‘We have to band together’: service user experiences of naturally occurring peer support on the acute mental health unit

ABSTRACT

Peer support has been proposed as a way to enhance the provision of mental health care; however, research has predominantly centred around formalised peer support programmes, with a dearth of studies exploring the anecdotally described phenomenon of naturally occurring peer support. This paper reports how naturally occurring peer support took place among service users in adult acute mental health unit settings, drawing on a thematic analysis of qualitative interviews gathered from four New Zealand facilities. Our analysis revealed three themes in relation to how peer support naturally occurred: (1) fulfilling a need to connect, (2) desire to improve the unit experience for others and (3) a sense of solidarity among service users. These interwoven but distinct themes provide a means for understanding naturally occurring peer support in the context of busy, under-resourced acute mental health settings and draw attention to its strengths, helping to fulfil service users’ need for support and connection in the absence of talking therapies or staff available to talk to. The findings highlight the potential for staff to recognise and facilitate these interactions in the acute care setting, and may help to dismantle stigmatising perspectives, demonstrating service users’ capacity for kindness despite being acutely unwell.

KEYWORDS:

• Peer support
• mental health units
• qualitative
• service users
• acute settings

Introduction

Living with mental illness in the context of mental health inpatient settings can be an extremely isolating experience. Service users on adult acute mental health units long for an available listening ear, yet frequently report staff being too busy to talk (Shattell et al. 2008; Stenhouse 2011). While some staff endeavour to provide listening support, others fail to view listening and talking with patients as a priority, citing competing demands due to the acute nature of presentations in the acute setting (Jenkin et al. 2021). Accounts of naturally occurring peer support suggest service users wish to engage with someone who can understand their challenges, with some fulfilling this need for connection through social relationships with other service users (Bouchard et al. 2010; Galloway and Pistrang 2019). Exploring the manifestations of naturally occurring peer support in acute mental health units is important given the potential to recognise, facilitate and accommodate these beneficial interactions as part of the acute mental health care model.

A peer support model in the field of psychiatry rose to prominence both within New Zealand and internationally in the consumer/survivor/ex-patient movement of the 1970s (O’Hagan 2011). With the closure of large state hospitals in many countries, patients were moved into the community setting with insufficient formal and informal support. People who had experienced this shift challenged the traditional model of mental health care, highlighting inhumane treatment and advocating for peer-run services that aligned with the values of empowerment and self-determination (Tang 2013). Since the deinstitutionalisation of mental health care, the value of peer support has increasingly been recognised (Repper and Carter 2011). One of the most common definitions in the literature is that proposed by Davidson et al. (2012) over twenty years ago, categorising peer support into three main types: (1) naturally occurring peer support, (2) peers participating in consumer-run programmes and (3) the employment of service users to provide support within traditional mental health services.

More recently, Gillard (2019) has provided a more person-centred definition of peer support, describing it as ‘what we do when we recognise our shared experiences of disadvantage and distress, make an inter-personal connection on that basis, and come together to support and learn from each other’. Reviews of the literature have highlighted the extensive benefits of peer support, including increased self-esteem and empowerment, increased ability to cope with stress, increased ability to communicate with mainstream providers, improved social functioning and enhanced quality of life (O’Hagan 2011; Repper and Carter 2011). However, research focused on the various forms of peer support that may exist in mental health care is, at best, emergent (O’Hagan 2011).

The vast majority of peer reviewed, published literature to date has centred around formalised peer support programmes (Bouchard et al. 2010). This means that findings reflecting benefits may not be generalisable to naturally occurring peer support where the providers of support are acutely unwell. Consequently, there is a need to further explore this phenomenon and address this knowledge gap. For example, two recent studies on acute mental health units explicitly focussed on naturally occurring peer support between service users, and highlighted benefits for both providers and recipients (Bouchard et al. 2010; Galloway and Pistrang 2019). Recipients reported improvements in their emotional state, behaviour and outlook on their situation, and that it assisted with recovery. Service users who provided support found it meaningful and fulfilling, and it was proposed that opportunities to help other service users on the unit may promote self-efficacy and conceptualisation of a more positive identity (Galloway and Pistrang 2019). A key finding of both these studies was that staff frequently failed to recognise or even actively discouraged peer support between service users, despite being ideally placed to facilitate these relationships.

