Recovery Identity Formation among Peer Supporters: A Qualitative Meta-Synthesis

1. Rationale for the study

For individuals with mental disorders, recovery signifies a comprehensive process in which individuals focus on their strengths, potential, and hope while leading meaningful lives. Accordingly, the World Health Organization (WHO) advocates against coercive and dehumanizing mental health treatment environments for individuals with mental disorders and proposes peer support services as part of the transition to person-centered and community-based services [1]. Peer support is a process that promotes recovery through mutual empathy and support among individuals with similar experiences [2]. Peer supporters serve as members of the treatment team to assist patients in their recovery while simultaneously acting as hopeful role models who share the recovery journey with patients as individuals who have personally experienced mental disorders [3].

Peer support services began in the United States in the 1970s and have now established themselves as an integral component of formal mental health services in several countries. In the United States, Australia, and the United Kingdom, peer supporters are recognized as mental health professionals and gain professional recognition through systematic educational programs and certification systems [4]. Previous studies have demonstrated that peer support services can positively influence the recovery of individuals with mental disorders and are effective in reducing symptoms of depression and anxiety [5,6]. Individuals with mental disorders who received peer support showed reduced readmission rates, decreased crisis interventions, and shortened hospital stays, contributing to overall reductions in healthcare costs [7]. Peer supporters' education programs are operating nationwide, and peer supporters are active in community mental health institutions [8].

However, domestic peer support services in South Korea are rapidly expanding within community-based mental health settings [9], and psychiatric nursing practice is simultaneously shifting toward recovery-oriented and team-based models of care [1]. Despite these developments, an integrated understanding of peer supporters' professional roles, developmental trajectories, and the structural conditions shaping their work remains insufficient. Existing qualitative studies are small in scale, heterogeneous in focus, and fragmented across institutions, making it difficult to conceptualize peer supporters as members of the mental health workforce from a coherent psychiatric nursing perspective.

At this transitional point, psychiatric nursing faces several unresolved challenges. There is no theoretical framework that clarifies the ontological position of peer supporters within clinical teams, and understanding of how personal recovery processes unfold alongside work responsibilities is limited. Furthermore, the influence of employment instability, organizational structures, and task expectations on the formation of professional identity has not been adequately examined. Prior studies have largely emphasized individual emotional or experiential changes, while offering limited analysis of the dynamic interactions among personal recovery, role negotiation, and institutional environments. These gaps restrict the discipline's ability to conceptualize peer supporters not as individuals narrating personal recovery stories, but as developing professionals embedded within complex mental health systems.

Therefore, a qualitative meta-synthesis is needed at this point to reorganize dispersed findings and provide a higher-level integrated interpretation of peer supporters' experiences. Qualitative meta-synthesis systematically integrates qualitative studies on a specific topic and generates new interpretations and insights, enabling the identification of patterns and themes that are difficult to discern in individual studies [9]. For topics such as peer support, which involve strong experiential and contextual characteristics, meta-synthesis is particularly useful for integrating knowledge accumulated from diverse perspectives and settings.

Accordingly, this study aims to systematically review and conduct a meta-synthesis of qualitative research on peer supporters for individuals with mental disorders in South Korea, in order to derive an integrated understanding of their experiences and roles. Through this approach, we seek to identify the current status of domestic peer support services, propose directions for systematic development, and suggest tasks for future research. The findings of this study are expected to provide practical evidence for the development of peer supporter training programs, improvement of work environments, and establishment of relevant policies.

2. Purpose

The purpose of this study is to gain an in-depth understanding of the experiences of peer supporters for individuals with mental disorders through the process of synthesizing and integrating the results of qualitative research on peer supporters' experiences among individuals with mental disorders, and to suggest directions for future research.

1. Study Design

This study is a qualitative meta-synthesis research that analyzed the results of qualitative studies exploring peer support experiences of people with mental disorders in Korea. The specific research procedures applied the 7-step meta-ethnography approach by Noblit and Hare [9] among qualitative meta-synthesis research methods.

2. Literature Search and Selection

In this study, the literature search and selection process corresponds to Step 1 'Getting started' and Step 2 'Deciding what is relevant to the initial interest' of Noblit and Hare's [9] 7-step meta-ethnography.

