The first time I tried to write about peer support—that emerging form of “service delivery” in which one person in recovery from what is described in the field as a “serious mental illness” offers support to another person who is in distress or struggling with a mental health condition—was in 1994. The manuscript was summarily rejected from an academic journal as representing what one of the reviewers described as “unsubstantiated rot.” That same article was eventually published 5 years later,1 and used by the President’s New Freedom Commission on Mental Health to support its recommendation that peer supports be implemented across the country.2 Now, more than a decade later and as peer support arrives at something of a crossroads, both of these reactions remain instructive.
First, there continues to be a large, unmet need for peer support across the country. Over thirty states have already secured Medicaid reimbursement for peer support, and many other states have found ways to fund peer support without Medicaid. Yet there remains a tremendous need for people to receive the message that recovery is real and possible for them, and to benefit from the support peers can provide. At the same time, there remain influential people in mental health systems (and government) who continue to think that peer support—along with anything else related to the concept of “recovery”—is nothing more than “unsubstantiated rot.” Perhaps this situation is no different from that of the diffusion of other innovations in medicine or society at large—like the transition from horse drawn carriages to cars—but it strikes me as an important consideration in deciding the future of peer support. And that is what I would like to address in this piece.
What is the nature of the crossroads at which peer support currently finds itself? As the discipline grows, so do concerns that persons in recovery are increasingly being exploited by their employers to provide more of the same unhelpful services that were already being provided by mental health staff but at a lower cost, with the added benefit of giving their agencies the appearance of being “recovery-oriented.” This reality was reflected all too clearly in a recent article in which peer staff were touted as a cheap way of helping “people with mental illness stay on their medications.” 3 These kinds of developments provide further evidence to self-help/mutual support advocates that peer support should not be provided within the context of mental health services at all, but should remain separate and apart from the mental health system, continuing to be the valuable “alternative” to treatment mutual support has been since the 1960s. From such a perspective, persons in recovery who occupy provider positions in conventional mental health programs are seen as committing a kind of betrayal. They are allowing themselves to be exploited (for pay) as a means of making it possible for systems of care not to have to change the same practices that harmed them in the first place; an instance of what Freire observed as the oppressed becoming oppressors.
There is no question that this does happen. I have seen it firsthand, and have been deeply disturbed by the ways in which peer staff have been under-used, misused, and unwittingly co-opted by mental health agencies that see no reason to change how they do business. But this is only one side of the equation. At the same time, but in different settings, I have seen the transformative impact that peer staff can have on the culture of mental health agencies. I have seen those people who viewed the introduction of peer staff as “unsubstantiated rot” become converts by witnessing the effects generated by these staff in the persons whom they support—people the staff had given up on as hopeless, impossible to work with, too “high risk,” or too disabled. One psychiatrist who had openly laughed in my face when I first suggested hiring peer staff acknowledged recently that he has become a staunch advocate of peer support because he has seen how much more peer staff can do with people than he ever was able to do as their physician. And he sees how much easier his own job has become as a result.
So, why not just tear the mental health system down and replace it entirely with peer-based supports? Why bother to transform a fragmented, over-medicalized, under-funded, and frequently toxic system—in part through the introduction of peer support—when it might be better just to offer caring, reciprocal, genuine human relationships?
The answer to which I have come thus far is that we need both. Peer support, like other innovative supports (e.g., supported employment), reaches only a small fraction of those persons experiencing distress or struggling with mental health issues. Even were funding for peer positions radically increased overnight, there would remain a need for other forms of care as well. That is because, compared to the large number of persons presenting for mental health care through conventional channels, very few people make use of self-help or mutual support options available to them in their community. This is not only due to the medicalization of distress, the resulting social habits, and a history of disproportionate funding (although these remain significant influences), but also due to the fact that people do not necessarily want to become part of a cause or a(nother) community, especially ones with which they do not identify personally. The majority of people fighting against mental health care are people who have been hurt by it. Other people, who may not yet have experienced such trauma at the hands of ‘helpers’, may not necessarily want to advocate for or against anything. They may simply want to get on with their own lives as best they can. For those people, and for the even larger number of people who experience mental distress and neither seek nor receive any help at all—formal or informal—new and other approaches are sorely needed. And, importantly, people need to have the opportunity to choose those forms of care and support that they will find most safe, comfortable, culturally relevant, and effective for them.
The partnership between peer supporters and non-peer (or non-disclosed) mental health staff is still early in its evolution. Before abandoning the mental health system, the millions of people who already rely on it, and the millions more people who do not yet seek help or derive any benefit from it, let’s see if we can make it better—in part through the efforts and influence of people in recovery. People in recovery know three very important things: 1) the ways in which mental health systems currently help people; 2) ways in which mental health systems currently fail and harm people; and 3) ways in which mental health systems could be better at educating, engaging, and supporting people and their loved ones in their own recovery journeys. If we can invite, value, and benefit from their accumulated wisdom, ideas, and energy, we might be able to create together a system that is more accessible, respectful, and responsive to all those in need—whether or not they choose to join, or to become invested in helping to further improve, the system that cared for them.
1. Davidson, L., Chinman, M., Kloos, B., Weingarten, R., Stayner, D., & Tebes, J.K. (1999). Peer support among individuals with severe mental illness: A review of the evidence. Clinical Psychology: Science and Practice, 6: 165-187.
2. U.S. Department of Health and Human Services. (2003). Achieving the promise: Transforming mental health care in America. Rockville, MD: Substance Abuse and Mental Health Services Administration.
3. Vestal C. ‘Peers’ seen easing mental health worker shortage. Stateline, September 11, 2013; 1–3. The PEW Charitable Trusts.