Studies of mental health inpatient experiences have further highlighted incidental findings in relation to informal peer support (Thomas et al. 2002; Gilburt et al. 2008; Shattell et al. 2008; Jones et al. 2010). For example, the strong culture of peer support in acute psychiatric units was found to be an extremely positive aspect of many service users’ hospitalisation and reported by service users as more beneficial than the care provided by staff (Thomas et al. 2002; Shattell et al. 2008; Jones et al. 2010). Likewise, Gilburt et al. (2008) found that interpersonal relationships were the overarching theme in service user accounts of psychiatric hospitalisation, with self-disclosure and shared experience being key factors that enabled communication. These findings provide evidence for how peer support relationships that are built on a foundation of understanding can lead to more authentic empathy and social connection (Mead and MacNeil 2006).

Research on service user experiences in the context of New Zealand acute mental health units is sparse. In a recent study exploring whether New Zealand acute mental health units were ‘fit for purpose’, Jenkin et al. (2021) described how staff priorities on the unit included keeping people safe and contained and talking with patients was viewed as a less important aspect of treatment, with a minority of staff believing it was ‘not their job’. Yet, most service users expressed the desire for someone to talk to, describing the need for friendships with other service users to improve quality of life while in care (Jenkin et al. 2021). This suggests there is an unmet need for meaningful interaction on the units, creating the drive to engage in naturally occurring peer support. These findings are supported by two other studies (Shattell et al. 2008; Stenhouse 2011) which describe the ways in which service users supported each other as consequence of the observation that staff were too busy to engage with them.

The aforementioned literature provides important insights into the value of informal peer support in the acute mental health unit setting; however, knowledge gaps exist around service users’ lived experiences of naturally occurring peer support. Further work is needed to explore these complex social relationships given the widely recognised benefits of peer support, and the potential implications for fostering these relationships as a valuable aspect of care. This paper addresses the research question: ‘What are the ways in which naturally occurring peer support takes place among service users in acute mental health units in New Zealand?’

Methods

Given the paucity of research around informal support in the mental health unit setting to date, we took an exploratory, qualitative approach to the topic. Data came from interviews with service users who took part in a large observational study focused on understanding the architectural design, therapeutic philosophy and social regime of the modern adult acute mental health unit in New Zealand (Jenkin et al. 2021). Staff and service users from acute mental health units were recruited to share their experiences of the architectural (physical and sensory) environment, therapeutic (recovery, therapy, activities) environment and the social organisation of the unit. Four of the twenty publicly funded adult inpatient acute mental health wards in New Zealand were invited for inclusion in the observational study, and chosen based on age, condition and location to gain a representative sample from across New Zealand.¹

Ethics approval for the original study was granted by the Central Health and Disability Ethics Committee (approval number 17/CEN/94) and locality consent was obtained from each of the four participating District Health Boards. The Ngāi Tahu Māori Research Consultation Committee reviewed and provided feedback on the research proposal. An ethics extension was granted to allow use of the de-identified (anonymised) data for the present study (17/CEN/94/AM03).

In line with ethics agreement, service users from each of the four units were recruited from a list, provided by staff, of inpatients from each unit who had been assessed by their lead clinician as well enough to participate, to give informed consent and who showed interest in the study. In total, 43 service users were recruited, ranging from 20 to 50 years old, with 20 identifying as female, 13 as Indigenous Māori, 27 as NZ European, and 3 as ‘other ethnicity’. Data on mental health status and length of stay was not collected. Written consent was obtained from all study participants prior to being interviewed.

A semi-structured interview schedule developed from topics arising in the literature was used to guide the interviews and covered a wide range of topics, including service users’ experiences and perceptions of the physical and social environment of the mental health unit. Service users were not explicitly asked about their experiences with peer support; instead, they were asked what their interactions were like with others in the unit with data relating to peer support emerging spontaneously. Interviews lasted between 30 and 90 min with the majority conducted face to face on the units by one of the researchers (GJ) and the remainder conducted by telephone. All interviews were transcribed verbatim, deidentified and analysed using inductive thematic analysis (Braun and Clarke 2006, 2019), whereby patterns in the data were identified to answer the research question: ‘What are the ways in which naturally occurring peer support takes place among service users in acute mental health units in New Zealand?’. For the purposes of this research, we recognise that peer support among service users can take place in a wide range of forms. This includes the more tangible aspects of peer support such as positive relationships and helping actions, but also a broader sense of solidarity and connection evident in the way service users related to each other. As our focus is on informal, naturally occurring peer support, in this paper we do not consider formalised peer support programmes where workers have been specifically employed and trained to provide therapeutic intervention.

