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.
Since when has the mandated imperative of “patients” become to become “nurses” rather than to “get well”, or, rather, since we are so bogged down in the “mental health” quagmire, to “get over it”. I personally feel that there are many of us who would be better off if there was no “mental health” quagmire to begin with.
I have ethical qualms about the “peer support” survival strategy but for an entirely different reason. I would compare the “peer support para-profession” to the prison trustee system that rightly was dispensed with a few years back.
“The “trusty system” (sometimes incorrectly called “trustee system”) was a penitentiary system of discipline and security enforced in parts of the United States until the 1980s, in which designated inmates were used by prison staff to control and administer physical punishment to other inmates according to a strict, prison-determined, inmate hierarchy of power.”
The idea of becoming a lifer in the “mental health” quagmire just doesn’t appeal to me in the slightest. I would like to think that it was possible, indeed permissible, for people to exit the “mental health” quagmire, at one time or another, if they so chose. If fortunes, or rather, misfortunes, can’t change, well, we’re lost anyway, aren’t we? I’d prefer to think that fortunes can, do, and will change instead.
I absolutely think that peer work is a way to exit the mental health system, in that it gives people with lived history a chance at employment. For me personally, I want to remain in the field because I am driven by advocacy. But if I wasn’t passionate for advocacy, it would behoove me to leave my peer roots behind as I move ahead. For me, I feel like I’ve suffered too much to go on as if it never happened, the years of suffering. Also I got an autism diagnosis recently, and I realize that my mental illness likely was triggered by being neurodivergent, trying to fit in with a neurotypical world. Unlike mental illness, autism is fundamentally who I am, it affects how I experience the world around me. I want people to know what it’s like, so that’s why I stay in the field. Btw the Trusty System is very corrupt, and it’s really wrong when peers are viewed like this. We are really an abused workforce.
“Workforce”? Minding people who aren’t in the “workforce” doesn’t make for much of a vital “workforce”. I don’t want to argue with you. As far as exits go, I just want to point out that there is always a door if anybody wants out.
Oh, I meant “workforce” like the “peer workforce,” people who are working professional peer specialists and earning a salary. Like minimum wage, and we work our butts off.
Yeah, and I was talking about this “peer specialist” business as a “sick” form of careerism. I’ve got nothing against kindergarten teachers either. I just think that, at one point or another, it’s time to leave the rubber nipple behind. “Peer specialism” can, and is, in some circumstances, what one might refer to as a “serious attachment disorder”.
The idea of professional “certified” human beings is preposterous. It sounds like you’ve ditched one label (“mental illness”) for another (“neurodiversity”). To me the idea of a “peer work force” is reminiscent of Invasion of the Body Snatchers. I know there are many others for whom this is not a confusing reference.
Do you honestly feel Frank that all those people employed to care for, support and/or educate, entertain and inform the vulnerable, the sick, elders, children, unemployed (over half the population) are lesser than others?
I would compare the “peer support para-profession” to the prison trustee system that rightly was dispensed with a few years back.
I got lambasted here a few years ago for comparing “peers” to overseers (or “drivers” as the case may be).
Removed for moderation.
“Also I got an autism diagnosis recently, and I realize that my mental illness likely was triggered by being neurodivergent, trying to fit in with a neurotypical world. Unlike mental illness, autism is fundamentally who I am, it affects how I experience the world around me.”
Like the “autistic” people, and like the “neurodivergent” The “mentally ill” also try to fit in. I think the “mentally ill” are also told by psychiatry that is who they fundamentally are. And “it”, who we are, how we think, obviously affects how we experience and interpret our world.
However, if that term suits you, and perhaps “autism” sounds better and less “sick” than “,mental whatever”.
Although I have to ask, did the label of “autism” delete your other labels”?
“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, ”
Well yes, actually a shrink is secretly diagnosing even his mama.
They tend to see their world as black and white, and everyone who does not fit that, is someone to be leery of.
Always afraid of that “manipulation”, which is really just shit like wanting control and power. Many of us suffer from paranoia 🙂
So it’s not you, in a shrink’s eyes everyone that is not with their protocol, is highly suspect.
“Manipulation” is just an indirect way of controlling one’s environment. The “Mental health” teams use it all the time.
What is it called when I give you give points or privileges for doing what I want you to do but taking them away when you don’t?
Manipulation. Case Closed.
