Peer support workers are distinct from clinicians because their authority is rooted primarily in lived experience rather than professional qualifications. They may have personal experience of substance use, treatment, recovery, homelessness, criminal justice systems or other challenges shared by the people they support. That experience can help workers establish trust, communicate hope and make treatment systems feel less alien to service users. It can also create demanding psychological and professional situations. A peer worker may recognize aspects of their own past in a service user’s story, encounter stigma about their history or feel pressure to prove that lived experience belongs in a formal healthcare environment. Supervision is the structured process through which staff can examine such experiences, consider risks, develop practice and receive support. In this context, it must do more than check whether paperwork is complete or targets have been met: it must help workers understand how to use personal experience without being consumed by it.

Daryl Mahon, the study’s sole author, interviewed 12 peer support workers employed in substance-use services. The interviews were conducted online, and the resulting accounts were examined with thematic analysis using a hybrid inductive-deductive approach. In qualitative research, thematic analysis is used to identify recurring patterns of meaning across participants’ descriptions rather than to calculate the frequency of predetermined variables. An inductive element allows themes to emerge from what participants say, while a deductive element uses existing concepts or research questions to guide interpretation. This combination can be useful when a field has an established theoretical vocabulary but remains underexplored in a particular setting. The study did not attempt to estimate the prevalence of particular supervision experiences across the entire peer workforce, and its sensitive data were not made publicly available because of confidentiality concerns. Its purpose was instead to provide a detailed account of how supervision is experienced by workers whose roles often sit between personal testimony, social support and professional service delivery.

The first theme portrayed supervision as a form of emotional containment. Substance-use services routinely involve crisis, relapse, grief, trauma, overdose risk and uncertainty. Peer workers can encounter these pressures while drawing on memories of their own lives, making emotional responses particularly complex. Containment does not mean suppressing feelings or treating them as evidence of weakness. In supervision, it refers to creating a reliable relationship and setting in which difficult emotions can be acknowledged, thought about and placed in context before they spill into practice or personal life. A supervisor may help a worker distinguish empathy from over-identification, recognize signs of stress and decide when a situation requires additional support. This reflective function is technically different from simply offering advice: it supports the worker’s capacity to process an event, understand its significance and choose a proportionate response. Participants considered supervision safer and more valuable when it provided that kind of protected space.

The second theme concerned role clarification. Peer workers often operate within organizations designed around professional hierarchies, clinical documentation and formal accountability. Their responsibilities may overlap with those of counselors, case managers or support staff, yet their contribution is not identical to any of these roles. Unclear boundaries can expose workers to conflicting expectations: they may be asked to share personal experiences, but not know how much disclosure is appropriate; to advocate for service users, but also to follow organizational procedures; or to build informal trust while maintaining confidentiality and professional limits. Supervision can make these tensions explicit. By discussing what a peer worker is—and is not—responsible for, it can reduce role ambiguity, support ethical decision-making and prevent personal relationships from becoming unsafe or unsustainable. In implementation terms, this matters because a job title alone does not establish a functioning role. The surrounding routines, authority structures and feedback systems determine how that role operates in practice.

A third theme captured what the study calls the negotiation of peer identity within professional systems. Bringing lived experience into a service can challenge assumptions about who counts as an expert. At the same time, peer workers may feel pressure to distance themselves from their histories in order to be accepted by colleagues, or to perform a simplified version of recovery that reassures the institution. Professionalization can bring greater recognition, stable employment and clearer standards, but it can also unintentionally strip lived experience of its distinctive value if peer workers are expected to behave exactly like every other staff member. The interviews indicated that supervision could either help navigate or intensify this tension. When supervisors recognized peer work as a specialized practice, workers could reflect on their identity without treating it as a problem to be hidden. When supervision was framed only through conventional clinical assumptions, participants found it disconnected from the knowledge and relationships central to their work.

That distinction is important because supervision has several functions that are sometimes collapsed into one. A managerial meeting may review caseloads, attendance, performance indicators and organizational policies. A clinical supervision session may focus on assessment, diagnosis, treatment planning or therapeutic technique. A restorative conversation may address stress, emotional impact and professional resilience. These functions can overlap, but the study suggests that peer workers need supervision designed specifically around their role rather than a generic version imported from another profession. Peer-informed supervision might include supervisors with knowledge of lived-experience practice, structured discussion of boundaries and disclosure, attention to stigma and power, and a clear understanding of recovery-oriented language. It might also incorporate peer workers’ perspectives into the design of supervision itself. The point is not to exempt peer workers from accountability, but to ensure that accountability does not erase the practice they were hired to provide.