The researchers independently read and re-read the transcripts to become familiar with the participants’ experiences in relation to their social and physical interactions with others on the unit. The first author (AC) initially identified and generated a list of preliminary codes with allocated data segments, then worked with three of the researchers (SM, GJ, EM) to discuss, revise and refine the coding schedule through an iterative process until a final list of codes had been agreed upon (Braun and Clarke 2006, 2019). As coding progressed, the researchers engaged with participant accounts and field notes to discuss and unpack the various ways in which peer support was talked about. After multiple rounds of coding were discussed among the research team, codes were sorted into discrete themes, or patterns of shared meaning, and relevant data extracts collated (Braun and Clarke 2019). Preliminary themes were reviewed, and consensus reached among the research team members. The final themes were reviewed against the original transcripts to ensure fit with the original data and to ensure they best described the experiences of the service users (Braun and Clarke 2006, 2019). Descriptive codes have been used in the reporting of our data to protect the identity of participants and indicate the unit (A, B, C or D), gender (M = male, F = female), and individual number of the participant.

In terms of reflexivity, in undertaking this analysis the research team contributed from diverse backgrounds and positions, including social science, public health, medicine and mental health inpatient service user experience. The authors recognise that given our position as Pākehā researchers, the analysis provided has limitations in that Māori service users’ experiences of naturally occurring peer support have not been explored through a Māori lens, and as such Māori participants are not identifiable in the results.

Results

In examining the ways in which naturally occurring peer support took place among service users in acute mental health units, the findings were grouped into three broad themes, each having sub-themes. The themes were: ‘fulfilling a need to connect’, ‘desire to improve the unit experience for others’ and ‘sense of solidarity’.

Fulfilling a need to connect

Participants talked about their experiences of naturally occurring social relationships as a means of fulfilling their need for social connection while on the unit. The forming of these social relationships was driven by several factors, thoughtfully negotiated, and underpinned by a desire for more opportunities to foster these connections.

Drivers and rewards

There were several factors that drove service users to develop social relationships on the unit. Participants explained how interacting socially with other service users was particularly beneficial in helping them to adjust to the unit environment, especially if it was their first time on the unit:

There were a couple of times where I did [feel lonely]. I think that was just due to the fact of my mental illness. And once I started interacting with people, and talking to people, you know it sort of got better. (Unit A, Female 1)

Like this service user, a number of participants described how social interactions with others on the unit helped to alleviate loneliness and sometimes the fear of the unknown which they experienced upon arrival. They also expressed the desire to simply talk to someone and share what they were experiencing.

Many participants commented on the lack of psychosocial support from staff who ‘don’t have time’ to stop and engage with patients, and that there were always people who ‘needed more help’. At the same time, participants empathically acknowledged the competing demands on staff and recognised they were limited in the time they had available to talk and engage with patients. This is turn drove participants to fill this void themselves, and engage with other service users who had both the time and desire to socially connect:

So, the patients were all sort of counselling each other really. (Unit A, Female 8)

As this participant indicates, the building of these social relationships was described by some participants as ‘counselling’, and highlights not only the perceived therapeutic nature of these social interactions between service users, but also the perceived lack of psychosocial support from staff. In the context of the acute mental health setting, this also draws attention to the fact that no units had any counsellors, psychologists or talking therapies onsite, other than a social worker and an occupational therapist. This lack of talking therapies was noted by participants in this study, who expressed a desire to have counsellors on the unit, and also recognised by staff in previously published findings from this study (Jenkin et al. 2021).

Participants also described how building mutually supportive social relationships with other service users assisted with their own and others’ recovery:

I guess I found a friend because we've got something in common. We're both going to do the same stuff, so I've got someone to talk to that I can relate to … so we back each other up. It's just like an AA meeting. Like alcohol … talk to some other alcoholics to find out what they do to stop it. (Unit B, Male 9)

Key to the emergence of many of these supportive relationships was finding ‘something in common’ which for most was their ‘shared’ experience of mental illness and a desire to support their own personal recovery and healing.

As a consequence of these driving factors, many participants described how they wanted to engage with their peers in a meaningful way, with some declaring these relationships as the most enjoyable and rewarding aspect of their unit experience:

I think they've been pretty superb at reacting positive to me. I sometimes feel a bit surprised, that they would want to be so equanimous towards me, when they don't even know me. Really, just loving people even though they're sick, which is amazing. (Unit A, Male 3)

This service user describes how surprised they were by the positive interactions they had with other service users, suggesting they had entered the unit believing others would not want to engage with them in this way because of their mental illness, a reflection of internalised stigma. ‘Loving people even though they’re sick’ could be interpreted as either recognising that people with mental illness were treated as deserving of love, or that people with mental illness were capable of forming loving, supportive relationships. Both interpretations reflect a beneficial reconceptualisation of mental illness, suggesting peer support relationships may help people to manage the internalisation of public stigma related to mental illness, and reclaim a more positive identity.

