The Integration of Peer Support Principles in Community Mental Health Policy and Practice: Toward Epistemic Humility

It is well-known that the mental health system has its fractures and inadequacies. This was true before COVID-19 and grew markedly when the virus took over and drained already-exhausted health care organizations. To resolve some of these decades-long disruptions and to attend to health care disparities, progressive mental health agencies have been pushing for more equitable and inclusive approaches to mental wellness.

The model of Intentional Peer Support (IPS) is at the forefront of some of these changes, raising consciousness and challenging policies that have harmed or failed to serve those seeking services. My motivation in writing this article is to bridge or refute the dualism that has historically characterized the relationship between clinical and Peer Support services; to acknowledge the obstacles of integrating both approaches; and to suggest that integration is not just possible, but already underway thanks to change agents in the mental health system.

IPS is a service/relational approach where staff with lived experience navigating the mental health system or having survived adverse events offer an alternative kind of support to individuals seeking services. IPS principles emphasize the importance of connection, mutuality, exploration of worldviews, and moving towards what people want in their lives versus what they do not want. Central to IPS is an attention to power dynamics. Whether it be the Peer Support team’s staff configuration, or the individual relationships staff have with folks seeking services, IPS challenges the hierarchical nature of interaction that is typical of clinical settings; staff certified in IPS work to share power wherever possible and interrogate where there may be power imbalances.

IPS also rejects the dynamic of “helper vs. helpee” and instead embraces co-exploration and -learning. Meetings with people may involve going out for coffee, going for a walk, going for a drive, and sometimes going into a person’s home. It can also be offered via telehealth or by phone. Some agencies offer Peer Support groups as well, with themes such as “psychiatric survivors,” “substance use,” or “hearing voices/unusual beliefs.” This multitude of offerings means that more people seeking services can find support while they wait to find, for example, a therapist while facing a six-month waitlist. Fewer people fall between the cracks.

Though there has been some progress made related to stigma and mental health conditions, like other forms of oppression, stigma can still live on within systems, institutions, and psyches. Not all community mental health agencies are on board with the idea of integrating Peer Support into their hierarchical, traditional delivery system. In my experience as both a therapist/clinical social worker, and as a peer support advocate, I’ve found that Peer Support workers hold a large share of stigma in our roles, precisely because of our lived mental health experience; we bear the burden of projections and microaggressions from colleagues that people in clinical roles do not have to face.

Inadvertently, the designation of a Peer Support role can reinforce the idea that clinicians and other mental health professionals are somehow free from mental distress or disability; this sets up an “us vs. them” dynamic if not watched for carefully. While Peer Support workers do have the unique freedom and responsibility to disclose more liberally our lived experiences – and this is less true for therapists and psychiatrists – this does not mean that those in clinical roles are immune from mental/emotional suffering, and in fact many clinical practitioners do have psychiatric conditions. I think partially because of this assumption, it is typical for mental health agencies to privilege clinical perspectives over Peer Support services and perspectives.

The tone across many agencies in response to Peer Support is that it is regarded as this esoteric, whimsical appendage to other mental health services, somehow paling in comparison to the breadth and depth of, say, psychodynamic theory or “evidence-based practices.” But I wanted to emphasize how IPS is serving a crucial role in the community mental health agencies that welcome it. It is true that many agencies are not on board and that tensions exist. But there are some with a more progressive lens (such as where I work) who embrace epistemic humility and systemic change, and they see IPS as being a part of that change. Such agencies find a way to integrate Peer Support by giving PS team leaders a voice at the table at “upper” leadership meetings; they put on trainings from outside PS-led parties for clinicians and case managers to engage; they discuss transparently how policy will change in light of some of this integration; clinicians and case managers participate in PS-led co-reflections on a bi-weekly basis in order to consult with PS staff about how they can use PS principles while still functioning in their clinical positions.

