Peer Support: What Makes It Unique?
Mead S., & MacNeil C,.
(2006). Peer Support: What Makes It Unique?
Rehabilitation. 10 (2), 29-37.
Peer support in mental
has recently gained significant attention. There is increasing talk
funding and credentialing, standards and outcomes. But what is peer
how is it different than services, even services delivered by people
identify themselves as peers? In this paper we would like to present a
perspective on peer support that defines its difference and also
integrity to the movement from which it came. We will offer some
practice and evaluation standards that may help different types of peer
initiatives sustain real peer support values in action.
Peer support for
people with similar life experiences (e.g., people who’ve lost
with alcohol and substance abuse problems, etc.) has proven to be
important towards helping many move through difficult situations
1989; Roberts & Rappaport, 1989). In
general, peer support has been defined by the fact that people who have
experiences can better relate and can consequently offer more authentic
and validation. It is also not uncommon for people with similar lived
experiences to offer each other practical advice and suggestions for
that professionals may not offer or even know about. Maintaining its
non-professional vantage point is crucial in helping people rebuild
of community when they’ve had a disconnecting kind of experience.
Peer support in
mental health however has a more political frame of reference. Whereas
support group’s form around the shared experience of illness, peer
mental health grew out of a civil/human rights movement in which people
affiliated around the experience of negative mental health treatment.
coercion, over-medication, rights violations, as well as an
version of their “story”). In other words, the shared experience has
to do with responses to treatment than the shared experience of mental
The Independent Living Movement has been the quintessential guide to
Living Movement grew out of a reaction to social, physical, and
barriers for people primarily with physical disabilities. It arose at a
when other movements were gaining headway in establishing rights for
groups of all kinds. Through a strategic advocacy initiative, the
Living Movement focused on three general areas: The first, to enforce
and benefit rights for people with disabilities; second, to develop a
thinking created by people with disabilities; and third, to create
services and advocacy centers (Deegan, 1992; DeJong, 1979).
to the IL paradigm, the problem does not reside in the individual but
the solution offered by the rehabilitation paradigm- the
features of the …professional-client relationship…The locus of the
not the individual but the environment that includes not only
process but also the physical environment and the social control
society-at large (pg 443).
the critical elements of peer support Solomon (2004) reminds us,
provided services need to remain true to themselves and not take on the
characteristics of traditional mental health services (pg 8).” Campbell
also notes that “consumer operated programs should present an
worldview (pg 32).” So what does it mean to stay true to itself, to
different worldview? Identifying skills and ingredients that support
difference will help in determining what constitutes “good outcomes”
programs. It will help us to become more self-evaluative and therefore
continuously build on emerging knowledge, and it will help us simply to
challenge, “how we’ve come to know what we know.”
have been many recent studies exploring the ‘critical ingredients’ of
support. Findings are congruent with the IL framework and offer both
and process standards (Holter et al., 2004; Solomon, 2004; Hardiman,
Structural standards are elements of peer initiatives that define the
rules and how the group is constructed. They include being free from
(e.g. voluntary), consumer run and directed (both governmentally and
programmatically), an informal setting with flexibility,
non-medical approach (e.g. not diagnosing, etc) (Solomon, 2004; Salzer,
Holter et al., 2004; Clay, 2004; Campbell, 2004; Hardiman, 2004). Process standards are more like beliefs,
styles and values. They include:
- The peer principle
(finding affiliation with someone with similar life experience and
having an equal relationship)
- The helper principle
(the notion that being helpful to someone else is also self healing)
- Empowerment (finding
hope and believing that recovery is possible; taking personal
responsibility for making it happen)
(self and system advocacy skills), choice and decision making
opportunities, skill development, positive risk taking, reciprocity,
support, sense of community, self help, and developing awareness
(Campbell, 2004; Clay, 2004).
these ingredients are clearly essential for maintaining a
relationship, they also may fall short of describing how to provide a
alternative. This is where it becomes crucial that we begin to define
practice elements that really lead to different assumptions about our
relationships and ourselves, different ways of thinking about our
and ultimately define our unique and valuable role in the larger ‘help’
arena. We must ask ourselves:
is it that we need to offer in order
to help people begin to see things in a new way?