Negotiating social relations

Many participants described being acutely aware that not all service users wished to socially engage with others or were well enough to do so, and were considerate and respectful of this:

Some people keep to themselves, some people want to interact. You just get to learn where they are. (Unit B, Female 2)

However, silent companionship was still perceived as a valuable form of peer support on the unit, with some service users describing how they enjoyed being in the physical presence of others without needing to converse.

Quite often I just sit alone, just for the peace and quiet, to be out in the fresh air, and yet still potentially in contact with people even though they don't [speak] to me and I don't [speak] to them. It's still nice to have people around, even if you're not talking to them. You get your quiet space but with people around … you can talk to them if you like. (Unit A, Male 3)

This negotiating of social interactions was often underpinned by a nuanced understanding of other service users’ needs and consideration of past adverse experiences. Many expressed considerable empathy for their peers and their prior struggles:

She's gone through a significant amount of pain. And what it is, is pain that being a female in a male-dominated world, and not having people that understand the implications of rape. (Unit B, Female1)

I think the background that she comes from is like very abusive and a lot of hidings involved. That's why she gets aggressive really quickly. (Unit D, Female 4)

Many participants discussed being able to identify others ‘pain’ and suffering, whether through talking with them or observing them, and in turn attempted to understand their social interactions with them on the unit. The capacity to have insight into the social milieu which they are part of highlights how service users on the unit can negotiate social relationships in a way that thoughtfully and sensitively contributes to informal peer support. While several participants expressed the need for staff who could relate to service users on the grounds of lived experience, during their time on the unit they recognised that they themselves had valuable skills and experience they could use to support others, thereby fulfilling the unmet need for empathic connection in the acute unit setting.

Desire for more interaction

Some service users described a lack of opportunity for social interaction with others on the unit, which in turn hindered the development of supportive relationships:

But it seemed to be something I was missing was some sort of thing that could get people interacting and all that sort of stuff. (Unit C, Male 3)

Participants’ accounts highlighted a desire for more opportunities for social interactions and suggested organised unit activities such as a shared meal, and unit design aspects which could facilitate this. For example, the courtyard was frequently identified by service users as a location where socialisation took place, however not all service users felt comfortable being in this space as it was regularly occupied by smokers. A non-smoking courtyard, or another suitable social area where people could gather was desired. The dining room was another space proposed as a location where increased socialisation could be facilitated:

It's good that they have the option that they don't have to eat in the dining room. But I just think it would encourage socialisation, swapping foods. You know, one time I swapped my dessert for someone else's dessert, and it just; it gives people that together time. Because otherwise everyone buggers off and does their own thing. The only time you get together is when you're smoking outside. (Unit A, Female 9)

However, the unit design and resources did not always allow for spaces where service users could socialise. For example, in Unit A, participants reported there were insufficient chairs for people to sit together in the dining room during mealtimes, with one participant describing how she felt unwelcome and excluded in this space.

Improving the unit experience for others

Many service user accounts demonstrated how they attempted to support their peers, and their desire to improve the unit experience for others. This occurred in two main ways: making the effort to welcome people upon arrival to the unit and performing a range of different acts of kindness.

Being welcoming

Several participants described the empathy they felt for others who had similarly experienced a stressful arrival to the unit, and attempted to provide support by making this process more comfortable for others:

Everybody's trying to make everyone else comfy and trying to introduce everyone straight away. Make sure they’re introduced quickly and see if they need a cigarette and coffee and get people talking to them and they relax and start enjoying their stay a bit more too. (Unit A, Female 8)

Welcoming others was recognised as important in helping them transition into the unit environment. Service users described how they initiated this themselves, given they had not experienced any sort of formal welcoming process organised by staff when they entered the unit. The lack of any formal welcoming was exemplified by one service user who reported an incident in which they thought they had been greeted by a nurse upon arrival, but it turned out to be a service user:

When we first came in some guy comes up and shakes our hands and goes ‘welcome to the ward … ’ and we thought it was a nurse. But it wasn't, turns out it was a patient because the nurses wear mufti you can't see, there's no identifying. (Unit A, Female 6)

Some service users questioned the absence of a formal introduction to the unit and expressed a desire for a formalised welcoming process, suggesting it would alleviate service user anxiety, and make it easier to get to know other service users:

