From outsider to insider? Moving towards epistemic justice for peer supporters within Aotearoa New Zealand’s mental health system

<p dir="ltr">Background</p><p dir="ltr">Mental health peer support has grown significantly worldwide within the last three decades. As with other nations, Aotearoa New Zealand is currently in the process of expanding the peer support workforce within its mental health system. This is a promising development because peer supporters have the ability to make unique epistemic contributions to service delivery due to their distinct lived experience epistemologies and practices. Indeed, policy documents tend to charactertise the potential of peer support as transformative. However, literature has indicated that peer supporters face challenges when working within traditional mental health spaces. These include distrust from other mental health professionals, struggling against a dominant biomedical framing of mental distress, feeling relegated to an assistant clinician role, and ambiguities concerning role definition and scope. In this thesis I explore whether and how these challenges may contribute to peer supporters experiencing epistemic injustice. </p><p dir="ltr">Aim</p><p dir="ltr">I sought to explore how peer supporters experience and understand the epistemic conditions within the mental health system and what causal mechanisms may contribute to epistemic injustice in this context. As part of this investigation, I aimed to identify key factors that can aid in protecting peer support’s epistemic qualities when situated within mainstream mental health services. </p><p dir="ltr">Methods</p><p dir="ltr">I took a critical realist informed, contextual epistemic injustice approach to this research. The main phase of the study comprised 28 interviews, with 14 peer supporters and 14 clinicians. Following this, I drafted themes and a preliminary framework for peer support epistemic justice and consulted with six peer supporters to review the framework and develop it further. I analysed data using a critical realist adaptation of thematic analysis that considered epistemic injustice within each domain of critical realism’s stratified conception of reality. These findings were synthesised following consultation in order to create a framework that may facilitate peer support epistemic justice within Aotearoa New Zealand’s mental health system. </p><p dir="ltr">Findings</p><p dir="ltr">Peer supporters are well positioned to aid in system and service transformation. Their knowledge is derived from lived experience of mental distress and mental health services, resulting in a unique standpoint to provide compelling and actionable insights. Peer support’s lineage is partly within activist grassroots movements which held mainstream mental health systems to account. Elements of this adversarial relationship continue, with peer supporters frequently perceived as a counterbalancing force to clinical orientated services. The transformative discourse associated with peer supporters in policy suggests that peer supporters possess knowledge that is compelling, distinctive and disruptive to existing systems.</p><p dir="ltr">Peer supporters operate within an epistemically precarious position in Aotearoa New Zealand. They are expected to transform the mental health system and challenge clinical culture within mental health services – while being paid less than other professions and lacking the usual markers of legitimacy that denote epistemic authority. Peer supporters are near the bottom of a systemic knowledge hierarchy which enshrines a medical episteme as the highest form of mental health knowledge. As a practice and knowledge system, peer support is at risk of losing its distinctive features and falling into a ‘mini clinician’ role. Being explicitly ‘out’ as having had mental health challenges can lead to stigmatising responses from mental health providers and further devalue how peer support knowledge is received. </p><p dir="ltr">The epistemic agency of peer supporters can be protected by developing robust peer support leadership positions, orientating clinicians to the peer support’s role and historical context and building up national-scale advocacy and representation. The move to integrate peer supporters into mental health services must be paired with a sustained effort to ensure their knowledge system and epistemic agency are protected. </p><p dir="ltr">Conclusions</p><p dir="ltr">Peer support knowledge systems can positively impact Aotearoa New Zealand’s mental health system and mental health systems around the globe. As a workforce that straddles the line between experiential knowledge and professional training, peer supporters are particularly equipped to strengthen the voice of tāngata whaiora (service users) who themselves are at a marked risk of facing epistemic injustice. However, actualising their potential will require attending to the structural and relational conditions within the system which inhibit flourishing of peer supporter knowledge. This research is among the first to investigate epistemic injustice within a peer support context. Peer support is positioned by policy as a force for transformation but this transformative capability rests upon a move towards epistemic justice.</p>