So, what's this thing called 'Peer Support'?

Peer Hub's co-founder, Vikki Price, explains the difference between the general understanding of the common phrase 'peer support', 'peer support' as a relational practice in mental health and roles which contain the phrase 'peer support' but are providing something different.

‘Peer support’ is quite a commonly used phrase. It's easy for people to assume that they know what it means because, generally, they do! Broadly, ‘peer support’ is used to describe a form of ‘moral support’ that specifically comes from people who share a particular experience, role or status. This could be anything from parents sharing tips on parenting, colleagues supporting each other through a tough period (like the Covid pandemic), and, commonly in education, study groups for completing homework. All of these things are forms of peer support. This general idea of peer support is quite broad, and usually simply means people with a shared interest helping each other out around that interest. It’s a fairly simple concept that we’re probably all familiar with.

But, when we talk about 'mental health type' peer support specifically, there are other things that we need to be aware of. Whilst the general concept might be similar – people with shared interests supporting each other – there are additional things at play. One of the things worth remembering is that peer support has not traditionally been something encouraged or offered by mental health services - in fact, it has often been actively avoided and service users have mostly been kept separate from each other unless supervised by staff. Peer support grew in communities partly to overcome this sense of isolation and difference from others, and partly in opposition to the separation of people who have experienced psychiatric care - especially when psychiatric hospitals started to close in favour of a community model of care. As a result, 'mental health type' peer support looks quite different to other kinds of help available in psychiatric services.

The Growth of Peer Support in Communities

Peer support for 'mental health type' experiences grew from grassroots communities that shared similar experiences, problems or disadvantages, and the shared interests in these groups can be quite broad or very specific. Where organic groups and supports started to formalise, peer support usually had an intention or purpose, which is not necessarily ‘recovery’ or ‘getting better’ - in fact, this type of community peer support might not label itself as 'mental health' related. Peer support can quite purposefully use a variety of ways to describe the types of experiences framed as mental health, mental illness or mental disorder, and look to other explanations or meanings for experiences of struggle, distress or unusual experiences.

Peer support’s intention can be as simple as forming connections and social relationships, solving a problem together or realising that there are other people sharing similar struggles. In communities of psychiatric survivors, peer support aims to avoid and undo the harms that can be caused by psychiatric diagnosis and long term psychiatric care. Indeed, moving beyond the assumptions of deficit/illness and the learned reliance on help that can get people ‘stuck’ in psychiatric systems is often a central purpose of peer support.

Depending on the type of experiences and the intention behind the peer support offered, peer supporters can set and agree quite different parameters for how they support each other or ways that they will be together. Peer supporters negotiate collective expectations of each other based on the needs of the pair or group, their learning from their own and shared experiences and what works best for their emerging relationships.

However different and diverse the group or community peer support is found in, the relationships within peer support often have key things in common:

1. They are non-clinical, so while people may talk about clinical elements of their experience, peer support is not led, guided, overseen or attended by people in a clinical capacity or based on clinical knowledge.

2. Peer support is based in a sense of solidarity, community and equity, where people have equal status

3. People come to peer support to receive and offer support from their own lived experience. They participate and contribute from a first-person perspective.

4. Peer support always involves some expectation of (or aspiration to) reciprocal and mutual relationships, shared decision making and collaborative learning.

5. There is a very strong focus on the relationships between peers in a way that is very similar to trauma informed principles – whether being 'trauma informed' is overt and intentional or not in its design.

It is the reciprocity, mutual responsibility and shared sense of purpose that’s an important distinction to differentiate peer support from the other forms of help available. Much of the help for people with mental health problems is unidirectional help: there is a person with a mental health problem and there is a person with expertise in solving mental health problems. The help is always focussed on the person with the mental health problem, 'the person in need of help' is rarely ever expected to help someone else. This is true across a number of different types of helping relationships: whether that is help from a carer or family member, help from a clinical or social care professional, help from charities or support in the community, or help from lived experience mentoring or coaching. In all of these relationships, the person with the mental health problem is the recipient of help, regardless of how collaborative the process is in deciding what the help is for, or what the help should be.

Peer support, however, requires shared responsibility, mutuality (or aspirations to mutuality) and reciprocity in the relationship. Peer support does not require there to be a need for help or problem solving, but where there is, the help, support and solutions are reciprocal and collaborative.

It’s important to note this difference between peer support and peer mentoring, which are often confused and mixed together in formal roles. In peer mentoring, the mentor is not the intended recipient of help but draws from their own experience to guide the learning and development of the mentee. This does not mean that they will not learn anything from the process of mentoring someone or from the experiences of the person they are mentoring, but the mentor’s learning is not the focus or intention of the relationship. Therefore peer mentoring cannot technically be peer support: mentoring styles and skills would be contrary to the core principles of mutuality and reciprocity in a peer relationship. In the same way, psychological interventions or clinical treatments cannot be peer support, since roles are set by the expertise held by one person and the receipt of help by the other; they cannot be mutual or reciprocal by their design.

