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The growing pains of peer support
We live in distinctly adolescent times for peer support. As a concept, it has grown beyond infancy, gradually moving from the periphery to occupy an ever more prominent place in mental health policy and practice across the western world. In this issue, several authors have described the ubiquity of peer support in the USA, Australia and the UK (Rogers, 2017; Gillard et al., 2017; Bellamy et al., 2017; Jackson and Fong, 2017). The past decade has seen the development of accredited and specialist training courses, widespread creation of paid roles and the expansion of community peer support initiatives (Crepaz-Keay, 2017). Under the umbrella of recovery, peer support has been identified alongside the development of recovery colleges as one of the key indicators of recovery-focussed change in UK mental health services (Shepherd et al., 2014).
Peer support has reached a point in its development which is hard to quickly surmise, given that the intense growth has brought with it controversy, and drawn attention to areas where further growth is needed, both in terms of research evidence (Bellamy et al., 2017) and changes in traditional mental health provision (Irwin, 2017). Its growth has taken place in ever more complex cultures of austerity and division, but nonetheless, peer support is a movement spilling out in all directions. Like a teenager, peer support occupies an uncomfortable “in-between” identity, one that is crowded with contradiction, ambivalence, and a desire to be accepted.
My own experiences with peer support track a somewhat similar process of growth. Seven years ago, facing unemployment, I was looking through the NHS jobs website when I came across six “peer support worker” posts. The advert read: “The role of peer support worker has been developed specifically for people who have lived experience of mental distress. Through sharing wisdom from their own experiences, Peer Support Workers will inspire hope and belief that recovery is possible in others”. As I read, I felt a rush of excitement ripple through me; there were people out there who saw my experiences as a source of wisdom, there was a way that they might become something more to me than a source of shame and failure.
I look back with breathless disbelief that fate acted as it did and I was offered a peer support worker job, given that I did not know what “mutuality” meant. I skim read “Recovery and social inclusion” (Repper and Perkins, 2009) and sort of got it, and sort of did not. And nonetheless I was offered a job as a peer support worker and began my second childhood, being raised in peer support, in the culture of the NHS. During this time, my understanding of peer support expanded from the singular experience I began with, to begin to appreciate the emotional, political and economic complexities that such a seemingly simple concept contains. I have worked, trained and researched in different peer support contexts, listened and read hungrily on topics of recovery, anti-psychiatry, trauma and inequality. I have learnt that peer support is not the simple solution I once thought it to be, but a philosophy with deep roots, trying to find space within the chaotic communities and mental health systems which we inhabit.
I can now look out on the ever expanding landscape of peer support and simultaneously find hope and despair. Collectively, the picture that is painted by the articles in this special issue is one of complexity, of head and heart, of success and trouble, of rampant progress and sad withdrawal. Although not explicitly, the debates in peer support have centred on some particularly teenage questions, questions that have been thoughtfully considered from different standpoints by the authors in this special issue.
How can I be popular?
While peer support has undoubtedly grown in popularity in recent years, with the widespread creation of peer worker roles across western mental health services, popularity on an international level does not necessarily translate to popularity within staff teams for individual peer workers. Peer workers continue to struggle to feel valued and appear credible when they are employed within traditional mental health services (e.g. Vandewalle et al., 2016; Mancini and Lawson, 2009).
The calls for higher quality research evidence may go some way to increase the popularity of peer support. Bellamy et al. (2017) provide a helpful overview of the existing research into the effectiveness of peer support. Currently, evidence is of a low quality and provides mixed results, often finding that peer support produces similar outcomes to traditional mental health services in terms of reducing hospitalisation, and slightly better outcomes in relation to increasing hope and empowerment. These fairly unremarkable findings may in part be due to the continuing focus on the outcomes prescribed by traditional mental health service provision. In peer support and recovery, “outcomes” are personally defined; indeed the outcome of peer support may simply be the peer support relationship itself. There is some difficulty in providing evidence for peer support without transforming it into a one-sided intervention to suit the needs of RCT protocols. From a philosophical perspective, this can be seen as an example of the medical/positivist paradigm privileging its own way of understanding the world, inappropriately applying its own standards to the evaluation of another paradigm. If we understand peer support to be part of a new paradigm, it must be judged within its own context using standards that are defined by this.
The process of bringing peer support into mainstream mental health provision has often resulted in some level of compromise; peer support is transfigured into a one-sided intervention, with quantifiable outcomes. This is a dilemma faced by so many teenagers; is it more important to be accepted, even if it means compromising one’s integrity? Such a dilemma invites another teenage question pertinent to peer support.