Major databases were utilized to search for qualitative studies on peer support experiences of people with mental disorders in Korea. The databases used were Research Information Sharing Service (RISS), Korean studies Information Service System (KISS), DataBase Periodical Information Academic (DBpia), and National Assembly Digital Library. The search terms were conducted by combining 'mental disorders', 'peer support', 'experience', and 'qualitative research', with no restriction on publication period. The retrieved articles were managed using a personal bibliographic management tool (Endnote 20).

The inclusion criteria for literature in this study were set as: (1) studies targeting people with mental disorders who experienced offering peer support, (2) studies applying qualitative research methods, and (3) studies published domestically. The exclusion criteria were: (1) studies that did not align with the research purpose, (2) studies applying methods other than qualitative research, (3) studies that did not undergo professional and academic review such as dissertations and posters, and (4) studies that were not original research or whose full text was not accessible.

The literature search was conducted from August 1 to August 15, 2025, and was performed by three researchers together. Initially, 237 studies were retrieved, and after excluding 113 duplicate papers, two researchers reviewed the titles and abstracts of 124 papers. Through the review of titles and abstracts, 107 papers that did not meet the selection criteria in terms of research purpose and methodology were excluded, identifying 17 papers. Among these, 8 papers with difficulty in obtaining full text were excluded, and finally 9 papers were selected (Table 1). The article selection process is illustrated in Figure 1 (Figure 1).

Table 1

Overview of Studies Included in the Meta-synthesis

Fig. 1.

Flow diagram of study selection.

3. Quality Assessment of Literature

In this study, quality assessment of the literature was conducted using the Critical Appraisal Skills Program (CASP) Qualitative checklist [10]. CASP consists of 10 items for evaluating literature, and higher scores indicate that the qualitative research was conducted systematically. Three researchers independently assessed the quality of the literature, and for items where researchers' evaluations differed, consensus opinions were derived through discussion. Scores were assigned as 1 point when meeting each item's criteria, 0 points when not meeting the criteria, and 0.5 points when uncertain (Table 1). All 9 literature selected in the final literature selection stage scored 6 points or higher (out of 10 points), which is the quality assessment criterion suggested in nursing research [11], and were included in the analysis (Table 2).

Table 2

Quality Appraisal of Included Studies

4. Qualitative Meta-synthesis

In Step 3, each study was read repeatedly to understand its original concepts and contexts. First-order constructs comprising participants' verbatim statements and second-order constructs representing the researchers' interpretations were distinguished and extracted as discrete meaning units. These meaning units were labeled with initial codes and entered into an Excel sheet, with each row linked to the original quotation, page number, and study number to preserve contextual meaning and allow constant checking against the source texts.

In Step 4, "Determining how the studies are related," the codes and concepts derived from each study were arranged in a cross-study matrix and organized chronologically by publication year. Through reciprocal translation, conceptually similar or overlapping codes across studies were systematically compared side-by-side. For example, codes such as "in-between staff and volunteer," "unclear role boundaries," and "confused identity as worker/patient" were translated into one another and then grouped into higher-order concepts capturing ambiguous ontological positioning (Table 3). During this process, at least two researchers independently compared the concepts, repeatedly returned to the original quotations to minimize semantic distortion, and refined the wording of the integrated concepts through iterative discussion until consensus was reached.

Table 3

Synthesized Themes of Experience of Peer Supporters with Mental Illness

In Step 5, "Refutational translation," the focus was not on identifying direct contradictions across the included studies but on exploring why certain experiences appeared in different forms depending on the participants' circumstances. Some studies emphasized the early challenges of peer supporters, such as heavy workloads, lack of confidence, or psychological strain, whereas others highlighted increased confidence, personal empowerment, or the emergence of new life meanings. Rather than interpreting these differences as conflicting findings, we examined how they reflected distinct stages of adaptation and recovery captured by each study. Through this process, we found that the variations stemmed from differences in the participants' temporal positions in their recovery journey and work adjustment, as well as the differing organizational contexts documented in each study. These variations were therefore understood not as mutually incompatible results but as parts of a continuous developmental process.

