Exploring Issues of Culture in Peer Work - A Qualitative Study
Hiremath, N., Byrne, L., Roennfeldt, H., Edwards, J.P., McKenley, C., Isaacs, A., & Bellamy, C.D. (2026). Exporing issues of culture in peer work – A qualitative study. Administration and Policy in Mental Health and Mental Health Services Research. https://doi.org/10.1007/s10488-026-01509-7
What is the experiece of culturally and racially marginalised (CARM) peer workers in behavioural health settings?
Take Home Messages
- CARM peer workers face systemic barriers, discrimination, and underrepresentation within behavioural health systems.
- Behavioural health services are often shaped by dominant white cultural norms that can exclude diverse and intersectional peer voices.
- Representation matters – peer workforces and leadership need to better reflect the range of intersectional communities they serve,
- Organisational barrier such as rigis criteria and alck of cultural responsiveness limit opportunities for CARM peer workers.
- Creating inclusive peer work environments requires structural change, cultural humility, and actively uplifting lived expertise from diverse communities.
Aim
This study explored the experiences of culturally and racially marginalised (CARM) peer workers in behavioural health settings (including mental health and alcohol and other drug sectors) to identify barriers to inclusion and ways to create more equitable and culturally responsive peer work environments.
Why is this Research Important?
- It highlights inequities faced by and opportunities for CARM peer workers that are often overlooked in peer workforce development.
- It shows that improving equitable and intentionally inclusive practice in peer work can strengthen culturally responsive support for service users.
- It provides evidence for policy and organisational changes needed to build fairer and more meaningfully responsive behavioural health systems.
Background
Peer work and Lived Expertise are key in shaping individual and collective understandings of mental health, addiction, and behavioral health service systems. Culturally and Racially Marginalized (CARM) people are underrepresented in Lived-Living Experience roles and often face barriers such as discrimination, limited opportunities, and services that reflect mainly white, dominant cultural perspectives. This lack of intersectional diversity often means services fail to fully meet the needs of all communities. While there is growing recognition of these broader issues, we still know little about the specific experiences of CARM peer workers.
Method
This study looked at factors that support the effective integration of peer roles within mental health service delivery, focusing on systemic issues around culture affecting peer workers. This included the lived experiences necessary for peer work, factors that make peer workers effective in these positions, and the organizational conditions that support their employment. Grounded Theory methods were used to guide data collection and analysis.
Participants
A 12-member expert advisory group of lived-experience leaders, industry representatives, funders, and researchers provided consultation and helped identify multidisciplinary organizations. The advisory group nominated 5 organisations they believed demonstrated a commitment to effective peer workforce development. The organisations included a mix of service types and locations (e.g. rural, urban, not-for-profit, private sector). Staff at all levels (peer workers, managers and non-peer workers) were invited to participate.
Participants included 132 individuals: 32 non-peer workers, 47 non-peer managers, 7 peer-designated managers, 38 peer workers, and 8 ‘other’ (e.g. human resources and administrative roles).
Participants were from various racial/ethnic backgrounds, including 15 identifying as African American or Black, 10 identifying as Multiracial, 7 identifying as Asian, 6 identifying as Hispanic, 2 identifying as Native American, 1 participant identifying as a Native Hawaiian/Pacific Islander, and 88 participants identifying as Caucasian American or White.
Data Collection
14 focus groups were conducted, and 8 individual interviews were conducted. Focus groups were organised for each cohort: non-peer workers, management, and peer-designated employees. Due to smaller numbers, peer managers could choose to attend either the peer worker or management focus group. Two peer managers chose to join the peer worker focus groups, while the rest opted for individual interviews.
Interviews and focus groups began with broad preliminary questions, consistent with grounded theory. The questions related to understanding what is essential to peer work, the barriers that exist for peer workers, and strategies for effective recruitment and employment of peer workers in their organisation. Questions were expanded and refined throughout the interviews and focus groups as participants contributed new concepts, including cultural issues.
