The inconvenient complications of peer support

By Alison Faulkner, survivor researcher (based on a talk given at the Refocus on Recovery conference in Nottingham, 2019)

To read Part 1 of this piece, please click here.

3.  A divided path?

The more recent development of peer support finds it being adopted by mental health services as a means of supporting people, with the employment of peer support workers in teams and on wards. This has, to my mind, created something of a divided path in peer support, because it represents a major departure from the origins of peer support within user groups and self-help spaces. It brings with it certain risks, not the least of which is to establish a peer as someone who is not of equal status. When someone is employed as a peer support worker, particularly in mainstream services, they are being employed and paid to deliver something that may or may not look like peer support as we know it... there are risks attached to this, as well as potential benefits from the nature of the support on offer. I would not wish to detract from the potential benefits of someone with lived experience being able to support others - but it is important to be aware of the risks.

Risks of co-option

Looking at this from a systems and service perspective, the power and status given to peer support delivered by mainstream services, is such that it might be attracting funding away from community based peer support within service user groups and voluntary sector organisations ... mental health services have the power to provide peer support without reference to, or acknowledgement of, what has been and is going on in their local communities. They also have the power to define and redefine what is and what is not peer support. There is a significant risk to user groups and user-led organisations of loss of funding for community  based peer support.

Peer support in mainstream services can be provided as an individual treatment intervention, which can mean a failure to engage with the collective, shared knowledge of communities, along with the assumption that one individual PSW can provide peer support to any and all service users supported by this team or this ward... They might find themselves a part of a service delivering treatment as usual - supporting mental health staff in their roles, encouraging compliance with treatments, even delivering control and restraint, ... is this in fact peer delivered servicesrather than peer support? I am not saying it is all like that, but it is clear that some has been drifting in this direction.

imagine implementing Peer Support Workers into teams that have no understanding of the work they do, why they do it, its ethos or its value, with no notice and not providing those PSWs with any support. Because that is what happened. We were enforced on teams that didn’t want us, that weren’t appropriate placements for us – one colleague was essentially forced to work on a forensic unit they used to be in, another in a CMHT they used to be attached to.” Hollie Berrigan: The Main Offender blog ‘Back from the brink’ @HoppyPelican

A major risk of peer support being provided as an intervention within services is the impact this has on outcome measurement and research. It now has to prove itself as an intervention: it is not enough that it might be about shared experience, mutual support, reducing isolation - now it has to be measured and compared alongside other interventions. As Steve Gillard (2019) points out, this means that research has to be in the form of randomised controlled trials and this then feeds back into practice skewing the nature of the peer support on offer... there is the real risk that research is leading us away from the original ethos of peer support. Gillard says that, to play a meaningful role in 're-imagining' peer support in mental health services, researchers need to "resist the gravitational pull of the evidence base; the replication and reification of a para-clinical model of peer support as the best peer support." (Gillard, 2019, p.343)  - for example, by paying attention to the values underpinning peer support in the design and reporting of trials.

The role of peer support in mental health services is often directed towards delivering recovery and embodying recovery by being an example of recovery yourself. Job descriptions often require people to have recovered, and services can at times be less than sympathetic to those who experience mental health crises. The training, certification and recruitment of peer workers - the professionalisation of the ethos - is at risk of becoming what Jijian Voronka refers to as a process of 'turning mad knowledge into affective labor'.  

Complications along the divided path

But is the divide as simple as that? In reality, we know that peer support as it is provided in the community and voluntary sector varies enormously... it cannot be conceptualised as one thing, which is exactly what the statutory sector seems to find frustrating. There are so many different terms used to describe it, there are many things that may qualify as peer support from self-care and self-help to campaigning groups and peer mentoring...drop-ins and user groups... how are we to identify it?