If a new patient comes in, there should be … maybe not right away because, you know, it's always nervous on the first day but there should be … I don't know, every second morning or whatever, everyone gets together, does their Mihi … says who they are, where they're from, and just let everyone know their name. (Unit A, Female 9)

Welcoming and introductions are especially important from an indigenous Māori worldview to establish links with others present, help people feel comfortable in unfamiliar surroundings, create a space that is safe to engage in and facilitate relationship building (Ihimaera 2004). A culturally appropriate admission process has been implemented in one of the units of this study, reflecting a commitment to some aspects of a bicultural model of care (Jenkin et al. 2021).

Acts of kindness

Many participants described providing peer support through a range of acts of kindness toward other service users. For example, some helped others to feel a sense of pride in their physical appearance by doing other people’s hair, makeup, nail polish and sharing clothes:

There was one that tried to kill herself, and I braided her hair like how my Nan used to do it. And then each braid I put different songs of her pain, of my pain, of the country. And so I used to (say), “Every braid you feel, you will just feel love, and you will feel wanted.” (Unit B, Female 1)

Straightening out people's hair, just doing them up. Like Helen, like I just helped her. You know, put their make up on, give her some clothes that she needs. Clothes are important because with your clothes it represents who you are. Yeah, so what Helen’s wearing right now is my clothes that I've given her just so she feels comfortable and relaxed. (Unit D, Female 4)

As displayed in these two participant quotes, these acts of kindness were viewed as attempts to help other service users feel cared for, and to improve their feelings of confidence and self-esteem. Self-neglect can be a consequence of many mental health struggles, and these acts of kindness relating to physical appearance reflect service users’ attempts to address this and bolster others’ sense of value and worth.

Boredom was frequently described by participants as an issue on the unit due to a lack of available activities. Some participants described taking the initiative to instigate activities for others on the unit to take part in:

Oh yeah, as a matter of fact I tried to get people into playing table tennis. So, we did have some games, that was quite good. (Unit A, Male 10)

So, I've already done marae-style in there. I've pulled one of the patients out, and we've slept in the lounge. Listened to music, to my favourite songs. (Unit B, Female 1)

The recreation of a marae-style sleepover in the acute unit setting displays how this service user attempted to create a space for connection with one of their peers, drawing on a cultural setting they associated with a sense of belonging and community.

Finally, some participants described sharing unit ‘hacks’ with each other, which were ways they had discovered to improve their experience within the confines of the unit environment. Passing on this knowledge to others was viewed as an act of kindness:

One of the patients that got me onto how you tick the boxes to get more food … you've got to get around the system. (Unit A, Male 10)

Yeah, my mate showed me what to do. He ripped his [pillow] open … and then poured the fluff into the pillowcase, because the pillows itself have got like a plastic lining. So you got your inner, and then a plastic lining, and then your pillowcase and you put your head on it and it goes [sound effect] like a balloon and every time you move its like that plastic. (Unit A, Male 4)

These examples of helping others to get more food or making their bedding more comfortable highlight how service users made the effort to pass on things they had learned during their unit experience to others, a form of instrumental support aimed at increasing the comfort of their peers and perhaps reclaiming a sense of power and autonomy.

Sense of solidarity

Naturally occurring peer support also manifested in a sense of solidarity among service users, in response to their shared experiences of stigma and discrimination due to mental illness, and their desire to be treated like ‘normal people’.

Shared experience of mental illness

A sense of unity and camaraderie clearly emerged from participants accounts and the way service users described themselves and their peers. The language participants used to refer to service users as a collective would typically be viewed as stigmatising, yet in this context reflected a sense of unity and reclamation of pejorative language.

We're all in it together, we're all crazy as fuck, we're insane. (Unit A, Female 9)

We're all nuts. (Unit B, Male 9)

One service user referred to other service users as ‘comrades’, metaphorical language which reflects a sense of collaboration against a common enemy. Another service user stated this explicitly, expressing a need to ‘band together’ against staff:

The loneliness, and then having us in like little rooms, in a fearful environment of being medicated with experimental drugs, and have people come in and assume mental superiority over us. You know, it's … we have to band together. And it's us versus them. (Unit B, Female 1)

Here, the power imbalance between service users and staff within the unit environment is highlighted, and it becomes apparent how this divisive view of ‘us’ and ‘them’ can fuel the need for service users to see themselves as a collective, providing them with the sense they have allies they can rely on through their shared experience.

