A recent study published in Qualitative Health Research reveals that despite the growing focus on inclusion in mental health peer support, these workers often experience exhaustion, slow rates of change to oppressive values and practices, and ongoing workplace exclusion.
Peer support work, which emphasizes solidarity, mutuality, and self-determination, has been increasingly incorporated into mainstream mental health practices. However, the study’s authors argue that multiple versions of inclusion are produced through socio-material practices, including research, with varying effects on peer support workers and mental health practices.
The study was conducted by Aimee Sinclair, Sue Gillieatt, Christina Fernandes, and Lyn Mahboub from Curtin University in Australia. They write:
“As Mad-identified scholars and allies, unsettling inclusion sits uncomfortably, given its status of moral imperative, achieved through significant social justice advocacy. We do not wish to undermine valuable advocacy that has seen inclusion brought to mainstream political agendas, the progressive effects of inclusionary measures, and the work of scholars who are continuously working toward social justice. It is this work that enables our analysis. However, we believe unsettling enactments of ‘inclusion’ is a discomfort worth sitting with to continue moving towards achieving dignified and socially just mental health services.”
The consumer/survivor/ex-patient (C/S/X) movement has long advocated for the right to self-determination and the value of experiential knowledge in addressing mental health issues. These advocacy efforts have contributed to de-institutionalization, recovery-oriented approaches, and the involvement of mental health service users in service design, delivery, and evaluation.
The researchers employ a post-structural analysis to examine how inclusion is produced. To do so, they adopt Carol Bacchi’s “What’s the problem represented to be?” (WPR) approach to explore how mental health research produces versions of inclusion, examining the implications for peer support workers and mental health practices.
By applying the WPR approach, the study analyzes how mental health research on peer support produces specific knowledge, assumptions, and problems of inclusion and peer support work. Through this lens, the authors present three problematisations of “inclusion” within the literature: inclusion as assimilation, integration, and co-optation.
Assimilation refers to the process by which individuals conform to the dominant culture or system in order to be included. For example, in the context of mental health peer support, this could mean that peer support workers are expected to adopt the language, values, and practices of the dominant mental health care system to be recognized as legitimate providers of care.
Inclusion as assimilation is a perspective that views the employment of peer support workers (PSWkrs) as a political move without sufficient evidence of efficacy and effectiveness. Proponents of this view argue that high-quality trials are needed to determine whether peer support interventions can resolve psychiatric symptoms or improve patient self-management.
This problematization is mainly driven by the dominant positivist paradigm in medical research, which focuses on gathering evidence about a singular reality. As a result, clinical measures in randomized controlled trials and meta-analyses have become the gold standard for measuring peer effectiveness. Unfortunately, these measures often decontextualize distress and support, neglecting social factors influencing outcomes.
The assimilation view of inclusion requires PSWkrs to adopt ways of thinking and working that align with psychiatric authority, producing clinical outcomes. This may lead to PSWkrs becoming “mini-clinicians,” focusing on individual identity and experience markers, such as diagnosis and history of accessing services, to support psychiatric outcomes. This approach often excludes alternative practices that challenge psychiatrization and leaves dominant mental health practices unquestioned. Inclusion as assimilation can involve PSWkrs having limited control and may implicate them in oppressive practices associated with treatment.
The second problematization of including Peer Support Workers (PSWkrs) in mental health systems involves treating inclusion as a foregone conclusion. These texts highlight the unique and valuable contributions of PSWkrs and the importance of maintaining the authenticity of peer support (PS). However, the problem is framed as a technical issue of overcoming barriers to inclusion, which can be related to PSWkrs, PS work, or external factors.
In this positioning, PSWkrs are often problematized as lacking the disposition or skills for mental health work, leading to suggestions for training and accommodations. Similarly, PS work is complicated due to factors like emotional stress, role confusion, and lack of professional standards. Therefore, solutions often involve making PSWkrs more like existing mental health workers through training, standardization, and credentialing.
External problems include stigmatization by non-peer staff, unsupportive work environments, and poor compensation. These problems are attributed to a lack of organizational readiness, with solutions focusing on more explicit policies, procedures, and job descriptions.
Thus, inclusion is constructed as integration, where aspects of PSWkrs’ lived experiences are valued, but the alternative epistemology they bring is often excluded. This approach to inclusion can conceal and reinforce oppressions and injustices, as limiting experiences are reduced to technical rather than political problems.
Co-optation refers to the process by which the dominant system or culture absorbs and repurposes elements of a marginalized group to maintain power and control. In the context of mental health peer support, this could involve the co-option of peer support practices and language by the dominant mental health care system, potentially undermining the original intentions and values of peer support.
In this section, the authors highlight the gradual shift in PS from a grassroots, user-led approach to a more institutionalized, professionally-led one. This shift is seen as problematic, resulting in a loss of integrity and the devaluation of lived experience expertise. The authors also critique essentialist narratives of co-optation, which can sideline the diversity and dynamic nature of PS and inclusion.
The literature on PS often fails to engage with issues of race, gender, class, sexuality, or diagnostic differences, which has led to the continued production of predominantly white, western, and ‘sane-performing’ PSWkrs. This exclusionary approach ignores the long history of mutual aid and expertise within marginalized communities and the differential effects of taking up a peer identity. The authors call for critical reflection and engagement with the experiences and expertise of marginalized groups.
Lastly, the analysis suggests that the co-optation problematization can erase dissent and complexity within the PS movement. The authors emphasize that PS has always existed within politics and that individuals are continually shaped by various forces. The authors encourage a more nuanced understanding of the psychiatric and mental health fields and the workers within them.
The authors argue that current constructions of inclusion may contribute to oppressive tensions experienced by PSWkrs, who are caught between wanting to practice in anti-oppressive ways and needing to exist within a system that readily excludes them. They suggest that researchers should engage in “self-problematization” to critically examine their own role in producing and reinforcing these notions of inclusion.
To move beyond current limitations in the concept of inclusion, the authors propose exploring how various inclusionary forces impact peer support in different contexts and across intersections of gender, class, diagnosis, and other axes of oppression. They suggest considering the productive potentials and limitations within both “inside” and “outside” engagements with mental health systems rather than focusing on an “authentic” form of peer support.
The study underscores the importance of engaging with uncomfortable reflexivity to enable more emancipatory possibilities regarding inclusion and peer support. The critical analysis of inclusion in mental health peer support highlights the need for further examination of the political effects of research and the potential for more inclusive and socially just mental health services. In addition, by recognizing and critically examining the different forms of inclusion, researchers and practitioners can work towards fostering a more inclusive and equitable mental health care system that values peer support workers’ unique perspectives and contributions.
The authors conclude:
“We have highlighted how dominant notions of ‘inclusion’ produced through research have potentially delimiting effects for PSWkrs and leave oppressive power relations unexamined. An alternative enactment of ‘inclusion,’ constructed predominantly through Mad/survivor research, provides the potential to move us closer to social justice outcomes if we continue to engage with its limitations and do not allow it to solidify. This critical reflection on the role of research in the production of ‘inclusion,’ whilst often uncomfortable, is integral for ensuring, as researchers, we are aware of the problematic effects of our own well-intentioned efforts and, thus, how we might continually adjust our practices such that we move closer to achieving justice and equality for individuals with lived experience of distress and/or psychiatric oppression.”
Sinclair A, Gillieatt S, Fernandes C, Mahboub L. Inclusion as Assimilation, Integration, or Co-optation? A Post-Structural Analysis of Inclusion as Produced Through Mental Health Research on Peer Support. Qualitative Health Research. 2023;0(0). doi:10.1177/10497323231163735 (Link)