Peer Support, Peer Problems
For Steve Harrington, president of the National Association of Peer Supporters, the loss of a relationship triggered a deep depression with psychotic features, resulting in hospitalization.
For Leah Harris, communications and development coordinator for the National Empowerment Center, it was her parents dying young from a combination of mental illness and the “toxic effect of overmedication and broken spirits,” and then her own treatment for mental illness during her youth.
They and other advocates describe years of languishing in traditional treatment settings until the peer support movement, with its emphasis on recovery and wellness, showed them another way.
Harrington and Harris are both certified peer specialists. The defining characteristic of peer specialists is that they self-disclose as persons who have received mental health treatment, and put forward their own recovery stories as a professional resource for others to tap.
“One of the biggest things that peers want and need for recovery is relationships — not just a relationship with a peer supporter but relationships in their communities,” said Harrington.
This raises obvious questions: What are the parameters of the peer-to-peer specialist relationship? What are the emotional stakes for those charged with maintaining a level of openness about their own struggles that traditional psychotherapy has long frowned upon?
For those within the peer support field, this question points up the issue of boundaries — specifically, the danger for the unwary peer supporter in becoming overly consumed by the plight of the peer client, to the point of harming the integrity of the therapeutic relationship and even jeopardizing one or both persons’ recovery.
“I don’t want to infect them, or for them to infect me.”
So said “Mary,” a small, elderly Hispanic woman whose warm, matronly demeanor failed to conceal how furiously her mind was working to process the input she was getting. “Them” is people with lived experience of mental illness.
It’s the Friday night of Alternatives, the largest and most visible national conference that is organized by and for consumers of mental health services. Mary’s comment was made during one of the event’s evening caucuses.
Mary is considering training to become a peer specialist. By her own account, she is a compulsive helper. In fact, the major sticking point for her is what she sees as her penchant for “codependency” — a tendency to become too deeply enmeshed in the tribulations of the people she tries to help.
The therapeutic relationship is necessarily a test of the ability to maintain strict boundaries in an emotionally charged setting. But for peer specialists — individuals with lived experience of mental illness who have trained to use their recovery story to help others — the personal stakes can feel much higher.
Most of the caucus attendees are peer specialists. These peer specialists spend much of the ensuing discussion trying to assuage Mary’s doubts. Mary is peremptorily concerned with the effect she might have upon a peer — and the effect that a peer could have on her.
“We have to make sure that we’re being friendly, but not friends,” said “Judith,” a certified peer specialist and caucus participant. “It’s the ability to know where your stuff ends and the peer that you’re serving begins. We need an understanding of limits and responsibilities in our role as a peer provider.”
A Growing Field
Boundaries are just one of the many hot topics that define this growing field. As of September 2012, 36 states had established programs that train and certify peer specialists. Certified peer specialists (CPS) now sit on the boards of state hospitals.
They accompany doctors and nurses on their morning rounds. They act as group facilitators, debriefers, trauma specialists, advocates and trainers. They chair human rights committees that make recommendations to hospitals for the purpose of reducing the use of seclusion and restraint and other dehumanizing practices. They are not just used as back-end troubleshooters but as front-end consultants and planners.
“For those interested in becoming peer specialists, the biggest hurdle they’re going to have is that the other staff that they work with are probably not going to understand what their role is,” said Dennis Bach, director of Austin, Texas-based Via Hope.
According to Bach, poor utilization of peer specialists’ skills remains the biggest problem within the field.
“Because of that lack of understanding, quite often individuals that are hired as peer specialists get assigned to do stuff that’s not appropriate — like drive a bus, or sort papers or whatever — instead of working with other people who are getting services, sharing their stories and helping people with their recovery,” said Bach.
Via Hope, a nonprofit funded by the Texas Department of State Health Services and the Hogg Foundation for Mental Health, offers a Certified Peer Specialist course that consists of a 35-hour training followed by a written certification exam. Participants must successfully complete both to become certified. Once certified, a peer specialist must earn at least 20 continuing education units every two years to maintain his or her certification.
As peer support emerges as a discipline, with its own best practices and delivery models, there is a growing concern that it risks being co-opted by the very systems it was meant to change — or that peer specialists’ efforts to acclimate to the incumbent cultures at their workplaces can blunt the creative tension that makes them most effective.
“Peer supporters, because of the environment, the culture, relationships with co-workers, they often, unfortunately too often, tend to perform and practice more like traditional clinicians than they do peer supporters,” said Harrington. “There’s a lot of reasons why that happens, but it’s been a concern of ours as an association for a very long time.”
Harrington makes a distinction between cooptation and professionalization, arguing that the latter is desirable even while the former is not. Against those who argue that any form of credentialism is anathema to peer support, Harrington thinks that it’s possible to uphold professional norms within the field without sacrificing its transformative edge.
“Professionalization deals with competency and training. Co-optation is more like enculturation,” said Harrington. “We have some peer supporters, a very small number, who say that peer supporters should have no training, should not be certified, to preserve the purity of peer support. Then we have others who say it should be a degreed profession, that you should be able to get at least a bachelor’s degree in peer support. Of course, reason tends to fall somewhere in the middle.”
A World Within, a World Apart
Leah Harris is adamant that peer support must remain a world that is definable and distinct from the surrounding culture in which it operates.
“I’m a strong advocate that peer supporters should not be getting a paycheck from the agencies that they’re working at, that they should be getting independent funding to be there,” said Harris. “Let’s say you’re a peer specialist working for ‘X’ agency, and you’re seeing some extreme problems going on. If you’re drawing a paycheck, there’s a level of fear of repercussion that might keep someone from speaking honestly about what they’re observing.”
While the peer support field strives to define itself, others stress that the peer support experience is bound to be as individual, and as difficult to circumscribe, as the peers themselves.
“Peer support is a person-to-person lived experience, an experience of meeting individuals where they’re at, in reference to their illness at the time,” said Ginny Thomas, a certified peer specialist and rights protection officer at Spindletop MHMR in Beaumont, Texas.
Thomas recounted a series of traumas in her life — a rape that resulted in a pregnancy and an abusive marriage among them – that not only gives her gravitas as a peer specialist but also makes her an avatar of what a recovery-centered ethic can achieve. She is involved with the RESPECT Institute, which trains mental health consumers in the skills and coaching necessary to transform their mental illness, treatment, and recovery experiences into educational presentations. This is in keeping with peer support’s larger emphasis on transforming illness sagas into recovery narratives.
“The ‘qualified mental health professional’ is the person who believes that the consumer doesn’t know anything, or doesn’t have the ability,” said Thomas. “Everybody needs to understand that everybody is on a level playing field, and have that respect.” Thomas even points to basic issues of workplace culture, such as the commingling of professionals with consumers in spaces — think restrooms, offices, break room refrigerators — that highly degreed clinicians might see as their sole preserve.
“There is a lifetime of education, and the education you do receive you can use and take throughout your life, throughout your recovery,” said Thomas. “If you want to be a peer provider, you have to take care of yourself first so you can assist somebody else.”
Evans, I. (2018). Peer Support, Peer Problems. Psych Central. Retrieved on April 6, 2020, from https://psychcentral.com/blog/peer-support-peer-problems/