In Step 6, "Line-of-argument synthesis," the concepts derived from both reciprocal and refutational translations were reorganized at a higher analytical level to construct a unified explanatory structure. The research team repeatedly clustered related higher-order concepts, moved back and forth between the integrated categories and the original studies, and developed third-order constructs that explained how seemingly fragmented findings from individual studies collectively portrayed the overall process of peer supporter experiences. Through this iterative synthesis, these experiences were organized across three distinct yet interrelated dimensions: ontological positioning, temporal development processes, and structural contextual factors, which together formed the basis of the final conceptual model.

In Step 7, "Expressing the synthesis," the synthesized concepts were systematically reconstructed into three overarching themes and seven corresponding subthemes. The adequacy of this thematic structure and its fit with the original data were repeatedly reviewed by all research team members, and the final version was reached through iterative discussions and consensus. To facilitate a comprehensive presentation of the meta-synthesis findings, analytical diagrams and detailed tables incorporating the three-dimensional analytical framework were constructed.

5. Managing Methodological Heterogeneity

To address heterogeneity across grounded theory, phenomenology, photovoice, and qualitative description studies, the researchers conducted integration at the concept level, comparing first- and second-order constructs following meta-ethnography recommendations [12]. The researchers repeatedly verified original quotations to preserve meaning across abstraction levels and abstracted visual-based concepts to levels equivalent to text-based concepts. Refutational translation was employed to distinguish philosophical from participant-based differences in conflicting concepts. In the line-of-argument synthesis, the researchers reorganized translated concepts across ontological, temporal, and structural dimensions to construct third-order constructs transcending individual findings; for example, role confusion, recovery experiences, and identity formation were integrated into identity negotiation as liminal persons. Iterative discussions among the researchers ensured interpretive consistency. Throughout the process, the analysis focused on experience rather than on a method to ensure comparability and integration validity.

6. Researcher Preparation

The principal investigator is a psychiatric nursing specialist and has extensive knowledge and experience in peer support programs for people with mental disorders, having served as the director of a community mental health center. All researchers took qualitative research methodology courses during their doctoral programs and have experience conducting numerous studies applying various qualitative research methods. Additionally, before beginning this study, they thoroughly studied various qualitative meta-synthesis related papers [11,13] conducted in the nursing field to learn specific research methods regarding research procedures and result interpretation.

1. Challenges toward the Possibility

Peer supporters' early experiences manifested as adaptive processes across ontological, temporal, and structural dimensions. At the ontological level, they struggled to identify clear criteria for roles, responsibilities, and treatment [14], perceiving themselves to be placed at a liminal boundary between staff and volunteers [15]. This ambiguous positionality triggered a renegotiation of recovery identity, leading to questions regarding professionalism and identity confusion [16]. At the temporal level, participants lacking sufficient social or practical experience [14] faced administrative burdens, including documentation and schedule management; furthermore, past traumas resurfaced while sometimes listening to others' suffering, causing them emotional exhaustion [15]. However, they gradually learned roles through colleagues and staff support and adapted to practical demands [14,15]. At the structural level, feedback exchanges within professional peer supporter collaborative structures provided relational support based on mutual subjectivity, forming a critical foundation for sustaining work [16]. Peer supporters faced the dual tasks of managing their own symptoms while supporting others [17], reporting difficulties balancing recovery and work due to insufficient systematic support mechanisms, alongside the pressure to provide emotional support [18]. This process extended beyond skill acquisition to the restoration of self-esteem through successful work experience. In summary, peer supporters strengthened their job performance capacity through continuous work execution, learning, adaptation, and confidence building, despite initial role confusion and practical burdens.

Starting from how to do things when entering a company, starting from orientation... Most had been isolated for a long time and were just starting to come out, so they had no experience with that... (A4).

Actually, we are still in recovery while doing meaningful work, but I sometimes think that peer supporters are still trapped in the framework of seeking correct answers and help (A9).

In my case, I had too little information, knowledge, or data about psychiatric disorders, so I searched the internet a lot, wondering if there was an easy way to handle this. I wasn't confident of doing well (A3).

Actually, I was scared of what to do. Wouldn't this person think I'm strange? Should I quit? (A6).

If a consumer employee enters as a consumer, peer supporter employee, actually becoming a member of an organization, you can't expect your demands to be unconditionally accepted. Whether you're a consumer or not, when you enter an organization, you must follow organizational rules... (A4).