kinds of relationships really build
can we construct reciprocal help so that it is not attached to any
role or interpretation of the problem (e.g. a non-medical
interpretation of the
Without thinking carefully about these
questions it is likely that peer support will be defined and judged
context of the dominant paradigm. Further, if we can establish some
parameters for all of peer support, it will support peers working in
service delivery system with a unique and fully distinguishable
thinking. If this framework becomes more widely known and considered,
should be less likelihood of cooptation. In order to create this
way of thinking it may be useful for us to consider some of the skills
support that build different kinds of help and ultimately a different
mental health has most often been defined as a process by which people
with mental illness regain a sense of hope and move towards a life of
choosing (President’s New Freedom Commission Report, 2003). While this
definition on the surface seems obvious, what remains hidden is the
which people have gotten stuck in a medical interpretation of their
experiences. With this stuckness comes a worldview in which one is
trying to deal with their perception of what’s wrong with them instead
what’s wrong with the situation. In other words, even if I have hope of
into a better life, I have been taught to pay a lot of attention to my
symptoms. This interpretation of my experiences leaves me constantly on
for what might happen to me should I start to get ‘sick.’ Even with
skills (learning to monitor my own symptoms), I find myself creating a
that is ultimately guided by something inherently wrong with me. With
understanding, I may continue to see myself as more fragile than most,
different than ‘normal’ people. I then continue to live in community as
outsider, no matter what goals I have achieved.
noted before, peer support in mental health grew out of an affiliation
the shared experience of negative treatment.
Yet it is the medical model that has given us language,
an interpretive framework, and a notion of what it means to ‘help.’ In peer support we may pursue different kinds of
which we start by thinking about “how we’ve come to know what we know.”
means actively examining how we have learned to name our experience,
utility the naming has now and create the ability to step back and
how that naming may be keeping us stuck.
Following is a
typical example of interactions where peer roles often fall short in
this new conversation
Helpee: My depression is really acting up lately and
my doctor says
I need to increase my medication but I don’t really want to.
Peer Helper 1: Boy, when my depression starts, I
have to take a bit
more medication or I get in trouble.
Peer Helper 2: Don’t you remember the last time you
didn’t do what
the Doctor said and you ended up in the hospital?
Peer Helper 3 What do you need to say to the Doctor
so that he
doesn’t increase them?
Peer 1 is
clearly operating on learned assumptions about help and borders on
Although the second helper’s role is more of an advocacy role, it is
presumed that the depression and the medication are the issue rather
may have happened situationally. We don’t learn what constitutes
sadness or grief, what the medication does and doesn’t do, what
means for that person, or about what is it that’s being medicated.
In a different
kind of conversation, new ways of thinking about the experience may
Helpee; My depression is really acting up lately and
my doctor says
I need to increase my medication but I
don’t really want to.
Helper: What does it mean for you when you say that
is acting up?
Helpee: Well, I’m sleeping more and don’t really
feel like eating.
Helper: Boy I can remember a time when it seemed
like every time I
didn’t feel too great I would interpret it as depression. I saw it as
illness that I had which meant, at best, that I could only learn to
it.. I had learned to think about many
of my experiences and feelings through the lens of illness andI started
kind of afraid of my own reactions. I’ve
had to work at thinking differently so now when I have some of those
I simply wonder if it’s just my body’s way of saying I’m exhausted or
Helpee: But the last time I felt like this I
ended up in the
Helper: Was that helpful?
Helpee: Well they changed my medications around
and gave me shock
treatments…at least I wasn’t so depressed anymore.
Helper: I wonder if there are other ways you
could think about what
you might need when you’re feeling tired a lot and not wanting to eat…
Helpee: Like what?
Helper: Well sometimes when I’m doing something
new or uncomfortable
I don’t feel very confident. In the past being uncomfortable led to
bed and not wanting to eat. Then I’d just call the Doctor and they’d
medication. Now I try to simply let it be ok to be uncomfortable.
going to bed I go to the gym, or I ask myself how others might react if
were feeling uncomfortable about doing something new.
doesn’t assume a medical definition of the problem and opens us to
other ways of thinking about the experience rather than trying to deal
‘it.’ Asking about the phenomena of eating and sleeping vs. calling it
depression, we change the direction and consequently the outcome of the
conversation. By sharing our own process with this shift we aren’t
other person what to do but offering our own critical learning
this sharing we are exposing the other person to a potentially larger
which may help them consider other ways of thinking about what’s
therefore options that were not previously available.
have learned about help in the mental health system pushes us to think
of it as
a one-way process. Even when we refer to the helper’s principle we are
talking about role reversal and we simply mean that now that we are in
helper role, we feel better just by providing help. This kind of help
to maintain static roles of helper and helpee.
Further, as Friere (1995) points out it is not uncommon for
moves from helpee into helper role to build a sense of confidence and
abuse power in much the same ways as was done to them. One starts to
as the more ‘recovered’ person and begins to see the relationship with
her peer as one of service. Unfortunately, this dynamic will never
to meaningful community integration. Mutual help in peer support (and
in community) implies both people taking on both roles with each other.
means sharing our vulnerabilities and our strengths and finding value
other’s help. If we continue with the example above, the conversation
have led to
Helper: I was just on my way to the gym, would you
like to come with
me? I’ve actually had some difficulty going alone, I always feel so
conscious about my body. I feel like everyone’s staring.
