I first learned about the peer specialist profession in 2013, while attending a rehabilitative day program in Queens, New York. Care coordinators talked about the work of peer specialists, how they tactfully self-disclose to the people they work with in order to facilitate healing. The profession intrigued me. I had spent my whole life trying to hide my 20+ years of emotional suffering, trying to blend in with a stigmatizing world, feeling miserable in this effort. Peer work seemed to be a profession that would relieve my deeply internalized shame and self-hatred.
To train properly in the profession, I attended the comprehensive peer specialist training program at Howie the Harp Advocacy Center, located in Harlem, New York. I learned about alternatives to the biomedical model of mental health care, a world that I had been entrenched in since middle school. Lecturers spoke about recovery-oriented values, such as person-centered care, trauma-informed care, harm reduction and tools such as the Wellness Recovery Action Plan (WRAP). We learned about the power of self-disclosure, how peer specialists can reach a suffering person in ways that clinicians cannot.
After earning my first full-time job ever (at the age of 29) as a peer specialist at the end of 2014, I had this immense desire to share peer work with the world. I wanted to shout it from the rooftops, that we peers exist, that we are valid people who need not live our lives in a closet in the name of normalcy, that we hold the keys to healing. The more I embraced peer values, the more I saw myself transform from disabled to thriving.
Thus, I took to the internet. I wrote blog posts about my alternative mental states and experiences, sharing my personal stories in order to illustrate the dignity of people who suffer. Then I started publishing articles on reputable online publications. The passion within me grew, and I started a peer wellness group on Facebook. The group continues on today, five years later, and has become a place of inquiry and support. (The group is called “What is Wellness? A Mental Health Discussion Group.”)
Through my online activities, I have met amazing friends and likeminded folks, who embrace me with all my quirks. While I had previously experienced estrangement in academic settings throughout childhood, adolescence and college years, mental health advocacy finally introduced me to a group of people who not only accepted me, but understood me at a fundamental level.
Continued passion for peer work and advocacy prompted me to pursue a master’s degree in social work at the Silberman School of Social Work at Hunter College. I wanted to effect change as a peer, sliding my foot in the clinical door, working from the inside to transform the mental health service delivery system.
In classrooms, I felt a lot of hope that my agenda could actually manifest. I bravely raised my hand and talked about the work of peer specialists, disclosing my own status as a peer, and imparting my belief in the power of harnessing stories. I was not alone. Another student spoke about her incarceration history, previous drug use, prostitution and being HIV positive. Both of us were respected amongst professors and students. This gave me confidence, that there would be a place for me in the social work profession.
A class called Practice Lab I acquainted me with fundamental principles of social work. This started with analysis of the National Association of Social Workers (NASW) Code of Ethics. The Preamble starts with a description of the foundation of social work:
The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty. A historic and defining feature of social work is the profession’s focus on individual well-being in a social context and the well-being of society.
The NASW Code of Ethics comprises numerous regulations that govern the ethical values of the social work profession. Failure to adhere to the NASW Code of Ethics can lead to disciplinary action by one’s employer, a peer review process, and/or legal proceedings. Expectedly, it is also a document that can be consulted in the case of ethical dilemma.
Yet one regulation haunts me:
Section 1.06: Conflicts of Interest
(f) Social workers should be aware that posting personal information on professional Web sites or other media might cause boundary confusion, inappropriate dual relationships, or harm to clients. (Emphasis mine)
Even today, as I read and reread this sentence, I fearfully recall all of my online activity. Articles where I have freely disclosed, in the name of fighting stigma. My Facebook group and daily social media musings. A simple Google search of my name immediately yields an author blurb from a poetry book I wrote, saying that I am a mental health advocate who has survived depression, anxiety and schizoaffective disorder.
Is my online peer activity a violation of regulation 1.06f? I continue to worry.
The NASW Code of Ethics smartly acknowledges the evolving use of “communication technology,” and its implications for maintaining “professional boundaries.” It advises social workers to remain mindful on applying ethical standards to these emerging technologies and their implications.
And given that this document was most recently revised in 2017, consider that our circumstances were quite different then. We were not facing the COVID-19 pandemic and stay-at-home orders. We lived our lives more in-person, and not as much online through Zoom meetings and social media.
Let us now consider dual relationships, a term that is used throughout Section 1.06. The NASW Code of Ethics defines it as such:
Section 1.06: Conflicts of Interest
(c) Dual or multiple relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively.