Why cannot you just accept me for who I am?
I recognised myself in Carlina Whitmore’s (2017) article, as she describes feeling unsure of herself as a Peer Worker, feeling like “the token mad woman”. I too remember wanting to “blend in fine”. Like Carlina, I slowly learnt that honesty, even when it is difficult, is what peer support rests on. In fact, it is what my own recovery rests on. Carlina describes navigating, and ultimately finding her place as a peer worker within mental health services. She suggests that honesty, even when it is difficult, is what has made her the peer worker that she is. For others, honesty even when it is difficult is what has caused them to withdraw from peer working within mainstream services. Sue Irwin (2017) has offered a first-person perspective on the issue of peer support in traditional contexts, describing the reasons why, ultimately, she could not continue to work as a Peer Support Worker in an NHS system. These two articles illustrate the diversity of experiences among peer support workers who question, react to and accept their working contexts to myriad different degrees.
There is no small element of rebellion and disagreement within peer support about the contexts that it takes place in and what this means for its identity. Many believe that peer support in mainstream mental health services is being co-opted (Brown and Stastny, 2016, that there is little chance of true mutuality surviving in medical, expert based systems (Filson and Mead, 2016; Scott, 2011). Mead and Filson (2017) explain, “as peer support is mainstreamed into traditional mental health services, it faces a dilemma: uphold the principles and values of peer support such as mutuality and shared power, or comply with job descriptions that can include the use of force”. In their article, they describe how Intentional Peer Support can be offered within any context and how this differs from traditional mental health approaches. This is helpful because many peers are faced with such a challenge and must find ways of both upholding the principles of peer support, and complying with their job descriptions. By becoming part of mental health services, which continue to use practices which are at odds with its philosophy, peer support walks a delicate tightrope between being part of the solution and becoming part of the problem.
Jackson and Fong (2017) have provided a hopeful example of wide scale adoption of peer support across their organisation, Flourish Australia. They illustrate the importance and power of wholehearted strategic support for new ways of working, which has translated into tangible HR policies and recruitment processes that have underpinned the wholesale adoption of peer working. The approach of Flourish Australia is exceptional in a landscape where the values of peer support continue to be misunderstood and undersupported (Gillard et al., 2015). Many peer workers, including myself, remain working within mental health systems as part of a “survivor mission” (Deegan, 2002). I stay because this is the system that I found myself in, this is the system that many people are forced into and that they see as their only hope. And if we do not try to change it, if we give up hope then what?
In many ways, community initiatives seem like a better fit with the mutual philosophy of peer support. Community-based peer support removes focus from fixing broken individuals, to place it on what affects our collective mental health (Crepaz-Keay, 2017). Locating peer support within communities acknowledges the inequalities that exist within them, and provides a means of repairing divides as well as supporting individuals. This shift addresses one of the common criticisms of recovery, that it depoliticises individual experience by removing it from its social context. In community-based peer support, peer workers can develop an awareness of inequality and poverty and how these directly affect health.
Crepaz-Keay’s (2017) article draws attention to the wide spectrum of peer support that exists outside of mental health services, and the importance of this. Several authors in this issue have contemplated the varied offerings that we consider to be peer support. The context and the content of peer support encompasses huge variety; peer support can take place within traditional mental health services, within peer-run initiatives, and within community contexts, by paid and unpaid, trained and untrained peer workers. With such variety, how can we be sure of our shared understanding of peer support? Does everything that is offered under the guise of peer support bear any similarity to what you or I understand peer support to be? The multiplicity of peer support approaches gives rise to the final teenage question, one that, in my experience, extends into adulthood.
Who am I?
There is a growing need to understand and protect the identity of peer support as it is colonised, embraced and co-opted in different mental health contexts. A helpful starting point is the conception of a clear values base that underpins peer support. There have been many incarnations of different values and principles which define peer support. Gillard et al. (2017) describe the process of developing fidelity criteria using existing literature and national expert panels in the UK. The resulting values include themes of mutuality, strengths focus, using experience and the importance of trusting relationships. These values, once clearly established, can be used as a means of understanding what kind of environment provides the most fertile ground for peer support. Related to this is the call for a better understanding of the mechanisms that underpin peer support (Rogers, 2017). Understanding these mechanisms will go some way to answering the question of what peer support is, and what makes it unique.
Perhaps an equally important question to “who am I?” is “what should I strive to be?” This is not a teenage question but one that we continue to revisit throughout recovery, and throughout life. Should peer support strive to be an approach that is integrated into services, should it strive for social change, community cohesion, the demise of psychiatry? As adulthood draws closer, peer support will face new challenges; will this adolescent movement rise up and rebel, or will it conform?