Data Analysis
Researchers reviewed and coded the interview data to find common patterns and themes, paying particular attention to issues like lack of representation and cultural barriers. Researchers with lived expertise (including CARM backgrounds) helped interpret the findings and themes were refined through collective team discussion to ensure they reflected the data accurately.
Results
Results showed key themes and challenges encountered by diverse CARM peer workers within behavioral health systems. Each of the themes also had a number of subthemes, which were things that were seen to either support or hinder the promotion of cultural responsiveness in settings that center lived experience and Lived Expertise.
The themes and subthemes are described below.
Theme 1: Potential enablers for CARM individuals in peer work contexts
Participants highlighted some things that can help people CARM communities succeed in peer work. These include recognising that peer support has long existed within diverse communities, having shared cultural understanding, and respecting people’s backgrounds and stories. While, overall, there were far more barriers than supports identified, it’s important to lead with these strengths so that culture isn’t only talked about in terms of problems or deficits.
Subthemes included Informal peer support was born in the community before behavioral health systems, which reflected the longstanding role of collective support and survival practices within many communities, and Usefulness of culturally aligned peer workforces from similar backgrounds, which highlighted the value of shared cultural understanding, representation, and connection within peer work contexts.
Relevant quotes for subtheme 1 (informal peer support was born in the community before behavioural health systems):
I came up against a similar circumstance… with the quote unquote African American family where the perspective was that “doctors ain’t have no couches in the cotton field, you have to…suck it up”. We had that perspective that if we, for generations have been able to handle this and we should be able to do it now because what you’re facing is nothing compared to what your grandma faced in the savannah… so having the peers – that’s like what we’ve been doing all along because there wasn’t no doctor’s couch in the cotton field, we only had each other. (Site 3, FG peers)
And there’s also generational [considerations]. You know, my parents are the generation that you, pull yourself up by your bootstraps. Part of that is a religious background, and part of it is just the way they were raised. (Site 4, FG peers)
Relevant quotes for subtheme 2 (usefulness of culturally aligned peer workforces from similar backgrounds):
I don’t think it’s about having the culture; it’s about being knowledgeable about the culture. So, I don’t necessarily think that we have to have the same exact culture in order to help somebody to be in recovery or to get them to recovery or whatever the case may be. But at least have the knowledge to be like, okay… you know, just differences, or these are the barriers that you’re looking at, you find a way to break them or do something about them. (Site 4, FG traditional workers)
But you would need that. You would need somebody of the same culture – (Site 4, FG management)
Now, if you want more people of color, well, then talk to your staff or your organization and say, ‘What do you think is the reason why people of color don’t come in here?’ (Site 2, INT peer manager)
Theme 2: Mental health and AOD systems are being dominated by perspectives of white culture
Behavioural health services often reflect the wider society, where power and decision-making are shaped by dominant (mainly white) perspectives. This creates systemic and structural barriers for CARM peer workers, including difficulty fitting into clinical ways of working, experiencing multiple and intersecting forms of discrimination, and seeing leadership roles mostly held by people from more privileged backgrounds.
Subthemes included Cultural barriers to activism and expressing anger, which explored how cultural beliefs and experiences of oppression may discourage some people from raising concerns or engaging in advocacy roles; Clash with clinical culture, which reflected tensions between participants’ cultural identities and dominant clinical workplace norms; CARM people experience multiple levels of prejudice, which captured experiences of racism, stigma, and intersecting discrimination within services; and Peer leadership positions are being occupied by the dominant culture, which highlighted concerns about leadership being disconnected from the lived realities of frontline peer workers and service users.
