a way to prove worthiness as a peer;\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eii. in a way that overwhelms a PSU, diminishes the PSU\u0026rsquo;s own experiences, or distresses the PSS; or\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eiii. to serve the PSS\u0026rsquo;s own purposes, such as venting, or prompting a PSU to provide emotional support.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.58\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Feeling comfortable discussing past, current or ongoing struggles or setbacks with PSUs in a way that is genuine but also does not discourage or distress the PSS or PSU.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.55\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Being internally aware about when and how much lived/living experience to share with PSUs, and managing situations when a PSU presses a PSS to share more about their experiences than the PSS is comfortable with.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.41\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. Managing situations when a PSS does not share key aspects of identity or experience with a PSU (e.g., difference in gender or sexual orientation, race/ethnicity, socioeconomic status), so that it may be difficult for a PSS to understand a PSU or for a PSU to feel understood. Being comfortable acknowledging differences and talking about them with PSUs when they come up.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.61\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Challenges in the Larger Context\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Managing situations where managers, supervisors or non-peer colleagues\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003ei. ask the PSS to share their lived/living experiences in settings or in ways that the PSS is not comfortable with;\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eii. share PSS lived experience with PSUs, colleagues, and/or community members; or\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eiii. ask PSS inappropriate questions about their mental health and treatment.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e*\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e3)Drawing Out and Supporting PSUs' Preferences, Perspectives and Ideas\u003c/span\u003e\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003ePSSs support PSUs to explore their own values, preferences, thoughts and ideas. PSSs do this in a way that is non-judgmental and shows genuine curiosity and interest in what PSUs express. PSSs do not try to convince PSUs what to do, say or think. PSSs follow PSUs\u0026rsquo; lead regarding if and when to meet, and what to do or talk about.\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSub-Skills. A PSS\u0026hellip;\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Maintains a non-judgmental attitude, using active listening skills to support PSUs in sharing and exploring their experiences, values, ideas, preferences and perspectives.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.94\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Makes reflections that fit well within the conversation and accurately restates or summarizes key content that PSUs bring up.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.56\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Gauges when a PSU doesn\u0026rsquo;t want to participate in certain activities or talk about certain things, or when they do not want to talk at all.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.63\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. Makes observations and offers ideas for a PSU to consider, without putting pressure on them to agree.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.56\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ee. Identifies and remembers key content from conversations or interactions with PSUs, and bring this into later conversations when relevant.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.50\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ef. Is comfortable acknowledging when they have misunderstood what a PSU is communicating. Acknowledges misunderstandings as needed and then returns the focus of the conversation to the PSU\u0026rsquo;s thoughts and ideas.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.91\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Practice Challenges\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Resisting a desire to fix things for the PSU, or steer them towards what the PSS thinks they should think or do.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.31\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Remaining patient, empathic and non-directive when a PSU is reluctant or unable to share their thoughts, ideas or preferences.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.28\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Remaining empathic and non-directive when PSUs raise topics that the PSS finds difficult or uncomfortable, or when they do not share ideas or opinions expressed by a PSU (e.g. topics connected to sexuality, privilege/oppression, substance use, political views, religious beliefs).\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.66\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. Handling situations when a PSS has concerns that a PSU\u0026rsquo;s thinking or reasoning may lead them to do something that is risky or harmful\u0026mdash;including suicidality or self-harm\u0026mdash;or that sets them back from their own goals. Knowing when it\u0026rsquo;s appropriate to break confidentiality to ensure safety.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.34\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Challenges in the Larger Context\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Navigating situations when clinicians or family members put pressure on a PSS to \u0026ldquo;make\u0026rdquo; a PSU change their thinking or behavior.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e*\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e4)Providing Empathy and Validation\u003c/span\u003e\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003ePSSs attend to, empathize with and validate PSUs\u0026rsquo; emotional expression and tone\u0026ndash;positive, negative and mixed. Across their interactions and communication together, PSSs create opportunities for PSUs to explore topics or ideas that are important or meaningful to them.\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSub-Skills. A PSS\u0026hellip;\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Provides validation and empathy that is rooted in the PSU\u0026rsquo;s perspective.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.74\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Recognizes and validates when PSUs indicate things that are important or meaningful to them. Creates opportunities them to explore these topics if they want to.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.77\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Recognizes and responds to emotional content PSUs express\u0026mdash;including positive, negative and mixed emotions in conversations or actions.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.71\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. Assesses and/or asks when it would be helpful to go deeper into emotionally significant topics and help PSUs explore further.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.61\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ee. Normalizes PSUs\u0026rsquo; experiences appropriately through reflections, observations, etc.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.84\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ef. Is comfortable discussing safety concerns and developing safety strategies, and confident about when and how to contact other providers due to safety concerns.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.57\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eg. Manages their own reactions to what PSUs may disclose, including vicarious trauma and distress. Knows how to seek support for themselves in processing these experiences and creating boundaries.