For many of us in the field of mental health and substance use disorder, the idea of peer services feels like a new and welcome change that brings with it equity and a workforce with a more complete perspective on lived experience.

Many people are surprised to learn that peer services have a long and distinguished history. Davidson, et al. (2012) points out that peer services were an “innovation” of the late 18h century in France. Pussin and Pinel, in developing their “moral treatment” moved away from standard treatments of their time, which often involved shackling and abuse. “In addition to being ‘gentle, honest, and humane,’ Pinel found these former patients recruited by Pussin to be ‘averse from active cruelty’ (which was a common management strategy in the asylums of the day) and ‘disposed to kindnesses toward the patients in their care” (Pinel).

While not generally described as “peer services,” 12 step programs, which began in the 1930’s with Bill W. using his lived experience to help others struggling with alcoholism, are perhaps the most widespread use of peers helping others who share their issues. There can be no disputing the power of identification, both in empathy and role modeling. The hope that comes from someone who has “walked in” your shoes and emerged on the other side, is invaluable.

The authors of this article are of the belief that, in many ways, we “are all peers,” in that our lived experience is often what brings us to the helping professions. However, asserting “that we are all peers,” obscures the unique challenges of the peer workforce as well as the commitment being made to utilize their, often painful, lived experience. Peer workers, in both mental health and recovery specialists in the field of substance use disorder, have chosen to work with people whose difficulties mirror their own. And that may be a fundamental difference between peer specialists, and mental health and substance use providers at large.

Peer Supervision and Support Work Group

A community health agency in New York State (which chooses to remain anonymous to protect the privacy of their peer workers) began to see a slow but steady deterioration in several of the peers employed by the agency. This agency had trained peer specialists who ran groups and did counseling and enjoyed full employee status (with salary, benefits, and paid time off). They also employed “outreach peers,” in their harm reduction program, who were often still using substances. These peers would go out into the community and reach those struggling with opioid addiction. They would use their community connections to deliver clean syringes, fentanyl and xylazine test strips, and inform their friends and peers of harm reduction services available to them. These outreach peers received a significant stipend (totaling a few hundred dollars for two weeks work) for their outreach, and associated paperwork documenting what work they had done (while keeping their contacts anonymous). The third type of peer worker was employed informally and compensated by stipend to perform tasks such as greeting visitors at the front desk and distributing Narcan kits and test strips or assembling Narcan and Safe (crack) Use Kits in the supply room.

Staff became aware of burgeoning problems among the peer workforce when a peer, who had been with the agency for many years, began to deteriorate after his housing became insecure. This began, for him, a spiral in functioning resulting in his becoming homeless and eventually relapsed with substances. At around the same time, other outreach peers began to exhibit concerning behavior around functioning and their own increased substance use.

While research supports the efficacy of peer services, (Bassuk, et al., 2016), there is no denying the vulnerability that working with one’s own issues may bring to an individual. To provide support to the agency’s peers, a Peer Supervision and Support Work Group was established. It was co-chaired by a mental health professional and a Certified Peer Recovery Advocate. The goal of supporting peers was expanded to vocational support after it was noted that outreach peers may be put in a bind in which they are fearful of losing a stream of income when that income is contingent on their connections with people using substances. This could potentially have the iatrogenic effect of concretizing an outreach peer’s presence with “people, places, and things” that are potentially harmful for them. In addition, trained peers, who (often) are in substance use recovery, are still exposed to harm reduction practices that could be triggering (such as clean syringe distribution). The committee developed a protocol that included the following:

Enhanced Orientation at Hire – Designed to normalize problems that might arise in the course of their work.

Life Skills Group – Designed to help support healthy living and wellness skills that may have not been learned during their period of substance use or psychiatric illness.

Vocational Enhancement Group – Designed to teach soft skills (such as conflict resolution, “managing up” and understanding one’s professional role).