Well the thing to do for people is to undo the effects of having been denied their needs as they grew up. The basic needs are to be known, to be cared about, and to belong. It must be ok for others to know what we think and feel, and if they want to keep up with that for some time, we feel cared about, and if that goes on long enough, we know we belong. If you don’t get this early in life, then the mind’s reaction results in feelings and behavior that they call mental illness. So, you have to first help them with getting their needs at present, and then go back and try to talk to those parts which are hurting still, and show them there is a new system now, and they don’t need to make those pains and feelings they thought they did. The big problem is people are not so generous to give us our needs now, so we can work out this solution. They will do anything else, but not that. I don’t know why, it must be written in some manual or law.
This is a very beautiful description of very deep work.
I think the best that a good therapist can hope to be is a good, fake, paid friend. The boundaries that they have drawn up as regards to ethics seem arbitrary. The very essence of the mental health profession is a boundaries violation. Mental health professionals feel they have a right to your innermost self, so they can analyze and “fix” you, because you are broken and they are healthy. In my experience, they use whatever they know about you, not to help you, but as ammo against you, so they can feel superior about themselves.
Conflicts of interest are the norm in the mental health industry. Mental health professionals are out of work if people are not “mentally ill.” Should psychiatrists and therapists help people and become unemployed? They are absolutely incentivized to keep people “sick” and in need of “mental health services.”
In any case, maybe you can defend your online presence as political activism on the behalf of the vulnerable–people who have been destroyed by the mental health industry.
A social worker may be able to help someone get government benefits, write a resume, or assist people in other practical ways. The only benefit that I got out of the mental health profession was my measly SSI Disability benefits. This qualified me for college grants. No mental health professional ever suggested that I might want to consider going to college, despite trying to dictate every aspect of my life and being. They knew that I was fundamentally inferior to them. They certainly didn’t help me navigate anything to do with applying for grants and scholarships.
I hope as a social worker you are able to help, rather than hurt people. If you are any good at what you do, you will hopefully be able to help people discover what it is that they want to do with their lives, how they wish to live, and how they desire to identify themselves. You may find labels of mental illness beneficial, but that doesn’t mean that everyone does.
I actually had a very good therapist who worked with me to meet MY goals, never once told me what to think about my life even when I asked her to do so. But this was back in the 80s before the DSM took full hold. I think such people are harder to find these days, but I do think there are times when having an objective person who is willing to listen and ask pointed questions about your thinking and decisions WITHOUT telling you what to do is extremely valuable. The problem is, most therapists seem incapable of being there for the clients without meeting their own needs at the clients’ expense. The DSM structure makes it that much easier to avoid the real issues or to work out the therapists’ issues on the client. And I’m not sure there is a way to actually train therapists to do this. It seems to have a lot more to do with the therapist’s own grasp on his/her personal issues and needs, and corresponding ability to set those needs aside and truly LISTEN to the what the client is saying instead of trying to “fix” the client’s life.
And she was an MSW, by the way.
I’m glad that you were able to find a therapist who actually helped you. That’s the mental health industry acting as advertised–helping, rather than hurting people.
My experiences with the industry have been so bad that I generally don’t feel too optimistic that it can ever actually help people. It needs a whole new re-envisioning.
I think I lucked out. Plus, it was a different time. I am not sure psychology/counseling students are even taught about the subconscious mind any more. But they get LOTS of “differential diagnosis” training in the DSM, sadly.
Hi Caroline and Steve,
Another way is what dfk (above) wrote. Beautiful description of deep healing work.
But, Caroline, I don’t think it can be done from a paid friend model. (I should say I’m invested here, as a social worker therapist who tries to work like dfk writes). It’s not about being better than or objective. It’s about taking a bunch of the complication out of the relationship so that helping the one person heal is more possible.
I think that healing in the context of a mutual friendship/partnership can be even more healing, but is also more complicated and more rare. They are different.
As a therapist, if I see myself as a friend, then I WILL want reciprocity, and when my feelings get hurt, I’ll become less able to focus on the client’s needs and helping the client understand their patterns. But, like you both mention, it’s really bad if the therapist is working their stuff out on the client. That’s why my main teacher said that therapists should always be in supervision, even after it’s is required. My feelings do get hurt, and I need to get clarity about my own stuff so it can stay about the client.
Perhaps a therapist might be well off to open a conversation with “what can I do for you that you cannot do for yourself”. Most therapists don’t bother trying to deprogram the person’s belief that they need a therapist.
Neesa, the other thing that I’d like to touch on is your age.
Now I’m OLD, and certainly it did not bring some incredible wisdom.