I think peer supporters are like pacemakers. I think they can support consumers who are in recovery (A5).

The most important role of a peer supporter is being prepared to be alongside them. Basically, being there together and treating them like friends, and talking to each other and working through them - I think that role is important (A5).

2. Discovering a Role as Peer Supporter

Peer supporters' experiences of "Discovering a role as a peer supporter" manifested across ontological, temporal, and structural dimensions. At the ontological level, the experience of their work being accepted by society and being recognized as having a meaningful role transformed their self-perception from feeling worthless as persons with mental illness [17]. This can be understood as a process of reconstructing their recovery identity. Peer supporters perceived themselves as making substantial contributions as organizational members and receiving social recognition through the experience of earning income [19], which functioned as a core mechanism for the restoration of self-esteem [20,21]. At the temporal level, changes emerged in family relationships as peer support activities continued, with cases reported of individuals who were previously subjects of protection and control gradually expressing their opinions confidently and performing active roles within their households [22]. This demonstrates the process of acquiring equal relational positions by establishing mutual subjectivity with family members beyond mere role changes. At the structural level, these experiences manifested as a process in which identity and roles as peer supporters gradually became established within organizational and social systems beyond individual internal changes and were integrated into stable professional identities over time.

Earlier, I would stay cautious and act centered around dad based on the family atmosphere. I couldn't do anything, but now I'm studying social work and taking a break, and dad followed me into social work. But I asserted, 'Dad, I'm not a social worker, I'm a peer supporter, and I'm definitely going to do this' (A1).

My thinking has changed. When I was suffering alone as a disabled patient, I only thought about myself. But now doing this, I can provide emotional help. I think I have those capabilities (A3).

I always say this, but if I look at money, I can't do this job. But I gain and learn more than I expected, so I just think of it as learning in the remaining time (A8).

I feel like I share a lot of strength with those people, and the listeners also say they're grateful for sharing, which makes me feel rewarded. I think that's also an opportunity to gain strength from our consumers (A7).

I bring up stories about trauma and see myself objectively, and by opening up about my recovery process, I think both I and the other person develop (A2).

The meaning of recovery for peer supporters is that I'm useful somewhere. Being comforted and recognizing that my painful experiences can be useful somewhere has great meaning (A9).

3. Finding the Value of Life

Peer supporters' experience of "Finding the value of life" was manifested across ontological, temporal, and structural dimensions. At the ontological level, peer supporters no longer defined themselves solely as persons with mental illness but came to perceive themselves as valuable beings capable of performing various roles as members of society and family [16], demonstrating the completion stage of recovery identity. The experience of accepting symptoms as part of life while continuing to grow without complete denial [17], represents a transition from an illness identity to a recovery-oriented identity. At the temporal level, changes were reported in which daily life, previously dominated by despair and helplessness, gradually became filled with possibilities and anticipation through continued peer support activities [19]. The process of forming positive feelings of hope for the future through small achievement experiences gained in daily life [20] is understood as a deepening of self-esteem restoration, encompassing not merely changes in self-evaluation but a reconstruction of meaning across one's entire life. At the structural level, this positive reconstruction of life was made possible by performing the social role of peer support activities, with environmental and institutional foundations that enabled participation in these activities serving as factors supporting daily changes and expanding self-perception. This demonstrates that individual recovery is not an isolated internal process but a social process realized within mutual subjectivity with organizational and social systems.

Being a peer supporter means sharing among patients, and just that can be positive for me, and people receiving it see me and want to become peer supporters, have possibilities, and make it a more developmental relationship (A2).

Recovery is a journey to find an authentic self. Meeting consumers and seeing their experiences like a mirror becomes a time for reflection and learning, and through this, I experience recovery in the process of actively understanding myself and finding life's value (A9).

Even with mental illness, I want to live a happy life like non-consumers. I want to become someone who makes others feel that they live really happily (A9).

I used to feel inferior and make comparisons, but now there's nothing like that at all (A8).

They say we're being discriminated against and excluded, but I didn't know what that meant. Did I understand myself seriously enough to think about such situations? Now, I've come to think that I must protect my rights (A3).