Amongst more skeptical clinicians, there is the fear that self-disclosure can cause the client to view the professional as more of a friendly acquaintance, bordering on the line of friendship. Therefore, it is considered unethical and not professionally competent.
Aside from blurring boundaries, self-disclosure has been criticized as disregarding the “importance and influence of unconscious psychological processes in the analytic relationship,” especially within the psychoanalytical approach. It can also invite role reversal, or perhaps fall into the same invasive category as offering a hug or exchanging a gift. To avoid this ethical quandary, it is easier for social workers to avoid self-disclosure altogether.
Clinicians may also feel uncertain about the professional application of self-disclosure, even if not entirely opposed to its use. A study by Knight (2012) showed that social workers felt unprepared by training programs in this skill, nor did they feel that this practice was supported by theory or clinical research. They also felt uncomfortable with discussing self-disclosure in supervision sessions or with coworkers.
Also consider: the clinical therapeutic relationship is different than that of peer to person. When working with a clinician, the agreement is that the person will talk freely, and the social worker will remain detached and objective. The client does not agree to hearing disclosure from the social worker, although its educated and tactful use could feasibly enhance therapeutic benefit for the client.
Compare this to the work of peer specialists. Through tactful self-disclosure, we establish mutuality. In its purest form, conversation resembles friendship, and would not even include a financial transaction as a peer “offering services.” Both people relate to one another, allowing for a conversation to naturally evolve. In the process, both parties are impacted. The friendly aspect of peer work purposely veers out of “professional” territory and into “social” territory, which is ultimately healing.
Yet peer specialists looking to enter the social work profession may find barriers to employment, specifically because of our peer support work experience. Employers may look at us with a critical eye, deeming us as unprofessional because our (former) peer work utilizes an “overly casual” style of engagement that blurs the line of the therapeutic relationship.
Employers may perceive tactful self-disclosure as something that needs to be unlearned in order for a peer to become clinically competent. It can even be seen as negative work experience, something worse than having no experience at all. This discrimination can manifest as soon as a potential employer reads the words “peer specialist” on a legitimately-licensed social worker’s resume. It can lead to not being invited for an interview.
Below, I will provide other statements from the NASW Code of Ethics that are additionally of concern to peer specialists entering the social work profession, followed by my own commentary.
Section 1.06: Conflicts of Interest
(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment.
Peer social workers are perfectly capable of being alert to potential conflicts of interest, and can easily avoid such as described. However, when in the workplace, discrimination may force a peer to come under the scrutiny of this statement, even wrongly. Our past experiences can be dug up as proof that we are not capable of “professional discretion and impartial judgment.”
Section 1.06: Conflicts of Interest
(c) Social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client.
A peer social worker can fully monitor themself and avoid these actions on their own. Yet even if they refrain from self-disclosure, their history of self-disclosure may follow them. Coworkers may even observe indirect (or nonexistent) hints of “overempathizing,” which can be wrongly painted as potential for a dual relationship that has not even occurred.
Section 1.06: Conflicts of Interest
(g) Social workers should be aware that personal affiliations may increase the likelihood that clients may discover the social worker’s presence on Web sites, social media, and other forms of technology. Social workers should be aware that involvement in electronic communication with groups based on race, ethnicity, language, sexual orientation, gender identity or expression, mental or physical ability, religion, immigration status, and other personal affiliations may affect their ability to work effectively with particular clients.
This is especially troubling. Amongst peer specialists and members of various radical collectives, most of our idea-sharing occurs online. We communicate through Facebook and other social media platforms, and we contribute to online publications such as MindFreedom and Mad in America. Many of us publish under our real names, and thus clients can find our work. Our opinions may scare some who are more aligned with the biomedical model, sowing seeds of doubt regarding our competence. Admittedly, I have been scared this way in the past, given my own roots in this perspective.
Yet especially in the year 2020, COVID-19 social distancing restrictions now force us to live online. Thus, more of us are likely to have an online trail that discloses personal details on our lives. Additionally, the wrongful deaths of George Floyd, Breonna Taylor and other persons of color due to police brutality have spurred masses of online mobilizing. Even progressive and radical-minded social workers engage in this advocacy, including many within the Hunter College social worker alumni network.
These online actions seem to be completely ethical. Consider Section 6 of the NASW Code of Ethics, entitled “Social Workers’ Ethical Responsibility to the Broader Society.” Recommendations for macro-level advocacy are described:
Section 6.04: Social and Political Action
(a) Social workers should engage in social and political action that seeks to ensure that all people have equal access to the resources, employment, services, and opportunities they require to meet their basic human needs and to develop fully.