But I can GUARANTEE you that how things are now, how you perceive
them, will change.
It is known that many psychiatrists actually change their perceptions
on stuff they used to believe or practice, or encourage others to believe.
Very often right close to retirement age.
So one wonders about
“truths”, “facts”. Don’t be too eager to accept someone’s appraisal
of you or your experiences. It is far from insightful to accept shit about
your experiences. Psychiatry will try to make you believe otherwise.
I am not belittling your age, or the age factor. But I think that you might
be wise to think of life as an ever evolving state. Start by advocating
for yourself, by defining yourself, not getting a professional shrink
or therapist to do that for you.
Very interesting (and praiseworthy) that the author would be interested in this issue, which is key to so many things. I see the entire “peer” apparatus as more than a Trojan Horse at this point, it is the point at which the psychiatric caste mentality attempts to “intersect” with the anti-psychiatry movement (with the intended effect of holding it back). The Toronto Principles (1982) stated that the psychiatric system cannot be reformed but must be abolished; the peer industry is the velvet glove covering the iron fist of psychiatric power, and a major tentacle of the psychiatric system.
Hoping this article stays up long enough for me to read it more thoroughly.
oldhead, there are coopted peer systems and kick ass beautifully powerful radical peer systems.
Do you know about Intentional Peer Support (IPS), for example, developed by peers for peers…as well as to teach non-peer clinicians? Have you heard the countless stories of people locked up in psych units, not having one clinician ask them what happened…except the one peer that visited them? I hear some version of that over and over, and hear so many people credit peers with showing them how to make meaning of their experiences and reclaim their lives and humanity.
And absolutely, the “system” wants to co-opt it. But I don’t feel it’s black and white. And I cannot discount all the stories of mad folks I know who have shared how others who have walked the path and found a way through, and come back to offer their stories and companionship, have saved their lives.
Nope, you’re not getting it. The very process of reclassifying human beings as “peers” is alienated, and alienating. That some so-called “peer” systems are “kinder and gentler” than others is secondary, just like some corporations being less noxious than others doesn’t justify the corporate dictatorship as a whole.
I doesn’t take “training” to visit a psychiatric inmate as a comrade.. The idea of being “certified” in consciousness and compassion ignores that we are in essence dealing with crimes against humanity, and professional “peers” serve the purpose of putting a human face on an inhuman system. Anyone who cares can be that drop of light in the darkness of captivity, there’s no need for it to be a “specialty.”
The purpose of psychiatry is to enforce conformity to system values, and to relate to it in any other way is to unwittingly collude in its mystification of human suffering, and its persecution of those who don’t fit in the box. And if you truly considers psychiatry to be a tool of repression, to look to it for approval lends far more credibility to it than it does to you.
BTW I don’t know any “mad folks,” only people who have romanticized and internalized their labels.
Neesa has hit on some very good tensions. As an ED for a peer run organization that provides Peer Support in a drop in center environment AND traditional treatment services such as case management, mental health assessment and psychotherapy, this article hits on some very practical ethical considerations that our practice deals with as well. However, we have found that when both disciplines are using the Recovery Oriented System of Care (ROSC) model, it helps tremendously to see the NASW ethical boundaries as a healthy guideline to ensure that the agency is providing person-centered services, with peers stating their recovery goals and providers coming alongside the peer to help them work on those goals.
The fact that anyone has to suggest that “person-centered services” should be a model of care tells us enough about the usual attitude of the “mental health” professions toward their ostensible “clients.” What other kind of help could possibly be envisioned, that is not centered on the person one is purporting to “help?”
LOL. Sorry but that phrase “person-centered services” causes me to chuckle.
I often wonder who is really at the center? Being the focus is not valuable, being the center of attention is not productive if psychiatry is involved.
And it’s becoming such an overused phrase. The whole MH society jumps in and uses it because it sounds so, er, “centered”.
It is oddly euphemistic, as I was trying to point out. I mean, who the f*&k else would be at the “center” of your considerations? It’s kind of an admission that the “care” they have been providing has had nothing to do with the person they are “treating!”
The other doozy is “person with lived experience.” Doesn’t this describe everyone who wasn’t born in a coma?
Maybe they mean “lived experience” of the nonsense and discrimination so many people experience at the hands of the “helpers” in the “mental health system?”
If you need to speculate as to what it means it’s clearly not a very useful term.