The fourth theme therefore focused on the need for peer-informed and organizationally embedded supervision. “Embedded” means that support is built into the institution’s ordinary infrastructure instead of relying on an individual supervisor’s goodwill or a worker’s ability to request help during a crisis. For supervision to protect role integrity, organizations would need to allocate time for it, define its purpose, train supervisors and make clear how concerns are escalated. They would also need to acknowledge that supervision cannot compensate for structural problems such as inadequate staffing, insecure employment, discriminatory attitudes or poorly designed peer roles. A supportive conversation may help someone manage a difficult encounter, but it cannot by itself repair an organization that treats lived experience as symbolic rather than substantive. Mahon’s findings consequently frame supervision as an implementation mechanism: one of the processes that determines whether a new workforce model is faithfully integrated into services or gradually absorbed into older professional patterns.

The study’s implications extend beyond the 12 people interviewed. Peer support is increasingly incorporated into responses to substance-use disorders because connection, credibility and hope can influence whether people engage with care. Yet the benefits associated with peer work cannot be separated from working conditions. A role that repeatedly exposes workers to distress without adequate reflection may produce burnout, withdrawal or turnover; a role with unclear boundaries may create risks for both staff and service users. Supervision cannot guarantee positive outcomes, and this study did not measure treatment success, worker retention or changes in service-user health. It also does not establish that one supervision model will work in every country or organization. Its contribution is more precise: it shows why the design of supervision deserves the same attention as the design of peer roles themselves. Future research could test peer-informed supervision models, examine how workers from different backgrounds experience them and connect supervision practices with measurable workforce and service outcomes.

For now, the message is straightforward but consequential. Employing people with lived experience does not automatically make a substance-use service recovery-oriented. The organization must also create conditions in which that experience can be used safely, ethically and without being forced into a purely clinical template. Supervision is where many of those conditions become visible: whether workers can discuss emotional strain, whether boundaries are negotiated rather than assumed, whether their expertise is respected and whether managers understand the difference between support and surveillance. Mahon’s study suggests that supervision should be treated as core infrastructure, not as a box to tick after recruitment. If peer workers are expected to sustain hope and connection for people facing addiction, the systems around them must provide the same qualities of safety, recognition and reliable support.

The research, undertaken at a community rehabilitation center in eastern Taiwan during 2018 and 2019, implemented a rigorous 28-hour training curriculum for PSWs before they engaged with service users. These peer workers, who themselves faced challenges from mental illness, underwent comprehensive preparation to equip them with skills necessary to deliver effective one-on-one support. The practical aspect consisted of eight internship sessions, where each PSW provided individualized support to two or three service users for approximately one to one and a half hours weekly. This structured approach ensured an intimate, sustained engagement designed to maximize therapeutic benefits.

One pivotal aspect of the study was the meticulous assessment of key psychological domains using validated measurement scales adapted for the Taiwanese context. Internalized stigma, a pernicious factor known to undermine recovery, was evaluated with the Internalized Stigma of Mental Illness Scale–Chinese version (ISMI–C). Self-efficacy, which reflects a person’s belief in their capacity to enact change, was measured through the General Self-Efficacy Scale–Chinese (GSS–C). Additionally, occupational competence, a determinant of one’s ability to function productively within social and work environments, was gauged using the Traditional Chinese–Occupational Self-Assessment Scale (TC–OSA). By integrating these psychometric tools, the researchers sought to unravel the nuanced psychological shifts elicited by peer support interventions.

The participant profile revealed a predominantly middle-aged cohort, averaging 48.9 years, with a slight majority of women comprising 58.1% of the sample. The bulk of participants resided in halfway houses, supportive communal living environments designed to aid individuals transitioning from institutional care to community integration. Most diagnoses among participants were schizophrenia, underlining the severity and chronic nature of illnesses involved. These demographic insights underscore the targeted population’s vulnerability and the critical need for interventions tailored to their complex psychosocial realities.

Upon completion of the program, one notable finding was the statistically significant enhancement in peer support workers’ capability to navigate their environment, as indicated by improvement in the TC–OSA “my environment” subscale scores. This suggests that undergoing structured training and delivering peer support fostered tangible growth in occupational competence among PSWs themselves, equipping them to better manage the environmental challenges inherent in daily living and employment contexts. Enhancing environmental mastery is crucial for sustainable community participation and quality of life for individuals with mental illness.

For the service users receiving the support, a critical positive outcome emerged in the form of meaningful financial gains. The study documented a significant increase in weekly income following the peer support intervention, from an average of USD 25.7 to USD 47.9. This almost doubling of income highlights the potential for peer support programs to facilitate not only psychological but also tangible economic empowerment for persons with severe mental illness. Increased earning capacity is a vital step toward self-sufficiency and social integration, marking a transformative leap in rehabilitation outcomes.