I believe that this regulation can easily be extended to include the peer community, given our interest in ensuring the dignity of people who find themselves entrenched in an oppressive mental health system.
Yet when we mobilize online, we share our stories to discover mutuality and establish solidarity. Solidarity strengthens our collective voice, and makes us strong enough to spearhead political action. But with restrictions on self-disclosure as outlined in the NASW Code of Ethics, are our affiliations with one another as empowered survivors ethically unsound? Especially considering that our activities are online, and easily findable…should we refrain from sharing?
And what if a fellow client is also in favor of systemic advocacy? What if they join the same online advocacy groups that we do, as peer social workers?
Section 1.06: Conflicts of Interest
(h) Social workers should avoid accepting requests from or engaging in personal relationships with clients on social networking sites or other electronic media to prevent boundary confusion, inappropriate dual relationships, or harm to clients.
It is simple enough to refrain from socializing on social media with clients. We can deny friend requests and ignore any messages they may send. We can put restrictions on the visibility of our postings. We can completely block a client, preventing them from seeing absolutely anything from our accounts.
Yet still, professional clinical colleagues may discover an online presence on social media, discovering that the prosumer still aligns with the peer movement as a person with lived experience. Of course, coworkers too can be blocked. Or maybe we can refrain from joining online groups where people alternative mental health practices? Maybe we can just lurk, and never post?
When we take extensive measures to hide our online presences to the world, it is a manifestation of going back into the closet of shame, denying the power of our stories and the life wisdom we have learned from our lived experiences. When I consider hiding my own story, feelings of detachment overwhelm me. I start feeling like I have no place in neither the peer community nor in the social worker workforce. I begin to lose my sense of identity, and toxic shame overtakes me again. It brings me back to the place I once was, when I felt I had to hide in order to fit in, where I felt estranged and rejected from society.
Fundamentally, the problem does not lie in the process of self-disclosure. The problem is that peer social workers face discrimination from clinicians, who fear that our use of self-disclosure is arbitrary and unregulated. They fear that our mental incompetence (evinced by our psychiatric histories) makes us ticking time bombs, that we will blurt out our stories incomprehensibly and harmfully. They do not consider that we have judgment, and can refrain from storytelling when it is not useful to the client.
Yet as peers, we also want to push the envelope to allow the field to develop in a more humane direction. Our knowledge of effective self-disclosure should be absorbed into clinical practice. Yet sadly, the barrier remains raised. Self-disclosure has been blamed as serving the needs of the provider more than the client, and could lead to a client perceiving a provider as incompetent. It may also indicate a lack of self-awareness and a product of countertransference.
During my time at Hunter College, professors articulated the need for those with disabilities to enter the social worker workforce. This statement gives me hope, yet I think it is more about ticking off a box on the affirmative action list. Something akin to having a sound-minded person in a wheelchair working on a treatment team, making the other clinicians feel warm and fuzzy at their inclusiveness. A person with a type of disability that is not going to compel clinicians to change the nature of their practice.
It is more difficult to include people with mental health disability histories in the social work workforce. When clinical circles dismiss the peer social worker’s expertise on tactful self-disclosure rooted in lived experience, our personal wisdom is also dismissed. This discourages the true integration of people with all types of disabilities entering the mental health workforce. It also creates a hostile work environment that perpetuates estrangement and internalized shame.
Therefore, the social work profession must evolve. In order to facilitate such, I suggest that peer clinicians (both practicing and aspiring) unite together as a subcategory within the peer community. We should discuss our grievances and fears of discrimination in the workplace. We should then draft a well-crafted mission statement that demonstrates our professional competence as clinicians, while also asserting the validity of peer practices such as tactful self-disclosure. The mission statement should also offer solutions on how these practices can be integrated into standard clinical approaches.
Our dialogue should be calm and collaborative. The goal is the exchange of ideas, the discovering of commonalities and the brainstorming of clinical practices that can allow the social work profession to evolve and remain current. Some social workers are already of a progressive mindset, such as recent graduates from Hunter College, so these discussions may prove surprisingly welcome.
With current clinical regulations and resultant restrictions, such as that on self-disclosure, we peer clinicians can feel drained of the passion that fueled our pursuit of clinical degrees in the first place. Yet as long as these discriminatory barriers remain in place, mental health service delivery will not be able to evolve in a humane direction, and workplaces will remain hostile.
The full text of the National Association of Social Workers (NASW) Code of Ethics can be read online here.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.