Peer Support Roles in Mental Health Services

Through understanding the dynamics of peer relationships, we can start to see how peer support work in a formal role can be particularly difficult and require refined and specialist skills. There’s lots to think about when moving peer support from the community from which it grew into a formal role in a mental health service. Many roles with ‘peer support’ in the title are actually more akin to mentoring or community support type roles, where the worker provides ‘help’ to the service user and is able to use their lived experience as part of this help. Indeed, many ‘peer support’ formal roles are not often offering much reciprocity or mutually at all, and so aren’t offering peer support.

There are many reasons why peer support roles in traditional mental health providers struggle to be reciprocal and share the responsibilities and decision making in peer relationships. Psychiatric systems are highly paternalistic about service users, and place a significant amount of responsibility and restriction on their staff through policy and regulation that don’t exist in organic communities. As well as having hierarchical, ‘command and control’ structures based on expertise in mental health, they are often assumed to know what is ‘best’ for service users, hold liability for their safety, and possesses the knowledge and skill in moving people towards clinical recovery; regardless of whether any of these things are realistic or feasible. In mental health services, a lot of the decisions about a service user are made by policy and regulation long before they even meet a peer support worker.

What makes peer support more difficult in mental health services is that peer supporters are often employed in entry-level roles with little or no decision making authority or professional autonomy. They are too low status in the organisation to be able to share decisions about how they will spend their time, negotiate their relational responsibility with service users or collaborate on potential outcomes: none of this is within their freedom to act as an employee. Where they are asked to hold fidelity to the ethos of grassroots and community peer support, they physically can’t if they are to stay within their role responsibilities and pay grade. By default of their status in the organisation and wider service design, their roles make them unable to share responsibility or power in a meaningful way.

[Whilst there are ways and means to design peer support programmes that offer opportunities for peer support to be effectively practiced in clinical and statutory services, this isn’t what this particular blog is about. I would refer readers interested in the subject of workforce design to our resource guide for peer support, our Implementing Peer Support Programmes training or our Pillars of Peer Support Professionalisation guide (download in PDF below.]

Pillars-of-Peer-Support.pdf

Download PDF • 5.97MB

The design and culture of mental health services, the outcomes they are aiming for, the policies and regulations they are subject to and how tasks, roles and responsibilities are viewed all stack up against effective peer support work. This is why peer support in peer led or user led organisations often looks very different to peer support in statutory or clinical-led organisations. In user-led organisations, their approach to peer support is often designed into their entire organisational structure, where in mental health services the entire organisational structure can be in direct conflict with peer support.

Overcoming the Confusion of Peer Support Roles

And here is the crux of the matter when it comes to lived experience workforces in large mental health providers, such as the NHS or similar organisations with a clinical focus, ‘peers’ who provide ‘support’ do not necessarily provide ‘peer support’. 'Peer' can simply be used to mean a person with lived experience, and so these two things – ‘peers who provide support’ and ‘peer support’ – are often confused by mental health service providers. The phrase ‘peer support’ in a job title or role profile may be used to describe many different kinds of help, but is rarely used outside user-led organisations or peer-led programmes to describe a role that provides peer support.

It is important for service users to have access to good information about what peer support workers employed by organisations offer, since peer worker roles are so varied and they do so many different things. There is very little homogeneity in these roles, and while many are presented as practicing 'peer support', the definition of 'peer support' has been much changed from how it is known in grassroots communities to fit a clinical frame of working.

What does this mean for Peer Support?

So, now you know what mental health peer support is, hopefully you will feel more confident in identifying whether someone who has ‘peer support’ in their job title is offering ‘peer support’, or if they’re actually doing something else. For people who might be thinking about getting involved in peer support, either in the community, as a worker or as a service user, this can help you make an informed decision about what is being offered, and if it’s something that you would like to try.

Peer support is not easy for staff in peer roles or service users who choose to try it. It is purposefully all at once very comforting, very challenging and very meaningful. it asks us to think critically about how we form relationships with others so that our relationships can be deeply connecting and trusting. For many people, peer relationships ask them to discover new ways of being with people that they have not been able to experience before either because they have been harmed by someone they trusted in the past, have learned unhelpful relational roles, or have not felt valued as part of their previous relationships. Within peer relationships, however, we find huge opportunities for growth, discovery and self-realisation.

In peer support we have to be prepared bring ourselves into the relationship as a full partner, and so peer support should never be inflicted on someone involuntarily. Service users should always have a choice as to whether to get involved in peer support, especially since peers often talk about things that are uncomfortable, difficult or stretching us out of our comfort zones in ways they haven't been able to with other people. Being unable to turn down peer support, or not being asked for consent to see a peer supporter, is a really good indicator that what’s being offered is not really peer support at all.

Peer support will not be right for everyone, and there are many possible routes forward in life: there is no ‘magic answer’ to mental and emotional suffering. At the best of times, peer support can be an incredibly connecting experience of humanity and evolution. Through peer supporters, I have been introduced to concepts and worldviews that I could not have otherwise imagined, and been really challenged in the way I have come to understand myself and the world around me. They have led me closer to accepting my flaws through their own flaws and mistakes, and they have taught me to be more forgiving, patient and kind towards myself. I have gained and shared much of myself through peer support, and found so much of my struggles reflected by others I have grown to love and respect; so much so that I can’t imagine me being in the place I am today without it.

And so, there are many of the reasons I advocate for good, values based ‘peer support’ to be part of mental health services, not just ‘peers who provide support’, and will continue to do so in my work with Peer Hub CIC.