It is a concept distinguishing between services delivered by providers who make recovery-oriented or treatment decisions for the recipient of the services (provider-centered) vs. services delivered by providers where the recipient of the services make recovery-oriented or treatment decisions for themselves, with the provider as a trained guide (person-centered). It is a very important and real distinction that makes a difference in one’s healthcare, whether it be mental or physical health.
The distinction is made because services are STILL delivered by some providers, based on the provider’s ideas of what is best for the individual to whom they are providing services.
I’d say by MOST providers these days. There are exceptions, but they are most definitely in the small minority.
I came at this a bit the other way around – first I got my MSW degree and started working, then I started posting stuff online, including my own story!
I haven’t been hassled about that, but I have an especially friendly work place.
I think it’s important to note that the code doesn’t say we will never post information about ourselves online, just that we will be aware it has an impact that may be unhelpful. But if what we are posting can also be helpful, we can definitely justify doing it despite the fact that it could also cause a problem.
And it’s true that what we post might make some people not willing to work with us. But knowing that doesn’t mean we have to shut up. I’ve seen something as simple as my posting something in my office about available support for LGBTQ people make someone not want to work with me, because they then perceived me as LGBTQ supportive. But that doesn’t mean I was wrong to post something.
Anyway, there are lots of contradictions to think about in social work ethics, even without bringing peer work into it. The whole thing about attempting to be some neutral clinician doesn’t sit that well with what social workers also sometimes like to think they are, social justice advocates!
Anyway, there are lots of contradictions to think about in social work ethics, even without bringing peer work into it.
I would second that. But bringing the in the whole “peer” angle surely makes things even more convoluted politically and theoretically. I don’t see why “system” people insisting that we are “peers” isn’t seen as immediately suspicious, just as it would be by anyone in day to day life confronted by someone who felt it necessary to point out that they are “equal” (except that this special category of equality is designated as “peerdom”). I consider “peers” to be just above “untouchable” status in the psychiatric caste system. Weird how the term is used to imply equity.
As for social workers per se I believe many of them who are well-meaning must live their lives with a sense of impotent frustration at knowing what is best for people is not on the agenda of the ruling class, no matter which party is in power.
The “peer” designation appears to me to be intentionally condescending, to mark these people as “not REAL professionals” so their views can be overridden when they threaten the status quo too directly.
There has been much debate about the proper term to describe this relationship. What would you suggest is a better designation?
I don’t know that I have one to hand, actually. Whatever you call it, there is a power differential, and any person who is really good at it knows this is a huge part of the dynamic and knows how to step down from their power and return the power to the client, and appreciates that the “peer worker” is actually in a BETTER place to do this. But the DSM attitude/philosophy speaks directly against this, encouraging and even in some ways requiring the “clinician” to see the “Mentally ill” as below them. And by analogy, the “peer worker” is below them, too.
Maybe we can call them “coaches” or “mentors” or something that doesn’t delineate their value as being a “peer” with people who are identified as being “beneath” the “professionals.” But the real problem isn’t the name, it’s the attitude of the professionals toward their clients, and by analogy to anyone who as been on the “client” side of the relationship. Condescension is both a consequence and a cause of the disempowerment of clients, and I see that condescension clearly indicated in attitudes toward “peer workers,” who are automatically seen as less wise, less emotionally stable, less effective, and less important than the so-called “professionals,” even when the opposite may well be the truth.
Prostitution is as good a term as any, I’d say. Or maybe “human work.”
“Peer” implies the existence higher ups, or greater authorities. The “peer-client” relationship is inherently a power relationship, regardless of the individuals involved. Particularly if the “peer” is paid, “certified,” or otherwise accorded special status based on such a designation.
Hey great article! So if it helps, even the most sketchy, sorry I mean “traditional” MH and Social Services agencies hire Peer Support Specialists and co-opt all the phrases that once held meaning like “empowerment”, “agency” and the works. MLM’s co-opt similar self help jargon to sell you shampoo that makes your hair fall out. Anywho I am not super knowledgeable around it but with that said one ethical concern I have with Peer Support is that those who identify as disabled could have their story exploited by agencies with unethical practices IE overdrugging, over diagnosis, not providing informed consent on lack merit of DSM, etc. Also it’s not the job of the oppressed to stop the oppressor. It’s the oppressor’s responsibility. Just saying. People shouldn’t be coerced into situations where their livelihood depends on them disclosing their stories, which are often deeply personal and traumatic to strangers, colleagues, online, the world etc. Plus a lot of people aren’t safe emotionally or otherwise to open up to. So yeah basically I’m scared for some Peers Support Specialists. Maybe I’ve been watching too many anti MLM videos lately which can be pretty brutal and although it’s not the same they essentially coerce their downlines into sharing all kinds of deeply personal information on social media to recruit other people into the MLM. Also, I am happily posting this anonymously and to further assert my boundary this will be my only comment on this article. Being empowered by sharing your story and genuinely helping others by choice is one thing and I applaud that 100% but having no where else to turn and the risk of exploitation scares me.