We are normal people

Many participants also strongly asserted that people who experience mental illness are normal people who deserve to be treated with care, suggesting a resistance to the disempowering treatment they felt they had received:

Mental health people are people at the end of the day, and they've got to be looked after. And in a way, catered for in a way that normal human beings would be treated, you know. (Unit A, Male 10)

Participants talked about how ‘people like us’ were made to feel ‘less than’ by the mental health system and wider society:

And people like us should not be dehumanised by the system. (Unit D, Male 3)

But just of mental health my idea is that nobody has got a right to feel superior to somebody else because we're all human beings. (Unit C, Male 10)

Participants defined themselves in terms of who they were and who they were not. For example, they referred to service users as being ‘intelligent’, ‘capable’ and ‘normal human beings’ and emphasised they were not children, not criminals, and not deserving of punishment:

Because everyone is intelligent, everyone's capable to do everything. It's just a matter of support that they need sometimes. (Unit D, Female 4)

Well, you know, we all have crises, and we just have to deal, you know, need help sometimes to deal with them huh? It is all a bit of a shame really because people are there; they're not there for a punishment. (Unit A, Female 8)

Some participants also described how they had previously held stigmatising attitudes toward other service users, but that their experience of being on the unit with others who had a shared similar experience had changed these beliefs:

I mean I was too scared to approach, maybe I had pre-judged, but approach them to start with. But … they just need to be cared about. I know they see people have mental health issues but we're still people. (Unit A, Female 6)

As this participant indicates, she had been afraid to interact with other service users, yet later regretted her judgement, reaching the understanding that those with mental illness, including herself, are simply people requiring care. This quote further reinforces how engaging with peers with shared experience of mental illness could help to address the internalisation of the public stigma of mental illness and enhance empathy towards themselves and others.

Discussion

To our knowledge, this is the first study to document naturally occurring peer support in service user accounts of their time on acute mental health units in New Zealand. Our research findings provide insights into the ways in which peer support manifested on the units and the benefits of naturally occurring peer support, while also identifying service users’ desire for facilitation of social interaction driven by the expressed lack of psychosocial support, i.e. lack of talking therapies and limited therapeutic engagement with staff. We consider each of these points in turn.

First, our results revealed the variety of manifestations of peer support that emerged on the unit. Service users reported several factors which contributed to the development of naturally occurring social relationships among peers, and the ways in which they negotiated these relationships. Many service users attempted to improve the unit experience for others through welcoming people and acts of kindness. Making the effort to welcome newly arrived service users demonstrated a clear desire from service users to initiate relationships and was also reported in a similar qualitative study that described service users helping others to navigate the unit on admission (Galloway and Pistrang 2019). In terms of acts of kindness, helping other service users take pride in their appearance was an area where women particularly bonded, and was felt as beneficial to positive self-esteem and identity.

The finding of service users instigating activities was likely a reflection of the dearth of meaningful activities on the unit reported by service users in this study and more widely by staff in Jenkin et al.’s (2021) paper. This suggests there are opportunities for those further along in recovery to assist the traditional activities organised and provided by the occupational therapists on the unit. This could provide benefits for patient self-efficacy, help to ease the burden on staff and alleviate boredom for both themselves and other service users. Sharing unit ‘hacks’ was a form of instrumental support beneficial for helping service users improve their unit experience. It reflects the strong bonds that develop among individuals in situations where they lack control, seeking to form alliances and regain a sense of agency in an unfamiliar environment.

A sense of solidarity arising from shared experience of discrimination is not unique to mental illness, and is evident in the myriad of communities where individuals belonging to stigmatised groups have united. Service users in our study took ownership of derogatory labels (such as ‘crazy’, ‘nuts’ and ‘insane’) to refer to themselves as a collective, an example of reclamation of disempowering language. This phenomenon has been described in the literature, where stigmatised group members use such terms to enhance affiliation, identification, and to express bonding (Sturaro and Fasoli 2021). It was apparent that this language was used for empowerment rather than an expression of internalised stigma, as service users took care to define themselves in positive terms and reject associations with ‘criminals’ and ‘children’. They expressed a need to ‘band together’ and vehemently advocated for humane treatment, reflecting the foundations of the consumer/survivor/ex-patient movement in which peer support is embedded.

