When you ask someone what the mental health peer community is about, you get an answer about something about the value of ‘lived experience’. A peer, they’ll tell you, is someone who can uniquely relate to you based on the fact that they have been in your shoes. They command no authority over you, and have no claim to a particular kind of training; their specialness comes from what they have experienced, and the empathy they will have for you based on that experience.
The idea of a ‘mental health peer’ is breaking down in front of our very eyes—and this is a symptom of the reality that bureaucratic administrations really don’t know how to deal with relationships.
You see, peer-ness is not a quality a person can inherently have or not have. Unlike, say biological sex or height, if you put a single person in a vacuum with no other humans present they could not be a peer–because you have to be a peer in relation to someone.
There has been a flurry of legislative moves to credentialise and professionalise peers across US states and all of them ignore this kind of absurdly simple fact. In the ontology defined by law, a peer is a type of person, and you can discern whether they are or are not of this type by evaluating them individually. And then, once you approve them as ‘one of this type’, they then become interchangeable with all others of the same type, modulo some differences in experience, aptitude etc. They are ‘peer professionals’.
Except–the reality of peership involves a person being a ‘peer to’ someone else. It is as if the state legislated a definition of ‘husbands’ and once someone got approved as a husband they were automatically qualified to be a husband to anybody. Ditto with, say, ‘friend’.
This bait-and-switch (of transmuting what was originally understood as a relationship between people into an identity that a person has as an individual) probably happened because of nobody’s intention, but rather as an unfortunate side-effect of the struggle by the peer movement to gain legitimacy and influence and acceptance within the mainstream medical and mental health system.
I think the consequences are pretty severe, severe enough to weaken the capacity of peers to do good work at all.
The influence of mental health peers arose as a reaction to what many saw as the undue power of clinical professionals over their patients, and the negative consequences of this power imbalance, including what many patients saw as a lack of empathy. for what they were going through Initially, peers cared for each other out of a desire for equal power relationships, and ones where the ‘patient’ could trust that their ‘carer’ could know what they were going through, by virtue of having gone through it themselves.
But professionalising and individualising peers makes it easy to slot them into the existing power structures of the mainstream system. This means that individual ‘peer workers’ who want to progress in their careers will gain more and more power within the system, thus removing the ‘equality’ and lack of power imbalance they had in their original form. Peer workers supervise other peer workers, and report to other clinical professionals, including on the decision to involuntarily commit someone. This erodes one of the key benefits of the peer as it originally developed–the provably equal playing field they were meant to have with the patient.
The second consequence of individualising peers is that they are then strewn out across a vast and complicated system, which serves many kinds of people very different from those they might actually be ‘peers’ to. Would you trust that someone has experienced what you experienced if they are of a different gender to you? Radically different age? What if you are experiencing suicidal thoughts and they have only ever experienced alcohol addiction? What if they resolved their struggles in a way that is antithetical to your values, such as coming out as gay or accepting social welfare? What if you don’t know any of this because you never get a chance to learn about their experience?
The idea that a peer has value in treatment because of their ‘lived experience’ is a proxy for their ability to empathise with the patient, for the patient’s ability to see them as a hopeful and dignified role model, and for the patient’s ability to see and trust the similarities between their experience and the peer’s. This is all about the relationship between the patient and peer as two particular people, and is not merely guaranteed by the peer having had any particular experience at all. None of this relational quality is described, measured, protected, or even discussed in any way when it comes to licensing and placing peer workers in jobs, except in the most general indirect way, or as a result of the peer worker’s personal preferences.
The fact that lived experience is now a fully load-bearing proxy for ‘ability to build a peer relationship with a client or patient’ means that as more and more people transmute their various kinds of lived experience into licensed professional peer worker roles, that proxy measure will become weaker and weaker. Since lived experience is determined entirely subjectively by the person claiming to have it, there’s also no current agreed-upon way to evaluate the quality of the person’s ability to build a peer relationship.
Integration into existing power hierarchies and using subjectively-defined lived experience as a proxy for peership that should actually be relational erodes the two things that gave peers unique capacities in the first place.
I’d expect the quality of peer work and the industry as a whole to degrade or at least not improve unless these two issues are properly addressed.
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Hi Jessica,
I agree that credentialing a "peer" seems a bit silly, but I do wonder if there is some worth in actually developing (or finding) a way to measure "ability to form relationships".
https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2018.01115/full
This is sorta close, but somewhat specific to romantic relationships.
Maybe its more like "capacity to form relationship with people who have experienced X". And it would have questions that would assess whether someone really "understood" the "lessons" that come from those experiences. That might be a way to match peers (or even therapists) to patients.
Thanks for the food for thought!