Despite these encouraging results, the study did not observe significant changes in other psychological parameters such as internalized stigma or global self-efficacy within the duration assessed. These findings illuminate the complex and multifaceted nature of mental health recovery processes, where shifts in deeply ingrained self-perceptions may require longer interventions or adjunctive therapeutic modalities to manifest reliably. Nonetheless, the improvements in occupational skills and income represent meaningful progress that supports ongoing refinement and scaling of peer-led models.

The Taiwanese context of this research introduces a culturally unique lens on peer support efficacy. Unlike Western countries where such programs have been extensively studied, societies in East Asia grapple with distinct social stigmas and systemic barriers surrounding mental illness. The research suggests that localized training curricula emphasizing peer workers’ real-life experiences in overcoming stigma could be a vital strategy in boosting self-competence and resilience among both PSWs and service users. This culturally adapted approach may enhance relatability and empowerment, critical to the acceptance and effectiveness of peer-led interventions in diverse settings.

Clinically, these findings have important implications for mental health policy and program development. Integrating PSWs into psychiatric rehabilitation teams can be an efficient means to address gaps in human resources while simultaneously enriching service delivery with unique empathic insights. The documented income improvements among service users signal that peer support can transcend psychological support alone and contribute to pragmatic outcomes that impact broader social determinants of health. Mental health services should therefore advocate for expanded training and sustainable implementation of PSW programs as complementary to traditional clinical care.

Methodologically, this study’s design of combining standardized psychometric assessments with a practical training and internship framework provides a replicable blueprint for future research. The relatively small sample size and the pilot nature of the intervention underscore the necessity for large-scale, longitudinal studies to validate these preliminary findings and further dissect the mechanisms by which peer support exerts its effects. Moreover, expanding outcome metrics to include quality of life, social connectedness, and community functioning could enrich understanding of holistic recovery trajectories.

Beyond academic and clinical realms, this research resonates with the broader narrative advancing mental health awareness and destigmatization globally. By showcasing peer support as an avenue for empowerment and economic upliftment, it challenges entrenched stereotypes that limit opportunities for individuals with severe mental illness. Personal narratives from PSWs, when harnessed in structured programs, serve as potent vehicles to dismantle stigma, foster hope, and catalyze social change toward inclusivity and dignity.

Technologically, the integration of validated scales adapted for the local language and cultural nuances exemplifies the importance of culturally sensitive tools in psychiatric research. This attention to linguistic and cultural relevance ensures that assessments more accurately capture participant realities, fostering data integrity and intervention alignment. As the field moves toward global mental health equity, such nuanced adaptations will be imperative in tailoring programs that reflect the lived experiences of diverse populations.

The Taiwanese experiment with peer support further highlights the potential role of community-based rehabilitation in bridging formal medical services and social reintegration. Halfway houses and community centers serve as pivotal nodes where peer support can be embedded within holistic care frameworks. This community-centric orientation aligns with recovery-oriented paradigms emphasizing empowerment, autonomy, and social participation as central to mental health outcomes.

Looking ahead, the trajectory for peer support services in Taiwan and similar contexts appears promising yet calls for sustained investment in training infrastructure, mentorship, and evaluation mechanisms. Health system stakeholders, policymakers, and practitioners must collaborate to institutionalize peer roles, ensuring adequate support, recognition, and integration within multidisciplinary teams. Such efforts will optimize benefits for both PSWs, who gain meaningful roles, and service users, who receive culturally resonant support conducive to recovery.

In conclusion, the pioneering study into peer support among persons with severe mental illness in Taiwan provides compelling evidence that well-designed training coupled with sustained individualized interventions can empower peer workers and improve employment outcomes for service users. While changes in internalized stigma and self-efficacy were not statistically significant in the short term, gains in occupational competence and income mark critical progress. These findings contribute significantly to the emerging global literature affirming peer support as a transformative force in mental health care and lay the groundwork for future expanded investigations and program development.

Subject of Research: The psychological and employment outcomes of peer support workers and service users with severe mental illness under one-on-one peer support services in Taiwan.

Article Title: The internalized stigma, self-efficacy, occupational competence and employment outcome among persons with severe mental illness under one-to-one peer support services in Taiwan.

Article References:
Cheng, KY., Wang, YL., Hung, WC. et al. The internalized stigma, self-efficacy, occupational competence and employment outcome among persons with severe mental illness under one-to-one peer support services in Taiwan. BMC Psychiatry 25, 412 (2025). https://doi.org/10.1186/s12888-025-06849-6

Image Credits: AI Generated

DOI: https://doi.org/10.1186/s12888-025-06849-6