Some PS leaders might raise their eyebrows with concern that IPS is being co-opted by the psychiatric system, but I don’t believe that is necessarily what is happening. While it is true that the mental health system has oppressed and traumatized many people (truly, and severely), it is also true that it is comprised of a diversity of individuals working in earnest to help people feel better; working to take in necessary feedback; and working to change systemically due to committed, positive change agents. The concern that IPS is just serving to make people more comfortable in the system and therefore amenable to treatment is an understandable point of caution. But, as someone also trained as a clinician, I think if that comfort is part of the role that IPS is playing, I don’t see that as inherently coercive or somehow manipulative; if an agency is incorporating IPS into its arsenal of tools to support people, it implies (we hope) that transparent and equitable conversations are happening about informed consent and peoples’ preferences for care—which is not the same thing as manipulation to make people more treatment adherent.

If clinicians or case managers are working to adopt PS principles while having to do things like assessment and diagnosis, they can still adhere to an ethos of transparency and open communication about diagnosis (its function, and how an individual thinks and feels about it). Flawed as the mental health system is, it is the only system we have; IPS is a gift of a resource for the system to use in what I see as a burgeoning commitment toward epistemic humility—a willingness to accept that there are ways of “knowing” and forms of expertise beyond those of clinicians; a one-down position that centers and elevates the wisdom of the person in their care. There are a multitude of reasons why PS can and should have a home in community mental health settings:

Peer Support and Mad Studies (a related perspective and philosophy) are built upon a foundation of postmodern, Foucault-inspired, and social justice-driven philosophy. As opposed to whimsical or somehow inferior to clinical interventions, Intentional Peer Support and Mad Studies are truly sophisticated bodies of work. It is also compatible with more contemporary, relational psychodynamic approaches that value and explore intersubjectivity. Both IPS and contemporary, intersubjective therapeutic models share a value of intellectual/relational humility with emphasis on the relationship as opposed to the individual. Both can be deeply empowering.

This stance of humility, with growing comfort with “not knowing,” and co-creating space for folks to empower themselves, is a feature of psychotherapy that is being taught in some graduate school settings, alongside anti-racism and liberation health models. To me, this suggests that the clinical world is going through a humbling paradigm shift. From what I’ve witnessed as a former graduate student, therapists-in-training are learning an abundance of theory and practice—some of which is used and applied once in the field, but some of which is also being “unlearned” and/or at least interrogated as potentially oppressive. The pomp and circumstance and mystical conceptions of therapy are gradually being dispelled to make it more accessible, more transparent, and more practical. As one of my former professors in grad school described it, we can think of therapy as “deep hanging out.” I’ve always loved that. We as clinicians can stop taking ourselves so damn seriously.

In the process of integrating Peer Support principles and perspectives to agency policies and practices, there must be a stretch of the imagination—an opening of the mind to envision and get creative with what we consider to be “legitimately” supportive. It also involves a willingness to offer participants the “dignity of risk” (i.e. a person’s right to self-determination, to make their own choices and decisions, even when those decisions could put them in harm’s way). This entails us sitting with discomfort and uncertainty, instead of (for example) forcibly admitting people to hospital psychiatric units against their wishes. It involves clinicians setting down any agenda of treatment planning with prescribed objectives and goals (at the rushed pace of insurance companies), and instead listening patiently: taking the time to understand a person’s context and all its complexity before we jump to any diagnostic conclusions. Successful and sincere integration can happen when our relevant and hard-earned clinical wisdom can exist alongside radical, liberatory wisdom—with appreciation for the paradox, a commitment to sticking with the uncertainty, and not getting it right all the time.

With the two perspectives equally respected, I believe there will be a lot less harm done, a lot more learning, and an opportunity to be creative in one’s work. Most importantly, the people we serve would be held in mind and heart with a care and consideration that they may not have previously experienced when seeking services. It can make the mental health system less of a perceived threat, and more of an entrusted, safe resource and tool.