Understanding The Challenges of Peer Support Work at One of the International Leaders of Recovery-Oriented Programming.

Parts of the Italian Mental Health System have been miles ahead of programming in the US in terms of understanding and building recovery-oriented programming, while dismantling care that fosters dependency and stigma among adults with mental illness. Fifteen years ago, my hospital in the US hosted a clinical team from the Friuli Venezia Giulia region of Italy, one of the most advanced programs in the world in terms of innovative programming.  They were touring US facilities to learn what we were doing and to share their experience.

At the time, I felt that our hospital was a US national leader in terms of recovery programming.  We had 20 Peer Support Specialists working in a wide range of programs.  We used peers in strategic and innovative ways.  We valued their input and perspective.

 The team from Italy wanted to observe mental health programming in the US, and so we had them sit in on meetings about our programs, including our Peer Support Specialist education meeting.  After they spent a day observing our programming, our Peer Support Specialists started asking them about their Peer Support programming in Italy.  By the time they were done describing their programming, all of my pride in our programs had dissolved and I was left with a painful sense of how far we had to go (and still have to go). 

These visitors from Italy talked about having Peer Support Specialists, half of whom were Family Peer Support Specialists (people whose lived experience focused on being a family member to someone with mental illness), integrated throughout their mental health system.  They had invested heavily in peer support.  For every 1,000 clinicians, they had 500 Peer Support Specialists.  Most of these Peers were part time and most were volunteers.  Peers were positioned in their programs so that a Peer was the first person that clients met when they started any treatment, and they were the last person they met with when they ended treatment.  No matter what programs clients were engaged in, they could easily find a Peer who would talk to them, answer questions about that service, and help advocate for them.  The visitors described a remarkably integrated system that was (and is) decades ahead of any program that I am aware of in the US.

There is a new article, published in the past 12 months, that reports on an interview study of the role of Peers in this very program within the Italian mental health system.  The research team, led by Dr. Giulia Pollice (2025), conducted a study in which they performed extensive interviews with Peer Support Specialists (they use the title “Peer Support Workers”), and clinicians.  Questions focused what services the Peers provided, what helped them integrate with the clinical team, and what challenges they faced in integrating. 

The results include:

1.       Peers Support Workers most commonly

provide the following services: 

·       Peer counseling.

·       Leading peer support groups.

·       Advocacy.

·       Education for clinicians.

·       Education for the community.

·       Helping clients with community

engagement.

·       Staffing peer-specific programming (e.g.

Recovery Houses).

2.      The benefits listed by clinicians and Peer

Support Workers for having Peers

integrated in the clinical team include:

·       They foster better empathy and

understanding of clients by the clinical

team.

·       They reduce self-stigma. 

·       They promote social inclusion by building

connections in the community and building

networks of community partners for

clients to connect to.

·       They are more effective advocates for

client rights.

·       They enhance understanding and respect

between clinicians and clients.

·       Their work advances the recovery of the

Peers themselves.

3.      Challenges that both the Peers and the

clinicians recognize include: 

·       Stigmatization from clinicians.

·       Misue of Peers by having them do work

that is not related to their role.

·       “Power imbalances” that lead to clinicians

limiting the role of Peers in changing the

program/system.

·       “Instrumentalization and manipulation” of

Peers by programs and clinicians.  This

term refers to efforts by clinicians to have

Peers use their influence and rapport with

clients to get the clients to do what the

clinicians want, separate from the clients’

recovery. 

 4.      When asked about how to improve the full

integration of Peer Support Specialists

into clinical programming, the

respondents suggested a number of

steps including the following:

·       Better training for clinicians about the Peer

Support Specialist’s role on the clinical

team and how to treat and use them.

·       Overall strengthening of the recovery

oriented culture of clinical programs.

·       Stronger institutional recognition of the role

and work of Peers.

·       Safeguarding the role of the Peers against

efforts to misuse them.

The article is cited below and is available online.  Given this is one of the most advanced mental health programs in the world, it is particularly important to see how they are using Peers and what challenges they are facing. 

To me, it is surprising that they are dealing with some of the very same challenges that we now see in the United States.  Healthcare organizations in both places clearly have difficulty fully training clinical staff to truly understand the special role of Peers and how to use them (and how NOT to use them).  Peers represent such a powerful tool, it seems tragic that because of lack of training, Peers are often misused or not used.  Everyone suffers from this failure: clients, family members, Peers, clinical teams, healthcare funders, and our communities. 

It is also important that this advanced system has highlighted the tendency of clinicians and clinical programs to use Peers in a way that is not for client recovery but for the goals of the clinical program – referred to as the “instrumentalization and manipulation” of Peers.  The paper makes it clear that this represents the efforts of clinical programs to pressure Peers to watch out for the program’s welfare over the welfare of their clients.  This includes efforts to silence their criticism of programming.  Again, this is such a costly mistake for programs and clinicians to make. 

In some ways it is comforting to realize that this very advanced program is facing the same challenges we are facing.  It should be sobering as well.  If we do not make changes to address these challenges, we will still be struggling with them in 10-15 years.  What a tragic waste of time and resources, given the clarity in which we now see the problems. 

REFERENCE

Pollice, G., Bodini, C. F., Menchetti, M., Da Mosto, D., Negrogno, L., Betti, L., ... & Quaranta, I. (2025). Exploring the Integration of Peer Support Workers and Their Experiential Knowledge in Mental Health Services: An Ethnographic Study from the Dual Perspectives of Peer Support Workers and Professionals in Trieste and its Region.