Mental Health Peer Support Worker Competence Framework: A Personal & Professional Reflection

Vikki is the managing director of Peer Hub CIC, a developing peer-led organisation in the North East of England launching in 2021.  When open, Peer Hub will offer peer alternatives to psychiatric services including alternatives to crisis and inpatient services, alongside development support for lived experience projects and a peer-led knowledge hub.  Vikki has two decades’ experience of formal and informal peer support, and was previously the Peer Support Lead at Tees, Esk and Wear Valley NHS Foundation Trust, where she led a peer-led trauma informed peer support programme.  She is passionate about peer-led innovations and the potential to form projects around social justice, human rights and lived experience expertise that reduce the focus on statutory services and create opportunities for social change to be led from within local communities.

Peer support holds a very dear place in my heart.  On being diagnosed with a psychiatric disorder many years ago, I entered a long period of feeling isolated and hollow.  It was my peers that opened the possibility that I could feel differently.  I was able to see parts of myself reflected in them, and seeing them as worthy of compassion gave me potential to see myself that way too.  It was finding solidarity in our otherness that led to my first step towards kindness for myself.  Together we grew relationships that allowed us to take chances on ourselves and each other.  Looking back, it feels really quite profound.

The forming of peer relationships was only the beginning; it was the possibilities of what might happen around and within them that made my experiences of peer support extraordinary.  Those relationships with my peers remain central to my life, and as unique as the people who formed them.  They are a continuous balance of the opposites that frame the human condition: fragility and strength, pain and love, dependence and autonomy, commonality and difference.  Taking responsibility for my part in these balances guided me in my discovery of these things within myself, and the feelings of emptiness lessened.  They were the incremental steps that led me to the person I am today, and still help me continue onwards through to new discoveries in the world.

Defining peer support through the lens of mental health services removes these unique experiences from its centre.  Clinical practice relies on a linear process from the helper to the helped, so there is little opportunity to discover ourselves through exploring our connections to each other.  And good clinical practice depends on therapeutic relationships, so the understanding of peer support’s relational focus is only the beginning of introducing the NHS to the parts of peer support that it hasn’t yet comprehended. 

There is an ideological barrier to overcome first, which is lodged in the perception that ‘psychiatric patients’ are problems to be solved, and largely absent of awareness or expertise of the solutions.  This makes it inconceivable that ‘unrecovered’ peers could serve any purpose to each other.  There is an inevitable impact of this on our identities, which is a common form of iatrogenic harm.  It lessens who we are and what we can offer the world, and I think it is also the cause of a good proportion of the stress experienced by the peer workforce.  The professionalisation of peer support by non-peer leaders risks cementing these perceptions within formalised peer support, rather than setting it in opposition where it belongs.

The absence of attention to peer leadership, grassroots principles and human rights movements has been the fundamental mistake in the NHS approach to implementing peer support roles.  When peer expertise leads implementation, it is possible for the practice of peer support in mental health services to bring something akin to the connection and solidarity found in grassroots communities: I have seen it done by peer supporters myself in the peer programme I led in the NHS, and it continues to evolve in NHS programmes led by peers elsewhere.  But, the NCCMH Mental Health Peer Support Worker Competencies aren’t designed to enable this kind of peer support practice, but rather to create a version that conforms with the existing NHS ideology and its reliance on clinical knowledge and pathways.  This is why peer support roles get stuck in the community support worker/HCA domains, much to the frustration of both peers and our colleagues.

Aside from peer leadership being absent from the design process, the Competencies’ draw their evidence from UCL’s analysis of existing knowledge in mental health services, which has been deemed sufficient to meet their purpose.  They have ignored the evidence suggesting that most peer programmes in NHS services (and some in the VCSE) are not really providing much peer support at all, and paid only cursory attention to peer-led resources and research.  Peers have already demonstrated that when we lead our own professional development, we are more than capable of doing a good job.  That HEE, UCL and NCCMH persist in on doing it for us just perpetuates the divide between the ‘us and them’, and frankly, it’s rather patronising.