In addition to which, it can fall into some of the same traps as peer support in mainstream services... perhaps it is not always peer-led, but staff-led; or perhaps it is designed as an intervention without recognition of what people can offer each other. Perhaps people are not supported well to be providing peer support. Sometimes people are paid but often they are providing it as volunteers, another issue that needs clarification and understanding; it can be fine in some circumstances, possibly even preferable if there is a relationship of equal standing at the heart of it - but there needs to be clarity and choice about these issues.

4. Finding common ground?

One of the ways in which some people and organisations have endeavoured to define peer support - or at least to find common ground - is through identifying the underlying values or principles that make an activity or group peer support: trying to clarify what it is that characterises this as peer support - and not some other form of support.

I have been involved in the work of several organisations seeking to identify peer support values and principles, including NSUN, Together, Mind and St George's/The McPin Foundation. All of these can be found on their respective websites. By bringing together these and the principles developed by the Scottish Recovery Network, ImROC and others, I developed a word cloud ... if there is any conclusion to reach from these then it is the central importance of mutuality or commonality, shared experience - which brings us back to that person of equal standing.

5.  Imagining our futures

So, my final question is: can we with our maturity of experience find ways of bringing those two paths back together? I think that it is possible, but we have to make a concerted effort. We need to...

  • Recognise the value of peer support in all its diverse forms and in diverse communities … a peer is not one-dimensional
  • Preserve the spaces for experiential knowledge to grow and develop – an end to austerity?
  • Develop research methods to allow us to capture collective benefits and social change: creative and flexible methods
  • Ensure that different approaches to peer support are acknowledged by services and commissioners
  • Raise awareness of the importance of community and collective experiential knowledge and action
  • Provide adequate and good support to everyone providing peer support
  • Be aware of the potential role of peer support in supporting our rights – linking with & learning from people in the Global South… the individual then goes out into the world with a different outlook – as an empowered agent, rather than an object of treatment.”USP-Kenya

I leave you with this quote from Shery Mead, founder of IPS in the States:

As peer support in mental health proliferates, we must be mindful of our intention: social change. It is not about developing more effective services, but rather about creating dialogues that have influence on all of our understandings, conversations, and relationships.” 

 

References

  • Faulkner, A. (2017): Survivor research and Mad Studies: the role and value of experiential knowledge in mental health research,Disability & Society.
  • Faulkner, A. and Kalathil, J. (2012) The Freedom to Be, the Chance to Dream. London: Together for Mental Wellbeing.
  • Gillard, S.(2019) Peer support in mental health services: where is the research taking us, and do we want to go there?, Journal of Mental Health, 28:4, 341-344, DOI: 1080/09638237.2019.1608935
  • Jones, N. and Kelly, T. (2015) Inconvenient Complications: On the heterogeneities of madness and their relationship to disability. Chapter 3 in Madness, Distress and the Politics of Disablement, ed. Spandler, Sapey & Anderson. London: Policy Press.
  • King, Colin (2007). “They diagnosed me a schizophrenic when I was just a Gemini. ‘The other side of madness’”. Chapter 2 in Man Cheung Chung, K. W. M. (Bill) Fulford, and George Graham, eds, Reconceiving Schizophrenia, Oxford University Press, Oxford, Pg 11-27.
  • Morgan, A., Felton, A., Fulford, B., Kalathil, J. and Stacey, G. (2016) Values and Ethics in Mental Health: An exploration for practice. London: Palgrave.
  • USP-K (Users and survivors of psychiatry-Kenya)The role of peer support in exercising legal capacity. Nairobi: USP-K uspkenya.org
  • Voronka, J. (2017) Turning Mad Knowledge into Affective Labor: The Case of the Peer Support Worker. American Quarterly, Volume 69, Number 2, June 2017, pp. 333-338.
  • Woods, A., Hart, A. and Spandler, H. (2019) The Recovery Narrative: Politics and Possibilities of a Genre. Cult Med Psychiatry https://doi.org/10.1007/s11013-019-09623-y