It became apparent that the unit environment and lack of autonomy experienced by service users were significant factors that influenced the development of supportive relationships among peers, with service users seeking connection not solely due to loneliness or boredom, but also as a survival strategy for everyday life on the unit. Sharing ‘hacks’ to help navigate a foreign environment and ‘banding together’ provides insights into the way service users may view their unit e­xperience, attempting to form allies and collaborate to endure their hospitalisation, rather than viewing it as a safe place where they could relax and receive care. Molin et al. (2016) suggest everyday life in psychiatric inpatient care is influenced by the quality of interactions that staff and service users have, and we would add that it is further influenced by the interactions between service users. Consequently, is in the interests of staff and models of care to encourage the empowerment of service users through these social relationships, providing them with a sense of support, comfort and normality which contributes to the settledness of the unit and eases staff burden.

The naturally occurring peer support which emerged from service user accounts had a number of benefits, including helping newcomers feel more comfortable on the unit, reducing feelings of isolation and supporting each other in recovery. Consistent with previous studies on naturally occurring peer support (Bouchard et al. 2010; Galloway and Pistrang 2019), we found that service users were considerate of their peers’ capacity for interaction, including knowing when to engage and when to give others space, as well as sensitive to the emotional needs of others, particularly those who had experienced traumatic events such as sexual assault. Further evidenced through service user accounts was a strength-based view of mental illness, with participants referring to their peers as ‘intelligent’ and ‘capable’. This salutogenic approach is an advantage of support provided by those with lived experience and aligns strongly with the recovery model, contrasting with a biomedical focus on one’s psychiatric condition which emphasises functional deficits (Xie 2013). Strength-based approaches have been associated with improvements across multiple domains for mental health service users. These include reducing hospital stay duration, enhancing recovery-relevant attitudes such as hope and self-efficacy, and facilitating greater goal attainment including employment and educational outcomes (Tse et al. 2016).

It was clear from our findings that naturally occurring peer support has a number of benefits similar to that of formalised peer support programmes. Although there are unique challenges, such as the fact that providers of support are acutely unwell, it has been demonstrated that service users still have the capacity for self-awareness and sensitivity to others’ needs. Naturally occurring peer support may also avoid some of the problems with contracting formalised peer support workers, including a power imbalance compromising reciprocity, the risk that peer support qualifications will erode ‘natural’ relationships, or pressure to conform to the dominant model of the mental health system (O’Hagan 2011).

Risks of naturally occurring peer support were not explored in this paper due to a lack of data in the interviews. However, several service users described the emotional risks of engaging with other service users, including feeling overwhelmed by trying to help others, making friends in psychiatric units only to find out later they had died, and a reticence to becoming too emotionally attached to others they met. This suggests service users did have some understanding of the risks of peer support, echoing the findings of Galloway and Pistrang (2019). We would also suggest that the lack of talk therapy and limited psychosocial support on the units means that peers may be shouldering the risks and traumas of others in the system without support themselves, and without opportunities to troubleshoot. Service users in this setting are vulnerable and therefore at greater risk of the emotional impacts of naturally occurring peer support. This points to the need for staff to understand the benefits and risks of this phenomenon for service users, enabling them to encourage peer support while managing potential emotional risks. As Galloway and Pistrang (2019) argue, naturally occurring peer support, while not always ‘smooth sailing’ should be a recognised aspect of an inpatient stay. Several studies have highlighted how concerns around the potential adverse effects of peer interactions can make staff less inclined to encourage these social relationships (Shaw 2014; Galloway and Pistrang 2019). Staff education is vital therefore to ensure the challenges experienced by service users and the concerns of staff are adequately addressed. While the safety of service users in acute mental health units is of utmost importance (Jenkin et al. 2021), we would argue it is also important that disproportionate risk aversion does not unnecessarily restrict autonomy, and inhibit opportunities for peer support that promote recovery.

Despite peer support occurring naturally and independent of staff intervention, service users craved more opportunities that would facilitate social interaction. Organised activities by staff could assist with the development of these supportive relationships. Service users desired a formalised welcoming and introduction process to meet other service users, and a shared meal was also suggested. Proposals in the literature to improve interactions on the unit include staff introducing new patients on the unit to peers (Bouchard et al. 2010), initiating a buddying system (Jones et al. 2010) as well as organising group activities as a way of improving interactions between staff and service users as well as among service users (McAllister et al. 2021).

Unit design could be optimised to facilitate supportive interactions. In one unit there were insufficient chairs in the dining room, and service users suggested that more tables and chairs in this area would enable more people to gather in this space for meals. Another unit in our study was a new facility, featuring open plan living spaces facilitating increased staff and service user interaction and socialisation. Courtyards are also important. The courtyard of an acute mental health facility can offer therapeutic value by providing a space for social interaction, yet the use of courtyards as ‘smoking rooms’ (common in three of the four units we studied) is detrimental to this (Jenkin et al. 2021). Well-designed, smoke-free courtyards should be standard to ensure all service users feel comfortable coming together, fostering connection and meaningful interaction (Jenkin et al. 2021).