Relevant quotes for subtheme 1 (cultural barriers to activism and expressing anger):
Some aspects of culture have had the rebellion suppressed out of them. Not even thinking that they have recourse to do anything about it. Culturally, they found that, ‘Hey, life has just been kicking me in the rear, and this is just another kick, that’s all it is’. (Site 3, FG peers)
…So, there may not be a lot of Hispanic peers, because the culture itself doesn’t allow for it. Whereas there might be more White peers… maybe it’s just our culture is more accepting of it at this point in time. …It’s not all the systemic issues of trying to prevent peers… and making it all good for the White people, but just the inherent issues within the culture. (Site 4, FG 3 peers)
Relevant quotes for subtheme 2 (clash with clinical culture):
I would find that very difficult to be a part of my culture let alone the only one from that culture in another culture because…they have their own clinical culture so that’s… my experience of that. (Site 5, FG peers)
We’re fortunate to have a strong peer culture here, I think it would be a lot more difficult in a place where the team is more scattered and maybe there’s one peer working on each team of all a bunch of clinical people. (Site 5, FG peers)
Relevant quote for subtheme 3 (CARM people experience multiple levels of prejudice)
Honestly, I’ll just tell this as an example from my own case; it’s not an inviting place for people of color who deal with stigma every day. That’s why I think it’s more of a spiritual calling. …I think dealing with systems… I have a lot of material. I did racial healing workshops and restorative justice … so what I’ve learned is that you can find the job, but you may not be able to find peace at that job. You may not find justice at that job; you may not know how to create peace at a place where no matter what role you’re in. Cause’, believe me, there are still some people who can’t believe I’m at corporate. I have three levels of prejudice. So, I would say sometimes when people would say they want a person of color, a woman, they may not want a gay person. (Site 2, INT Peer)
Relevant quotes for subtheme 4 (peer leadership positions are being occupied by the cominant culture):
The people in power are from a very specific background [and] a very specific way of seeing things, and…the culture of the workplace is developed by them. (Site 3, FG peers)
If we value this idea of lived experience, it has to be intersectional; it has to also understand that to have it truly reflect people and be peer, it has to be peers. It can’t just be the white guy that went to Yale and … are actually quite privileged and have been really cushioned their whole lives from being impacted greatly by what is clearly not that serious in the wider scope of things… It’s just, it’s bananas! … when you see people who work for a year and then, they want to be managers already, and I’m like, ‘it’s a sense of entitlement …. (Site 3 INT, peer manager)
They keep bringing in people who are non-peers or, I’m gonna say ‘barely peers’, because in a place like this, …suddenly people who don’t identify as peers and they didn’t, …they’ve never been hospitalized and they don’t have serious mental health concerns that have created barriers in their lives in any kind of substantive way, and over time if they see …a peer position of leadership they suddenly say, ‘yea well, I’ve always been depressed’ which may be true but I also think there’s something really interesting that’s happening here… I guess if you’re… like in [location removed], in the public mental health system most people are Black and Brown and poor, so if we’re really talking about not having an us and them, and having full representation, and you have a peer leadership position…and you have someone who doesn’t have a serious history … like I have feelings about that … I think it’s like the people who made the decisions are non-peers. (Site 3 INT, peer manager)
Theme 3: CARM people not having a voice in the peer movement
CARM communities often don’t feel heard or able to speak up in the peer movement. Workplace norms and expectations are usually shaped by dominant culture, which make it harder for people from different backgrounds to express themselves or feel included. This theme included the importance of CARM communities being able to voice their opinions and the culturally prescribed standards of behavior within a workplace, reflecting the lack of voice CARM communities have in a widely ‘white’ Peer Movement.
Subthemes included The importance of CARM communities being able to voice their opinion, which highlighted how cultural expectations and the dominance of white perspectives within the peer movement may discourage some people from expressing anger, strong emotions, or personal struggles, contributing to isolation and reduced inclusion. Prescribed standards of behaviour in the workplace reflected concerns that behavioural health systems often enforce narrow and culturally biased expectations about acceptable behaviour and communication, which may exclude or disadvantage CARM peer workers.