Helpee turned helper: Wow I used to feel that way
and it kept me from
even wanting to use the locker room. Finally I just asked myself if I
about what anyone else looked like. I
realized that we all kind of think about ourselves and decided that
one really was paying attention. That thinking took practice, but now I
pretty comfortable at the gym. I’d be happy to go with you if you think
nature of this interaction helps both people see themselves in multiple
throughout the conversation. It is this level of mutuality that most
community type relationships and allows us to move towards full
rather than feeling simply integrated in the community.
It is crucial that even with paid peers we
must figure out how the relationship can be more mutual and reciprocal. Perhaps we can consider it our job to model
peer support rather than to be a
provider of service.
that helps explore each individual’s subjective experience is important
beginning to redefine recovery. The new use of language, however,
especially difficult when we are doing peer support in a traditional
When we are working with a team of traditional providers it becomes a
simple and quick communication to talk about symptoms, illness, coping
peers we find that we are misunderstood if we use other language and in
to feel part of the team, we begin to talk about people in medical
(sometimes even without the presence of the peer). For example: Dr. A
a peer specialist in the hall one day and asks him how Peer One is
symptoms. The Peer Specialist says: “gee Dr. A, Peer B seems really
today.” Aside from the fact that this conversation should not be
without the presence of Peer B the symptom language has generated a set
assumptions that have major implications, and secondly, what are both
assumptions about symptoms and what constitutes them. Unfortunately,
simple conversation may result in the team deciding to increase peer
language supports a different conversation as we saw previously. If we
the code language of mental health we find that we are having very
conversations, which then require a different type of response. One
this shift in language might include talking about experiences instead
symptoms, The language of experiences allows not only for unique
that particular event, it also presumes only one person’s
this starting point we can explore other ways of knowing as well as
on how the use of medical language keeps us stuck.
As long as we
continue to adopt the language of mental health, we are stuck in power
structures that impose a narrow meaning on our words and conversations.
assume a lot about our experiences as they’ve been interpreted by the
traditional system. It becomes easy to talk about “my depression,”
I’m feeling pretty down and out today. This leaves us with a
is intrinsic to us, generalizable to others, and occurs because we have
The language and constructs of mental illness begin to limit our much
subjective experience. If we can struggle with the language of the
play with metaphor, take the time to really explain to each other, we
conversation that is rich with possibility rather than limited by what
about the illness.
We have talked
about the need for mutuality in the peer support relationship but what
mean by mutuality?
is assumed that both people learn from each other
people figure out the rules of the relationship
structures are always on the table and negotiated
helping relationships, it is assumed that it is primarily up to the
take responsibility for making the relationship work. When things are
working so well this kind of dynamic has led helpers to feel like
‘doing something wrong,’ or to blame the
other person for not trying. We stop saying what we see, what we need
begin to disconnect, falling into an assessment and evaluation role
working on it together. On the other hand, as patients we have been
taught that we cannot or don’t have to take responsibility in a helping
relationship. We fall into believing that we are victim to our own
and then wonder why people disconnect or take over when we say things
In peer support
relationships it is important to remember that it is not our task to
evaluate each other but rather to say what we see (our perspective),
feel, and what we need to build connection. For example,
Peer 1 : I can’t go with you today, I’m really
Peer 2: When you talk in the language of suicide
I feel kind of
scared and a little bit frustrated. If you’re feeling lousy and don’t
go out with me, I need for us to figure out a way to talk about it
In this scenario
rather than starting a suicide risk assessment, we are once again
use of language without presuming it means imminent action. We bring
relationship back to negotiating what will work for both of us and we
that both our needs are important.
safety: Sharing Risk
We cannot talk
about doing something fundamentally different until we address the
safety and the fact that it’s simply come to mean risk assessment in
of mental health. We’ve been asked, “Are you safe, will you be safe,
sign a safety contract? As recipients this has left many of us feeling
fragile, out of control, and has left us thinking of safety as simply
someone else’s discomfort. If we don’t begin to address issues of risk
power, we cannot help but replicate many of these dynamics in peer
For most people
a sense of safety happens in the context of mutually responsible,
relationships. It happens when we don’t judge or make assumptions about
other. It happens when someone trusts/believes in us (even when they’re
uncomfortable), and it happens when we are honest with each other and
own discomfort. It is with this interpretation of safety that we can
take risks and practice alternative ways of responding. We can choose
who to be
with, when we can be there, and we can begin to talk about shared risk.
risk in peer support tackles the issue of power, what it’s like to lose
abuse it, or balance it. We talk about how we each are likely to react
feel untrusting or disconnected. We begin to pave the way for
relationship during potentially difficult situations. This level of
works well in trusting relationships but is critical to the health of a
support group or program.