Sorry I lied. One more comment. When I say “identify as disabled” I am not implying that I believe MH disabilities aren’t real. No disrespect meant to anti psychiatry. Just different viewpoints here.
“MH disabilities” aren’t real because “MH” isn’t real.
I think you have a “healthy” viewpoint. One does not have to shout from the rooftops that one is gay or heterosexual.
Identifying as disabled when one is not disabled is self-deprecating. Doesn’t make any difference if you shout or whisper. And “mental health” isn’t real in any reality, unless we redefine the meaning of language AND reality.
Of course disability exists. But there need not be close to as much as there is. Physical therapy is known to lessen disability. Mental therapy is known to increase it. If they changed mental therapy to a physical therapy, the outcome would be much better. Take 50 sad, fearful, shy kids and do 2 years of physical therapy that includes playing, sports, sewing, canoeing, wood chopping/sawing….etc etc and not just once per week.
They say it’s too costly. But it’s not to costly to create disability? Of course not. Creating disability makes for a lot of jobs. Our present setup is not at all inclusive, and those that can’t perform like robots are referred to as disabled.
In societies like the hopi, how much “disability” was there?
Can I coax you into another comeback to say what’s MLM stand for?
I thought it was Marxism-Leninism-Maoism. 🙂
Hi Neesa, I’m so excited you are joining the radical tradition of social work!
Well, there’s a radical tradition in SW, and a gatekeeper tradition. I hope Hunter is teaching you about social workers like Bertha Capen Reynolds, who believed that when her clients marched in the streets, it’s social workers’ responsibility to get out of the office and march with them, but ALSO to bring it back to the office and start organizing about the terrible working conditions of our own profession!
Yeah, I’m a sister social worker (SW) and a therapist. And I have also struggled with the Code around dual relationships, making services financially accessible, and other issues. I actually have a lot of respect for the document **in the hands of seasoned SWs**, because it is the collected evolving wisdom of so many who took up the work. I agree with Ron Unger who draws attention to the importance of the qualified language of a lot of the points.
It is a frustrating aspect that there are so many seeming ambiguities and conflicts in the Code—but that is also what makes it a nuanced document, able to be wrestled with for the incredibly complex issues of being human and trying to be ethical around issues of power imbalance, etc. Beware of it in the hands of black and white thinkers, though, who will try to use it as a weapon.
But I have been so lucky to find a supervisor who brings all of her decades of experience to wrestle with it with me to support me in my very outside-the-box work as a SW who is out about my lived experience of madness and radical mental health perspective.
I definitely share my stories when it seems in service to clients, and this supervisor is completely supportive. And I continue to navigate the complex challenges of dual relationships of the very small radical mental health community. But I actually agree with carefully considering the potential impacts, often unintended, that these can have. I don’t think it’s about figuring out what is 100% safe to do, but what is reasonable, considered risk. And sometimes we make mistakes. And then we try to be accountable, if we are brave and ethical enough.
I hope you have supportive supervisors, too! It makes all the difference (I’ve had supervisors from hell–don’t confuse them as representing the profession).
And then I hope you help the Code become an even better document/guide!
Yes, being a peer worker is different from being a peer-clinician/clinician with lived experience. I think it would be a fascinating discussion to explore that. Please let me know if you’d be interested in creating a presentation (panel discussion, maybe?) for Rethinking Psychiatry. That would be amazing and I’d be really interested and would help, if you wanted. You can reach me through [email protected].
I think “marching with the clients” is such a brave thing to do.
It would be very difficult to make that decision to join the marches.
I mean it is very likely that one just ends up losing credibiity, a job, respect,
future employment, and to boot, protesting is probably in the DSM.
Again, where’s everybody marching?
Please let me know if you’d be interested in creating a presentation (panel discussion, maybe?) for Rethinking Psychiatry.
STILL “rethinking” psychiatry after all these years? Didn’t you hear? — the thinking has been completed. The conclusion: psychiatry is a fraudulent branch of medicine which must be abolished.