Relevant quotes for subtheme 1 (the importance of CARM communities to be able to voice their opinion):
I think the traditional peer work has been made up of sort of middle-aged Caucasian people who were hospitalized that like got upset, and I’m thankful for that movement, but that hasn’t been my experience. My experience has been sort of like, I haven’t had a lot of agency over my life, so you put me in the hospital and tell me when it’s time to get out. You know, I didn’t get furious over being in the hospital. I didn’t like it, but I wasn’t furious. I didn’t have a distinct rebellion, so I think there are more voices that could be incorporated into the peer movement. (Site 3, FG peers)
Letting people know that you can accomplish anything [is important], and many people don’t have an understanding of what it is because we don’t talk about these things, especially amongst cultures [like] Afro American, Afro Caribbean, we don’t discuss these things. And we don’t seek help… so for me it’s really important to have a presence and being able to stand up and to say, ‘ok this is something that I contend with’ – to give people hope, to be able to say, ‘you’re not alone’. Or, “you’re not the only ones that deal with this or have dealt with that’, so that was really important for me. (Site 3 FG peers)
Relevant quote for subtheme 2 (prescribed standards of behaviour in the workplace):
So, their [dominant perspectives’] standards are a certain way. …The rest of us who don’t fit into that find it very difficult. I know [this is] one of the things that I find very difficult to deal with as a Black woman; we believe in being direct. And the worst thing you can tell us is, ‘We’re fake.’ It’s the worst thing you can tell a Black woman, ‘You’re fake’. What, my hair might be fake, my nails might be fake, but don’t tell me, I’m fake! You know what I mean? [This has been what] My experience of working in services has been, because it’s very much the culture, is very dominated by the larger culture, [where] the focus is on diplomacy and politeness and being nice. (Site 3, FG peers)
Letting people know that you can accomplish anything [is important], and many people don’t have an understanding of what it is because we don’t talk about these things, especially amongst cultures [like] Afro American, Afro Caribbean, we don’t discuss these things. And we don’t seek help… so for me it’s really important to have a presence and being able to stand up and to say, ‘ok this is something that I contend with’ – to give people hope, to be able to say, ‘you’re not alone’. Or, “you’re not the only ones that deal with this or have dealt with that’, so that was really important for me. (Site 3 FG peers)
Theme 4: Challenges faced by CARM people to take on peer work roles and within peer work contexts
CARM peer workers face several challenges, including being stereotyped or people making assumptions about them, difficulty meeting certain stigmatising job requirements, and feeling pressure to work harder to prove themselves. Cultural beliefs about mental health can also add stigma, which may make it harder for some people to enter and stay in peer work roles.
Subthemes included Multiple assumptions are made of CARM people, requiring them to confront stereotypes, which reflected experiences of stereotyping, racism, and being reduced to cultural assumptions rather than recognised as individuals with intersecting identities. Rigid criteria create unequal opportunities and barriers highlighted how employment requirements, police checks, certification processes, and English-only training pathways can exclude many CARM people from peer roles. The impact of culture in behavioral health care captured how cultural beliefs, worldviews, and practices shape understandings of mental health and approaches to care. CARM individuals need to work harder to prove themselves reflected perceptions that people from CARM backgrounds are often expected to exceed expectations to gain acceptance or credibility. Finally, Mental illness is still stigmatized within diverse cultures explored how stigma, spiritual interpretations of distress, and diagnostic definitions of peer work may discourage participation in peer roles and further reduce culturally responsive representation within the workforce.