Enhanced Orientation

The first recommendation of the workgroup is an Enhanced Peer Orientation upon hire. This peer directed and led orientation is designed to clarify (in writing) what the specific goals and tasks are for each person as they begin their role in the agency, introduce the topic of managing work related triggers, identifying supports both inside and outside the agency to deal with difficult periods at work, understanding that supervision is for vocational support and growth, and understanding our/their role as agency representatives. In addition, the Enhanced Orientation would include a quarterly check-in with peers to assess if there are aspects of the work that cause them distress and if they have current supports. Outreach peers would be asked about current use of substances (responding to this inquiry would be completely voluntary, as it is understood in this role, at a harm reduction program, that their use of substances remains their choice). It was agreed by the workgroup that increased use of substances (and therefore health risks) could be an iatrogenic problem of participating in the Outreach Peer program while continuing to use drugs.

Life Skills Group

The second recommendation is to provide a Life Skills Group. It has been noted that those with significant lived experience, around both substances and/or mental illness, may have missed certain developmental experiences (such as managing money, planning meals, basics of keeping a home clean). This group is designed to provide a supportive, non-judgmental space for people to learn skills, including low-cost community activities, healthy eating, and healthier coping skills. It is recommended by the work group that group participation come with a stipend or gift card (such as a grocery or laundromat card) to provide an incentive for attendance as potential participants may not know, without attending, what benefits this group could provide for them.

Vocational Enhancement Group

The third recommendation is a Vocational Enhancement Group. A possible problem identified by the workgroup is that peers without formal training (particularly those participating in the syringe exchange program), might not see a pathway for further vocational growth. The concern is that while appreciating the opportunity to receive a stipend, as well as the esteem they get from supporting the agency’s goals, they may not experience themselves as capable of more. Since the syringe exchange program utilizes peers who are currently using substances to reach their community, this could have the unintended consequence of preventing a peer from moving towards other healthy activities, as doing so might result in losing their assignment with the agency. While fully respecting all peers’ right to choose their level of involvement with substances, the Vocational Enhancement Group would help each person evaluate vocational goals and possibilities. In addition, topics of the group might include what it means to be a professional, dealing with conflict at work, and utilizing pre-existing skills (even if they are “street skills”). It was also recommended that group attendance be encouraged with a small stipend or gift card for the same reasons cited above.

By providing concrete support around issues of competency and functioning, in a supportive and non-stigmatizing manner, the hope is that peers will experience growth in functioning in all aspects of their lives. Evidence has shown that peer workers can enhance recovery and services (Bassuk, et, al., 2016; Davidson, et al., 2012) for those in crisis. The goal of targeted vocational and emotional support is to strengthen the recovery of those who are working to make this happen.

Elaine Edelman, PhD, LCSW, CASAC-Adv. (NY State), is Professor of Practice (Social Work and Addictions), at Kansas State University and can be reached at [email protected]. Michael Collins, CRPA, RCPF, CHW, is CCBHC Vice President of Peer Services at Interborough Developmental and Consultation Center and can be reached at [email protected].

References

Bassuk EL, Hanson J, Greene RN, Richard M, Laudet A. Peer-Delivered Recovery Support Services for Addictions in the United States: A Systematic Review. J Subst Abuse Treat. 2016 Apr; 63:1-9. doi: 10.1016/j.jsat.2016.01.003. Epub 2016 Jan 13. PMID: 26882891.

Davidson L, Bellamy C, Guy K, Miller R. Peer support among persons with severe mental illnesses: a review of evidence and experience. World Psychiatry. 2012 Jun;11(2):123-8. doi: 10.1016/j.wpsyc.2012.05.009. PMID: 22654945; PMCID: PMC3363389.

National Practice Guideline for Peer Specialists and Supervisors. National Association of Peer Supporters. (No date provided.)

Pinel P. A treatise on insanity. Shefield: Todd; 1806. [Google Scholar]

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Weiner DB. The apprenticeship of Philippe Pinel: a new document, “Observations of Citizen Pussin on the Insane”. Am J Psychiatry. 1979; 36:1128–1134. doi: 10.1176/ajp.136.9.1128. [DOI] [PubMed]