Our findings provide insight into how naturally occurring peer support was largely driven by service user experiences of staff being unavailable to talk in depth with them. Many service users experienced positive interactions with staff but were acutely aware of the pressures they faced with regards to understaffing and time constraints, and frequently reported staff as too busy. This was similarly reflected in interviews with staff, who felt overwhelmed by their workload and lamented the lack of time they had to spend interacting with patients (Jenkin et al. 2021). There are many avenues for improvement in this area, including increased staffing, a more time-effective paperwork system, and greater emphasis on the therapeutic value of talking to service users (McAllister et al. 2021). The building of trustful relationships between staff and service users has been shown to compensate for an otherwise poor environment, suggesting quality over quantity of interactions may be most important for everyday life in the acute mental health care setting (Molin et al. 2016).

However, service users also expressed a desire for staff who had ‘been through stuff’ and could relate to them on the basis of similar lived experience. Several service users in our study even sought the opportunity to provide formalised peer support on the unit in the future. Research has indicated that peer support workers can be equally valuable compared to health professionals performing the same role (Repper and Carter 2011), and that it could be a more cost-effective way to provide care (Trachtenberg et al. 2013). Employing or contracting former service users in peer support roles is clearly a way to provide meaningful therapeutic care for patients while simultaneously alleviating the demands on staff and warrants further investigation. An existing example of this is the Buddies Peer Support Service, where peer volunteers with lived experience of mental distress provide support to service users in acute mental health units (Kites Trust 2022).

Strengths and limitations

Our study contributes to the emergent literature on naturally occurring peer support by examining this phenomenon through the accounts of service users in adult acute mental health unit settings in New Zealand. By using in-depth interviews with a large sample of participants from four different inpatient units, we were able to capture the common themes reproduced in different settings, increasing their validity. Furthermore, while we never sought to explore naturally occurring peer support in the original study, it emerged as a major theme in the data. Although service users were not asked about their perceptions of benefits or risks of peer support or questioned around facilitators and barriers to the development of supportive relationships, the broad scope of the data provided us with a comprehensive view of the context in which naturally occurring peer support takes place.

The present study also had limitations. In accordance with our ethics protocol, service users were selected based on the lead clinician’s assessment of their competence to consent and being well enough to participate, as well as their willingness to be involved. This means the participants included in the study may have been further along in their recovery, and therefore more likely to engage in and report positive peer interactions. It is important to note that the reports of peer support in this study reflect the experiences of our participants and may not be representative of all adult acute mental health service users. While the benefits of naturally occurring peer support are highlighted by the findings of our study, potential risks were not explored due to a lack of data in the interviews. However, we believe there is value in recognising these accounts, as naturally occurring peer support is an unmistakeable phenomenon that has previously been overlooked. Additionally, the four selected units are only a subset of the twenty adult acute mental health units in New Zealand, and therefore findings may not be generalisable to other mental health units in this country, or overseas. However, many of our findings of the ways in which peer support took place and the benefits of these relationships are consistent with those reported in other work (Bouchard et al. 2010; Galloway and Pistrang 2019). Additionally, as previously noted, our study has focused on naturally occurring peer support and therefore findings may not be generalisable to formalised peer support programmes. Finally, Māori service users’ experiences of naturally occurring peer support were unable to be explored through a Māori lens, and as such Māori participants have not been identified in the results.

Conclusions

We found a range of ways in which naturally occurring peer support took place among service users in adult acute mental health units, enabling the recognition of the positive aspects of these relationships. Our study highlighted that service users desired greater facilitation of social interaction and proposed several ways in which this could be enacted, with implications for staff training and unit design. Furthermore, these findings draw attention to the humanity and compassion demonstrated by a population frequently stigmatised as being self-absorbed, dangerous and anti-social. Further work is required to investigate staff perspectives on naturally occurring peer support in this setting, and how peer support can be integrated into models of acute mental health care services.

Acknowledgements

We thank the four district health boards for their participation in the research and all the participants who gave so generously of their time and experiences.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by a Marsden Fast Start from the Royal Society of New Zealand [grant number UOO1623].

Notes

1 The study protocol is accessible at http://www.ANZCTR.org.au/ACTRN12617001469303.aspx.