Relevant quotes for subtheme 1 (multiple assumptions are made of CARM people, requiring them to confront stereotypes):
I feel that there’s sometimes a lack of being open to the concept of intersectionality and not every person has the same exact experience just because they might kind of look like someone else and being open to that. I’ve had people make a lot of assumptions about my experiences, what I’ve been through, what I haven’t been through, demographic information, like where I grew up, how I grew up. (Site 3, FG peers)
I don’t think it mattered where I was from, or my lived experience, or how I conceptualized the world that I interacted with. I think she [non-CARM colleague] was nice, and she meant well, but you know, I think it’s one of those things, being nice and meaning well isn’t enough if you don’t view people as whole people with their own experiences. You’re just kind of perpetuating more stereotypes… I think it varies from person to person. I’ve had people who, you know, belong to similar demographics to myself who didn’t ask questions and made assumptions about [other] groups of people. I think it just varies from person to person, their level of curiosity and desire to learn about others, but I would say as a woman of color in this field, I’ve definitely been able to connect more, I guess, with other folks of color. (Site 3 Peers)
Relevant quotes for subtheme 2 (rigid criteria create unequal opportunities and barriers):
Because most of the peers are individuals that are Black and have been to jail, and you know, things of that nature. Now every peer is different, mind you, but I’m saying, speaking of being a Black peer and having worked with Black peers. There’s a law that, in the beginning, waived individuals who had past situations of going to jail or prison or whatever, that were, you know, convicted of some things. And so, they were able to get jobs working with different individuals in a community. Now you have to go through a whole situation of clearing up your name. So that kind of deterred a lot of individuals to do this work. And then every time you turned around, people, individuals, were bringing up the past. You know, if you’re in recovery and you’re seeking to better yourself, why does that have to be a slap in your face all the time? (Site 4, FG peers)
It was just the challenge of finding a certified peer and finding someone that was bilingual, and they never overcame that hurdle – (Site 4, FG management)
Relevant quotes for subtheme 3 (the impact of culture in behavioural health care):
Culture’s definitely gonna play an important part of it. I mean … one of the 4 tasks of IPS (peer practice theory Intentional Peer Support) right there is worldview… so, of course, worldview is gonna play a part in…how things are. My whole perception of mental illness and how I regulate it and navigate through it is informed [by] what I know of my culture, and…what I don’t know of my culture is probably working against me, so the more you know about it, I think that helps orient you in a firmer practice of recovery and peer support. (Site 3, FG peers)
…the part that is really hard for me here, coming from my culture, is that you don’t have a welcoming practice for the people that we are introducing to our program. You bring ’em in, you dump all this stuff at the nurse’s station. I told them, ‘I don’t like the nurse’s station.’ This is what I did with the people that were on my caseload: I brought them to the dining room. First thing my mum says whenever she meets new people is, ‘Are you hungry?’ Sitting and eating with people is how [you] get a relationship. (Site2, INT peer manager)
Relevant quote for subtheme 4 (CARM individuals need to work harder to prove themselves):
But then it goes back to being a very cultural thing, you know, to be a man of color, you have to fight that much harder, you have to go above and beyond what is expected of you. Before, if] you used to have a BA, you have opportunities for employment, but now that’s not the case. You [need to] have [post] graduate and above, so the expectation is you gotta push and push and push, so have to sacrifice … you know it’s overwhelming, it’s exhausting, it really, really is…. (Site 3, FG peers)
Relevant quotes for subtheme 5 (Mental illness is still stigmatised within diverse cultures):
But I think something that also needs to be paid attention to is that there is some systemic prejudice, but there’s also some cultural prejudice. But in the Hispanic culture that is very prevalent down here, mental illness is still very much looked at as something that is a curse or judgment from God, and that you just need to go and pray about it. (Site 4, FG peers)
I know for me being part African American part native American Indian you know …we believe in shamans for our native American [side] so things related to sort of wellbeing you go to the shaman and you know he does blessings or dancing and …it’s again always a male, [whereas] amongst African American community it’s something that we would not talk about openly or publicly. (Site 3, FG Peers)
Discussion and Conclusion
This study explored how cultural responsiveness is understood and experienced in peer work currently, focusing on the perspectives of CARM people alongside peer workers, staff, and managers in behavioural health services. Overall, the findings showed both potential strengths and significant challenges.
The findings of this study highlight the need for systemic and structural changes to make sure peer work environments are inclusive, equitable, and reflective of the diverse, intersectional communities they serve.
To better support intersectional CARM peer workers, behavioural health systems need to be more culturally responsive, meaningfully inclusive, and actively address barriers formed by the system in relation to people’s different identities, stories and experiences. This means unpacking systemic bias, removing organisational obstacles, and genuinely embedding justice, equity and intersectionality so services better reflect the communities they serve.