When we think
about how to stay on track, how to not drift back to old ways of doing
being, one helpful process can be to formulate standards specific to
support. The standards would represent statements about the alternative
worldview that peer support tries to create - the ideal, or ‘what ought
in the helping relationships. While we have addressed some of the
efforts in exploring ‘critical ingredients’ earlier in this paper, here
would like to offer further thinking about developing standards
First, the kind
of knowledge peers bring into the support relationship can be best
characterized as practical knowledge, or a lived knowledge from which
and understanding are embedded in contextualized lived experiences
2002). When persons operate from this kind of lived knowledge,
is known is not necessarily evident, but rather is expressed through
values and stories that have been formulated through participation in a
historical community – in this case that of being persons who have
mental health services.
So when peer
support communities explore how they are different and what they know,
sophistication of the knowledge they posses is often not easily brought
surface. The challenge presented in developing standards for peer
support is in
finding ways to translate practical knowledge into clear accounts of
the ideal” and why this is so. This ‘realizing process’ goes beyond
from peers related to how they act - to digging deep to discover what
all peer supporters know.
support knowledge is passed on through an oral culture and storied ways
meaning. This means that being attuned to the practical knowledge of
support will require adopting a narrative framework for articulating
support standards (MacNeil & Mead, 2004). It is a good method of
can get very tricky when peer support practices are under the umbrella
service organizations or when peer organizations are providing
services. Sometimes it can be difficult to tease out whose narratives
really being represented.
As one example,
an organization can be viewed as a collection of people who interact
and other primarily through dialogue (Cambell, 2000). In this dialogue
have the opportunity to constrain or influence each other’s way of
acting – and it is inevitable that this collection of people creates
organizational belief system. And within the organizational belief
are more influential or dominant narratives that steer the activities
organizational culture. In this regard, narratives are both structures
and meaning (Bruner, 1984).
the development of standards in peer services or support communities,
it can be
very helpful to discuss within an organization the kinds of discourse
guide their activities. With that, we can then reflect upon whether
organizational narratives more so represent the attributes of peer
if (consciously or unconsciously) they reflect a drift towards more
service practices. This process of examination also can create and
platform for mutually responsible dialogue.
thought about standards development takes a transformative stance
2005). We assume it is possible to transcend thinking and practices
been shaped by the lens of dominant narratives or power structures
process of developing standards for peer support. Elevating different
historically marginalized narratives can help us to redefine the
new solutions and step outside of the box in our thinking about program
standards. Likewise, creating processes of deliberation among
participants who hold different viewpoints about ‘what ought to be,’
viewpoints are situated from different positions of power, can have
influences on shaping shared understandings about standards, and can
better represent traditionally disenfranchised narratives (House &
1999; MacNeil 2002).
also exists to broaden the scope of evidence-based practices.
practices have mostly been described by
their program structures (staffing, case load size, etc.) and have
the ingredients of the helping processes that occur within each
which research has shown to be related to how people change and grow
2003). Thinking further about standards
of peer support guided by the constructs offered in this paper (Achieving Difference, Critical learning,
Mutuality: Redefining help, Language Use, Redefining safety: Sharing
risk) will help us to push our thinking around the
parameters of evidence-based practices and to frame how peer
different from other services – whether professionals or peers provide
Last of all, we
have given some forethought to next steps beyond developing standards,
involved in creating ‘measurement’ strategies that are coherent with
and standards of peer support. We must remember that the history of
support shows us a culture that emerged as a response to doing things
differently. Peer support programs are not intended to be routine
practices. It seems to us then, that the measurement of peer support
should also look and feel very different. The fidelity of peer support
embedded in its storied culture and consideration should be given to
narrative measurement strategies that can be acculturated into peer
the method of fit will also help to sustain the evaluative practices
This is a future challenge for the field of evaluation and peer support
working in services: Can we do peer support?
currently a national trend towards integrating peer services within the
traditional delivery system. Certified
peer specialists are funded through various Medicaid and VR waivers and
recipients are finding meaningful support with their paid peers.
role has been beneficial in acknowledging the expertise of lived
has also offered recipients a forum to speak about their experience
differently, be exposed to strong role models, and develop new skills
strategies to help them heal and recover.
if done well, can provide hope, role modeling and simple safe
While the task
of the peer provider may coincide with the task of peer support, (e.g.
on recovery strategies, or sharing like experiences), there may also be
where the peer provider simply is not allowed to challenge the medical
description of the client’s experience. While empowerment and
important tools one can learn from a peer provider, it is not likely
conversation may entail the “deconstruction” of the client’s
can’t both work for the medical system and refute its very foundation.
development of this practice of doing peer support we can begin to help
providers create a platform from which to offer their unique
Perhaps it is here, with this new influence, that other providers may
begin to question the over-medicalization of people’s experience.
it is important that we don’t lose sight of true peer support in our
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