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.77\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Practice Challenges\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Responding and managing (and knowing how to seek supervision/support) when feeling overwhelmed or unable to genuinely understand or validate emotional experiences or ideas that PSUs talk about, such as those connected to trauma; racism, sexism, homophobia, transphobia or other forms of oppression; and extreme or unusual experiences related to mental health.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.58\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Offering a normalizing perspective when appropriate, without discounting a PSU\u0026rsquo;s experiences.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e**\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Knowing how to avoid making reflections or responses that come across as inauthentic, exaggerated or misaligned with what PSUs are communicating, including over-empathizing or being excessively enthusiastic or positive.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.35\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. Handling situations when a PSU thinks (or appears to think) that the PSS can\u0026rsquo;t really understand them due to different styles of communication, personal experiences, identities, cultures and values, socio-economic status, etc.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.42\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ee. Knowing how to pace or structure time with a PSU so that, if needed, there is time to debrief, address safety concerns and/or discuss ways the PSU could follow up with the PSS or other providers.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.65\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ef. Recognizing when topics may be too activating or unhelpful to explore with PSUs in peer support, and knowing when and how to assist a PSU in getting additional support from other providers.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.58\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Challenges in the Larger Context\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Navigating differences in perceptions between young people (i.e., PSSs/PSUs) and older adults (supervisors, co-workers, PSUs\u0026rsquo; family members) regarding statements, behavior or activity that is normal, versus what is dangerous, threatening or risky.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e*\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Navigating clinical staff\u0026rsquo;s lack of clarity about whether the empathy and validation provided by PSSs is therapeutic, and how this differs from providing psychotherapy.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e*\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e5)Supporting Motivation and Activity\u003c/span\u003e\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003ePSSs are attentive to things PSUs say and do that provide information about what motivates them, including values, commitments and passions, as well as relationships and activities that bring satisfaction or joy. PSSs support PSUs in exploring these motivators from their own perspectives. When PSUs show interest, PSSs partner with PSUs to develop activities, plans or goals based on what emerges.\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSub-Skills. A PSS\u0026hellip;\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. During conversations and activities with a PSU, notices and offers openings for PSUs to recognize and explore their motivators, including\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003ei. aspirations, interests and passions;\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eii\u0026hellip;personal, family and cultural values and commitments; and\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eiii. activities and relationships that bring joy, satisfaction, pleasure, or a sense of accomplishment or achievement.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.73\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. During conversations and activities with a PSU, notices and offers openings for PSUs to recognize and explore their ideas and preferences related to wellbeing, including self-care, wellness, personal safety and harm reduction.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.59\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. During conversations and activities with a PSU, notices and offers openings for PSUs to build recognition about the people, groups and organizations that support their aspirations, values and wellbeing, or that could do so.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.59\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. When PSUs show interest, works with them to plan and engage in activities that reflect PSU motivators and preferences (i.e., as explored in conversations described above).\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.40\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ee. Uses opportunities that arise during conversations, interactions or activities to reflect PSUs\u0026rsquo; awareness of their personal growth, learning, progress and success, even when changes, progress or accomplishments are small.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.73\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Practice Challenges\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Managing any desire to \u0026ldquo;get\u0026rdquo; a PSU to pursue goals or activities when they are not internally motivated to do this.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.59\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Knowing how to respond when a PSU has passions, goals or sources of pleasure that the PSS sees as harmful, unrealistic or undesirable.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.50\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Remaining patient, empathic and non-directive when a PSU does not talk much, does not bring up motivators, values, commitments and activities, and/or generally does not seem to express interest, joy, excitement or motivation.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.32\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. Understanding the difference between reflecting/supporting a PSU\u0026rsquo;s own perceptions of their strengths, growth, learning and progress, versus giving praise or affirmation from the point of view of the PSS or other people.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e**\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Challenges in the Larger Context\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Responding to supervisors, other treatment team members or family members when they expect or direct a PSS to pursue goals or activities that are not in alignment with a PSU\u0026rsquo;s preferences or motivators.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e*\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Negotiating situations when organizational rules or culture dictate what sorts of PSU activities are meaningful or important, thereby limiting the support that PSSs can offer when PSUs are motivated to engage in other kinds of activities.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e*\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e6)Supporting Personal Agency and Empowerment\u003c/span\u003e\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003ePSSs are attentive to opportunities to support PSUs in exploring options and making choices about mental health treatment and other aspects of their lives.\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eSub-Skills. A PSS\u0026hellip;\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Is attuned when a PSU expresses thoughts related to having a mental health diagnosis and mental or emotional experiences that are unusual and/or stigmatized, and provides an opportunity for them to explore these thoughts further if they wish. This includes exploring the meanings and values that PSUs attach to their experiences.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.82\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Is attuned when a PSU touches on topics related to mental health treatment and other strategies for improving/maintaining wellness and mental health, and provides an opportunity for them to explore these thoughts further if they wish.