As a result of the exclusion of peer support expertise from their design, the Competencies have settled on greater compromise of grassroots principles than was needed.  To the credit of the ERG, the changes they have made are very welcome, particularly the inclusion of trauma informed approaches and the removal of interventions.  Still many issues from the original draft remain, and it has created an unnecessary separation between peer support workers and service users.  Empathy reads as if it can be prescribed rather than genuinely felt; solidarity through shared experiences has been traded in for embodying hope for recovery; and the exploration of stories and their meaning has been conceded to their use for persuasion.  The value of peer support in these competencies has been rooted in enabling the pursuance of goals, rather than the many other things peers offer, such as finding the time to just sit together and coalesce in the darkness, an often welcome alternative to the push towards ‘wellness’. 

Assimilating peer support into the NHS will not close the divide between ‘them’ and ‘us’.  These competencies have indeed compromised and come towards the grassroots, but the authors still haven’t grasped the essence of peer support.  The risk is that they continue to place the duty on NHS managers to lead its implementation, when this hasn’t worked well for peer support thus far.  While the ERG has managed to create spaces between the lines that could be exploited by peer leaders, they remain few and far between in the NHS and face many barriers to their work.
The skills and knowledge to professionalise peer support do not exist in clinical professions or public services – only the frameworks and policies that set its limitations can be found here.  These Competencies are just further evidence that when non-peer authorities attempt to write the script on our behalf, more often than not we end up in positions of opposition.  Peer supporters cannot be responsible for resolving this when mental health services refuse to let go of the pen.  For this to be resolved, they need come to us and ask us to do the writing.  Only then will mental health services realise the alternative possibilities peer support can offer, which was the reason for its implementation in the first place.

Selected reference material:

Ahluwalia, A. (2018) Peer Support in Practice (Implementation Guide), Inclusion Barnett
Basset, T., Faulkner, F., Repper, J. and Stamou, E. (2010) Lived Experience Leading The Way Peer Support in Mental Health, Together UK
Blanch, A., Filson, B., Penney, D. (2012) Engaging Women in Trauma Informed Peer Support:
Curtis, L. , MacNeil, C. , & Mead, S. (2004). Leading successful peer programs: Our visions/our outcomes. Charleston, WV: The Consumer Organization and Technical Assistance Center. 
Deegan, P. E. (1992). The independent living movement and people with psychiatric disabilities: Taking back control over our own lives. Psychiatric Rehabilitation Journal, 15(3), 3–19.
Faulkner A (2012) ‘The Freedom to be, the Chance to Dream’: Preserving User-led Peer Support in Mental Health, Together UK,No%20health%20without%20mental%20health%3A%20an%20implementation%20framework.
Faulkner, A.and Basset, T. (2012), “A helping hand: taking peer support into the 21st century”, Mental Health and Social Inclusion, Vol. 16 No. 1, pp. 41-47.
Faulkner, A & Basset, T. (2012). A long and honourable history. Journal of Mental Health Training, Education and Practice, The. 7. 53-59. 10.1108/17556221211236448.
Gillard, S.Peer support in mental health services: where is the research taking us, and do we want to go there?,Journal of Mental Health,1080/09638237.2019.1608935
MacNeil, C. and Mead S (2005), A Narrative Approach to Developing Standards for Trauma-Informed Peer Support, American Journal of Evaluation
Mead S. and Filson, B. Becoming part of each other’s narratives: Intentional Peer Support, In J. Russo & A. Sweeney (Eds.), Searching for a rose garden: Challenging psychiatry, fostering mad studies. PCCS Books.
Mead, S., & MacNeil, C. (2006). Peer support: What makes it unique? International Journal of Psychosocial Rehabilitation, 10(2), 29–37.
Penney, D (2018) Defining “Peer Support”: Implications for Policy, Practice, and Research, Advocates for Human Potential US
Penney, D., & Prescott, L. (2016). The co-optation of survivor knowledge: The danger of substituted values and voice.In J. Russo & A. Sweeney (Eds.), Searching for a rose garden: Challenging psychiatry, fostering mad studies (p. 35–45). PCCS Books.