For what it is worth, what I believe peer support to be is part of a new paradigm, a different way of understanding human growth, a relational way of holding “recovery” between people, a human process worth fighting for, that demands attention, that needs space. I believe it to be at odds with current ways of understanding mental “illness” and I believe that we must acknowledge that clearly, so that we can mainstream mutuality in a way that does not change the meaning of the word, or ignore the difficulties involved in doing this. To me, becoming an adult means acknowledging the fallibility of the system that raised me, and finding my own way of living, and values to live by, not merely for the sake of teenage rebellion, but for the sake of a meaningful life.
Bellamy, C., Schmutte, T. and Davidson, L. (2017), “An update on the growing evidence base for peer support”, Mental Health and Social Inclusion, Vol. 21 No. 3, pp. 161-7.
Brown, C. and Stastny, P. (2016), “Peer workers in the mental health system: a transformative or collusive experiment?”, in Russo, J. and Sweeney, A. (Eds), Searching for a Rose Garden: Challenging Psychiatry, Fostering Mad Studies, PCCS Books, Monmouth, pp. 183-91.
Crepaz-Keay, D. (2017), “Peer support in community settings: getting back to our roots”, Mental Health and Social Inclusion, Vol. 21 No. 3, pp. 184-90.
Deegan, P.E. (2002), “Recovery as a self-directed process of healing and transformation”, Occupational Therapy in Mental Health, Vol. 17 Nos 3/4, pp. 5-21.
Filson, B. and Mead, S. (2016), “Becoming part of each other's narratives: intentional peer support”, in Russo, J. and Sweeney, A. (Eds), Searching for a Rose Garden: Challenging Psychiatry, Fostering Mad Studies, PCCS Books, Monmouth, pp. 109-17.
Gillard, S., Foster, R., Gibson, S., Goldsmith, L., Marks, J. and White, S. (2017), “Describing a principles-based approach to developing and evaluating peer worker roles as peer support moves into mainstream mental health services”, Mental Health and Social Inclusion, Vol. 21 No. 3, pp. 133-43.
Gillard, S., Holley, J., Gibson, S., Larsen, J., Lucock, M., Oborn, E., Rinaldi, M. and Stamou, E. (2015), “Introducing new peer worker roles into mental health services in England: comparative case study research across a range of organisational contexts”, Administration and Policy in Mental Health and Mental Health Services Research, Vol. 42 No. 6, pp. 682-94.
Irwin, S. (2017), “Why I chose to leave mainstream psychiatric services: a peer supporter’s personal perspective”, Mental Health and Social Inclusion, Vol. 21 No. 3, pp. 153-60.
Jackson, F. and Fong, T. (2017), “Why not a peer worker?”, Mental Health and Social Inclusion, Vol. 21 No. 3, pp. 176-83.
Mancini, M.A. and Lawson, H.A. (2009), “Facilitating positive emotional labor in peer-providers of mental health services”, Administration in Social Work, Vol. 33 No. 1, pp. 3-22.
Mead, S. and Filson, B. (2017), “Mutuality and shared power as an alternative to coercion and force”, Mental Health and Social Inclusion, Vol. 21 No. 3, pp. 144-52.
Repper, J. and Perkins, R. (2009), “Recovery and social inclusion”, Mental Health Nursing Skills, Bailièrre Tindall, London, pp. 85-95.
Rogers, E.S. (2017), “Peer support services: state of the workforce-state of the field in the USA”, Mental Health and Social Inclusion, Vol. 21 No. 3, pp. 168-75.
Scott, A. (2011), “Authenticity work: mutuality and boundaries in peer support”, Society and Mental Health, Vol. 1 No. 3, pp. 173-84.
Shepherd, G., Boardman, J., Rinaldi, M. and Roberts, G. (2014), “Supporting recovery in mental health services: quality and outcomes”, Centre for Mental Health and Mental Health Network, NHS Confederation, London, 34pp.
Vandewalle, J., Debyser, B., Beeckman, D., Vandecasteele, T., Van Hecke, A. and Verhaeghe, S. (2016), “Peer workers’ perceptions and experiences of barriers to implementation of peer worker roles in mental health services: a literature review”, International Journal of Nursing Studies, Vol. 60, August, pp. 234-50.
Whitmore, C.M. (2017), “Just a peer finding my way in a crisis house”, Mental Health and Social Inclusion, Vol. 21 No. 3, pp. 191-4.
About the author
Emma Watson is a Peer Support Development Lead at Peer Support Development Team, Nottingham NHS Trust, Nottingham, UK.