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.68\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Is attentive when a PSU is considering a decision or change, helps them to recognize options, explore choices and take action that is aligned with their values and goals.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.82\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. Models and offers strategies for accessing sources and information about various options and choices.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.55\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ee. Offers strategies that can help a PSU effectively advocate for their own choices, preferences and goals.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.59\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ef. Assists PSUs in understanding power differentials (e.g., between individuals with different identities or roles, or between individuals and organizations, institutions or systems) and how these may impact their ability to make progress on their goals. Provides PSUs with information and strategies on how to work with, negotiate with or confront power structures as they pursue activities and goals.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.73\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Practice Challenges\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Remaining comfortable, empathic and non-judgmental when a PSU\u0026rsquo;s interpretation of their mental health experiences or choices regarding treatment are difficult for a PSS to understand or accept.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.68\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Being able to talk with PSUs\u0026mdash;and manage own reactions\u0026mdash;about situations in which a lack of power and/or resources poses significant barriers to PSUs\u0026rsquo; efforts towards their goals.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.64\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ec. Supporting a PSU in situations in which other treatment team members, or other key people in a PSU\u0026rsquo;s life, may be pressuring a PSU to accept a specific interpretation of their mental experiences, or to accept specific treatment recommendations.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.64\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ed. Keeping what a PSU says confidential, unless the PSU specifically provides permission to share; and making sure PSUs understand any exceptions when confidentiality might be broken.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.75\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRelated Challenges in the Larger Context\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ea. Responding appropriately when treatment team members or family members expect a PSS to speak for a PSU about topics or issues that the PSU has not given permission for the PSS to discuss with others.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e*\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eb. Managing and responding to situations when treatment team members or family members pressure a PSS to undercut a PSU\u0026rsquo;s agency, for example by asking the PSS to \u0026ldquo;get\u0026rdquo; a PSU to comply with the team\u0026rsquo;s/family\u0026rsquo;s view of treatment or medication.\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e*\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e* These key challenges in the organizational context were not included on the survey and were thus not rated by respondents.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e** These items were substantially changed from their original forms, so the ratings provided in the survey do not apply to the revised items.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"youth peer support, peer support practice, peer support skills, peer support on-the-job challenges","lastPublishedDoi":"10.21203/rs.3.rs-6180371/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6180371/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003e\u0026nbsp;Peer support for older adolescents and young adults has become increasingly available as a formal mental health service. Alongside this increasing availability has been a steady accumulation of studies examining the potential for peer support to lead to positive outcomes for peer support users. However, a consistent refrain from the literature on peer support is that research and practice are hampered by a lack of theory-based models that specify the activities and skills of specific peer support roles, and describe how skillful practice is linked to outcomes. As part of a larger study intended to help fill this gap, the current study aimed to define and validate a set of key skills and related challenges in one-on-one peer support for older youth and young adults.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e The study engaged peer support specialists (PSSs) and peer support users (PSUs) from first episode psychosis (FEP) and non-diagnostic-specific (NDS) programs across the United States in a series of discussion groups focused on the activities, skills and outcomes of effective peer support. Qualitative analysis of the discussion group material led to the specification of six general skill areas and, within each of these, a series of sub-skills and key practice challenges. In a second phase of the study, the PSSs reviewed a document describing these, rated the importance of each of the skills and challenges, and provided open-ended feedback on wording and conceptualization. Based on feedback, wording of practice skills and challenges was finalized, and a set of related organizational challenges connected to each skill area was added to the document.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e All of the mean importance ratings for sub-skills and challenges were above 4.25 on a 5-point scale for which 4 = \u003cem\u003every important\u003c/em\u003e and 5 = \u003cem\u003eextremely important\u003c/em\u003e. PSSs from FEP and NDS programs provided similar ratings for sub-skills and challenges, with a few exceptions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e The final document produced from this study contains information about skills and challenges that has similarities to other studies of PSS skills, but also has unique features. Results from the study have practical implications for training, supervision and organizational development to support the PSS role.\u003c/p\u003e","manuscriptTitle":"Key Skills and Challenges in One-on-One Peer Support for Older Adolescents and Young Adults with Serious Mental Health Conditions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-10 07:25:10","doi":"10.21203/rs.3.rs-6180371/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-05T05:46:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-04T16:35:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174435571101335720614444295291153790692","date":"2025-10-16T12:44:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"141772858983746705890484349538348499223","date":"2025-10-15T10:41:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-13T19:42:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15142979862702368227443573971641815339","date":"2025-09-09T11:40:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T17:54:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T08:39:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"262358246612834942785744550751550453665","date":"2025-06-22T18:29:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187655869088971581426067357483379930375","date":"2025-06-16T16:05:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-06T13:03:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-04T11:57:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-27T22:27:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2025-03-27T22:26:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bcc16746-2d42-43ba-b801-ceb5e1812906","owner":[],"postedDate":"June 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T06:23:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-10 07:25:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6180371","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6180371","identity":"rs-6180371","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}